Fox News turned over the issue of pap smears and pelvic exams to the opinion of one physician, and allowed her to call the American College of Obstetricians and Gynecologists and the American College of Physicians guidelines “shocking” and “outrageous.” Yet no one from ACOG or ACP is given the opportunity to comment.
Aside from the issue of balance, there are many factual errors in the science in this piece, particularly in the section on Pap smears. Of our 3 reviewers on this piece, the physician-reviewer, with expertise in women’s health, said she discounted the credibility of the article because of the medical misinformation and lack of balance in that first section on cervical cancer screening. That’s too bad, because the topic raised in the second part, on the value of pelvic exams, is a worthwhile area for debate. It is part of a larger discussion on the value of periodic visits — “annual exams” — that allow a doctor and patient to develop the shared medical history and level of trust that some say is a crucial part of excellent and effective health care, even if it is a difficult area to measure.
We strive for healthy health care debate. But turning over a television network (and part of its website) to one physician’s opinion – and not labeling it as such – is neither fair nor balanced. The piece should be labeled as one physician’s opinion. And even if that were done, where are opinions of the physicians who recommended the new guidelines that she criticizes, physicians who certainly have credentials equal to or superior than the author’s, and who also spent substantial time in a group effort to balance the available evidence?
There is, of course, a cost angle to this discussion. But it is dealt with in a cavalier, opinionated, non-evidence-based manner, rather than as one factor in considering how to use medical resources to produce the greatest health benefits.
The physician-author writes about the ACOG guidelines on pap smears: “frankly, I see it as more of an economic decision than anything else.”
It’s interesting that one of Fox News’ readers left this comment online about the story: “Of course the author has a financial gain in telling women to go to their obgyn yearly. “
There was no quantification of potential benefits or of harms in the Fox News piece, but the guidelines by ACOG and ACP provided ample quantification, evaluation of the evidence, explanation of methodology, and references.
A consensus group made up of experts and representatives from the American Cancer Society and the national cervical pathology society estimated that annual screening has a marginal effect on detection of cervical cancer. For women in their 20s, the lifetime risk of dying from cervical cancer is 0.03 in 1000 for annual screening vs 0.05 per 1000 for every 3 years of screening. The likelihood of detecting high-grade precancerous changes is similar with every year vs. every 3 year screening.
The article fails the public by presenting the opinion of a single doctor above that of a panel of experts that arrived at a consensus judgment after a structured, deliberative consideration of the evidence. Apparently in this case, one head is considered better than two or more.
As stated above, no quantification of harms was provided. Indeed, no mention of the harms of such screening was made.
There is no discussion of the risks of more frequent screening, such as overdiagnosis (finding and treating precancerous changes that revert to normal in the great majority of women). Procedures done to evaluate and treat abnormal Pap smears can themselves cause harm, such as cervical stenosis (narrowing) that can lead to pregnancy complications and miscarriage – not to mention the discomfort, anxiety, and cost associated with the procedures.
Only one personal anecdote: “I watched a 28-year-old woman die of cervical cancer during my OB-GYN residency, and it was horrible.”
Health care guidelines should not be established based on individual anecdotes.
There are also factual errors in the piece.
The article cites risk factors that may increase cervical cancer risk (multiple sexual partners, smoking, and with emphasis in the original – using the birth control pill for more than 5 years). But it neglects to note that women who had multiple sexual partners, smoked, or took the birth control pill were very well represented in the studies that compared different intervals for Pap screening – and there was no evidence for a difference in cancer detection or overall benefit in those women. That’s because the absolute risk conferred by these 3 risk factors is extremely low.
Furthermore, it’s not clear whether these factors are truly causes of cervical cancer or just associations with the presence of human papilloma virus (HPV), the known cause of cervical cancer. HPV screening, an important medical advance in cervical cancer screening that is one of the main drivers of the recommendation to screen less frequently, is an integral part of the new screening recommendations; but its relevance is not made clear in the article.
There was no overt disease-mongering in the piece. However, it could be argued that since cervical cancer deaths are quite rare in the US, exaggeration of cancer risk associated with less-frequent Pap screening is, indeed, a form of disease-mongering.
We’ll give the story the benefit of the doubt on this one.
There were no independent sources in the piece – only the opinions of the physician-author.
The entire piece was about one physician’s opinion about screening guidelines – an imbalanced discussion of the alternatives to follow the recommendations or not. There was no evaluation of the evidence behind the alternatives.
The availability of pap smears and pelvic exams is not in question.
No claims of novelty were included in the piece.
It’s clear that the piece was based on one physician’s opinion, not on a news release. So it gets a back-door “satisfactory” grade. Which isn’t much, given the circumstances.