With Routine Medical Tests and Procedures, Choose Wisely

Hal C. Lawrence III, MD, ACOG Vice President, speaking during the press briefing.

Hal C. Lawrence III, MD, ACOG Executive Vice President, speaking during the press briefing.

Open lines of communication are the basis of successful doctor-patient interactions. However, when it comes to medical tests and procedures, doctors and patients alike can easily slide into cruise control without taking the time to discuss what’s truly needed, appropriate, supported by evidence-based research, and in the best interest of the patient’s care.

With this in mind, ACOG has teamed up with the Choosing Wisely campaign—an initiative that aims to spark a conversation about commonly performed tests and exams in different areas of medicine. By taking a critical eye to routine health care practices, we can make better decisions on how to provide thorough and comprehensive care while avoiding unnecessary, redundant, or even risk-increasing procedures.

Today, at a joint press conference with 16 other partnering organizations, ACOG made the following recommendations:

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.
Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.
Ideally, labor should start on its own initiative whenever possible. Higher cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age.
In average–risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems and to have appropriate screening with consideration of a pelvic examination.

4. Don’t treat patients who have mild dysplasia of less than two years in duration.
Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average–risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

5. Don’t screen for ovarian cancer in asymptomatic women at average risk.
In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

Learn more.

Guest Blog: A Changing Tide—Have New Pap Test Recommendations Taken Hold?

David Chelmow, MD

David Chelmow, MD

If you’ve been following women’s health news, you know that a lot’s changed recently with Pap screening. Over the last decade, health organizations including ACOG, the American Cancer Society (ACS), and the US Preventive Services Task Force (USPSTF), have been reviewing research to determine how we can best prevent cervical cancer without excessive testing and unnecessary medical intervention.

The latest round of recommendations issued by each of these groups in 2012, building on guidance from ACOG in 2009, is generally consistent. All three organizations agree that for most women, cervical cancer screening should:

  • begin at age 21
  • stop after age 65 or following a hysterectomy in which the cervix has been removed
  • be performed every three years (Pap test only) OR every five years in women over 30 who’ve received negative results on a simultaneous Pap and human papillomavirus (HPV) test

The Centers for Disease Control and Prevention (CDC) recently published two studies looking at the use of Pap testing from 2000 to 2010. Much of what they found was good news and strongly suggests that doctors and patients are increasingly following the new recommendations. Fewer women younger than 21 were tested, and there was less Pap screening of women who had hysterectomy.

Unfortunately, there was also disappointing news. Many women continued to receive unnecessary Pap tests, including more than half of women younger than 21. Given the frequency of HPV infection in this age group, these young women are at significant risk for harms of testing without any expected benefit of cancer prevention. A much better strategy for prevention in this age group is HPV vaccination, but data from other sources suggest only a small portion of eligible women are receiving the full three-shot course of the vaccine. Additionally, 60% of women age 30 and older who had a hysterectomy continued to get Pap testing over this timeframe, according to CDC. Only a few of these women will need continued testing.

The studies also found that women age 22 to 30 who have never been screened increased from 6% to 9%—disturbing data considering most cervical cancer occurs in women who have never been screened or have not been screened in more than five years. Women age 30 to 64 who did not have health insurance were also less likely to be up to date with Pap screening in 2010 than in 2000.

For women to get the best protection against cervical cancer, they should get the HPV vaccine and be screened using the Pap and HPV tests according to ACOG recommendations. Let’s hope that the 2010—2020 summary finds that more women are getting screened according to the recommendations.

David Chelmow, MD, is professor and chair of the department of obstetrics and gynecology at Virginia Commonwealth University Medical Center in Richmond. Dr. Chelmow is a member of The American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology.