Talk:Pap test

ASCUS

We should have a separate Wikipedia page for this particular Pap result. I was doing a search to find out the recommended management of this lesion, but ASCUS brought up a fungus. —Preceding unsigned comment added by Mattbeckwith (talk • contribs) 00:53, 7 November 2008 (UTC)

Not much point in having a separate page about it until there is enough material to warrant a split. (Reduces duplication, makes it easier to read and easier to maintain to keep test results here until this page gets too big.) Zodon (talk) 04:58, 7 November 2008 (UTC)

Only for sexually active women?

The article says only sexually active women need have a regular pap smear. Why?.

Because it is a sexually transmitted disease

Ack! There's typically something like a 10 year lag between initial HPV infection and the development of cervical cancer. So "sexually active" is misleading - should be something more along the lines of "ever had sex." Reminds me of the slippery semantics of Clinton's "meaning of is is" question. Retroid 15:40, 5 August 2006 (UTC)

Sexually active is the current jargon. But I agree that for a general audience, ever had sex would be better. (Also worth adding that it can be transmitted in same-sex relations, so women who have only had sex with women are also at risk.)

Zodon (talk) 08:35, 16 February 2008 (UTC)

My country even recommends pap smears for women who've never had sex. While their literature states the HPV can cause cervical cancer, at no point do they state outright that the ONLY way one develops cervical cancer is from HPV. Is HPV a leading cause or a sole cause? 217.166.94.1 (talk) 08:49, 26 October 2009 (UTC)

Some guidelines do recommend Pap screening, regardless of whether a women has had sex. (e.g. ACOG). This may be to cover for those who don't wish to admit to having had sex. May be afraid that if link Pap smears with sex that will make the prevention message less palatable to some, or may be a more complex message for people to understand. (For instance there is some variety of what people call having had sex. And various forms of contact can spread HPV.) Since most adults in the US have had sex, the guideline writers may not figure the 5% or so who haven't are worth making an exception for. However, other guidelines (e.g. USPSTF) specify that only applies to those who have had sex. (And some guidelines ignore same-sex relations, even though HPV can be transmitted in same-sex intercourse.)

As far as I know, HPV infection with a high risk type is a necessary cause of cervical cancer. (i.e. don't get cervical cancer if haven't had an infection, but having had an infection does not mean will get cervical cancer.) Zodon (talk) 09:39, 6 April 2010 (UTC)

You can never finitely determine that a person cannot have cancer based off viral infection alone. Very rarely though still possible, defective protooncogenes become oncogenes which cause uncontrolled cell growth and differentiation. Statistically unlikely but biologically possible! Tabithapadilla (talk) 14:58, 7 April 2010 (UTC)

Jargon

seems to have a lot of jargon that may not be strictly necessary to convey the most salient info. Also, the jargon is all at the beginning. I'm worried that a lot of readers will get derailed by the hard technical stuff and may not make it to the interesting/important bits toward the end (how often to get tested, origin of the term "Pap" etc). Any objections to a radical de-jargonectomy? Or at least to moving the jargon down out of the Intro section? Retroid 15:48, 5 August 2006 (UTC)

Some other articles

[1]

Notable paragraph

Instead of the old method of scraping off some cells from the cervix using a spatula and "smearing" them onto a slide that can be looked at under the microscope, the sample is taken using a plastic brush which is then placed in a vial of fluid. The smear feels exactly the same for the woman, but for the staff in the laboratory the sample of cells is much easier to analyse. When practice nurses or GPs smeared cells on a slide using a spatula, lots of other types of cells would also be transferred making it difficult to see if there was any abnormalities and sometimes there would not be enough cells on the slide for the laboratories to make a proper assessment. But with LBC all the cells from the cervix are preserved in the fluid and can be separated out before being put on the slide making abnormalities much easier to spot. Although LBC is easier for laboratories, the data on whether it will help to pick up more abnormalities is unclear.

Agnes Nixon

http://en.wikipedia.org/wiki/Agnes_Nixon "Nixon is believed to have written the first medical related storyline on a soap opera. A friend of Nixon's had died from cervical cancer, and Nixon wanted to do something to educate women about getting a Pap smear. She wrote it into Guiding Light by having the lead character, Bert Bauer, encounter a cancer scare. This storyline aired in 1962; Nixon had to work around some difficulties of getting this storyline to air, as she could not make use of the words “cancer,” “uterus,” and “Pap test”. However, after this storyline the number of women who took a Pap smear surged dramatically . In 2002 she received a special Sentinel for Health "pioneer award" for her work on Guiding Light."

Doesn't Nixon's storyline that influenced women to have a pap smear deserve a mention on the Pap Smear page?

Explanation of changes re: Pap test as a screening tool

I've changed the part which was about the Pap test being a screening tool for ectocervical, endocervical and endometrial malignancies. This is because the sampling devices and the test itself were never designed to sample the latter two areas. There is this an issue of the cells being consistently and reliably there. Endocervical cells are more likely to be present, as part of the sampling device enters the endocervical canal and scrapes off cells - however, not all the the endocervical tissue can be sampled due to the anatomy. The endometrium would rarely be directly sampled using a device designed for taking a Pap test. In certain circumstances, such as post-treatment, particularly, post-trachelectomy, the lower uterine segment may be directly sampled and these can cause diagnostic problems. Cells from the endometrium do exfoliate (cf menstruation) and so may be present on the cervix at the time when a Pap test is taken. Again, over time, abnormalities have come to be recognised in these cells - so screening staff are trained to recognise them - in case they are there. I have myself identified them and patients have been diagnised with endometrial cancer, however, this would be better described described a fortutituous than by design. Similarly, cells have been seen in Pap tests from for example, ovarian adenoarcinoma (due to exfoliation and occasionally metastasis). I changed it because I thought to state that it is a tool for these two anatomical sites was misleading. C Geary 22:47, 16 January 2007 (UTC) Ms Geary

Template added

I added a "technical" template to this page because it is difficult to understand exactly what is being said, it needs to be simplified in some sections for general readers. Please remove the template after corrections have been made to the article. Mermaid from the Baltic Sea 17:25, 3 February 2007 (UTC)

Effectiveness

"BMJ 1997;315:953-954 (11 October) Letters (snip) "It may be that deaths from cervical cancer in women born since 1930 are being halved by screening. If so, then the number of deaths in 1995 would have been 2000 in the absence of screening instead of 1339 (which would represent a doubling of the observed 661 deaths in women born since 1930). This saving of hundreds of lives comes at a high cost. Department of Health statistics show that in England and Wales each year about 800 000 women have abnormal smears; 166 000 of these abnormalities are severe enough to warrant referral for investigation and treatment. A tiny minority of these women are actually helped.

The NHS cervical screening programme is among the best in the world, and 30 years' experience has shown much about the inherent complexities and limitations of early detection as an approach to preventing cancer. It is easy to make simplistic claims about screening. In the long term we will do more for the public by being honest.

A E Raffle, Consultant in public health medicine "

- one of a large range of estimates, but one of the more defensible. Richard Keatinge 17:16, 26 April 2007 (UTC)

I doubt the assertion that prior to the PAP smear, cervical cancer was the leading cause of cancer death in women. I am looking at an NCI graph of cancer mortality trends for women, 1950 to 1990, and it shows the leading causes of cancer death in 1950 to be breast cancer (about 27 per 100,000) and colorectal (similar). Cervical cancer in 1950 is way down at around 11 per 100,000. Graph doesn't go back further and I haven't found a graph on line yet that does. The graph DOES show cervical cancer going down, so I'm not questioning that at all. Eperotao (talk) 00:05, 6 March 2011 (UTC)

Ref 2 Coste et al BMJ

This reference which is cited to to give the figures of the sensitivity of liquid based versus conventional cytology was controversial within the cytology community. The study design was considered by many to be flawed in comparing conventional and liquid based cytology, leading to a bias towards the conventional.
This can be seen in regards to the correspondence/rapid responses to the article on the BMJ website. I would prefer this information to be removed - I will endeavour to find more robust figures and references to be cited instead.

C Geary 15:20, 13 July 2007 (UTC)

Coste et al is an important work. Unless it is withdrawn by the authors, it certainly meets the Wikipedia standard of verifiability. If there is conflicting information on the matter, it would be better to summarize them and provide references to those views in addition, rather than suppressing this information.

Zodon (talk) 08:29, 16 February 2008 (UTC)

Proposed merge of pap smear and pelvic examination

• Oppose merge. As an entity, the pap smear is a subset of the pelvic examination. The pap smear article is long enough to stand on its own. What needs to happen is-- the pelvic exam article needs to be expanded. I propose the Practical aspects section be moved and a main article link is created in the pelvic exam article. Nephron  T|C 17:58, 14 October 2007 (UTC)

  That's sounds reasonable. My logic in adding the tag was to combine the two in order to expand pelvic and to get people adding to the article and its subsets. Then once pelvic got to a reasonable size to split Pap and any other sub-procedures back out onto their own. Feel free to remove the merge tags. Optigan13 22:32, 14 October 2007 (UTC)

• Oppose merge. People are obviously gonna look for pap smear first on Wikipedia. The test is easily recognizable and popular compared to "pelvic examination". So from the ease point of view, this article should be left alone. dirty but clean 05:05, 29 October 2007 (UTC)

I was wrong: there is discussion. I removed the tags. Cburnett 23:05, 1 December 2007 (UTC)

Privacy!!

Good god people, shouldn't SOME recognition be made of how freakin' INVASIVE and uncomfortable this examination is for the patient!?? How about a mention of maybe some medical research into a HPV detection method that does NOT require such invasive practices??? SOMETHING!! --Promus Kaa 05:13, 19 October 2007 (UTC)

If you can find a well-referenced piece about this sort of thing in a reliable source, then I would say by all means put it in. Not simply personal-experience type pages, though. 86.132.138.84 18:06, 15 November 2007 (UTC)

I think a pap smear is a small price to pay and quite effective if you compare death due to cervical cancer in the developed and developing world (PMID 15761078). There has been a fair deal of work on improving the experience-- e.g. BMJ. 2006 Jul 22;333(7560):171. Epub 2006 Jun 27. Free Full Text. There is also a study on self-collected samples -- PMID 11988136 (The acceptability of self-collected samples for HPV testing vs. the pap test as alternatives in cervical cancer screening). Here is a list (PubMed) of a few more studies. Here is another list. Nephron  T|C 18:54, 25 November 2007 (UTC)

I would agree that something should be included about patient discomfort and also if that acts as a deterrent to screening. — Preceding unsigned comment added by 114.198.97.208 (talk) 07:47, 27 February 2013 (UTC)

Not to be flippant, the number one risk factor for death from cervical cancer is inadequate cervical cancer screening. In fact, the majority of women who die from cervical cancer have never had a pap smear. D.c.camero (talk) 00:06, 1 June 2018 (UTC)

Aurel Babes

Aurel Babes, a romanian scientist, was the first to publish a paper on cervical cancer screening test by cervical cytology, allthough Papanicolaou is generally credited for this discovery.

There is an article on Wikipedia about Babes.

http://en.wikipedia.org/wiki/Aurel_Babe%C5%9F —Preceding unsigned comment added by 193.231.120.239 (talk) 17:56, 21 October 2007 (UTC)

Move to 'pap test' (from pap smear)

I moved the article to pap test from pap smear. This is logical if one considers the fact that many labs now use liquid-based cytology, i.e. the cells scrapped from the cervix are:

• put into a liquid and then, via automation, put onto a microscope slide --as opposed to
• smeared onto a microscope slide directly and then fixed.

See: PMID 17724676 for comparison/reasoning why this is becoming the new standard - Cancer. 2007 Oct 25;111(5):285-91.) and [2] Nephron  T|C 19:17, 25 November 2007 (UTC)

Annual screening is not "generally recommended"

This statement is very misleading. "It is generally recommended that sexually active females seek Pap smear testing annually, although guidelines may vary from country to country."

There is significant evidence that screening every 3-5 years is still effective, is more cost effective, and poses less risk from false positives. Further, many guidelines recommend less frequent screening. So to say that annual screening is the norm is misleading.

If this statement is to be left, it clearly needs a citation to a reputable source that asserts that annual pap smears are generally recommended. As well as notation that the mater is debated. I think a better fix would be to point out the variety of guidelines, (e.g.

"It is generally recommended that females who have had sex seek regular Pap smear testing. Guidelines on frequency vary, from annually to every five years."

Either way, an explanation of the trade-offs on frequency is also in order. [Cost, risk of false positive, long time for transit from infection to cancer]

I will gather a few citations for this.

Zodon (talk) 08:06, 16 February 2008 (UTC)

Rationale for changes made

My recent edits reflect recommendations for 1-3 years between Pap smear testing/screening. This is what all reputable sources I could find say, and I could find no source that recommends more than 3 (unless otherwise advised by a doctor). All general (reputable) health sites I've found say 1-3 or 2-3 years ( [3] [4] [5] ), and any of these site citing primary sources use the same three authoritative sources that I've used to cite the article: USPSTF, ACOG, and ACS. If you are aware of reliable/current data suggesting otherwise by all means edit and cite, but I feel it would have to be fairly substantial to change to anything other than 1-3 or 2-3 years. The ACOG also recommends another Pap test 6-12 months after initial abnormal test, so that was changed as well. Zach99998 (talk) 13:50, 5 June 2010 (UTC)

However you seem to have only looked at US sources. If you look at other developed nations (EU, former members of British commonwealth, etc., you will see that 3-5 is more typical. Therefore 3-5 includes US (USPSTF, ACOG, and ACS says 3 is okay for many women) as well as many other nations. Zodon (talk) 04:57, 27 September 2010 (UTC)

Incorrect Information

Editors should be aware that the user Drsavard who proposed these changes does consulting work for QIAGEN pharmaceutical company, which is the owner of Digene, maker of the HPV test. Therefore they have a potential WP:COI regarding HPV testing. Zodon (talk) 05:59, 11 May 2008 (UTC)

I am a medical doctor specializing in internal medicine. I thought the Human Papilloma Virus Testing section would benefit from adding a visual. Thus, I propose that the following graphic be adding to the above mentioned section:

The original graphic can be found on http://www.thehpvtest.com/under-30/HPV-test-the-pap-HPV-faq.html. I have permission to repost this image on Wikipedia.

I would also like to propose the following edits:

Existing Text
By adding the more sensitive HPV Test, the specificity may decline. However, the drop in specificity is not definite.

Updated Text
By adding the more sensitive HPV test, the specificity may decline. However, the drop in specificity is not significant.

Existing Text
Regarding the role of HPV testing, randomized controlled trials have compared HPV to colposcopy. HPV testing appears as sensitive as immediate colposcopy while reducing the number of colposcopies needed.[10] Randomized controlled trial have suggested that HPV testing could follow abnormal cytology[4] or could precede cervical cytology examination.[6] We recommend that we delete this sentence. It is mentioned in one study from the American Journal of Obstetrics and Gynecology, but it’s not relevant. The study looked at how to manage ASC-US patients.

Updated Text
Regarding the role of HPV testing, randomized, controlled trials have shown that the HPV test is significantly more sensitive than cytologyand it is FDA-approved for use along with the Pap for routine screening of women 30 and over, or as a follow-up evaluation of women of all ages with inconclusive cytology results.

Existing Text
The potentially pre-cancerous changes (called dysplasias or cervical or endocervical intraepithelial neoplasia) are usually caused by sexually transmitted human papillomaviruses (HPVs). The test aims to detect and prevent the progression of HPV-induced cervical cancer and other abnormalities in the female genital tract by sampling cells from the outer opening of the cervix (Latin for "neck") of the uterus and the endocervix.

Updated Text
The pre-cancerous changes (called dysplasias or cervical or endocervical intraepithelial neoplasia) are almost exclusively caused by sexually transmitted human papillomaviruses (HPVs). The test aims to detect the appearance or progression of cervical cancer or pre-cancerous lesions by sampling cells from the outer opening of the cervix (Latin for "neck") of the uterus and the endocervix.

Existing Text:
It is generally recommended that sexually active females seek regular Pap smear testing. Guidelines on frequency vary, from annually to every five years. If results are abnormal, and depending on the nature of the abnormality, the test may need to be repeated in three to twelve months. If the abnormality requires closer scrutiny, the patient may be referred for detailed inspection of the cervix by colposcopy. The patient may also be referred for HPV DNA testing, which can serve as an adjunct to Pap testing.

Updated Text
In the United States, medical guidelines generally recommend that females begin getting an annual Pap smear three years after they first become sexually active or at the age of 21, whichever comes first. Practices differ in other countries, but are generally similar. If a Pap result is inconclusive or appears abnormal, an HPV DNA test (which looks for the presence of the virus that is the primary cause of cervical cancer) can determine whether further examination is needed. If an HPV DNA test is done automatically at the same time as the Pap – a practice that is approved in the United States when women turn 30 – annual testing is not necessary. If both the Pap and HPV test are normal, the current guidelines say re-testing is needed only once every three years. Research conducted in Europe and elsewhere, however, suggests that re-testing could be delayed even further – to five or six years – since the HPV DNA test is so sensitive in identifying women at risk.

Existing Text
In the United States, physicians who fail to diagnose cervical cancer from a pap smear have been convicted of negligent homicide. In 1988 and 1989, Karen Smith had received pap smears which were argued to have "unequivocally" shown that she had cancer; yet the lab had not made the diagnosis. She died on March 8, 1995. Later, a physician and a laboratory technician were convicted of negligent homicide. These events have led to even more rigorous quality assurance programs, and to emphasizing that this is a screening, not a diagnostic, test, associated with a small irreducible error rate.

Updated Text
A report in the International Journal of Cancer found that about one-third of cervical cancers occurred in women whose last Pap smears had appeared normal. In the United States, physicians who fail to diagnose cervical cancer from a pap smear have been convicted of negligent homicide. In 1988 and 1989, Karen Smith had received pap smears which were argued to have "unequivocally" shown that she had cancer; yet the lab had not made the diagnosis. She died on March 8, 1995. Later, a physician and a laboratory technician were convicted of negligent homicide. These events have led to even more rigorous quality assurance programs, and to emphasizing that this is a screening, not a diagnostic, test, associated with a small irreducible error rate. This concern about missing pre-cancerous cells and cancer has also been one of the driving forces behind increased adoption of HPV DNA testing along with the Pap for older women.

Existing Text
Studies of the accuracy of HPV testing report:
• sensitivity 88% to 91% (for detecting CIN 3 or higher)[4] to 97% (for detecting CIN2+)[6]
• specificity 73% to 79% (for detecting CIN 3 or higher)[4] to 93% (for detecting CIN 3 or higher)[6]

Updated Text
Studies of the accuracy of HPV testing report:
• sensitivity94.2% to 97.4% (for detecting CIN2+) to 97.6% (for detecting CIN3+)
• specificity 92.9% to 93.6% (for detecting CIN2+)

I would also like to recommend that we delete the following paragraph entirely:
A study published in April 2007 suggested the act of performing a Pap smear produces an inflammatory cytokine response, which may initiate immunologic clearance of HPV, therefore reducing the risk of cervical cancer. Women who had even a single Pap smear in their history had a lower incidence of cancer. "A statistically significant decline in the HPV positivity rate correlated with the lifetime number of Pap smears received.

If no one protests, I'd like to make these changes within the next 48 hours.

Drsavard (talk) 15:51, 14 March 2008 (UTC)

The graphic is misleading and it isn't clear that it will help clarify the connection between HPV and cervical cancer. The vertical scale is quite misleading, it seems to suggest that cervical cancer has a comparable incidence to that of HPV. (Rather than HPV being very common, and cervical CA rare.) Also, the apparent complementary shapes of the graphs might confuse. Since it takes years for cervical CA to develop after HPV infection, not clear that this is good way to illustrate. Don't think it is a particularly helpful illustration here. (If vertical scales were fixed (both per 100,000) it might be better (and yes, I realize that the CA part might be invisible at that scale.)) Also, it should be noted that this graphic comes from the web site of the maker of the HPV test.

On the suggested edits to "Regarding the role of HPV testing..." Oppose changes. The "Updated text" is less specific. Certainly the coverage of HPV testing could be improved, but should move toward what has actually been demonstrated, not to vaguer statements. (It has been demonstrated to be useful for follow-up of abnormal cytology.) It has not been demonstrated to be more effective or more cost effective in screening, either as primary screening, or in combination with Pap smears.

Saying that it is more sensitive is not helpful in that don't specify sensitive for what (for HPV, for high grade disease, for low grade, etc.) Also, in screening, specificity is more important than sensitivity, so saying something more sensitive without caveats may mislead. (Many people don't understand importance of specificity in screening.) So think should retain the references and information there, and add to it, rather than overwriting it with vaguer statements.

On the suggested edits to "The potentially pre-cancerous" - seem okay, except should keep the word "potentially" (both initially and in the last sentence). Most CIN regresses without treatment, so only some of it is pre-cancerous.

On changes to "It is generally ..." Oppose. Proposed changes moving away from international view and away from NPOV. Annual screening is not typical of other countries. 3-5 year screening period much more typical, US is atypical. HPV test is only one option for follow-up of abnormal, Close-followup with Pap smears and colposcopy are others (depending on severity).

Annual testing is not necessary, regardless of whether an HPV test was collected. As noted above, annual testing is not the norm in most countries. Also, screening guidelines such as USPSTF (evidence based medicine) recommend Pap screening every 3 years. The USPSTF found no direct evidence that annual screening achieves better outcomes than screening every 3 years. (US Preventive Services Task Force (USPSTF), Guide to Clinical Preventive Services, Williams & Wilkins, Baltimore, MD, 1996 and Guide to Clinical Preventive Services 2006, USDHS, AHRQ Publication number 06-0588. http://odphp.osophs.dhhs.gov/pubs/guidecps/ http://www.ahrq.gov/clinic/uspstfix.htm)

Likewise, "ACS and others have recommended, since before 1980, that conventional cytology can be safely performed up to every three years for most women." (Smith, RA; et al.; American Cancer Society Guideline for the Early Detection of Cervical Neoplasia and Cancer, CA Cancer J Clin 52(1):8–22, 2002.)

