"It is a truism that the prisoner always knows more about the prison keeper than the prison keeper knows about him. But the deeper human tragedy is that the prisoner, who knows so much about the prison keeper, runs the risk of becoming like him." James Alan McPherson, A Region Not Home: Reflections From Exile, New York: Simon & Schuster, 2000.

June 24, 2004

Still A Long Way To Go

nother scandal in health care. The experts are clueless ("taken aback" and "quite surprised"), but "no one is suggesting fraud or mendacity." Nope.

Testing the cervix of patients who don't have one is just a habit doctors have gotten into, and besides, their patients expect it. The "situation" just seems to "reflect doctors' habits."

That and blaming the victims is the best explanation the system, i.e., the perpetrators themselves and their publicists, can come up with.

In my experience, most doctors have internalized their IRS designation as corporations. A corporation is a state chartered organization whose legal and single-minded purpose is to make profit. The human personification of such an entity could be likened to a profit-making zombie and that goes a long way to explaining the medical care that is meted out to the non-wealthy in the cradle of democracy.

How would the establishment respond to, say, auto mechanics, billing the owners of diesel engine-powered cars for replacing spark plugs year after year? They'd scream fraud and demand a police crackdown with prison terms for the perpetrators. Their solution to the problem would be state licensing, strict surveillance, and harsh punishment to eliminate the cheats.

A Long Way, Really?

Would the Times accept the argument from the National Association of Auto Mechanics, that their members had simply gotten into the habit of changing sparkplugs and, besides, the owners expected to have their non-existent sparkplugs changed anyway? Sure.

Why this remarkable difference in response?

My guess is that doctors are perceived by the media as being accepted into the corporate capitalist establishment while auto mechanics are perceived as mere proletarians. As in the ante-bellum South, the transgressions of slave-owners, especially against slaves, were ignored while those of slaves, even minor ones, were punished with flogging or worse.

It seems, we haven't come as far as we thought.

OTTO

June 23, 2004

10 Million Women Who Lack Cervix Get Pap Tests

s many as 10 million women who have had hysterectomies and who no longer have a cervix are still getting Pap tests, a new study finds.

The screening Pap test looks for precancerous cells in tissue scraped from a woman's cervix and can prevent what would otherwise be a common and deadly cancer. But testing most women without a cervix makes little sense, leads to false positives and wastes money, said Dr. Brenda E. Sirovich, a research associate at the Outcomes Group at the Veterans Affairs Medical Center in White River Junction, Vt., and the study's lead author. Each test costs $20 to $40, she estimated.

The women in question do not include the 1.1 million who had a hysterectomy and still have a cervix, which is at the base of the uterus, nor the 2.2 million who had their uteruses and cervices removed because they had cancer or precancerous cells in their cervix. (Doctors occasionally leave the cervix behind in hysterectomies, although a large study found no particular advantage to doing so.) In both of these groups, Pap tests are warranted. But most women who have their uteruses and cervices removed do so for reasons other than cancer, like noncancerous fibroid tumors, Dr. Sirovich said.

Dr. Sirovich said she was taken aback by her study's findings.

"We were actually quite surprised," she said. "These women are being screened for cancer in an organ that they don't have."

The 10 million women having unnecessary Pap tests constitute about 12 percent of the 85 million women currently being screened, Dr. Sirovich said.

No one is suggesting fraud or mendacity on the part of the doctors or laboratories. Instead, Dr. Sirovich and others say, the situation seems to reflect doctors' habits and women's expectations.

In their paper, published today in The Journal of the American Medical Association, Dr. Sirovich and her colleague, Dr. H. Gilbert Welch, analyzed national data on Pap testing and on hysterectomies over 10 years.

Not only are most women who have had hysterectomies having Pap tests, they found, but the proportion having them also held steady, at 68 percent, from 1992 to 2002. No professional organization recommends Pap tests for most women without a cervix.

The screening guidelines "either have not been heard or have been ignored," the investigators wrote.

When a woman does not have a cervix, a doctor scrapes cells from her vagina instead, sending them off to be examined. And that, cancer experts say, is problematic.

Vaginal cancer is exceedingly rare, and tests of vaginal cells are much more likely to result in false positives than they are to find vaginal cancers. A result is unnecessary vaginal biopsies that can result in their own false positives. As a result, women can end up having vaginal tissue removed to treat a cancer that is not even present.

Dr. Alfred Berg, chairman of the department of family medicine at the University of Washington and the former chairman of the U.S. Preventive Services Task Force, which issues medical practice guidelines, said Pap tests in women without a cervix had been "a longstanding issue." Since 1988, Dr. Berg said, the task force has issued more and more adamant statements against it, to little avail.

"We're all fascinated as to why this should be," Dr. Berg said. In part, he said, it might be because the American public is convinced that cancer screening is an unmitigated good, making women and their doctors reluctant to give up a test as simple and popular as the Pap.

"We have a thing in this country about cancer screening," Dr. Berg said. "It has a deep social value, and when evidence points in another direction, people are very skeptical."

Another possibility, Dr. Sirovich said, is that evaluations of doctors and health care systems count the percentage of women who have Pap tests, giving little incentive to advise against the tests.

Gynecologists are also puzzled.

"It's kind of hard to figure out," said Dr. Kenneth Noller, who is professor and chairman of obstetrics and gynecology at Tufts-New England Medical Center. Dr. Noller is an author of the cervical cancer screening guidelines issued by the American College of Obstetrics and Gynecology, which does not recommend Pap tests for most women who have had hysterectomies.

Dr. Noller said he suspected that a reason the test was being done in these women anyway was that doctors were used to it.

"It's a relatively cheap and easy procedure," he explained. "It's sort of become a habit."

Dr. Alan Waxman, another author of the obstetricians and gynecologists' guidelines and an associate professor of obstetrics and gynecology at the University of New Mexico, said women expected the test.

"Many women equate the Pap test with the pelvic exam," Dr. Waxman said. "So they come in every year for their Pap test even if they don't need it any more."

He spelled out a scenario. "The woman didn't need to be tested," Dr. Waxman said. But she had a Pap test anyway. "The test shows a mild abnormality. Then she gets treated, just to be on the safe side." Now the woman is labeled as a cancer patient. "It all adds anxiety, discomfort, and expense," he said.

"Many physicians don't consider the consequences of false positives," Dr. Waxman said.

Instead, he explained, they worry about the consequences for themselves if they counsel against a Pap test for the rare woman who turns out to have vaginal cancer. "If the doctor didn't do a Pap test, then there's the litigation threat," he said.

Dr. Noller said he tried to dissuade women who do not need Pap tests.

"I will present the facts to them," he said. "I will try to talk them out of it."

But, he said, "if they still insist, I would probably do it."