You and I are constantly bombarded with commercials urging us to have that Pap test or that PSA. Do you want to live? Don’t you want to live to see your grand kids? Every year, there are millions of Americans undergoing pap tests for cancer of the cervix, colonoscopy for colon cancer, chest x-ray for lung cancer and PSA for prostate cancer. It makes sense. If you catch cancers early, you can perhaps stop them in their tract and avoid death. It is just like everything else. Take care of small problems before they become big ones.
Cancer in general fits the category of a small problem that can be prevented from becoming a big one. lt starts as one cell that multiplies and grows. It encroaches on organs. It invades our blood vessels and spreads throughout the body to cause malfunction, suffering, and death.
In its early stage,that is at the begining and for some time, its presence evades our attention. We don’t see or feel it until it reaches a critical size. If we can detect it when it is small, the surgeon can cut it out with the knife or the medical oncologist can administer drug or radiation to exterminate it. And that is why screening seems important.
We undergo screening in order to detect disease before it is big enough to cause pain or other dysfunction in our body. Our technology affords us this opportunity. Our Pap smear displays the abnormal cells before there are enough of them to make the cervix bleed. The Ct scan will unearth any tumor as big as a pin head. The PSA test that the urologist uses to diagnose prostate cancer measures a marker, a chemical that indicates the presence of cancer, in the amount of one millionth of a gram. That is very impressive indeed.
The question of whether we have a Ct scan to detect lung cancer early, or pap smear to pick up cervical cancer in a curable state seems a no brainer. However we should all be very careful. The use of these tests have downsides. They can undoubtedly save lives. But some of these tests themselves have not been shown to do what they were designed to do. Furthermore, they can lead to a cascade of unnecessary testing with its associated cost, pain, and constant anxiety. Rarely, they can cause death, the very thing they were supposed to prevent or delay.
And why is that? A magazine article mentioned a few months ago the most important discoveries of the last few years. One of them involves the growth of cancer. We have found that some cancers are very aggressive. They multiply very fast and kill us in no time. Others, however, divide very slowly and remain with us all our lives until we are done with by cardiovascular disease. Still, some cancers are successfully detected early by our immune system and are destroyed before they can harm us. The difficulty for us is deciding which of these should be treated.
The experts via the American College of Obstetrician and Gynecologists (ACOG) and the well respected United States Preventive Service Task Force (USPSTF) have analyzed all the existing evidence and have revised the guidelines for cervical cancer screening. Teenagers do not have to undergo smear in order to obtain their Birth control pills from their gynecologists. They can wait until they reach 21 years old and if it’s normal they can have one every three years. At thirty, a woman is recommended to have a pap smear every three to five years depending on whether the testing includes high risk HPV.
Very few cancers will be missed with these new guidelines. These young ladies will be spared the anxiety and all the complications, however rare, associated with screening: infertility, incompetent cervix, preterm labor, and of course expenses.
As for the old physical examination and counseling, there is no change: as needed or every year. More, especially in medicine, is not necessarily better; it has taken us a long time to learn that.
Edouard Coupet, M.D., F.A.C.O.G. 