March 15, 2013 | 10:38 am

Azithromycin Might Kill You, but That’s Not Why You Shouldn’t Take It

Posted by Albert Fuchs, M.D.

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This week the FDA issued a warning about the antibiotic azithromycin (Zithromax). The media stories have some patients terrified and some of them are calling me convinced that azithromycin is poison, a reliable agent for suicide.

What’s the hubbub about?

Azithromycin is in a family of antibiotics called macrolides, which also includes erythromycin and clarithromycin (Biaxin). Erythromycin and clarithromycin have long been known to very rarely cause fatal abnormal heart rhythms. It was thought that azithromycin didn’t have this rare side effect.

In May of last year the New England Journal of Medicine (NEJM) published a study that tried to confirm this. The study compared rates of sudden death while taking a course of azithromycin to the risk while taking amoxicillin, ciprofloxacin, levofloxacin, or no antibiotic. The study was not randomized. It simply matched hundreds of thousands of antibiotic prescriptions to death certificates.

The study found a tiny increased risk in patients taking azithromycin. How tiny? Compared to taking amoxicillin, taking azithromycin contributed 47 additional cardiovascular deaths per 1 million antibiotic courses. That’s one extra death per 21,276 courses. If you took 5-day azithromycin courses continuously, it would take 291 years to take that many courses of antibiotics. That’s a much slower way to die than, say, hemlock.

All patients did not have the same risk of having a fatal heart rhythm abnormality. Older patients, patients taking medications for heart rhythm abnormalities, and patients with heart disease, certain EKG abnormalities, and certain electrolyte abnormalities were at greater risk of this side effect. The patients at highest risk face one additional death every 4,100 courses of antibiotics, while those at lowest risk have one additional death every 110,000. These are very, very small risks.

So doctors should try to avoid all macrolides in high risk patients. But patients should probably forget the whole thing and avoid azithromycin for a different reason.

The reason you should avoid azithromycin is the same as the reason you should avoid all antibiotics. The risk of Clostridium difficile infection and the risk of antibiotic resistance is much greater than the miniscule risk of a fatal rhythm abnormality. That’s what should be scaring you about antibiotics. This is especially true of azithromycin because its convenient 5-day course, the Z Pack, has become a household name and patients ask for it even when antibiotics are very unlikely to help. It is very likely that the last Z Pack you took was for a cold, or for acute bronchitis, or for an early sinus infection, all of which resolve without antibiotics.

It would be a sad irony if we needed the irrational fear of extremely rare side effects to counter the irrational exuberance that patients have for unnecessary antibiotics. I hope instead that educated patients armed with reliable information will make good decisions.

Learn more:

F.D.A. Raises Heart Alert on Antibiotic in Wide Use (New York Times)
FDA Strengthens Warnings On Pfizer Antibiotic (Wall Street Journal)
FDA says Zithromax can cause fatal irregular heart rhythm (Reuters)
Azithromycin (Zithromax or Zmax) and the risk of potentially fatal heart rhythms (FDA Drug Safety Communication)
Azithromycin and the Risk of Cardiovascular Death (NEJM, May 2012)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

March 1, 2013 | 12:50 pm

Normal Test Results are Often Not Reassuring

Posted by Albert Fuchs, M.D.

A CT scanner. Not a good test for anxiety. Photo by 1weezie23/Wikipedia.

Every primary care doctor has been faced with this situation. A patient reports vague symptoms and is very worried that they are a sign of a catastrophic illness. The symptoms aren't even slightly suggestive of the disease the patient is worried about, but the patient’s neighbor’s brother-in-law was just diagnosed with the same disease, and so the patient is pretty sure that he has it too. The doctor is not at all suspicious that the patient has this disease. The doctor believes that the patient is simply anxious, and that his symptoms are either caused by his anxiety or are normal bodily sensations that are being magnified and given lots of attention because of the news about the neighbor’s brother-in-law.

What can the doctor do? One option is to order a test – a CT, a MRI, blood tests, whatever would rule out the specific disease the patient is worried about. The doctor is not ordering the test because he is actually curious about the results. He thinks the probability of an abnormal result is extremely low. He is ordering the test simply in the hopes that a normal result will reassure the patient, decrease the anxiety, and maybe even lead to the resolution of the symptoms by letting the patient focus on something else.

The temptation to order the test is pretty great (especially if the doctor owns the testing equipment). But will it work? Will the normal test result fix the problem?