No problem with more detail covering the ACS, etc. guidelines (been meaning to do that) - but need to use care to give equal weight to other major POVs. And especially to maintain NPOV with regard to HPV testing, since it is new and relatively unproven and there is considerable variation in opinion about its value.

On change starting "In the United States ..." - it appears that primarily added the first and last sentences. First one seems okay (though not immediately clear that it should be in that location). The last one should have a citation, and would be better in the section on HPV testing. (While HPV testing may be prompted by paranoia, it is not the only such measure, so should not overshadow the rest. The concluding sentence of that paragraph is better as it is.)

Oppose changing the sensitivity and specificity numbers, unless they are mis-quoted from Kulasingam. If you have other numbers want to add (with citations) - fine. If there are problems with some of studies/etc. need to be discussed, not just overwrite with a particular POV.

On paragraph "A study published in April 2007" deletion - why delete? No case is presented of why it is wrong/harmful/etc. Is it not supported by the citation? Is it a POV? Why?

Hope this helps. Zodon (talk) 03:27, 15 March 2008 (UTC)

You have a lot of comments, so let me try to respond one by one:

• I do not feel strongly about the graph, so I’ll remove it.
• As mentioned in my other edits, there is a wealth of data that supports the use of HPV testing for routine screening of women 30+. See my full comments on page [insert link].
• I have made clear in the revised edits below that in reference to the HPV test, sensitivity refers to CIN 3 and cancer (since I agree that sometimes CIN 2 is treated with “watch and wait.”) Note, though, that to be consistent, the sensitivity/specificity ranges cited for conventional and liquid-based cytology should have similar detail. Since most studies for cytology cite results for CIN 2+, I have updated the copy to include this parameter, as well as to include the most recent data. Likewise, for HPV testing, we can retain the lower end of the sensitivity/specificity ranges, but since the preponderance of recent data is now at the upper end, I have reflected that in my edits.

In addition: I have to disagree on one significant point. I consider sensitivity to be of equal importance to specificity. I – and my patients – would prefer to be told that they might be at risk, and then find out later they are fine, than to be surprised later with a diagnosis of invasive cancer. Most of the experts who speak at conferences on this topic agree. (Sensitivity is particularly important in low-resource countries, where frequent medical visits by women are not practical and a broader definition of “at-risk” is needed.)

• I agree that annual screening is not the norm ex-U.S. and have reflected that in my revised edits. However, although you are right that there are other methods for following up on ASC-US Paps, and I acknowledge that in my revised edits, all of the experts at the various conferences I attend – as well as the literature -- regard triage with HPV testing to be the gold standard.
• Finally, we can retain the reference to the April publication you mention, but then I would move it to the end of the conventional Pap section.

Thus, see my revised edited copy below:

However, it is not a perfect test. "A nurse performing 200 tests each year would prevent a death once in 38 years. During this time she or he would care for over 152 women with abnormal results, over 79 women would be referred for investigation, over 53 would have abnormal biopsy results, and over 17 would have persisting abnormalities for more than two years. At least one woman during the 38 years would die from cervical cancer despite being screened."[2] In addition, 2005 study published in the Journal of the National Cancer Institute found that 32% of invasive cervical cancers were due to Pap detection failure. Testing for HPV along with the Pap for women over 30, as well as the HPV vaccine, may offer better prospects in the long term.

•••

By adding the more sensitive HPV test, the specificity (correlation with actual disease) may decline. However, the drop in specificity is not significant.7

•••

Randomized, controlled trials have shown that the HPV test is significantly more sensitive in identifying women with cervical disease (CIN 2, 3 or cancer) than cytologyError! It is FDA-approved for use along with the Pap for routine screening of women 30 and over, or as a follow-up evaluation of women of all ages with inconclusive cytology results.

•••

Abnormal cell changes (called dysplasia or cervical/endocervical intraepithelial neoplasia) are almost exclusively caused by sexually transmitted human papillomaviruses (HPV). The Pap is designed to detect the existence of cervical cancer or potentially pre-cancerous lesions by sampling cells from the outer opening of the cervix (Latin for "neck") of the uterus and the endocervix.

•••

In the United States, medical guidelines generally recommend that females begin getting an annual Pap smear three years after they first become sexually active or at the age of 21, whichever comes first. Practices differ in other countries, with routine Pap testing often recommended every three to five years. If a Pap result is inconclusive or appears abnormal, further evaluation is needed with repeat cytology or – as many experts now recommend -- an HPV DNA test (which looks for the presence of the virus that is the primary cause of cervical cancer). Whatever method is used for follow-up evaluation – repeat cytology or HPV DNA testing – a colposcopy exam is normally performed if results are abnormal.

The HPV DNA test also is approved in the United States for routine screening of women over 30, when they are most at risk of developing cervical cancer, along with a Pap. If both the Pap and HPV test results are normal, U.S. guidelines recommend re-testing once every three years. Research conducted in Europe and elsewhere, however, suggests that re-testing could be delayed even further – to five or six years – since the HPV DNA test is so sensitive in identifying women at risk.

•••

A report in the International Journal of Cancer found that about one-third of cervical cancers occurred in women whose last Pap smears had appeared normal. In the United States, physicians who fail to diagnose cervical cancer from a Pap smear have been convicted of negligent homicide. In 1988 and 1989, Karen Smith had received Pap smears which were argued to have "unequivocally" shown that she had cancer; however, the lab had not made the diagnosis. She died on March 8, 1995. Later, a physician and a laboratory technician were convicted of negligent homicide. These events have led to even more rigorous quality assurance programs, and to emphasizing that this is a screening, not a diagnostic test, associated with a small irreducible error rate. This concern about missing pre-cancerous cells and cancer has also been one of the driving forces behind increased adoption of HPV DNA testing in addition to cytology for older women.

