Introduction
Pap smear entails a gynecological screening procedure for early detection of both premalignant and malignant ectocervix cancer processes. Factors underlying the change in the frequency of undertaking Pap smear include cost effectiveness of the method, development, and use of effective HPV vaccine, diminishing accuracy of the Pap smear screening test and progression rate of dysplasia. These factors are of great importance in solving the problem of frequency of Pap smear on childbearing women.. Although Pap smear remains an effective method for early detection of cervical cancer, many medical treatment facilities are changing the Pap smear requirement for women of childbearing age from once per year to once every three years simply because factors such as development of vaccines cost effectiveness and inaccuracy of the method reduce the importance of an annual pap smear.
The Pap smear procedure involves the collection of cells from the cervix of the uterus and examination of these cells under a microscope. This procedure helps in detection of abnormality in cells at an early stage. Cells abnormalities detected are the pre-cancerous changes of the cervical intraepithelial. The changes are results of sexually transmitted human papillomavirus (Sasieni, & Cuzick, 2009, p. 296). It therefore means that women who have had no sexual contact should not undertake Pap smear screening. However, those indulging in sexual acts should undergo the test once in every three years to allow development of the cancer to detectable levels if there were any HPV infection in the initial sexual encounter.
Dysplasia
In pathology, dysplasia denotes abnormality in development of cells characterized by expansion, decrease in number and change of location of mature cells in a body tissue. It is an indication of an early tumor process occurring in the tissues or organs of the body. Microscopic examination of dysplasia identifies abnormality of cells by observing cells of different sizes, abnormal cell shapes, abnormal cell pigmentation, and unusual number of dividing cell during the time of observation (Smith, 2002, p.10). An example of dysplasia is the cervical intraepithelial neoplasia simply referred to as the cancer of the cervix. Pap smear can detect dysplasia in cells at an early stage and thus help in containing the disease at that stage. For cervical cancer screening, dysplasia therefore remains an important factor to consider in increasing the time between normal screenings of cervical cancer because women of childbearing age engaging in sexual activities can contract the HPV virus leading to development of the dysplasia. Infection of the cervix by the human papillomavirus is the initial step in the progression from a normal functioning cervix to a cancerous cervix. Transmission of the virus usually through sexual activities creates a high likelihood of development of a dysplasia on the surface of the cervix as the HPV viruses induce the formation of abnormal cells on the epithelial lining of the cervix. Full development of cervical cancer can take many years, but the process takes an average of 12 months to develop (Biscotti, &Dawson, 2005, p. 281). This starts from a cancer cell on the surface of the cervix forming abnormal shape and size and then it multiplies. Due to diminishing sensitivity of Pap smear, screening of the cervical cancer after every one year would not adequately detect cancerous cells but screening after every three years would detect any possible cancer cells present.
Dysplasia develops into stages and levels from the initial infection by the virus to the full development of the tumor. These levels include the initial stage characterized by mild dysplasia, abnormal cells occupying a third of the cervical surface. The recommended treatment at this stage involves radical hysterectomy, surgical removal of the lymph nodes or radial therapy (Marrazzo, 2001, p. 947). In most cases, the dysplasia at this stage is less than 4cm and therefore the treatments prescribed are effective. Furthermore, the large early stage characterized by the tumor increasing to more than 4cm in size, epithelium has lost cell identity and cells remain proliferating without regulation. Abnormal cells make up to half of the thickened epithelial surface. The recommended treatment involves the use of radial therapy and cisplatin-based chemotherapy or a combination of the two followed by hysterectomy. In addition, the advanced stage bears severe dysplasia in which the abnormal cells cover the entire cervical surface and the basement of the cervical epithelial tissues (Marrazzo, 2001, p. 949). The recommended treatment entails radiation therapy and cisplatin- based chemotherapy.
Risk factors
Various factors increase women’s susceptibility to cervical cancer. These factors include HIV infection, smoking, multiple pregnancies, family history of cervical cancer, hormonal contraception, stress and stress related problems and dietary factors (Dumme, &Unger, 2007, p. 813). These factors are worth considering in determining the frequency of Pap smear screening test for the detection of cervical cancer because they place women at a higher risk of developing cervical cancer than men. Failure to detect and treat the condition early can result into increase in death rate of women. Screening of the cervical cancer after every three years reduces the likelihood of false negative result as within the three years any cancer cells present would have developed to levels easily detectable hence giving accurate results.
