Why are women being told to forgo cervical cancer screenings?
21 November 2009
Only days after a government panel recommended cutting back screenings for breast cancer, another body has advised that women undergo less frequent screenings for cervical cancer, and begin them at a later age. The American College of Obstetricians and Gynecologists (ACOG) published guidelines Friday recommending that women not have Pap smear screenings until age 21, and that the frequency of Pap smears be scaled back after that.
The Pap smear is a highly effective screening procedure that has been credited with reducing deaths from cervical cancer by more than 70 percent since its introduction 50 years ago. Through the collection of cells from the cervix and their examination for abnormalities, Pap smears can detect cancer at its earliest stages, when it is most easily treated. The American Cancer Society estimates that 11,270 new cases of cervical cancer will be diagnosed in 2009, and 4,070 women will die from the disease.
What, then, lies behind these new recommendations that will radically alter the administration of a screening test that has been proven to save the lives of tens of thousands of women in the US? Promoters of the new guidelines argue that they are “science-based.” In reality, the recommendations are in line with a wholesale restructuring of the health care system aimed at defending the profits of the health care industry at the expense of the well-being and lives of ordinary Americans.
What is being developed is an institutionalized rationing of health care, in which the wealthy will have access to the most advanced and effective tests, procedures and drugs, and the working class majority will be denied them. Behind the attempt to present these recommendations as impartial and objective science is massive pressure from the corporate-financial elite and the Obama administration to solve the crisis of American capitalism at the expense of the living standards and lives of working people.
Women and the public at large have been shocked and outraged by these proposals to cut back on cancer screenings, and rightly so. They come as the US Senate is set to debate the latest version of health care legislation promoted by the Obama administration. Both the House and Senate health care bills are based on drastic cuts to Medicare and aim to slash medical costs for the government and the health care industry.
Despite claims that the new ACOG guidelines, as well as the recommendations of the US Preventive Service Task Force (USPSTF) to cut back on mammograms, are advisory, they will undoubtedly in due course be seized upon by government agencies and private insurers to deny these vital screening procedures, or require patients to pay for them out-of-pocket. As a spokesman for America’s Health Insurance Plans, the main health insurance lobby, told CNN on Wednesday in relation to the USPSTF’s new recommendations on mammograms, “Most of our member companies look at the task force guidelines as the standard.”
The ACOG had up to now recommended that women begin having Pap smears three years after their first sexual intercourse, or at age 21, whichever came first. This was to be followed by annual screenings. They now advise moving baseline cervical screening to age 21, regardless of sexual activity. For women age 21 to 30, the ACOG now advises screening every two years, instead of annually. For women age 30 and older who have had three consecutive negative tests, they recommend screening once every three years. Women with certain risk factors are advised to undergo more frequent testing.
Alan G. Waxman, MD, of the University of Albuquerque, who drafted the document developed by the ACOG, stated: “The tradition of doing a Pap test every year has not been supported by the scientific evidence. A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful.”
Among the potential harms cited by the ACOG are anxiety caused by false-positive results and procedures to treat what may turn out to be non-cancerous lesions. While not to be discounted, such anxiety is hardly life-threatening. Many women would counter that the annual peace of mind on receiving a negative test result far outweighs such anxiety.
Having an annual Pap smear, along with getting a prescription for a mammogram, is one of the main reasons women go to their obstetrician-gynecologist or family practitioner on an annual basis. As a result of the new guidelines, some doctors justly fear that many women will skip their preventive health care visits altogether.
In relation to the new guidelines for adolescent women, the ACOG states that moving up the age to 21 “is a conservative approach to avoid unnecessary treatment of adolescents which can have economic, emotional, and future childbearing implications.” They argue that precancerous lesions (dysplasia) related to HPV (human papillomavirus) occur at a higher incidence among adolescent girls, and that most of these HPV infections clear up on their own within one to two years. They also cite as a risk of adolescent screening “a significant increase in premature births… documented among women who have been treated with excisional procedures for dysplasia.”