A study published this week in JAMA Internal Medicine attempted to answer that question. Researchers compiled all previous published randomized trials that assessed diagnostic testing done for symptoms that were unlikely to represent serious illness. They found that on average the patients’ reported anxiety and symptom severity did not decrease after the result was normal.

So when the disease being investigated is very unlikely, ordering a test just to reassure a patient doesn't actually reassure the patient.

It might be more effective to take the time to understand the cause of the anxiety. Perhaps the patient is actually very close to the neighbor’s brother-in-law and is himself devastated by the bad news and simply needs to express how sad he is for his friend. Or perhaps he has health anxiety (hypochondriasis) and has been to a dozen doctors in the last six months with different symptoms getting myriad normal tests. The former just needs some sympathetic listening. The latter needs cognitive behavioral therapy. Neither benefit from diagnostic testing.

Another reason to avoid testing for a disease that is very unlikely in a given patient has to do with math. I wrote last year that screening for most diseases is not helpful. One of the reasons is that no test is perfect. If the likelihood that the disease is present is extremely small, an abnormal test is more likely to be caused by an test error than by the disease being present. So testing patients that are almost certainly healthy raises the possibility of false positives due to test errors. That won’t reassure anyone and will likely lead to more tests to pursue the spurious abnormal result.

Doctors need to learn to say to patients “That doesn't sound worrisome. Let’s just keep an eye on it.” without being dismissive. Patients need to learn that a system that pays more for testing than listening will deliver more testing than listening.

Learn more:

In many patients, diagnostic testing isn't reassuring after all (LA Times)
'Worried Well' Often Ignore Negative Test Results: Study (US News)
Reassurance After Diagnostic Testing With a Low Pretest Probability of Serious Disease (JAMA Internal Medicine)
Doctor, Test Me for Everything (My post from last year explaining why some screening tests are harmful)
It’s Not All in Your Head: How Worrying about Your Health Could Be Making You Sick and What You Can Do about it (A very helpful and authoritative book for patients with health anxiety)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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February 22, 2013 | 3:33 pm

Healthcare That You Should Avoid, part 2

Posted by Albert Fuchs, M.D.

A chest X ray. One of many
tests you shouldn't have
routinely. Credit: Aidan
Jones/Wikimedia commons

16% of all spending in the US is on healthcare. About half of that is spent by federal, state, and local governments, and the other half is spent by the private sector. In 1970 about 7% of all spending was for healthcare. Total annual spending on healthcare per person has increased from less than $1,000 in 1970 to about $8,000 now.

Defenders of our current healthcare spending are quick to point out that while we’re spending much more, we’re getting much better healthcare. New technological developments are constantly bringing better treatments to patients, and patients are living longer. The increased expense, they would argue, is worth it. But we shouldn't believe them. In all other sectors (housing, transportation, food, …) quality improves while prices drop. We spend a smaller fraction of our money on transportation than we did a generation ago despite the fact that cars are safer and more fuel efficient and that commercial airline travel is inexpensive enough to be enjoyed by the middle class. We are right to expect medical care to become both better and cheaper over time.

Why hasn't it? I believe our current insurance payment system rewards overutilization and drives prices up. (I wrote a series of posts analyzing the issue in 2009.) Because the vast majority of healthcare dollars are not paid by the patients receiving the care, there is little disincentive to provide care that has little or no benefit. In fact there is a great incentive to the doctor to provide as much such care as possible.

Besides high prices, this has resulted in a healthcare culture in which doctors offer and patients have come to expect tests and treatments which have been proven to be entirely without benefit. Last April in an attempt to educate both doctors and patients about interventions that are valueless, the American Board of Internal Medicine Foundation partnered with a number of physician specialty societies and formed an initiative called Choosing Wisely. I wrote about it at the time. The program listed 45 different tests and treatments in nine different specialties that doctors shouldn't offer and that patients should question.

This week, Choosing Wisely has expanded this list. Many new physician specialty societies have come on board and the list of valueless tests and treatments has grown to 90. Among the new recommendations are:

• Don’t perform EEGs for headaches. The American Academy of Neurology finds that EEGs don't help in diagnosing the cause and do not improve outcomes.
• Don’t recommend feeding tubes in patients with advanced dementia; instead offer oral assisted feeding. The American Geriatrics Society reviewed the evidence that careful hand-feeding is as safe in patients with severe dementia and that tube feeding leads more frequently to agitation and worsening skin sores.
• Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. The American Geriatrics society reminds us of the risks of motor vehicle accidents, falls and hip fractures can more than double in older adults taking sleep medicines.
• Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age. The American Academy of Pediatrics reminds us that these medicines have little benefit in young children and have potentially serious side effects.

