Re: The lowly PAP smear...
From: art fougner, md (evsono@pipeline.com)
Sun Jul 23 11:39:34 2000
recently it's come to our attention that acog may indeed be a four
letter word.
art
At Sun, 23 Jul 2000, jkulkin wrote:
>
>I'm surprised to see quotes like this after the ACOG study at Duke. Comments?
>
>Jay
>
>"Joanne Bulley, MD" wrote:
>
>> I have had several patients between October 1998 and now have cervical
>> CIS with normal Paps in the preceeding 3 years...!!!!
>>
>> My comment included that with the ThinPrep - you are protecting the
>> woman who no shows for a 5 or so years. The quoted 50% improvement -
>> really is going from (I Think... numbers and I do NOT get along)
>> something like a 5% false negative to a 2.5% false negative. Clinically
>> this is a negligible difference IF your patient ALWAYS comes back.
>>
>> Since to truly be at low risk your patient needs to
>> 1) begin intercourse after age 18 (75% plus have had sex with at least
>> one partner by age 18)
>> AND 2) have one sexual partner from first day of sex to the day of death
>> (how many on the list can claim this - male or female)
>> AND 3) her partner must have only had sex with her
>> AND 4) she should have never smoked.
>>
>> Since going into private practice - I have been a bit amazed at the
>> number of women coming ot me with no pap for 7-20 years!!! 2 of them
>> were something like 5 years AND the last one was abnormal but they did
>> not follow through with any follow up (and whoever their previous doc
>> was did not go to the great lengths I do to get them in...) I have had 3
>> carcinoma in situs in the past year in women with less than 3 years from
>> her last normal pap. One who had had ASCUS at first prenatal, normal at
>> 6 week PP, inflammation without atypia at 1 year PP and CIS at 2 years
>> PP.
>>
>> Shit happens.
>>
>> I also have had one woman (around 8 years ago) in the low risk group
>> (presumeably stable relationship and 3 normal paps at yearly intervals)
>> who had a 3 year hiatus and came back with invasive CA amenable to
>> radical hyst. (Unfortunately, she had wanted another baby...)
>>
>> With the current sexuality - women and men of all socioeconomic groups
>> seem to think with their gonads.
>>
>> Some crude estimates are that 85% of boys have sex by 18 and 85% of men
>> have extramarital affairs and 75% of girls have sex by 18 and 75% of
>> women have extramarital affairs.
>>
>> I ASSUME all my patients have the sexual history to not truly be low
>> risk.
>>
>> So - while I agree that for the low-ish risk, seemingly monogamous woman
>> who will come in every year - the 'old' Pap is fine technology. However
>> - once you start doing the new technology on a few women - your A** will
>> be GRASS if you are ever asked, "Doctor, I understand in the year XXXX
>> you did the ThinPrep on some patients but not on others. Most
>> importantly not on the patient I am representing. Can you tell me why?"
>> etc.
>>
>> This is one place where I have decided to give in. When we get our 1
>> year data (for the 4 gyns and myriad FP's, IM's, PA's and ARNP's) on
>> results with new vs results with old - I will post them.
>>
>> Joanne
>>
>> At Sat, 22 Jul 2000, Braun, R. Daniel wrote:
>> >
>> > Why is everybody so sure that the thinprep is better???? It may be
>> >slightly more sensitive for LGSIL, but that doesn't make it any better.
>> >Especially if the woman comes in every year. The person in whom the Thin
>> >prep might be better is the lady who hasn't been in for a pap in 5 years and
>> >won't be back for another 10 years. How many of your patients fit that
>> >description?? When is the last time anyone saw a patient with cervical
>> >cancer who had had a pap smear in the last 5 years????
>> >So why do we have to go to a more expensive test just because it is newer??
>> >
>> >Dan
>> >
>>
>> --
>> Joanne Bulley, MD
>> Keene, NH, USA
--
art fougner, md
A series of 1000 cases begins with but a single anecdote.
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