Clinical Decisionmaking

Cervical smears in previously screened postmenopausal women are poor predictors of cervical neoplasia

Gynecologists continue to debate how often postmenopausal women need Pap smears to screen for cervical cancer. Current recommendations range from discontinuing screening at 65 years of age in previously screened women with a history of normal cervical smears to lifelong screening at less frequent, but undefined, intervals.

Recent studies have demonstrated a low incidence of important cervical disease in previously screened women older than 50 years of age. In fact, a new study concludes that because of poor positive predictive value (chance that a positive smear actually indicates precancerous or cancerous cells), cervical smears should not be performed within 2 years of normal Pap smears in postmenopausal women. This approach would avoid many false-positive test results leading to needless patient concern, followup diagnostic testing, and invasive procedures, explain the researchers.

The researchers, who were supported in part by the Agency for Healthcare Research and Quality (HS07373), used cervical smears collected prospectively during the Heart and Estrogen/Progestin Replacement Study of postmenopausal women who still had a uterus and were suffering from coronary artery disease. The women were followed an average of 4 years at 20 different sites. Cervical smears were done during the women's annual visits to the study gynecologists. The researchers identified 2,561 women who had normal cervical smears at study entry and an abnormal cervical smear at the first or second annual visit. Women were randomized to either estrogen/progestin replacement therapy or placebo.

The positive predictive value of any smear abnormality identified 1 year after a normal smear was 0 percent; the positive predictive value of abnormalities found within 2 years was 0.9 percent. Within 2 years of a normal smear, 110 women in the trial (23 per 1,000 person-years) had a cytologic abnormality. Of these, all but one were false positive. In hormone-treated women compared with non-hormone-treated women, the incidence of cytologic abnormalities was not significantly higher.

See "The positive predictive value of cervical smears in previously screened postmenopausal women: The heart and estrogen-progestin replacement study," by George F. Sawaya, M.D., Deborah Grady, M.D., M.P.H., Karla Kerlikowski, M.D., and others, in the December 19, 2000 Annals of Internal Medicine 133(12), pp. 942-950.

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