Feel free to browse the list yourself. It is a fascinating gallery of bad medicine. I must confess that I’m guilty of some of the misdeeds myself. I have a handful of older patients who take Ambien (zolpidem). How delighted will they be when I refuse their pharmacy’s request for the next refill and tell them that there are safer alternatives?

Choosing Wisely is a worthwhile effort. It may prevent patient harm and improve care. But I suspect it will not make a dent in costs. As long as doctors have a financial incentive to provide inappropriate care, some of them will. As long as patients have little financial incentive to assure that their care is appropriate, many of them will not.

Learn more:

Medical Waste: 90 More Don'ts For Your Doctor (Shots, NPR’s health blog)
Group Urges Health-Test Curbs (Wall Street Journal)
Doctors list overused medical treatments (Los Angeles Times)
Choosing Wisely

My last post about Choosing Wisely: Healthcare That You Should Avoid

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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February 15, 2013 | 2:41 pm

The Pathogens on Cupid’s Arrow

Posted by Albert Fuchs, M.D.

“Love is a burning thing
And it makes a fiery ring”
-- Johny Cash

On Valentine’s Day some think of chocolate, or wine, or flowers. Physicians think of sexually transmitted infections (STIs). This week with perfect timing, the Centers for Disease Control and Prevention (CDC) released two studies quantifying the burden of STIs in the U.S. The studies estimated the nationwide burden of eight STIs – chlamydia, gonorrhea, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, HIV, and trichomoniasis. The results showed that there are about 20 million new cases of these STIs annually, and that the prevalence of STIs, that is the number of new and existing infections at a given time, is 110 million. Over half of the STIs, both in terms of new infections and prevalent infections, are due to HPV, the virus that can cause genital warts and cervical cancer. And most of the infections are in young people between the ages of 15 and 25. How romantic!

As if that wasn’t enough to throw a wet blanket on the national mood, this week’s Morbidity and Mortality Weekly Report followed up on a story I first wrote about a year ago – the emerging threat of multi-drug resistant gonorrhea. Gonorrhea remains a serious public health threat in the U.S. with over 300,000 new cases reported in 2011. Peruse my post from a year ago for the detailed history of the gonorrhea bacterium repeatedly overcoming whichever antibiotic we use against it. Since the 1940s gonorrhea has developed resistance to sulfanilamide, penicillins, tetracyclines, and most recently fluoroquinolones. That leaves cephalosporins as the last family of antibiotics uniformly effective against gonorrhea.

This week’s report warns that strains of gonorrhea resistant to cephalosporins have been isolated in Japan, France, and Spain in the last few years. Strains in the U.S. remain sensitive to cephalosporins, but laboratory measures of cephalosporin sensitivity in isolated strains are slowly decreasing. No other effective antibiotic alternative is on the horizon, so the appearance of cephalosporin-resistant gonorrhea may essentially mean the appearance of untreatable gonorrhea. How romantic!

So as we approach the end of the antibiotic century, perhaps we should all try to rediscover the virtues of monogamy. That may sound quaintly retrogressive, but no more so than the notion of having no treatments for common infections.

“You must remember this
A kiss is still a kiss
A sigh is just a sigh
The fundamental things apply
As time goes by”
-- Herman Hupfeld

Learn more:

'Ongoing, severe epidemic' of STDs in US, report finds (Vitals, NBC News)
CDC Warns of Super-Gonorrhea (ABC News)
'Severe epidemic' of sexually-transmitted diseases is sweeping the nation, warns CDC on Valentine's Day (Daily Mail)
CDC Grand Rounds: The Growing Threat of Multidrug-Resistant Gonorrhea (Morbidity and Mortality Weekly Report)
Incidence, Prevalence, and Cost of Sexually Transmitted Infectious in the United States (CDC Fact Sheet)

My last post about multi-drug resistant gonorrhea: Untreatable Gonorrhea – The Next Infectious Threat

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 25, 2013 | 3:15 pm

Newsflash: Smoking is Very Unhealthy

Posted by Albert Fuchs, M.D.

Image credit
Wikimedia commons

I have shocking news. Smoking is very very bad for you.

