Unnecessary testing for cervical cancer in women younger than 21 years and in those who have had a hysterectomy is costing about $850 million annually in the United States. It also poses clear risks without documented benefit.
So conclude Nancy Morioka-Douglas, MD, MPH, and Paula Adams Hillard, MD, both from Stanford University in California, in a viewpoint published online April 8 in JAMA Internal Medicine.
"Cervical cancer screening is a prime example of where we can do less without compromising the health of our patients," writes Michael LeFevre, MD, MSPH, from the University of Missouri in Columbia, in an accompanying invited commentary.
The extent of this unnecessary testing was highlighted earlier this year in a report from the Centers for Disease Control and Prevention, as reported at the time by Medscape Medical News.
Drs. Morioka-Douglas and Hillard and Dr. LeFevre explore in some detail the use of the Papanicolaou (Pap) test in 2 populations: women younger than 21 years and women who have had a hysterectomy. They point out that the guidelines of numerous professional organizations, as well as the US Preventive Services Task Force, recommend against such testing.
Testing Against Guidelines
Drs. Morioka-Douglas and Hillard explain that screening women younger than 21 years is not recommended for several reasons. Cervical cancer is rare in adolescents, and abnormal cervical cytologic findings related to human papillomavirus (HPV) infection are common in this group, they note. Screening these women leads to unnecessary testing and treatments for lesions that would spontaneously regress, and treatments are associated with risks, they add.
Nevertheless, it is being carried out. They estimate that 4.7 million women younger than 21 years have an annual Pap test in the United States. They calculate that this unnecessary testing costs approximately $500 million per year (using a laboratory fee of $103 per Pap test, based on 2011 Medicare fee schedules). This does not include the cost of additional testing to investigate positive screening results.
Guidelines also recommend against Pap testing in women who have had a hysterectomy for a benign condition. However, such testing is being carried out in about 3 million women per year (about 1 million of whom are older than 65 years), Drs. Morioka-Douglas and Hillard note. They estimate that this costs approximately $350 million per year, not including the cost of additional investigations.
"Swimming Upstream"
Even when the cost issue is left out of the debate, Pap testing in these 2 populations can result in more harm than good, writes Dr. LeFevre.
He acknowledges that it is hard to get physicians to do less testing and patients to accept less testing. It is like "swimming upstream," he adds.
The forces to do more are powerful, and with screening, so often the mantra is "if we can save even 1 life, it is worth it," he notes.
There are also liability concerns; the failure to diagnose a problem that later causes significant morbidity or mortality is a leading cause of litigation, he points out. "Are there comparable lawsuits for overuse of medical testing?" he asks rhetorically.
Testing More Frequent Than Recommended
Even in women who meet the recommended criteria for cervical cancer screening, there is evidence that more testing than is recommended is being carried out.
Results from a survey of 2087 primary care physicians, published online April 8 as a research letter, show that most would recommend testing earlier than the 3-year interval that is now recommended for women 30 years and older with a negative test result for oncogenic HPV and a concurrent normal result on Pap testing.
"Primary care providers consistently reported that they would recommend Pap testing sooner than recommended by guidelines, especially after normal cotesting results," the research letter concludes.
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