Clinical Review

How to keep the annual visit annual

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Pap test or no Pap test, every woman needs a yearly exam, for reasons vital to her health—and to ObGyn practice.


 

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An ObGyn in the audience steps up to the microphone after my lecture on cervical disease screening.

"Ever since the new recommendation that some women might need a Pap test only every 3 years, I've been concerned that a lot of my patients will just stop coming in. They won't ask my opinion; they'll read about it in one of their women's magazines…and then I'll notice that a lot of my regular patients who came in once a year just won't be coming in."

Are we committing economic suicide and alienating our patients if we implement screening guidelines that do not insist upon a Pap test for every woman, every year? It's a fear that many ObGyns share.

It doesn't have to be that way. In our practice, we've discovered that following overall good health screening guidelines is an opportunity to build the practice, strengthen relationships with our patients, and improve women's health.

True, the American College of Obstetricians and Gynecologists' recommendations do state that an interval of 3 years between Pap tests is appropriate in specific cases.

Nowhere is it suggested, however, that we dispense with the annual visit.

To the contrary, the US Preventive Services Task Force (USPSTF) advises every American woman to take a copy of its "Checklist for Your Next Checkup" to her doctor, and ask which of the following screenings and strategies are right for her, and how often she should have them: mammogram, Pap test, cholesterol check, blood pressure, colorectal cancer tests, diabetes tests, depression, osteoporosis tests, chlamydia tests and tests for sexually transmitted diseases, hormones, breast cancer drugs, aspirin, and immunizations.

The good news is that new cervical screening technology means we can recognize or rule out HPV infection with unprecedented accuracy, more swiftly identify and treat precancerous lesions, and better prevent cervical cancer. Popular misconceptions may threaten to make some women skip their annual exams, but we can counsel every patient—and demonstrate by the care we provide—why it is not recommended that women skip their annual visit.

Use the annual visit for comprehensive care

Many of our patients seldom if ever see another physician (despite writing their PCP's name on their intake sheet in our office). Consequently, many of them never get comprehensive health screening unless we provide it. Besides being "the right thing to do," screening for and identifying other problems at the annual visit allows us to schedule follow-up visits to evaluate or monitor treatment of those problems, if we do not otherwise refer the patient. Such follow-up visits, if they are in our scope of practice, are good for the practice and for the patient.

HPV SCREENING

Negative concurrent cervical cytology and HPV DNA testing:

  • Risk of unidentified CIN 2/3 or cancer is about 1 in 1,000
  • Negative predictive value for CIN 2/3 is 99% to 100%

Triage using reflex HPV DNA testing after liquid-based ASC-US cytology:

  • Eliminates the need for a repeat office visit
  • Is a more sensitive triage tool than repeat cytology
  • Refers fewer women to colposcopy

Cytology-negative/high-risk HPV DNA-positive/age 30 or older:

  • Does not call for immediate colposcopy. Instead, repeat both tests in 6 to12 months, and refer to colposcopy only if high-risk HPV persists or if cytology is LSIL or greater.

High-risk HPV and ASC-US or LSIL cytology, but not CIN 2/3 at initial colposcopy:

  • Risk of CIN 2/3 within 2 years is about 10%

Women 30 years and older who have negative combined cytology and HPV DNA results should be rescreened no more than every 3 years

Source: ACOG Practice Bulletin No. 61

Patient satisfaction will increase due to the opportunity to "one-stop shop," and I've found that patients truly appreciate our concern for their overall health.

Telling patients that the Pap test is not needed this year (because they had a negative Pap and negative HPV test last year) has not been a problem. They know that when they come in for their annual visit, it is not just about the Pap test. They are coming in for "well woman care."

It's not as difficult as it looks

Screening can mean asking just a few questions, and very little extra work. For example, we weigh and measure patients anyway, so it is a simple matter to record the body mass index (the medical assistant can calculate it with a simple program made available by the USPSTF). Refer patients for colonoscopy when guidelines call for it or send the patient home with test cards. The depression screen can be as simple as 2 basic questions. The bladder health screen can be 3 or 4 more questions. You can order lipids and other labs.

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