Pap Smears - How are They Done - Properly?

[VH-MLE]

I have had a thread running (which didn't attract much attention unfortunately) on cervical cancer and spread to the lymph nodes.

Basically, my wife has always had her regular pap smears at two yearly intervals in line with recommended medical practice and each had always returned a completely normal result.

In May 2005, my wife was diagnosed with cervical cancer, despite having had a pap smear 14 months earlier that was deemed normal. Her 2 oncologists have suggested that given the size of the tumour at the time of initial diagnosis, it would definitely have been there when she had the pap smear that was deemed normal. As far as staging goes, her cervical cancer was staged as a 2A, which meant it hadn't spread beyond the immediate area and with convential treatment (radiation and chemotherapy), the cure rate was in the vicinity of 90%. Until relatively recently everything had been going well but a semi recent CAT/PET scan revealed cancercous lymph nodes that have now been removed but have unfortunately changed my wife's prognosis from good to not so good.

Needless to say I am extremely angry at how this situation developed in the first place (she is only 42 and we have 3 kids aged 4, 7 and 10 and is deeply loved by us all) and I am seeking answers as to why/how this situation developed in the first place.

Therefore to the medical fraternity out there, I would be extremely grateful for your procedure for conducting pap smears and the safeguards you may or may not have in place to prevent a situation such as the one we are currently experiencing from taking place.

Thankyou in anticipation.

VH-MLE

[Mac the Knife]

I'm so very sorry for your situation VH-MLE.

I'm not a gynaecologist, but I deal with cancer all the time.

1) The normal routine screening Papanicolaou smear does not generally sample cells in the os of the cervix (the canal that leads to the uterus) - perhaps there was malignancy there.

2) Although invasive cancer is often preceeded by dysplastic changes, it doesn't have to be. It is rare, but not uncommon, to see skin cancers arising in areas where there is no background of sun damage or dysplastic change.

3) The world isn't perfect unfortunately. Sometimes minimal dysplastic change can be missed, but remember, dysplastic change is NOT a sure-fire indication that invasive cancer will ensue. Often dysplastic changes regress, so minimal dysplasia is usually treated by repeating the smear a few weeks later.

Life is terribly unfair sometimes.

[obgraham]

VH, I also hope things are looking up for your wife, and I offer you both my best wishes. I did respond to your other thread, and my comments there are relevant to your question here. I am a gynecologist of some 30 years experience.

Regarding your question: when the pap specimen is taken, it is important to sample the ectocervix (the outside) along with the endocervix (a bit up the canal). There are several different ways to do it, some using a single sampler, some using two.

When the slide is read at the lab, the technician will report "endocervical cells are present", or some equivalent, to signify that indeed both components are present on the slide. Lack of endocervical cells on the slide can indicate an inadequate sample, OR (and this is important) a configuration in which the endocervix is not putting out reachable cells. In some cases the patient will be brought back for another sample, but there are still some women whose pap does not, despite repeated efforts, produce those cells. By and large the process of cervical change is slow, so repeat paps will usually overcome this procedural problem.

Most cervical cancers are on the ectocervix, easily reached by the pap. A few are hidden up in the canal itself. They fester there for a long time before suddenly showing up in a more advanced state. Sometimes they originate in the more unusual cell types in the cervix. Although they are uncommon, endocervical-originating cancers are notorious for not showing up on the pap.

I don't know if this all helps you. Like the previous poster said, there are limitations to the pap smear, and the presence of the cancer does not suggest to me that her prior paps were performed inappropriately. I encourage you to discuss this with her gyn oncologist, to explain the particulars of her specific condition.
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Graham MD

[VH-MLE]

Thankyou Mac and Graham for your comments.

I, unfortunately, do not have a good understanding of the technical terms you have expressed - all I am trying to establish is whether the pap smear should have picked up an anomaly if it was done properly i.e. using the prescribed pap smear technique(s). At this point in time, I am finding it very difficult to not blame the doctor that did her last pre-diagnosis pap smear for the mess we are currently in.

I haven't been able to come to terms with my wife's (and indeed our families) misfortune in the way this has panned out - it is totally unjust and unfair.