In 1964 the US Surgeon General issued a report summarizing the known adverse health effects of smoking. At that time about 40% of American adults smoked. A widespread campaign followed informing Americans about the link between smoking and lung cancer, emphysema, stroke, and heart attacks. Federal law required the placement of health warnings on cigarette packages, and school children all learned about the adverse health effects of smoking.

By 2010 the prevalence of smoking decreased to 19% of American adults, mostly because of more people quitting (rather than fewer people starting). But from 2004 to 2010 the prevalence of smoking has changed little. We seem to have reached a steady state, a nadir of smoking despite the now well-known health hazards. And while smokers were much more representative of the general population in the 1960s, they are now disproportionately poor and less educated. Current smokers are also on average younger than non-smokers, since so many smokers quit as they get older.

This week the New England Journal of Medicine (NEJM) published two studies that attempted to quantify the differences in longevity between smokers and non-smokers. The studies followed hundreds of thousands of men and women and compared the information about their smoking status to their longevity and cause of death.

The results were fairly dramatic. On average, those who never smoked live over 10 years longer than those who continue to smoke their whole lives. For those between 25 and 79 years old, the death rate for smokers is three times that of those who never smoked. Those who quit also did much better than those who didn’t. Those who quit between the ages of 25 and 34 lived 10 years longer than those who continued smoking, almost reaching the longevity of those who never smoked. The benefit of quitting decreased with increasing age, but never disappeared. Smokers who quit between the ages of 55 and 64 still lived 4 years longer than those who kept smoking.

My regular readers will recognize that these are not randomized studies, and they therefore deserve some skepticism. That’s true. One study was controlled for alcohol use, educational level, and body mass index, but one can easily imagine other confounding factors (poverty, poor access to health care) that may be more prevalent among smokers and independently increase the risk of death. So we can’t be certain that the effect of smoking is as large as the study suggests. Still, the studies add to a mountain of evidence that has already established the risk of smoking. And a randomized study will never be done, so we will never be able to measure the risk exactly.

The bottom line is that smoking is likely to cut your life short. Quitting at any age has benefits. Sooner is better.

The author of an accompanying editorial in the same NEJM issue concludes with this concern.

Because smoking has become a stigmatized behavior concentrated among persons of low social status, it risks becoming invisible to those who set health policies and research priorities. Yet, the need for greater attention to the policies known to reduce the prevalence of smoking remains urgent. As former Australian Health Minister Nicola Roxon has said, “We are killing people by not acting.”

But the increasing “invisibility” and disenfranchisement of smokers seems to me inevitable. For half a century we have very successfully educated people about the risks of smoking. We have waged a campaign that has made it clear that smoking is hazardous and we have tried to make it uncool. We cannot simultaneously applaud our important success while being surprised that those most resistant to the message are those whom information and solid judgment are least likely to reach.

All diseases that are predominantly acquired through behaviors, like HIV or cervical cancer, follow the same pattern over time. As education about prevention of the disease spreads, those who have access to information and value their health will stop contracting the disease. A generation later those who are still engaging in the risky behaviors are very difficult to reach. Few problems are more intractable than people in free societies choosing to harm themselves.

Further progress in decreasing the prevalence of smoking is likely to be incremental and slow. I suspect further attempts at addressing this problem through policy will involve tradeoffs, not solutions.

Learn more:

Smokers Lose 10-Plus Years of Life, Studies Find (Wall Street Journal)
Quitting smoking prolongs life at any age (LA Times)
Putting a Number on Smoking’s Toll (NY Times)
21st-Century Hazards of Smoking and Benefits of Cessation in the United States (NEJM article)
50-Year Trends in Smoking-Related Mortality in the United States (NEJM article)
New Evidence That Cigarette Smoking Remains the Most Important Health Hazard (NEJM editorial)

Tangential Miscellany

Seven years and over 300 posts ago I decided to start writing a weekly health news blog. Since then my posts have been republished in half a dozen publications, started some fascinating debates, and I hope educated and stimulated you. Thank you for reading. I promise to try not to bore you in the next seven years.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 18, 2013 | 12:40 pm

Curing Clostridium difficile with, um, Feces

Posted by Albert Fuchs, M.D.

Electron micrograph of C.
dif. bacteria. Image credit:
CDC PHIL(6260) /
Louis S. Wiggs

[This post is grosser than most. You may not want to read it over lunch.]

Last year I warned that Clostridium difficile (C. dif.) infections are becoming more common.

