Why I'll never have another smear test
New research suggests cervical screening doesn't work - and could even do more harm than good.
Can it really be true? Anna Saybourn thinks so
guardian.co.uk0,3604,960943,00.htmlOpen ↗ Anna Sayburn Thursday May 22, 2003
The Guardian
For the past 15 years, I have obligingly trotted down to the doctors' every three years, breathed
deeply, chatted with the practice nurse and tried to ignore the discomfort as the speculum opens me
up for inspection. I have done it because regular cervical screening is what sensible, health-
conscious women do. It's recommended. It's better to be safe than sorry. Except maybe it isn't.
Last month, the British Medical Journal published research that suggests that I, and millions of
other women, may have been wasting our time. In order to save one life from cervical cancer, the
research found, 1,000 women would need to be screened for 35 years. Worse, the researchers
suggested that testing might do "more harm than good": women born after 1960, they found, have a 40
per cent chance of having a smear test labelled abnormal at some point in their lives - with all
the anxiety, investigation and treatment that implies - even though the chances of this leading to
cancer are minimal. Michael Baum, emeritus professor of surgery at University College London and a
cancer screening expert, calls the research "absolute dynamite. Any intelligent woman reading that
would make an informed decision not to go for cervical screening". The paper talks of the anxiety
caused to the thousands of women who get borderline or abnormal results every year. Anxiety is the
least of it. A friend recently phoned me in floods of tears, to read out her letter from the GP. It
said her smear showed "mild dyskariosis". Being an inquisitive type, she had looked it up in the
medical dictionary, which told her she had cancer. Mild dyskariosis means small changes to cells,
which could, one day, turn malignant. In the vast majority of cases they don't. According to the
BMJ paper, which looks at the 348,419 women screened for cervical cancer in the Bristol area from
1976 to 1996, 156 women in every 1,000 had abnormal results, but only one in a 1,000 showed signs
of invasive cancer. Dr Angela Raffle, consultant in public health medicine in Bristol and author of
the BMJ paper, began the research because she was struck by how many women were being referred for
colposcopy (microscopic examination of the cervix) after abnormal smear test results. "Originally,
people thought everybody with an abnormality would go on to get cancer, and we have come round to
realising it is just a phenomenon of screening," she says. "Cell changes are very common and all of
us have them, and they go away; it is impossible to predict who is going to go on and get cervical
cancer." But no one had bothered to tell my friend that. In fact, in 15 years, I don't remember
ever being given any information about cervical screening, the accuracy of the test, the possible
results I could receive, or having any explanation of the results when they come through in the
post, months after the test. Just pop your knickers off and get up on the couch. There could be a
reason for this. Raffle says that the screeners realised in the 1980s that they needed to screen
and treat enormous numbers of women in order to make an impact on mortality figures. Most would not
have gone on to get cancer - but a very small number would, and it was these women they wanted to
catch. If women realised how unlikely it was that they would personally benefit from screening, the
screeners might not have got the numbers they needed to reduce cervical cancer deaths. I tell her
that my conclusion after reading her paper is to withdraw from the screening programme. Cautiously,
she falls back on the "can't be too careful" argument. "What would I regret most? If I got cancer
and I hadn't been for screening, I would never forgive myself," she says. But my chances of getting
cervical cancer are minimal, I say. "Some women would say: 'I loathe hospitals and I'm very
confident in my own health. If I had to go to colposcopy I would regret it.' Those women are best
not coming for screening," she admits. The evidence against the usefulness of universal cervical
screening keeps coming. An audit in Leicestershire in May 2001 found that a third of the women who
did go on to develop cervical cancer had had normal smear test results. The test - microscopic
inspection of a few cells scraped off the cervix - is not very sensitive and can easily miss
changes, either because the cells sampled don't show them or because they arise in the three to
five years between screens. Then there are the false positives - the number of women worried and
upset by "abnormal" results, which put them straight onto a conveyor belt of annual smear tests or
further procedures such as colposcopy and biopsy. For every death prevented, acccording to Raffle's
research, more than 80 women undergo further investigation and more than 50 are treated. But while
cervical cytology (examination of the cells taken from the cervix) may be far from perfect, there
are others who argue that it is better than nothing. "If somebody suggested in 2003 we [should]
introduce cervical cytology, no randomised trial would ever show it was worthwhile," admits Dr Anne
Szarewski, clinical consultant for Cancer Research UK. "However, it is impossible to turn the clock
back. We haven't got anything to replace it with. "It can be uncomfortable; some women find it
humiliating and it is true the majority will not benefit," she admits, but, she says, the 42 per
cent fall in the mortality rate from cervical cancer since the 1980s shows that for those who do
develop cancer, the benefits are very real. "There are approximately 14,000 women alive to day who
would not be if they had not had cervical screening. Women need to realise its limitations and not
get so incredibly worried when they have an abnormal smear." In a letter to the BMJ, Professor
Peter Sasieni from the Wolfson Institute of Preventive Medicine in London, says women should view
cervical screening not as a test for cancer, but as "a costly and imperfect insurance policy"
against the "catastrophic" but unlikely event of cervical cancer. So it comes down to the level of
risk with which we are happy to live. And now that I know my likelihood of an abnormal smear is so
much higher than ever having cervical cancer, I think I'll take my chances until the test improves.
What does Michael Baum think of my decision? "You are not being irresponsible or reckless. You are
making a serious, thoroughly well-informed choice and I would like to extend that choice to all
women," he says. I wonder how long it will take the rest of the medical profession to come round to
his point of view.