nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Friday, October 19, 2007

IS THE PAP SMEAR ON THE WAY OUT?

I couldn’t let this one go by without a couple of observations (for the females). First, this data does not mean that you can stop getting your Pap smear. There are some minor issues with the experimental design, and the interpretation of the results, but the HPV test looks like a good “adjunct” (i.e., helpful when done also) test. It is not “standard of care,” at least yet. If anybody would like to get into to the weeds on this study, let me know.

This is another of those “get it done” situations in preventive medicine (like the flu shot*). In my 32 year career, nothing is more tragic than a woman with cervical cancer. This disease takes years and years to develop, it is so slooooow. Many, if not most, of the cases come from not getting Pap, blood test…or both (preferable), because the cancer can be detected waay before it fully develops.

Even more tragic is that cancer in a woman in her 20’s, because she wrongly assumed that cancer is for old folks only.

D

JAMES J DOUGHERTY, MD, MPH

*By the way, Flumist (the nasal spray) is just as effective as the shot, if your clinic or doctor offers it. Contrary to rumor it doesn’t cause the flu…it can give you a snotty nose for a day or two. And remember, both methods do not “take” in everybody (actually only 3 out of 4), we’re just looking for enough herd immunity to stop the spread of the disease. Flumist is an “attenuated” form of the live virus. Ingenious stuff: it was created by selecting for a genetic strain of the “real” flu virus that can only grow in low temperatures, like the nasal mucosa (but not in the body…or lower respiratory tract). So you get the immune response, but not the disease. Neato.

HPV test may diagnose cervical cancer more accurately than Pap smear, studies indicate. The CBS Evening News (10/17, story 3, 1:40, Couric) reported, "Doctors are telling us tonight [that] a new test could replace the Pap smear for detecting cervical cancer." HealthDay (10/18, Gordon) adds, "A test to detect human papillomavirus (HPV) -- which causes most cervical cancers -- was far better than the standard Pap smear at catching malignancies," according to two new studies published in today's issue of the New England Journal of Medicine. HealthDay continues, "Pap tests have been the standard screening test for cervical cancer for the past 60 years. More recently, the liquid-based or thin-smear Pap test was developed, and it was initially thought that this newer technology would offer significant advantages over the traditional Pap test." But studies have not shown that the newer Pap test is significantly better. Since "most cervical cancers are caused by HPV, the test to detect HPV infection is also an option for screening in addition to the Pap test." The studies published today sought to compare these tests. In the first randomized test, MedPage Today (10/18, Smith) notes that Marie-Hélène Mayrand, M.D., of McGill University in Canada, and colleagues, "assigned 10,154 women, ages 30 to 69, to one of two groups -- a 'focus on Pap' group, which got a Pap smear followed by the viral test, and a 'focus on HPV' group, which got the HPV test first, followed by a Pap smear." The trial lasted from September 26, 2002 through February 3, 2005. They "found that the viral test...correctly identified cervical intraepithelial neoplasia (CIN) of grade two or three 94.6 percent of the time, compared to 55.4 percent for the Pap test." However, "the specificity of the viral test was 94.1 percent, compared to 96.8 percent for Pap testing." For the second study, conducted between May 1997 and November 2000, "Swedish researchers randomly assigned 12,527 women ages 32 to 38 to get a Pap test (and form a control group) or a Pap test combined with a test for...[HPV] using polymerase chain reaction." They found that "[a]t baseline,...the proportion of women in the two-test group who had CIN2, CIN3, or cancer was 51 percent higher than among the women who only got the Pap test." However, "at the subsequent screening, following treatment where appropriate, the rate in the two-test group was 42 percent lower than in the control group." The researchers attributed "[s]ome of the differences" to "over-diagnosis at baseline."

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