Cervical cancer is the fifth leading cause of cancer death among women. But since doctors started performing the Papanicolaou (Pap) smear test in the 1940’s, the number of deaths from cervical cancer has decreased substantially. In fact, the Pap smear is recognized as the most effective cancer-screening test in history.

The National Cancer Institute recommends that all women have a Pap smear at least once every three years to check for abnormal cells on the cervix. But for a number of women who have had a complete hysterectomy (which includes the removal of the cervix), this test is no longer necessary, unless the surgery was done to treat a cancerous condition. And in 1996 the US Preventive Services Task Force officially declared that women who have undergone a complete hysterectomy for a non-cancerous condition no longer need routine Pap smear screenings.

But according to a new study in the June 23/30, 2004 issue of the Journal of the American Medical Association, in 2002 nearly 70% of women who had undergone a hysterectomy still received a Pap smear test—roughly the same proportion as ten years earlier, before the task force recommendation. A similar study from the US Centers for Disease Control and Prevention reported in Obstetrics and Gynecology in 2001 came to an almost identical conclusion.

About the Study

This study included data from 187,670 women aged 18 and older who reported having undergone a hysterectomy between 1992 and 2002. The researchers looked at the proportion of these women who had received a recent Pap smear test during each of the ten years studied. They then compared the proportion of women who reported having had a recent Pap smear in 1992, 1996 (the year the national recommendations were released), and 2002.

The Findings

When the researchers applied their data to the US population estimates, they found that in 2002 an estimated 21% of all women age 18 and older had undergone a hysterectomy, a proportion that was about the same for the previous ten years. Of the women with a history of a hysterectomy, in 1992 an estimated 68.5% had undergone a Pap smear within the previous three years, compared to 69.4% in 1996, and 69.1% in 2002.

Even after taking into account women whose Pap smear may have preceded a recent hysterectomy, hysterectomies that left the cervix intact, or hysterectomies that were performed to treat a cancerous condition, it was still estimated that in each of the years, roughly 50% of the women had unnecessary Pap smears performed.

How Does This Affect You?

This study suggests that at least half of all women who have had a hysterectomy—an estimated 10 million women—are undergoing unnecessary Pap smear screenings. While it is unlikely that any harm comes to women from receiving this unnecessary cancer screening, individuals and insurance plans must cover costs that may reach several hundred million dollars year. If recommendations are so clear, why haven’t things changed in the eight years since the national recommendations were released?

There are several possible reasons for this: perhaps the most likely explanation for the study’s findings is that some doctors are ignoring the recommendations (or are unaware of them) and are continuing to screen women who have had hysterectomies. The U.S. Preventive Services Task Force is both influential and respected, but it is only one of many sources of advice, information, and guidelines, that doctors turn to. Another explanation might be that since this study was based on self-reported data, some women may have over-reported Pap smear testing. These women may have received a pelvic examination for some other reason and incorrectly assumed that a Pap smear accompanied the test. Women sometimes fail to understand the difference between a pelvic examination and a Pap smear and assume that they are always performed together.

This study highlights the importance of asking your doctor questions: whether it’s a routine screening test such as a Pap smear, a surgical procedure, or a drug prescription, it’s important to understand what is being recommended and why . By being an aware and informed patient, you will improve the healthcare that you receive.

Public health messages are often aimed at getting people to perform a certain behavior—such as getting screened for cervical cancer. These types of messages are very important since they can effectively improve health outcomes for millions of people. In the case of Pap screenings, there has been a 70% to 80% decrease in death due to cervical cancer—mostly due to this one test—because people have gotten the message and are getting screened. Now it’s time for a “new” message to be widely heard: most women do not need a Pap smear after hysterectomy. This study underscores how important it is to evaluate public health messages on an individual level to see how they affect you. And if you have any questions at all, discuss them with your doctor.