HIV infection destroys the body’s ability to defend against infections such as human papillomavirus and therefore the lack of body defense leads to infection of the cervix by the HPV virus, which in turn causes cervical cancer prevalence in HIV women victims. On the other hand, cigarette smoke remains carcinogenic and smoking puts women at a high risk of contracting cervical cancer. Smoking has a potential to induce cancer cells to proliferate. Furthermore, multiple pregnancies place women at an increased risk of developing cervical cancer. Multiple pregnancies imply multiple sexual contacts hence increasing the chances of transmission of the HPV virus, which in turn leads to development of cervical cancer in women and therefore putting them at higher risk. Hormonal contraception causes hormonal imbalance within the cervix and it can induce cervical cells to develop into cancer cells. Women usually use hormonal contraceptives in their pursuit to family planning, which further puts women at an increased risk of developing cervical cancer than men. Early use of contraceptives and pregnancies also contribute to cervical cancer development, which results into abnormal shapes of the epithelium cervical cells. Stress can lead to depression and other associated disorders, which cause hormonal imbalance in the body. The hormonal imbalance can stimulate cell change in the cervical surface resulting into cervical cancer. Family history of cervical cancer places women at an increased risk of developing the cancer more than men develop because the human papillomavirus is specific to the cervix and it triggers cancer cells proliferation specifically to the cervical epithelial cells. These cervical cells only appear in female’s reproductive system and not in male reproductive system. Therefore, women are at a higher risk depending on their biological makeup.
Prevention of these risk factors depends on the type of risk factor, for instance, HIV infection would require the control of HIV spread through abstinence, use of condoms and being faithful to one sexual partner. In recommendation, to solve the problem of annual Pap smear screening would require application and adoption of other family planning methods other than the use of hormonal contraceptives and strict avoidance of contraceptives at early age would help to prevent the development of cervical cancer. Smoking as a risk factor would require a decision by the victim to stop smoking in order to alleviate the problem. Avoidance of stress and good stress management would help reduce stress induced cervical cancer hence reduce the frequency of Pap smear screening.
HPV vaccination
Human papilloma virus has two types of vaccines. The vaccines prevent infections caused by certain specific species of HPV virus that cause the cervical cancer. These two vaccines presently in market are Gardasil and cervarix, both protecting type 16 and type 18 of the papilloma virus (Demay, 2007, p. 107). These vaccines have also the potential to prevent other cancers such as anal, vulvar, penile and virginal. The availability of human papilloma vaccines is a major factor of consideration in deciding the frequency of undertaking Pap smear screening test simply because regular vaccination would help to prevent the infection by the HPV virus as the vaccine would offer protection and thus diminish the need to carry out a Pap smear screening test. Effective utilization of the vaccines diminishes the need to carry out annual Pap smear test.
Gardasil and cervarix prevent the initial infections by type 16 and type 18 of the virus. These two types of the virus account for about 70% of the cervical cancer cases. Gardasil alone offers protection to type 6 and type 11 of the virus, which both account for about 90% of all the reported cases of genital warts (Demay, 2007, p. 100). Cervarix on the other hand, offers protection against type 45 and type 31. These vaccines offer 100% protection and therefore vaccination is more cost effective in preventing the development of cervical cancer than the regular Pap smear screening test. The vaccination therefore, becomes more economical to carry out as compared to the annual Pap smear screen.
As indicated above the two vaccines prevent the infection of the high-risk types including type 16, 18, 31 and type 9 of the papilloma virus. Other viruses generally referred to as low risk types include types 23, 56 and 66. They are relatively not harmful and therefore not offered protection against by the vaccines. The relatively lower risk type 12 remains unprotected against but hardly will it elicit any cancer causing signals to the cervical epithelium cells. After the initial human papilloma virus, vaccination, a last and final jab, usually offered after four years, would offer adequate protection against high-risk types and low risk types of HPV virus. The HPV vaccination is relatively less expensive than Pap smear screening test and after the last jab; it offers protection for the entire lifetime; therefore, reducing the frequency of undertaking a Pap smear screening test as people are under protection.
Pap smear screening test
Although thought by many to be most effective screening test for cervical cancer, Pap smear has limitations and shortcomings, which make it imperfect. Pap smear cannot detect minute abnormal cells during the early stage of cancer development. It is indeed difficult to detect such cells on slides. Bloody and mucus slides would prevent precise detection of the early abnormal cells in the slides (Cutts, Franceschin, & Goldie, 2007, p. 719). These limitations call for repetitive procedures, which can cause pain to the patient. The false positive results obtained from Pap smear procedures can cause anxiety to the patient and call for regular follow up tests, which are very expensive to bear. With the low economic status of many people, Pap smear becomes exceedingly expensive to be carried out annually hence most of the involved authorities and bodies prefer to have it done every three years. The limitations of Pap smear screening test remain to restrict 100% effectiveness of the test and therefore false positive and negative results cause detrimental outcomes to the patient. It can in fact cause unexpected stress, which in turn induces development of cervical cancer in women. Sample collection for Pap smear testing poses a major shortcoming as the cells collected represent a small percentage of the total cells in the cervix, these samples collected could be inadequate, leading to inaccurate results. The sample cells may be at different developmental stages implying difficulties in differentiating between the abnormal cells and the normal cell as the number of abnormal cells may inadequate. The adoption of the three-year period between Pap smear screening tests would allow enough time for cell differentiation allowing accurate detection of cancer cells if any. Interpretation of results also poses a limitation to the Pap smear testing procedure even with the experienced physicians. Cells in a slide can dry up distorting the results obtained and therefore making Pap smear not to be 100% reliable (Winer, Hughes, & Feng, 2006, p. 264). In the United Kingdom, Pap smear screening test only saves one person out of fifteen thousand people screened for cervical cancer. Pap smear screening done after three years would reveal more accurate results than those done yearly and thus help increase the number of lives saved from cervical cancer in the United Kingdom.
Newer technology and application of new methods have helped improve the accuracy of Pap smear screening by altering the procedures of slides’ preparation and analysis to give better resolutions. These newer methods decimate anxiety, expense of repeat and inconveniences caused by the inaccurate Pap smear screening test. These newer technologies comprise of thinprep Pap smear, auto pap, papnet, and automated screening test system (Winer et al, 2006, p. 265). Although it is expensive to acquire new technology and apply, I recommend the use of the newer technology to facilitate accurate screening of cervical cancer. In thinprep Pap smear method, the preparation of the samples differs significantly from the ordinary Pap smear test in that thinprep Pap smear involves making of a vial, which then goes for laboratory for examination. This technique shows an increase in accuracy to about 65% in detection of low-grade abnormalities. Auto pap is a primary screening procedure, which the patient undergoes before any analysis. Its sensitivity is high and studies report it to have detected 33 suspicious cells from a sample of 25000 cells more than a conventional pap smear screening test. Papnet involves evaluation of samples using computerized systems whereby the samples evaluated are the abnormal samples and focus is on the area with the highest number of abnormal cells. It subjects slides to a high-resolution video screen for proper visualization by the technician (Cutts, et al, 2007, p.720). These newer technologies improve the preparation and analytical procedures of the conventional Pap smear screening test and therefore overcome the shortcomings of the conventional Pap smear. The development of these newer technologies implied that the conventional Pap smear was not accurate and effective enough to detect cell abnormalities and therefore the need to carry out Pap smear screening tests once a year with the unreliable Pap smear procedures diminished.
The cost of carrying out a pap smear is another factor contributing to the change by many health care facilities from one Pap smear per year to one Pap smear every three years. The cost of a single pap smear varies from one Doctor to another charging an average of $50 to $200; this is the cost for those people without health insurance covers (Contran, Kimar &Tucker, 1999, p.99). As a result, patients have to wander among several doctors before settling for a single test. High costs of Pap smear screening necessitate reduction in the frequency of carrying out the screening test from yearly to once after every three years. The detection of abnormal cells in the first Pap smear screening test calls for a strict follow up to eliminate the cancerous cells and thus doctors recommend for regular expensive Pap smear tests. The high cost of Pap smear test has made people to turn to HPV vaccination. The cost effective HPV vaccination enables the low-status women to acquire the much-needed protection from contraction of cervical cancer. Vaccination therefore reduces the need to carry out annual Pap smear.
Insurance companies offering health insurance covers also benefit by reducing their annual expenditure on cervical cancer cases with the adoption of once per three years’ Pap smear screening. From this new plan, insurance companies save an estimation of about $200000. It is also beneficial to the country’s economy as it reduces the overall medical expenditure of an economy. The culture of saving also trickles down to the patients and the citizens who save considerable amount by using the HPV vaccination. This will effectively eliminate the possibilities of human papillomavirus infections, which result into cervical cancer.
On the other hand, the argument that the health care reform bill, which advocates for increased medical insurance cover would increase the need for many to take regular Pap smear tests simply because the insurance cover would cover the heavy financial burden accompanying the test. This does not necessitate the need to have Pap smear screening done annually as other facts other than cost need consideration as well (Cote, Suster, Weiss & Weidue, 1999, p.149). However, the decision on the reduction of the frequency of taking a pap smear lies with the patients and depends on the cost and other underlying factors such as the accuracy of the test and its effectiveness. These other factors would outweigh the cost of undertaking the test, which the insurance cover meets and therefore decrease the frequency of undertaking Pap smear tests. Moreover, healthcare reforms emphasize on health care and health education, which are paramount aspects in the pursuit of providing adequate health to the citizens. Health education on cervical cancer and the available vaccination programs would change the need by many to undertake Pap smear test and opt to take other preventive measures such as HPV vaccination. Early provision of better health care to all citizens as emphasized by the health reform bill would protect them from viral infections such as the human papillomavirus. This would therefore translate into fewer visits to hospital for Pap smear screening test.
Conclusion
Although many people regard Pap smear as an effective gynecological procedure for the elimination of cervical cancer, it is not 100% accurate as it bears limitations and shortcomings like the other screening procedures. Therefore, due to its inaccuracy and other factors such as cost effectiveness, progression rate of dysplasia, risk of developing cervical cancer, effectiveness of the HPV vaccination and the effectiveness of the Pap smear test, doctors recommend for reduction in frequency of Pap smear tests per year per person.
Effective HPV vaccination helps to reduce the chances of developing cervical cancer as it protects against high-risk types 16 and 18 of the HPV virus thus reducing the regular visits to healthcare facilities for Pap smear test. Moreover, the cost effectiveness of the Pap smear and other procedures such as HPV vaccination cause many people to use HPV vaccination other than the Pap smear. Inclusion of newer methods in the screening procedure signifies inaccuracies in the Pap smear test and therefore not 100% reliable. The data obtained on Pap smear accuracies shows a non 100% reliable results due to less sensitive screening processes of sample collection and analysis of results. This justifies the change from once per year to once per three years’ Pap smear test.
References
Biscotti, C., & Dawson, A. (2005). Assisted primary screening using the automated Thinprep imaging system. American journal a clinical pathology, 123(2), 281-283.
It describes the application of the thinprep imaging system on the conventional Pap smear procedures to increase the accuracy of the conventional Pap smear procedures. It denotes the limitations and shortcomings of the conventional Pap smear and offers solutions to the limitations.
Contran, R., Kimar, V., & Tucker, C. (1999). Robbins pathologic basic of disease. London: WB Saunders.
It exemplifies the pathological progression of diseases from acute to chronic stages. It also describes the pathogenesis of the cervical cancer, diagnosis, and treatment. It gives an overview of disease causes, symptoms and possible prevention and control measures.
Cote, R., Suster, S., Weiss, L., & Weidne, N. (1999). Modern surgical pathology. London: WB Saunders.
It describes the newer surgical methods and technologies applied to curb inaccuracies of results obtained from the older pathological procedures and laboratory methods used. It highlights the effectiveness of the newer methods of pathological diagnosis.
Cutts, F., Franceschin, S., & Goldie, S. (2007). Human papillomavirus and HPV Vaccines. Bull world health organ journal, 85(8), 719-721.
It describes the human papillomavirus, its infection rate, epidemiology, treatment, diagnosis, and prevention. It gives an overview of the prevalence of the virus among women. It also covers the vaccine and vaccination against Human papillomavirus species. It gives an outline of the efficacy and effectiveness of the vaccine in protecting against the virus.
Demay, M. (2007). Practical principles of cytopathology. Chicago: American society for Clinical pathology press
It gives an account of the practical procedure including protocols applied in cytological examination of samples. It offers a systematic practical laboratory procedures and principles adopted in cytopathology. It denotes on possible areas of error during a screening testing process.
Dumme, E., & Unger, E. (2007). Prevalence of HPV infection among females in the United States The journal of the American medical association, 297(8), 813-814.
It describes the prevalence of HPV infection among women and exemplifies that those women with more sexual partners, those taking hormonal contraceptives, those smoking and those indulging in sexual activities at an early age are at higher risk of contracting the infection.
Marrazzo, J. (2001). Pap test screening and prevalence of genital HPV among Women Who have sex with other women. American journal of publihealth, 91(6), 947-949.
It describes the Pap smear screening process involving the sample collection procedure, laboratory analysis of the samples, results analysis, and evaluation. It gives an overview of the HPV prevalence on women who had sexual contact with people of the same sex. It shows possibilities of transmission of the HPV infection by sexual contact between two females.
Sasieni, P., & Cuzick, J. (2009). Effectiveness of cervical screening with age, Population based case-control study of prospectively recorded data, 339(2), 296-299.
It describes cervical screening and gives a comparison between the results obtained from different age groups. It gives a descriptive data on the effectiveness of the cervical screening with varying age over populations. It gives a cost comparison of cervical screening tests and the use of vaccines to contain the disease.
Smith, R. (2002). American cancer society guideline for the early detection of cervical Neoplasia and cancer. American journal on cancer, 52(3), 10-12.
It gives a guideline on the detection of neoplasia and cancer by using Pap smear and denotes shortcomings and limitations of the Pap smear for the early detection of cervical cancer. It gives alternative more sensitive and specific procedures to cover the limitations and shortcomings of the Pap smear procedure.
Winer, R., Hughes, J., & Feng, Q. (2006). Condom use and the risk of genital Human papillomavirus infection in young women. The New England journal of Medicine, 354(25), 264-265.
It describes ways of preventing the infections of human papillomavirus and points on the effective use of condoms as one method. It describes the progression of human papillomavirus and gives an explanation on how it induces cancer formation in cervix. It outlines the diagnostic procedure of cervical cancer and gives recommendations in cases of positive results.