Pap smears must be a strong contender for the worst best thing to happen to gynecology.
The test, alongside HPV vaccinations, functioned as the linchpin of a prevention program that has dramatically reduced the incidence of cervical cancer in the United States. A 2018 estimate found that Pap test screening alone led to a reduction of up to half a million cases of cervical cancer over three decades.
But the experience of getting the procedure — where a speculum is inserted in the vagina to expand its opening so that a swab can reach the cervix and collect tissue, to be analyzed in search of abnormal, potentially cancerous cells — can range from uncomfortable to outright traumatic.
As a result, the very experts who have been recommending Pap screening as the most effective tool to reduce — or even eliminate — cervical cancer are celebrating new guidelines that make the test obsolete as a screening tool for most women after the age of 29.
The guidelines, published Jan. 5 by the Health Resources and Services Administration, now recommend that average-risk women aged 30 to 65 self-collect swab samples to test for HPV, mail them into a lab, and receive their results remotely: no doctor’s visit, no in-person exam.
Gynecologists hope the switch to at-home screening will increase cervical cancer screening rates, which have been falling. But some also see a downside: Because the Pap smear was such a central part of preventive health care for women from a young age, the test helped form the habit of routine checkups, which is part of the reason women are more likely than men to engage with health care providers. Could the new guidelines lead to fewer women seeing a doctor for well visits?
At-home screening is ‘absolute game changer’
For decades, women have been undergoing Pap tests routinely, yearly at first, then every three or five years per more recent recommendations. Under the previous guidelines, women under 30 were encouraged to get a Pap test every three years, but all other women until age 65 could have their health care provider perform the much simpler HPV test, which looks for the high-risk strands of the virus that could cause cancer with a simple vaginal swab. (For most women over 65, screening is not recommended.)
But the number of women following through with their cervical cancer screening has gone down in recent years, with 23% of women overdue for a screening as of 2023, compared to 14% in 2005.
“This change … will hopefully and likely increase the number of women who are undergoing screening,” said Kathleen Schmeler, a professor of gynecologic oncology and reproductive medicine at the MD Anderson Cancer Center. “There are populations of women who have never been screened or are way behind on their screening, so offering other options like an at-home test … gets rid of some of the barriers,” she said, noting that studies have shown women prefer self-collection over going to the doctor’s office.
Many patients would skip a Pap smear to avoid a pelvic exam, said Meghan Eagen-Torkko, a certified nurse midwife and sexual and reproductive health equity researcher in Detroit. She called the new guidelines “one of the biggest improvements to health care access that we’ve had in decades.”
Screening performed in an office can be distressing for the estimated 25% of gynecology patients who have experienced sexual trauma in their life and want to avoid pelvic exams, she said. This is true, too, of trans and nonbinary patients. “Having a pelvic exam can be a deeply dysphoric event for them,” she said, which can lead to avoiding necessary care, including cervical cancer screening. “If I can offer them something that is under their control, that they can do in privacy … but they’re still going to get the same information, that to me is an absolute game changer,” she said.
Not a replacement for well woman visits
Still, one of the things that Pap smears have done is get women to routinely visit their health provider. “Most people equate: ‘I have to get my screening’ to ‘why I would go for my annual gynecologic exam’,” said Kemi Doll, director of the Grace Center for Gynecologic Research and Cancer Equity at the University of Washington.
But a shift away from Pap smears had already begun: The use of Pap smears became less frequent with the arrival of in-office HPV testing and the introduction of the HPV vaccine two decades ago. That showed a flaw in the way Pap smears were put at the center of women’s well visits, Doll said. “When we essentially relied on the Pap to bring somebody in for their annual exam, we really did a disservice, because we didn’t communicate all the other things that are important about that annual exam, like all the other gynecologic health that’s important,” she said.
Michelle Drew, the founder and executive director of the Ubuntu Black Family Wellness Collective in Wilmington, Del., said she worried the at-home exam may be interpreted as a license to skip a broader women’s health screening, and fears that this may lead to issues, for instance increased rates of undiagnosed sexually transmitted infections.
An opportunity for education
Experts said the new guidelines could provide an opportunity for a public health education campaign reminding women that their well exams aren’t just about cervical cancer screening. And they could help providers offer better visits: Rather than spending time collecting the sample and squeezing uncomfortable or rushed conversations around the procedure, gynecologists and midwives have an opportunity to dedicate time to their patients’ other health needs, said Eagen-Torkko.
“Maybe the fact that you do the test is a great prompt to make your appointment anyway, because you still do need to see the gynecologist, we still need to screen you for other symptoms of other cancers that frankly are on the rise compared to cervical cancer,” said Doll.
In itself, the at-home test comes with an opportunity of interaction with a health care provider, who needs to be able to interpret the results and put them into context: a positive HPV result, for instance, doesn’t mean someone has cancer. “We need to make sure people are connected in the right way to health care providers,” said Schmeler.
“Lots of countries are already doing this, and have been very successful in having that connection to the health care providers so that when you get a test, there’s a plan for how you’re gonna receive the results and then, be connected to the follow up,” she said. “If [patients] just do a test at home and then you know they find out they’re positive and nothing happens or they can’t get in, then that’s a problem.”
The link with the health care provider is especially important because, while the topline message is that HPV tests can be done at home, whether or not a woman qualifies for that will depend on an algorithm that takes into account their age and previous screening results. “I worry actually about people who have higher risk factors, being scooped up in guidelines that aren’t actually designed for them,” said Doll.
One thing that the new guidelines may not improve is access to screening among uninsured people. The only HPV at-home test approved by the FDA is called Teal Wand, and it is currently priced at $99 for insured patients and $299 out-of-pocket. The Affordable Care Act mandates that preventive services included in official guidelines are covered by insurance without cost-sharing, though this doesn’t affect uninsured patients, who are already more likely to forgo screening.
“Unfortunately … when we see medical innovation like this that is more easy … we usually actually see a widening of the disparities because it’s just more available to people who already have the access,” said Doll.