Again, such concerns do not justify forgoing screening for young women that might detect cancer which could be lethal if left untreated. Dr. Carol L. Brown, a gynecologic oncologist and surgeon at Memorial Sloan-Kettering Cancer Center, said that a not insignificant number of girls beginning to have sex at age 12 or 13 might be prone to develop cervical cancer at an early age. She told the New York Times, “I’m concerned that whenever you send a message out to the public to do less, the most vulnerable people at highest risk might take the message and not get screened at all.”
At present, 11 percent of women in the US report that they do not have their regular Pap smear screenings. There is nothing in the new recommendations about reaching out to this section of the population to ensure that they be tested.
These women―disproportionately poor and without access to adequate medical services―stand to suffer most from the ramifications of the ACOG’s new recommendations. No small number of them who heed the advice of this body will undoubtedly pay with their lives as a result of a disease that has a 96 to 99 percent five-year survival rate if caught in its earliest stages.
A 1996 report on cervical cancer from the National Institutes of Health (NIH) of the US Department of Health and Human Services showed that one-half of women who had been newly diagnosed with invasive cervical cancer had never had a Pap smear, while another 10 percent had not had the screening in the previous five years. They wrote: “The unscreened populations include older women, the uninsured, ethnic minorities, especially Hispanics and elderly blacks, and poor women, particularly those in rural areas.”
Centers for Disease Control data on HPV-associated cancers and poverty levels, for 1998-2003, showed that in US counties where fewer than 10 percent of residents live below the federal poverty level (FPL), about 10 in every 100,000 women are diagnosed with cervical cancer each year. By contrast, in counties where more than 20 percent live below the FPL, almost double the rate―or about 19 women in 100,000―are diagnosed with cervical cancer.
For women in the world's poorest nations, the situation is even more dire. According to the National Cervical Cancer Coalition (NCCC), women in developing countries account for about 85 percent of the estimated 473,000 yearly cases of cervical cancer worldwide, and the 253,300 deaths annually from the disease.
In the face of such evidence, the recommendations of the American College of Obstetricians and Gynecologists will ultimately result in an overall decrease in screening for cervical cancer and have deadly consequences. Those who suggest that opposition to the panel’s recommendations amounts to crisis-mongering and “politicization” of the issue are serving, whether intentionally or not, cynical and reactionary motives.
In a New York Times News/Analysis on Friday, Kevin Sack writes of the new recommendations on breast and cervical cancer screenings: “This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.” According to this reasoning, procedures proven to save lives are a wasteful exercise in overindulgence.
The Times has conducted a relentless campaign in support of the Obama administration’s health care proposals. In scores of articles and editorials, the chief organ of the American liberal establishment has championed legislation taking shape in Congress that it knows will erode health care for millions. Central to these proposals are the outright slashing of hundreds of billions of dollars for Medicare and the development of panels of “experts” to conduct comparative effectiveness research to justify deep cuts in services.
This research will be aimed at curtailing and eliminating “unnecessary” tests and procedures. Undoubtedly high on the list will be precisely the type of cancer screenings that are now being recommended be cut back and eliminated for entire segments of the population. According to the article by Sack, the widespread opposition that will inevitably arise to such attacks on basic health care must be countered by what he refers to as “science-driven medicine.” For too long, he says, “the mantra of early detection” has mandated over-testing and overspending.
In the case of the new guidelines on cervical screenings, the purported science is full of holes. Utilizing virtually the same statistics on Pap smears that have shown a dramatic decrease in cancer deaths due to the test, the data is now being used to recommend a radical change in the way it is administered. The ACOG offers no analysis of the socioeconomic conditions of the women they include in their data pool. The estimated one-tenth of the female population that never has a Pap smear is not discussed.
In making these recommendations, not a word is said of the insurance companies that stand to save billions from reduced outlays, while ordinary Americans are relegated to a class-based system in which they will receive cut-rate, inferior care. This week’s recommendations to cut back screenings―for breast cancer, and now for cervical cancer―serve as a warning on the future of health care in America.
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