A study published in April 2007 suggested the act of performing a Pap smear produces an inflammatory cytokine response, which may initiate immunologic clearance of HPV, therefore reducing the risk of cervical cancer. Women who had even a single Pap smear in their history had a lower incidence of cancer. "A statistically significant decline in the HPV positivity rate correlated with the lifetime number of Pap smears received. [Moved up from the HPV testing section.]

•••

Studies of the accuracy of conventional cytology report:

• sensitivity (for detecting CIN 2, or moderate dysplasia, or greater): from 50% , to 72%.[4]
• specificity (for CIN 2 or greater): from 71% to 97%.7

Studies of the accuracy of liquid-based cytology report:

• sensitivity (for detecting CIN 2, or moderate dysplasia, or greater): from 61%[6] to 85%. , ,
• specificity (for CIN 2 or greater): from 64%20 to 97%.21

Studies of the accuracy of HPV testing report:

• sensitivity (for detecting CIN 3, or pre-cancerous dysplasia, or higher): as low as 88%, [4] but most studies have found higher rates, ranging from 93% to 100%. , , , ,
• specificity (for detecting CIN 3 or higher): 73% to 93% [4] ,

71.224.215.219 (talk) 20:08, 28 April 2008 (UTC)

EDIT WARNING Various problematic markup revised and reflist-talk dropped below. — MaxEnt 21:18, 18 May 2020 (UTC)

References

Karen Smith

In Technical aspects section there's the following story:

“ In 1988 and 1989, Karen Smith had received pap smears which were argued to have "unequivocally" shown that she had cancer; yet the lab had not made the diagnosis. She died on 1995-03-08. Later, a physician and a laboratory technician were convicted of negligent homicide. ”

I have added {{citation needed}} mark. But the bigger question remains. Did it really happen? I tried searching for it on Google, but the only Karen Smith that is somewhat related to Pap test or cervical cancer is a currently living doctor gynaecologist...

Should we just delete this story from the article?

--Alsh 14:28, 6 April 2008 (UTC)

Effectiveness and leading cause of death

The recent edit stating that cervical CA was a leading cause of death of women before the Pap test seems questionable/possible overstatement. From the cervical cancer article: "Worldwide, cervical cancer is the fifth most deadly cancer in women." (World Health Organization (February 2006). "Fact sheet No. 297: Cancer". Retrieved on 2007-12-01.) While this includes many places that have Pap smear screening programs, it still includes many that don't. Given the improvements in sanitation, maternal health care and prevention of communicable diseases (which have significantly reduced other causes of death in women) it seems unlikely that cervical CA was a leading cause of death. (Perhaps some qualifier was dropped, e.g. cancer death?).

The statement that "Since the introduction of the Pap test, deaths caused by carcinoma of the cervix have been reduced by up to 99% in some populations where women are screened regularly." Also seems problematic. Not that it isn't true, but perhaps it overplays the effectiveness of Pap screening. Adding some perspective might help (e.g. typical improvement attributed to Pap screening, or range, what populations showed most improvement, etc.) Not saying that Pap smear isn't highly effective, but 99% seems higher than the statistics I remember seeing. (Have to go check my notes.) Zodon (talk) 10:00, 3 January 2009 (UTC)

The "99% reduction" figure seems very hard to believe based on the detailed info provided about the effectiveness of the UK program. If only 50% of cervical cancers are detected in the UK THROUGH screening, it doesn't seem very likely that screening in other places was so effective that it reduced the number of deaths by 99%. —Preceding unsigned comment added by 74.38.254.45 (talk) 17:01, 20 March 2010 (UTC)

Post Partum Pap Smear

Would a Pap Smear be affected if a woman just gave birth? Would a Post-Partum Pap Smear be confused from a woman's sudden change of body chemistry due to birth? Or hormones? —Preceding unsigned comment added by 65.104.237.178 (talk) 20:04, 6 February 2009 (UTC)

It could be affected. Repair/changes in the cervical cells more likely to cause problems than body chemistry, etc. Pap smear should be at least 8 weeks Post-partum. (Think reference for this is Koss page 368, but have to check that) Zodon (talk) 22:11, 6 February 2009 (UTC)

Babes or Pap test

I totally disagree that Babes was the first to describe the vaginal smear test as we know it from Papanicolaou. If you compare the two techniques, one can see that they are totally different in their design and concept. —Preceding unsigned comment added by 195.134.113.33 (talk • contribs)

I have removed your edit partly because of non-encyclopedic language, and partly because it doesn't have a citation. Please provide a citation to a WP:MEDRS and then we can work it in to the article. Thanks. Zodon (talk) 21:22, 12 March 2009 (UTC)

World perspective on the PAP from the WHO

http://data.un.org/Data.aspx?d=WHO&f=inID%3aHSC15 Will maybe generate a map.Doc James (talk · contribs · email) 17:58, 13 November 2009 (UTC)

can trichomonas be found in a pap test

can trichomonas be found in a pap test —Preceding unsigned comment added by 173.75.177.74 (talk) 18:33, 6 January 2010 (UTC)

Yes it can. In fact, pap smears are good for a lot of things, like herpes and yeast infection. As the page is written now, it makes it look like pap smears are used almost exclusively to diagnose HPV or cervical cancer, which isn't true. The EMedicine pages have some good stuff if anyone has spare time. —Preceding unsigned comment added by Pathogenesis (talk • contribs) 02:42, 9 May 2010 (UTC)

Saying it is good for them is a bit of an overstatement. It can find various other conditions, but in many cases it isn't as good at detecting them as other tests. Zodon (talk) 05:38, 13 September 2010 (UTC)

"Cervical screening" page

I think it's a bit misleading to have content on liquid based cytology and HPV testing in a page titled "Pap test", because they are all different tests which are used for cervical screening. I'd propose a separate page on "cervical screening" which contains general information on cervical screening and the different types of test, which links through to this page. Jah998 (talk) 13:42, 28 March 2011 (UTC)

I have moved the sections on types of screening and HPV tests to cervical screening as it contains information on other types of cervical screening test than the Pap test. Jah998 (talk) 14:37, 28 March 2011 (UTC)

I oppose the split. In particular splitting liquid based (LB) Paps onto a separate page doesn't make sense. LB versus conventional Paps are just different procedures for preparing the slide. The collection is the same, the reading is done in the same way, it is just a matter of different handling of the samples in between. (Which also has different results for effectiveness as a screening test.) Eventually there might be enough material to warrant separate coverage of LB, but currently LB is hardly explained at all.

The coverage of cervicography and HPV testing could probably better be handled by splitting out separate articles on those topics, keeping a summary in the main article. But there should be just one main article, and it should remain Pap test. Zodon (talk) 09:11, 12 August 2011 (UTC)

I disagree. 'Pap test' is a very US-focused term. For example, in the UK, it's called a 'smear test', or just 'cervical screening'. I think it makes more sense to have an overall page on 'cervical screening' that discusses all the different methodologies, then links through to other pages where necessary. Thoughts? HenryScow (talk) 12:08, 19 October 2011 (UTC)

The name of the article is not important, per WP:Name. Other common names for the test should be redirects to whichever name the article resides under. (So if it is called a smear test or whatever - those should just be redirects to Pap smear.)

As far as the methods listed - liquid based cytology is still a Pap smear (it is just a different collection method, but it is still prepared into a slide just as with the conventional Pap). There is not enough material here to warrant a separate article on liquid based. Putting it in a separate article gives the false impression that it is a different test.

The material about "Testing in resource-poor areas" and "Other options" is just research into possible ways of using HPV testing. At best it would be under research (doesn't warrant much coverage until it becomes real).

Likewise "Visual inspection to detect pre-cancer or cancer" is something that has been tried, and so far hasn't panned out. (There have been numerous tests, such as cervicography, etc. which have been tried.)

HPV testing is so far approved as an adjunct to Pap smear screening (e.g. for triage of abnormal results). There are trials (some noted above) considering the possibility of using it for primary screening. It could make sense at some point to create an article about HPV testing. But so far all of the other methods are essentially variants of Pap smear, HPV testing or Colposcopy. Creating an article about cervical screening just means an extra article to maintain. Zodon (talk) 05:24, 15 March 2012 (UTC)

"Most women contract HPV soon after becoming sexually active"

Pretty sure most women don't contract HPV at all (at least, not yet). Sounds like something you'd hear Senator John Kyl say at a pro-abstinence-only-education-bill signing party (as a non-factual statement). 184.18.13.121 (talk) 15:46, 15 April 2011 (UTC)

I'm pretty sure the meaning of the statement was more accurately, "Most women who contract HPV, do so soon after becoming sexually attractive (in their 20's)." But I removed it because it was poorly written. ~Ttony21^{(talk, contribs)} 02:26, 11 August 2011 (UTC)

Most women do contract HPV (HPV is the most widely spread STI, e.g. more than 80% of US women, with similar levels in other parts of the world, as evidenced by cervical cancer incidence). (See Human_papillomaviruses#Epidemiology)

So the sentence means exactly what it said. Most women do contract HPV, and most of them do so soon after becoming sexually active.

So I restored the sentence. I thought it had the benefit of being brief, but if you think it is too concise for clarity we can try to improve it. Zodon (talk) 08:57, 12 August 2011 (UTC)

The specific claim that (1) "most women contract it" and (2) "most who do contract it do so soon after becoming sexually active" implies (3) "most women contract it soon after becoming sexually active", is fallacious; for example, say 80% contract it, and 60% of those contract it soon after becoming sexually active -- then (1) and (2) are both satisfied, but (3) is not -- that would only be 60% of 80% = 48% of the total population. However, it is obviously possible to satisfy all three, but the data -- even in in the article linked to justify the claim -- doesn't seem to back it up. There is data that supports (1) (so my initial gut feeling that most women don't contract it was flat out wrong), but I don't see any that supports (2)...from the article: "Estimates of HPV prevalence vary from 14% to more than 90%" -- and most of them seem to be on the lower end. It seems the only way to get over 50% is is to look at the proportion who get it at least once in their lifetime.

In any case, since I'm not a doctor or an epidemiologist, I'm not going to remove the sentence...but in hopes of attracting someone more credible and knowledgeable than me to take a look at it, I am going to make the claim explicit -- the sentence will be changed to "More than three quarters of all women will contract HPV at some point in their lives, and more than half of all women will contract it soon after becoming sexually active." That way, no one can look at it and think "Oh, they must mean 'most women who DO contract it contract it shortly after becoming sexually active'", which is how I interpreted it as well...the only reason I said anything was because I thought it was a humorous / unfortunate choice of words. 184.18.13.121 (talk) 20:12, 10 September 2011 (UTC)

The assertion that most women contract HPV shortly after after starting having sex is not based on reasoning from 1) and 2). The discussion above was pointing out that 1) and 2) and 3) are all verifiable, not reasoning from 1 and 2 to derive 3.

I reverted the change to the wording of the section because it was not supported by the reference given, and it made the paragraph less clear by introducing material that was not directly relevant. The point is that those who recently started sex are at low risk of cancer, but highly likely to show changes due to initial HPV infection, so they should not be screened. In this context the only relevant claim is 2 "most who do contract it do so soon after becoming sexually active."

