Why I don't have smears

article today in the Independent.

In answer to criticism received; no, I don't think that discussing why I don't have a smear test is irresponsible.

I do think it's bad practice to cajole and occasionally frighten women into smear tests. These are the Scottish information booklets presented to women having a first smear, and thereafter. There is no information about the NNT – it does say that '1 in 10′ will be recalled, but it doesn't say what proportion need treatment and what proportion of these will benefit. This information is also missing from the English leaflet.

Currently, women are encouraged to have a smear. GPs are incentivised to do so. This means that when a woman comes in with a symptom that needs sorted, there is a detraction from the woman's agenda. This presents a conflict. I can't quote research because it, shamefully, hasn't been done – but there are women who do not wish to have a smear and who are asked, time and again, why they are not 'complying' with the medical screening targets. This can cause distress and can even prevent women from coming to see the doctor about symptoms. Many doctors have seen this pattern.

I don't expect people in general to realise this, but it cannot be ignored. There are many discussion forums on the internet where women discuss the issues they have faced when they have wished to decline a smear. Women have felt humiliated, bullied, harried. It's not fair and it's not right.

To me the problem is that we advertise smears as the usual. We don't individually consent and explain screening in the same way as we would other interventions – like a prescription or an operation. We do not recognise that it is a completely valid choice not to have screening. Doctors cannot and should not force their own value judgements onto anyone else – either to have or not to have a cervical screening.

I'm happy to explain my rationale because I am concerned that a great many women are being directed into cervical screening without knowing that it's a choice and without giving fully informed consent. I want to see better discussions of the pros and cons. This isn't recognised well – here's a response to some research on the uptake of cervical screening written by myself and Professor Susan Bewley. It didn't occur to these researchers that some women may have wanted not to be screened.

Here's Angela Raffle's, and colleagues, bottom line

In the NHS cervical screening programme around 1000 women need to be screened for 35 years to prevent one death
Over 80% of women with high grade cervical intraepithelial neoplasia will not develop invasive cancer, but all need to be treated
For each death prevented, over 150 women have an abnormal result, over 80 are referred for investigation, and over 50 have treatment
Before the 1988 relaunch of screening with strict quality standards, for each death prevented there were 57000 tests and 1955 women had abnormal results
That's useful, clear information, to women considering a cervical screening test. It explains the high risk of a false positive relatively speaking, so that an abnormal smear can be contextualised. It also makes clear the small but present chance of a smear stopping a death from cervical cancer.
It's not for me to tell women what to do, or what not to do. It is my job, as a GP, to explain the pros and the cons – and that's what we need to be doing better. Respecting women's autonomy means respecting a decision to have, or not to have, the test.
It's worth noting what Archie Cochrane said of cervical screening:  "never has there been less appeal to evidence and more to opinion"


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Published on March 20, 2012 08:20
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