VH-MLE

[slim_slag]

vh-mle,

I understand the sensitivity (detection of true positive cases) of pap tests is no greater than 80%, and that is if everything is done properly. So 20% or women with changes will be missed each time.

So, 10000 women with cervical changes are smeared, even with best current practice 20% will be missed which means 2000 will slip through. No problem, as cervical cancer is usually slow to develop.

50% of these changes revert to normal, leaving 1000 women with changes going to the next smear.

Two years later, these 1000 women with changes have smears, 20% are missed (with best practice). 200 women therefore go forward to the next smear with changes, but in the interim 50% revert to normal, leaving 100 ladies.

Smear three and 100 women have changes from the time of the original smear. 20% are missed (with best practices) leaving 20 women with changes which have not been caught for 4 years, and possibly as long as 6. By the time of the next smear 50% of these will have had these changes for a possible 8 years, which is getting worrisome. That's 10 people out of the original 10,000 - only 0.1% which sounds really good for a screening process, but not if you are that 0.1%.

So, although my numbers were chosen to make the maths easier, you can see how it's quite possible for people to be missed by the system even with best practice. Cervical screening depends a lot on the fact that cervical cancer is usually slow to progress, and a lot of changes revert anyway, so you have lots of chances to catch it. It's been incredibly succesful in preventing many early deaths, but it will never prevent them all.

I am sorry for your situation, but it's an unfortunate fact of life that some people are just unlucky.

[obgraham]

vh:
Slag's assessment of pap statistics is pretty well spot on. I apologize for using too much doctor-speak.
My basic point is that the pap system is very successful at detecting the majority (but not all, as Slag points out) of cervical cancers.
But there is a particular type of cervical cancer that starts in the deeper tissues, higher up. Every case like this I saw had a string of recent normal paps, just as you describe. They notoriously do not reveal themselves on the pap.
I don't have an opinion on your specific and unfortunate situation, except to say that it does not suggest to me that she received improper care regarding her paps.
Again, you and your family have my best wishes for good health.
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Graham MD

[Mac the Knife]

VH-MLE, again my deepest sympathies for your family's misfortune - if life was just and fair then this is indeed totally unjust and unfair.

obgraham (as the real expert in this field) has given an excellent explanation and slim_slag's assessment of the screening techniques is indeed "spot on".

You say, "....I am finding it very difficult to not blame the doctor that did her last pre-diagnosis pap smear for the mess we are currently in". Your reaction is very understandable, but there is no indication that anything was done wrong, and as obgraham has tried to explain, it is not at all impossible that your wife should have progressed from a normal pap smear to invasive CA within 14/12.

It's a bit like a man who has a clear check for colon cancer one year and is diagnosed as having invasive colon cancer the next. Most cancers spend quite a long time at a very treatable stage (that is why screening tests like pap smears and colonoscopies are useful), but a minority start and progress so quickly that they are just not present at screening. It is very likely that this was the case with your wife. You also need to rememember, amidst your shock and grief, that it is not the doctor or technician who gave your wife cancer.

I am not a trained counseller, but I have spent more than half a lifetime dealing with newly diagnosed cancer patients, particularly women with breast cancer, so sadly, I know very well what I am talking about. Elizabeth Kubler-Ross classified the 5 stages of grief - the first is Denial (it can't be true), the second (which you are struggling to cope with) is Anger (why me/her?). I very strongly suggest that you seek counselling to help you manage this most difficult time - I am quite sure your wife's primary gynaecologist will be able to connect you with someone who will help. Your reactions are perfectly and completely normal, but you need someone to assist you to understand your feelings and help you deal with them.

Getting stuck in the early stages of grief will eat you up and destroy the many chances of happiness together that you still have, so please please, get professional counselling NOW - it won't change the situation, but I promise that speaking your heart to someone who truly understands will help immeasurably.

Mac

[VH-MLE]

Dear Mac, Graham and slim,

Sorry for not getting back to you a little sooner. I would like to thank each of you for your valuable input and best wishes for my wife - I am very grateful.

Regards.

VH-MLE