Solutions offered for inconclusive Pap tests

Tuesday, January 15, 2002

WASHINGTON -- More than 2 million American women enter medical purgatory every year: Their Pap smears come back inconclusive. The laboratory found something abnormal but couldn't tell if it was an early sign of cervical cancer or not.

It's a high-anxiety time, one that -- in these days of 10-minute doctor visits -- women too often grapple with on their own. How can they tell if it's a false alarm, as the vast majority will be, or if they're actually developing cancer?

Now the American Medical Women's Association has developed the first patient guidelines to explain their three options in layman's terms -- and delineate the group's top choice: a simple test for the virus that is the major cause of cervical cancer. If you don't have human papillomavirus, or HPV, you can relax about that inconclusive Pap.

Patients need easy-to-understand information because inconclusive Paps are such a complex issue that "even your most educated women will have trouble understanding, and the medical community doesn't always have the time to explain," says Debbie Saslow, the American Cancer Society's cervical cancer chief.

But don't expect strong agreement that HPV testing is the top choice. It's a confusing test. A negative test rules out cancer for now, although women can always get infected later. After a positive test the patient may need further examination, even though the vast majority of HPV cases aren't harmful.

"The bottom line is there's no one right answer," Saslow cautions.

Indeed, the new guidelines are causing some consternation. Long-awaited physician guidelines from the leading cervical cancer medical societies are due in about two months. Yet AMWA scooped its sister medical organizations, distributing the patient brochure this month with some funding from Digene Corp., the HPV test's maker.

Some experts call the brochure too simplistic.

"All of the traditional approaches to managing patients with abnormal Paps in fact give you good results and should be considered safe," says Dr. Tom Wright, a co-author of the pending physician guidelines. "To me, the real problem with the AMWA guidelines is that I think they are not evidence-based and ... look only at the short-term costs."

Cervical cancer strikes 12,900 American women each year and kills 4,400. It usually grows slowly, so regular Pap smears can catch it early -- often, when cells are just beginning to turn cancerous. Early detection can help doctors cure or even prevent cervical cancer.

But Paps aren't perfect. More than 2 million a year are deemed "ASCUS" -- they contain "atypical squamous cells of undetermined significance." In plain English, some cells appear abnormal, but it's unclear if they're precancerous or if some benign condition is to blame.

Only 5 percent to 10 percent of inconclusive Paps turn out to be cancerous or precancerous. The trick is sorting out which women really are at risk and quelling unnecessary anxiety in the rest.

AMWA's new patient guidelines aim to help by explaining women's three options:

--Many doctors recommend simply repeating the Pap. Paps are easy and widely available. But three repeat tests must be done, one every four to six months, to be sure no danger signs were missed.

That means it can take over a year to be sure that an ASCUS result was a false alarm. Also, missed work, childcare issues and the price tag -- about $159, AMWA says -- for three visits to the doctor may make that a hard choice for some women.

--Get a colposcopy, in which doctors examine the vagina and cervix with a lighted magnifying instrument and, usually, take a biopsy, a snip of tissue to examine under the microscope. Results from a colposcopy with biopsy are usually -- and quickly -- definitive. But the biopsy can be painful and it costs about $450.

--An HPV test, which AMWA says costs between $49 and $85. The patient brochure doesn't acknowledge that a positive HPV test will lead to more tests and more expenses.

Some 40 million Americans have HPV, a sexually transmitted virus. While a few of the over 70 strains can cause cervical cancer, the vast majority are symptomless and the body can get rid of them without harm.

A recent National Cancer Institute study found that a negative HPV test provides a 99 percent chance there's no cervical cancer, and HPV testing actually is a little more accurate than repeat Paps among those ultimately diagnosed with precancer.

"The real power of the HPV test is these negative results," says AMWA co-author Dr. Angel Houghton, a Texas gynecologist.

But the American Cancer Society's Saslow urges each woman to consider all the choices outlined in the new patient brochure and pick the one best for her.

"There's a big emotional cost of having an HPV test and having it come back positive and still, in most cases, it's not going to be anything," she cautions.


EDITOR'S NOTE -- Lauran Neergaard covers health and medicine for The Associated Press in Washington.


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