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  • <div class="section1"> Definition

    The Pap test is a procedure in which a physician scrapes cells from the cervix or vagina to check for cervical cancer, vaginal cancer, or abnormal changes that could lead to cancer. It often is called a “Pap smear”.

    Purpose

    The Pap test is used to detect abnormal growth of cervical cells at an early stage so that treatment can be started when the condition is easiest to treat. This microscopic analysis of cells can detect cervical cancer, precancerous changes, inflammation (vaginitis), infections, and some sexually transmitted diseases (STDs). The Pap test can occasionally detect endometrial (uterine) cancer or ovarian cancer, although it was not designed for this purpose.

    Women should begin to have Pap tests at the age of 21 or within three years of becoming sexually active, whichever comes first. Young people are more likely to have multiple sex partners, which increases their risk of certain diseases that can cause cancer, such as human papillomavirus (HPV).

    The American Cancer Society (ACS) updated its guidelines concerning Pap test frequency in late 2002. In brief, women should continue screening every year with regular Pap tests until age 30, every two years if using the liquid-based Pap test. Once a woman age 30 and older has had three normal results in a row, she may get screened every two to three years. A doctor may suggest more frequent screening if a woman has certain risk factors for cervical cancer. Women who have had total hysterectomies including the removal of the cervix do not need Pap tests unless the hysterectomy resulted from cervical cancer. Those over age 70 who have had three normal results generally do not need to continue having Pap tests under the new guidelines.

    Women with certain risk factors may have yearly tests. Those at highest risk for cervical cancer are women who started having sex before age 18, those with many sex partners (especially if they did not use condoms, which protect against STDs), those who have had STDs such as genital herpes or genital warts, and those who smoke. Women older than 40 may have the test yearly, if experiencing bleeding after menopause. Women who have had a positive test result in the past may need screening every six months. Women who have had cervical cancer or precancer should have regular Pap smears.

    Other women also benefit from the Pap test. Women over age 65 account for 25% of all cases of cervical cancer and 41% of deaths from this disease. Women over age 65 who have never had a Pap smear benefit the most from the test. Some women have the cervix left in place after hysterectomy and will continue to receive regular Pap tests. Finally, a pregnant woman should have a Pap test as part of her first prenatal examination.

    The Pap smear is a screening test. It identifies women who are at increased risk of cervical dysplasia (abnormal cells) or cervical cancer. Only an examination of the cervix with a special lighted instrument (colposcopy) and samples of cervical tissue (biopsies) can actually diagnose these problems.

    Precautions

    The Pap test is usually not done during the menstrual period because of the presence of blood cells. The best time is in the middle of the menstrual cycle.

    Description

    The Pap test is an extremely cost-effective and beneficial exam. Cervical cancer used to be a leading cause of cancer deaths in American women, but widespread use of this diagnostic procedure reduced the death rate from this disease by 74% between 1955 and 1992. A 2003 study reported that the test reduces rates of invasive cervical cancer by as much as 94%. In 2003, the FDA approved a new screening test that combines DNA testing for the HPV type that causes the most cases of cervical cancer with the standard Pap test, increasing its screening value.

    The Pap test, sometimes called a cervical smear, is the microscopic examination of cells scraped from both the outer cervix and the cervical canal. (The cervix is the opening between the vagina and the uterus, or womb.) It is called the "Pap" test after its developer, Dr. George N. Papanicolaou. This simple procedure is performed during a gynecologic examination and is usually covered by insurance. For those with coverage, Medicare will pay for one screening Pap smear every three years.

    During the pelvic examination, an instrument called a speculum is inserted into the vagina to open it. The doctor then uses a tiny brush, or a cotton-tipped swab and a small spatula to wipe loose cells off the cervix and to scrape them from the inside of the cervix. The cells are transferred or “smeared” onto glass slides, the slides are treated to stabilize the cells, and the slides are sent to a laboratory for microscopic examination. The entire procedure is usually painless and takes five to 10 minutes at most.

    The newer method called liquid-based cytology, or the liquid-based Pap test, involves spreading the cells more evenly on a slide after removing them from the sample. The liquid-based method prevents cells from drying out and becoming distorted. Studies show that liquid-based testing slightly improves cancer detection and greatly improves detection of precancers, but it costs more than the traditional Pap test. Trade names in 2003 for liquid-based Pap smears were ThinPrep and AutoCyte.

    Preparation

    The Pap test may show abnormal results when a woman is healthy or normal results in women with cervical abnormalities as much as 25% of the time. It may even miss up to 5% of cervical cancers. Some simple preparations may help to ensure that the results are reliable. Among the measures that may help increase test reliability are:

    • avoiding sexual intercourse for two days before the test
    • not using douches for two or three days before the test
    • avoiding tampons, vaginal creams, or birth control foams or jellies for two to three days before the test
    • scheduling the Pap smear when not menstruating.
    However, most women are not routinely advised to make any special preparations for a Pap test.

    If possible, women may want to ensure that their test is performed by an experienced gynecologist, physician, or provider and sent to a reputable laboratory. The physician should be confident in the accuracy of the chosen lab.

    Before the exam, the physician will take a complete sexual history to determine a woman's risk status for cervical cancer. Questions may include date and results of the last Pap test, any history of abnormal Pap tests, date of last menstrual period and any irregularity, use of hormones and birth control, family history of gynecologic disorders, and any vaginal symptoms. These topics are relevant to the interpretation of the Pap test, especially if any abnormalities are detected. Immediately before the Pap test, the woman should empty her bladder to avoid discomfort during the procedure.