As indicated by the dead link flag, the source has changed. this edit fixed the dead link However the source no longer supports this item.

In looking back through the wayback archive for the page in question I have not yet found the version that did support the item. As such I have added a note indicating that additional/fresh citation would be helpful. Zodon (talk) 22:51, 10 September 2011 (UTC)

I have made an additional suggested change to the sentence in question, changing it from "Most women contract HPV soon after becoming sexually active" to "Most women who contract HPV do so soon after becoming sexually active." (Basically another phrasing of 2 above.) In this context this is the important observation. I hope that clarifies the matter.

Sorry if my edits were confusing or appeared to not acknowledge the discussion here, we were evidently both editing at once. I was in the middle of composing this response and it took longer than I expected. Zodon (talk) 23:06, 10 September 2011 (UTC)

painful smear tests

There is a lot on the Internet about women finding smear tests very painful It is totally unnecessary for there to be any pain or discomfort at all. Women need to ask the nurse to use what is called a "virginal spectrum" which is half the size of the normal spectrum but still large enough for the nurse to see your cervix. They can also put some numbing cream in your vagina beforehand. — Preceding unsigned comment added by 86.161.16.236 (talk • contribs)

There is no such thing as a "virginal speculum" (or 'virginal spectrum' for that matter) There are different sizes and shapes of specula which can be chosen depending on anatomical differences, but there is not one designated specifically for women who have never had intercourse. Pain and discomfort are to different things. A pelvic examination will often be uncomfortable, but should not be frankly painful. If the exam is painful, then it could indicate that the person has a pathology that needs evaluation. "Numbing cream" should not be needed for an examination. Part of the examination is determining if there are areas that are painful. It is important to note that to allow them to be evaluated, and any numbing of the area would hinder this. If you experience pain or discomfort, discuss this with your healthcare provider. D.c.camero (talk) 16:41, 11 June 2018 (UTC)

Vaginal examination

I think searching for 'vaginal examination' should not direct here. Pelvic examination should be improved to cover internal vaginal exams during labour. — Preceding unsigned comment added by Sarahjeantaylor (talk • contribs)

I agree, vaginal examination and pap smear are not synonymous. A pap smear can be done during a vaginal exam, but that is where the connection ends. In fact, most vaginal exams do not include pap smear as pap smear is a specific test to screen for cervical dysplasia/cancer. D.c.camero (talk)

Medical Implementation

Cyberfreeworld (talk) 18:51, 23 March 2013 (UTC) Would like to see a section that shows more about the actual practice of this test. After research when did FDA (for example) approve this. When did medical providers actually begin using this test. Were there any objections or attempts to prohibit use of Pap tests (smear). Was there any controversy about its effectiveness in the early days? This should be under History.

Mum's the word?

The Papanicolaou test is a method of cervical screening used to detect potentially precancerous and cancerous processes ... The test was independently invented in the 1920s by Dr. Georgios Papanikolaou and Dr. Aurel Babeș and named after Papanikolaou.

Named after: You had one job. Care to explain yourself, or mum's the word?

A possible solution is to create a redirect from Georgios Papanicolaou (no such page as of today) to Georgios Papanikolaou and then standardize on the 'c' spelling within this article. — MaxEnt 21:06, 18 May 2020 (UTC)

On a moment's further thought, if I were moved to rectify this small inconsistency, I'd probably link "Georgios Papanicolaou" in the first instance (either through the proposed redirect, or by textual override to the existing link title) and then gloss this first instance with "(also spelled Papanikolaou)". And then standardize on the 'c' spelling for the rest of the voyage. — MaxEnt 21:11, 18 May 2020 (UTC)

Wiki Education assignment: UCSF SOM Inquiry In Action-- Wikipedia Editing 2022

This article was the subject of a Wiki Education Foundation-supported course assignment, between 8 August 2022 and 20 September 2022. Further details are available on the course page. Student editor(s): Christophermlee, Seyvonneip, Sophiakalei (article contribs). Peer reviewers: Yslee22, Zetinoy, Ymesfin.

The addition of sensitivity and specificity of pap smears was well written and easy to understand. I thought the gender-affirming care section was written with an objective lens and contained several clinical pearls! I appreciated the elaboration of the light microscopy technique but the following sentence doesn't add much to the section: "Screening with light microscopy is first done on low (10x) power and then switched to higher (40x) power upon viewing suspicious findings." Great job! Zetinoy (talk) 07:06, 17 September 2022 (UTC)

— Assignment last updated by Zetinoy (talk) 06:37, 17 September 2022 (UTC)

Peer Review

The article covers a broad range of topics falling under the umbrella of Pap smear. The photos of smear samples with descriptions below are helpful. The addition of gender-affirming care section is inclusive of people who may not identify as cis-gender women. The incorporation of statistics to corroborate effectiveness bolsters the informative nature of the article. The procedure section seem a bit jargon-heavy, so maybe reducing the amount of technical terms (or at least following up the use of technical terms with a brief explanation in few words) may be helpful. Lastly, it is uncertain how much value/benefit the "Experimental Techniques" section adds to the article, but overall a great update and revision of the previous article. Yslee22 (talk) 17:37, 16 September 2022 (UTC)

Wiki Education assignment: UCSF SOM Inquiry In Action-- Wikipedia Editing 2022

The introduction to the page offers great insights and an overview of the subject matter without being too overbearing to the reader. Your team did a great job of balancing just how much information to provide in the introduction to keep readers fully informed. In doing so, it also creates a nice segue into the more detail-heavy sections later in the article. All the major details are also substantiated by articles, and so the References sections is very extensive, offering lots of outside sources for readers to reference. Ymesfin (talk) 01:26, 17 September 2022 (UTC)