C. dif. is a bacterium that infects the colon causing severe, sometimes life-threatening, diarrhea. C. dif. infection is frequently a complication of antibiotic use. Antibiotics can kill the normal bacteria in the colon and establish an opportunity for C. dif. to proliferate. After a course of antibiotics, a person can remain susceptible for a few months, and subsequent exposure to C. dif., usually in a healthcare setting, can lead to infection.

The mainstay of C. dif. treatment is more antibiotics, typically vancomycin or metronidazole. But these antibiotics don’t always work, and in many cases the C. dif. infection is not eradicated and the diarrhea recurs.

For over 50 years investigators have suspected that restoring normal gut bacteria could treat C. dif. infection. In 1950s the bacterium C. dif. had not yet been isolated, but the severe colon infection that sometimes followed antibiotic use was well known. In 1958, physicians in Denver treated patients with C. dif. colitis with enemas containing feces from healthy people. They reported that their patients rapidly and dramatically improved and urged further study of this treatment.

Since then, antibiotic treatment for C. dif. was discovered, and the idea of curing C. dif. by restoring normal bacteria languished, mostly because the thought of treating a patient by giving him feces is aesthetically so unappealing. Nevertheless as C. dif. became more prevalent in recent years, and as antibiotic treatments became less effective, many gastroenterologists have resorted in desperation to treating these very sick patients with donated feces, either by enema, or through a colonoscope, or through a tube inserted through the nose to the small intestine. Invariably the success rates were extremely high, but this treatment never gained legitimacy, partially because of the lack of a rigorous trial comparing it to accepted antibiotic treatment, and partially because of the enormous yuck factor.

This week the New England Journal of Medicine published online a study that should convince the skeptics, if not the squeamish. Researchers in the Netherlands randomized patients with C. dif. infection who had already failed one course of antibiotic treatment. The patients were randomized into three groups. One group received the standard antibiotic treatment of vancomycin for 14 days. A second group received vancomycin for 14 days followed by a solution that flushes out the intestines by causing diarrhea (similar to a colonoscopy preparation). The third group received vancomycin for 4 days, the solution that flushes out the intestines, and then an infusion of feces through a tube inserted through their nose into the small intestine.

The research protocol made many strides in minimizing the unpleasantness of the stool infusion, and patients tolerated it very well. The infused “material” was provided by anonymous donors who were screened for infectious diseases. I’ll spare you the details of how the donated material was prepared, but the very curious can read the NY Times article about this study. Suffice it to say that the patients don’t see the infused solution. They only experience a plastic tube in their nose.

The results were quite dramatic. In fact, the study was stopped early because the differences between groups were so great. 81% of the patients receiving the feces infusion were cured after the first infusion, and most of the rest were cured with a second. In the antibiotic group about a third were cured, and in the group receiving vancomycin followed by the intestinal flushing solution, only about a quarter were cured. Many of the patients receiving antibiotics requested the feces infusion after the trial ended.

This should convince physicians and patients that if a first course of antibiotic treatment has failed, fecal infusion is a rational next step. It is hoped that eventually researchers will find and culture the bacteria that are responsible for inhibiting the growth of C. dif. so that eventually patients can swallow capsules of live cultured bacteria, eliminating the need to deal with human waste.

Learn more:

When Pills Fail, This, er, Option Provides a Cure (NY Times)
Faecal transplants succeed in clinical trial (Nature)
Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile (NEJM Original Article)
Fecal Microbiota Transplantation — An Old Therapy Comes of Age (NEJM Editorial)
My previous posts about C. dif.:

Clostridium difficile Infections on the Increase
A New Treatment for Clostridium difficile

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 11, 2013 | 11:31 am

This Year’s Flu Season Isn’t Mild

Posted by Albert Fuchs, M.D.

Photo credit:
CDC

The last two years have graced us with atypically mild flu seasons. This year we’re not so lucky. The flu season seems to have started early, and at least on the East Coast is quite severe. This week Boston has declared a public health emergency as their emergency departments became swamped with flu cases. In Pennsylvania, a hospital erected a tent outside its emergency department for the increasing number of flu patients. The number of flu cases is increasing in California too, though we may be a week or two behind the wave of illness that has struck the East.

What should we all do to avoid getting sick?

• Everyone over 6 months (except for a few exceptions) should get the flu vaccine.
• If you get sick, stay home except to get medical care.
• While sick, limit your contact with others as much as possible.
• Wash your hands frequently with soap and water or with hand disinfectant, and avoid touching your eyes, nose, and mouth.

There are antiviral medicines that can decrease the duration of the flu. They are only recommended for people who are likely to have serious complications from the flu – pregnant women, older people, or people with chronic illnesses. If you are in those categories, contact your doctor at the first sign of flu symptoms. Antiviral medications are more effective the earlier they are started.

The season hasn’t peaked yet, and may turn out to be just moderate. We’ll know in a few weeks. In the meantime I recommend a little social distancing until the worst is behind us. Stay a couple of feet away from people. Say hi with a friendly wave instead of a handshake. Write an IOU to be redeemed in the spring for the hug and kiss with which you usually greet a friend. She’ll thank you if it turns out either of you is about to get sick.

And get your flu shot.

Learn more:

Flu Season Strikes Early And, In Some Places, Hard (Associated Press)
As Cases Spike, Flu Season May Be Peaking In Boston (Shots, NPR health news)
Number of NYC flu cases higher than in past years (Wall Street Journal)
Google Flu Trends for Los Angeles Seasonal Influenza: Flu Basics (Centers for Disease Control and Prevention)
Key Facts About Seasonal Flu Vaccine (Centers for Disease Control and Prevention)
Hospital Opens Emergency Tent in Midst of Increasing Flu Cases (NBC Phiiladelphia)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 4, 2013 | 3:37 pm

Many Women Who Don’t Need Them Are Still Getting Pap Tests

Posted by Albert Fuchs, M.D.

Cervical cells collected in
Pap tests: normal cells on
the left, precancerous cells
on the right.
Ed Uthman/Wikimedia
Commons

My regular readers know that I frequently bemoan the fact that we have no effective way to test for most cancers, and that in many cancers early diagnosis does not improve survival. Cervical cancer is one of the few exceptions. Since Georgios Papanikolau developed the test named after him, the Pap test has dramatically reduced the incidence and mortality of cervical cancer.

More recent advances have shown that cervical cancer is caused by human papilloma virus (HPV), a sexually transmitted infection. Specific testing for HPV is now frequently performed in addition to the Pap test, and a vaccine against the most dangerous strains of HPV is likely to further decrease cervical cancer incidence.

We also now understand that the changes that HPV cause are detectable years before cervical cancer occurs, so the interval between tests can be quite long. Current recommendations are for all women between the ages of 21 and 65 to have a Pap test every three years. If HPV testing is also used, women over 30 can be safely tested every 5 years.

Women over 65 who have been previously tested and have had normal test results are unlikely to benefit from further testing. Also women who have had a total hysterectomy (surgery in which both the uterus and cervix are removed) do not need further Pap tests, because they don’t have a cervix. (An important exception is women who have had a hysterectomy because of cervical cancer or pre-cancerous changes.)

This week brings us evidence of too much of a good thing. The current issue of Morbidity and Mortality Weekly Report (MMWR) published a survey of women over 65 and women who have had hysterectomies. It asked them if they had a recent Pap test. Two thirds of women over 65 answered affirmatively as did 59% of women who have had hysterectomies. I found that as surprising as if 59% of bald men were still going to their barber regularly. It’s hard to know what’s behind this behavior. These women can’t benefit from the tests they’re undergoing. Perhaps this is a manifestation of long-established habits for both the doctors and the patients. Another possible explanation is that some of the women surveyed are simply wrong. The study didn’t actually check medical records, and some of the women may have thought that they had been tested when they hadn’t. Obviously, the most pernicious possibility is that many doctors are still recommending useless testing to patients who trust them. (If Medicare paid for haircuts one wonders how many bald men would still go to their barbers, just for the attention and social interaction, and how many barbers would sent reminder postcards to their bald patients.)

So if you’re between 30 and 65 and are having both Pap tests and HPV testing and your results have been normal, give yourself 5 years between tests. And if you’re over 65 and your tests have been normal, or you no longer have a cervix, congratulate yourself for permanently escaping cervical cancer and feel free to forego further testing.

Learn more:

Pap Tests For Cervical Cancer Are Often Wasted (Shots, NPR health news)
CDC: Women with hysterectomies getting unneeded Paps (USA Today)
Cervical Cancer Screening Among Women by Hysterectomy Status and Among Women Aged ≥65 Years — United States, 2000–2010 (MMWR)
Announcement: Cervical Cancer Awareness Month — January 2013 (MMWR)
US Preventive Services Task Force recommendations for cervical cancer screening
My post in 2009 summarizing the recommendations for Pap tests: Should You Have a Pap Smear?

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment