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Women's health
My speculum nightmare
Cervical screening compliance
continues to improve, but some women still avoid the
dreaded smear. Could HPV self-tests be the way to catch
the stragglers?
By Gillian Woodford
"Does that hurt?" the nurse
asked. "Um, no, it's ok." She went back to work, prodding
my innards with an instrument resembling a tiny toilet
brush. After several (painful) adjustments of the metal
speculum, she stood up, scratched her head, and removed
it. "I'm going to have to get some help." Minutes later
she returned with another nurse. Repeat scene one. "Your
cervix is sideways or something," said the second nurse.
"We'll have to get the doctor." They covered me up again,
passed me some magazines, and left. Half an hour later
they returned with the doctor, who grabbed a speculum
from the table (not warming it first), ordered me into
position, took the sample, and was gone before I could
ask her about my "sideways" cervix.
Is it any wonder women are
avoiding the stirrups in droves? This harrowing experience
occurred in the UK, where nurses have been doing Pap
smears for a number of years. A new study there by Cancer
Research UK is trying to find out if HPV self-testing
could be a solution for Pap prodigals. Women there are
being sent home with a kit containing swab, test tube,
and questionnaire, which asks them to report not only
on the experience of using the kit, but also about how
they feel about in-office smears. A similar study was
conducted by McMaster researchers and published in the
CMAJ in 2000. It found that among women who had previously
had abnormal cytologies, HPV self-tests showed same
or higher specificity than physician exams, although
sensitivity was slightly lower. About 93% of women found
self-sampling acceptable versus 79% for speculum exam.
Despite these results, self-testing is still not available
in Canada. (For more on HPV testing see An alternative
to beat PAP's high false-negatives on page 26.)
Though its incidence has
dropped by 50% in the past quarter century, cervical
cancer is still the third most common cancer among Canadian
women aged 25-49. Screening compliance currently stands
at about 74%. Compliance has always been a class issue
-- poor women and minority women traditionally under-attend
screenings, sometimes for religious and cultural reasons.
Could self-screening help us get around these problems?
Not everyone's so sure. Dr
Richard Gruneir, an ob/gyn from Leamington, Ontario,
has some doubts. "I'm pretty sure those women aren't
going to be doing the self-screening, I think it would
be the people already getting tested. They tend to have
a different personality. It could be good for women
who hate doctors though."
And how about replacing office
smears with self-tests? Dr Gruneir isn't enthusiastic.
"If anything it will improve compliance, but I wouldn't
recommend it replacing the physician test," he says.
"We don't go in expecting to find abnormalities. Really,
the Pap is an excuse to get the woman in the office
to have the ovaries and uterus palpated [to pick up
other abnormalities]."
In Canada the guidelines
recommend screening roughly every 1-3 years, depending
on a woman's age and risk factor. In the US, all women
are advised to have an annual test. "I'm often suspicious
when the guidelines are so different," says Dr Gruneir.
"I often feel ours are driven by cost. This isn't a
bad thing for the Pap test itself, but as I said since
it's an excuse to get the patient in, that isn't so
good."
Maybe it's a good thing then
that American women are hooked on their annual Paps.
A recent study from the Annals of Family Medicine shows
that women in the US are leery of risk-based cervical
screening, preferring to play it safe with annual pelvic
exams.
Further reading: Cervical
cancer special section, Nov/Dec issue of Ann Fam Med
www.annfammed.org;
Cancer Research UK HPV project:http://sci.cancerresearchuk.org/studies/mse/hart/
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