    Aftercare

    Harmless cervical bleeding is possible immediately after the test; a woman may need to use a sanitary napkin. She should also be sure to comply with her doctor's orders for follow-up visits.

    Risks

    No appreciable health risks are associated with the Pap test. However, abnormal results (whether valid or due to technical error) can cause significant anxiety. Women may wish to have their sample double-checked, either by the same laboratory or by the new technique of computer-assisted rescreening. The Food and Drug Administration (FDA) has approved the use of AutoPap and PAPNET to doublecheck samples that have been examined by technologists. AutoPap may also be used to perform initial screening of slides, which are then checked by a technologist. Any abnormal Pap test should be followed by colposcopy, not by double checking the Pap test.

    Normal results

    Normal (negative) results from the laboratory exam mean that no atypical, dysplastic, or cancer cells were detected, and the cervix is normal.

    Abnormal results
    Terminology

    Abnormal cells found on the Pap test may be described using two different grading systems. Although this can be confusing, the systems are quite similar. The Bethesda system is based on the term “squamous intraepithelial lesion” (SIL). Precancerous cells are classified as atypical squamous cells of undetermined significance, low-grade SIL, or high-grade SIL. Low-grade SIL includes mild dysplasia (abnormal cell growth) and abnormalities caused by HPV; high-grade SIL includes moderate or severe dysplasia and carcinoma in situ (cancer that has not spread beyond the cervix).

    Another term that may be used is “cervical intraepithelial neoplasia” (CIN). In this classification system, mild dysplasia is called CIN I, moderate is CIN II, and severe dysplasia or carcinoma in situ is CIN III.

    Regardless of terminology, it is important to remember that an abnormal (positive) result does not necessarily indicate cancer. Results may be falsely abnormal after infection or irritation of the cervix. Up to 40% of mild dysplasia reverts to normal tissue without treatment, and only 1% of mild abnormalities ever develop into cancer.

    Changes of unknown cause

    ASCUS or LSIL cells are found in 5%–10% of all Pap tests. The most common abnormality is atypical squamous cells of undetermined significance, which are found in 4% of all Pap tests. Sometimes these results are described further as either reactive or precancerous. Reactive changes suggest that the cervical cells are responding to inflammation, such as from a yeast infection. These women may be treated for infection and then undergo repeat Pap testing in three to six months. If those results are negative, no further treatment is necessary. This category may also include atypical “glandular” cells, which could imply a more severe type of cancer and requires repeat testing and further evaluation.

    Dysplasia

    The next most common finding (in about 25 of every 1,000 tests) is low-grade SIL, which includes mild dysplasia or CIN I and changes caused by HPV. Unlike cancer cells, these cells do not invade normal tissues. Women are most susceptible to cervical dysplasia between the ages of 25 and 35. Typically, dysplasia causes no symptoms, although women may experience abnormal vaginal bleeding. Because dysplasia is precancerous, it should be treated if it is moderate or severe.

    Treatment of dysplasia depends on the degree of abnormality. In women with no other risk factors for cervical cancer, mild precancerous changes may be simply observed over time with repeat testing, perhaps every four to six months. This strategy works only if women are diligent about keeping later appointments. Premalignant cells may remain that way without causing cancer for five to ten years, and may never become malignant.

    In women with positive results or risk factors, the gynecologist must perform colposcopy and biopsy. A colposcope is an instrument that looks like binoculars, with a light and a magnifier, used to view the cervix. Biopsy, or removal of a small piece of abnormal cervical or vaginal tissue for analysis, is usually done at the same time.

    High-grade SIL (found in three of every 50 Pap tests) includes moderate to severe dysplasia or carcinoma in situ (CIN II or III). After confirmation by colposcopy and biopsy, it must be removed or destroyed to prevent further growth. Several outpatient techniques are available: conization (removal of a cone-shaped piece of tissue), laser surgery, cryotherapy (freezing), or the “loop electrosurgical excision procedure.” Cure rates are nearly 100% after prompt and appropriate treatment of carcinoma in situ. Of course, frequent checkups are then necessary.

    Cancer

    HPV, the most common STD in the United States, may be responsible for many cervical cancers. Cancer may be manifested by unusual vaginal bleeding or discharge, bowel and bladder problems, and pain. Women are at greatest risk of developing cervical cancer between the ages of 30 and 40 and between the ages of 50 and 60. Most new cancers are diagnosed in women between 50 and 55. Although the likelihood of developing this disease begins to level off for Caucasian women at the age of 45, it increases steadily for African-Americans for another 40 years. Biopsy is indicated when any abnormal growth is found on the cervix, even if the Pap test is negative.

    Doctors have traditionally used radiation therapy and surgery to treat cervical cancer that has spread within the cervix or throughout the pelvis. In severe cases, postoperative radiation is administered to kill any remaining cancer cells, and chemotherapy may be used if cancer has spread to other organs. Recent studies have shown that giving chemotherapy and radiation at the same time improves a patient's chance of survival. The National Cancer Institute has urged physicians to strongly consider using both chemotherapy and radiation to treat patients with invasive cervical cancer. The survival rate at five years after treatment of early invasive cancer is 91%; rates are below 70% for more severe invasive cancer. That is why prevention, risk reduction, and frequent Pap tests are the best defense for a woman's gynecologic health.

    Source: The Gale Group. Gale Encyclopedia of Medicine, 3rd ed.

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