The Papanicolaou test (also called Pap smear, Pap test, cervical smear, or smear test) is a screening test used in gynecology to detect premalignant and malignant (cancerous) processes in the ectocervix. Significant changes can be treated, thus preventing cervical cancer. The test was invented by and named after the prominent Greek doctor Georgios Papanikolaou. An anal Pap smear is an adaptation of the procedure to screen and detect anal cancers.
In taking a Pap smear, a tool is used to gather cells from the outer opening of the cervix (Latin for "neck") of the uterus and the endocervix. The cells are examined under a microscope to look for abnormalities. The test aims to detect potentially pre-cancerous changes (called cervical intraepithelial neoplasia (CIN) or cervical dysplasia), which are usually caused by sexually transmitted human papillomaviruses (HPVs). The test remains an effective, widely used method for early detection of pre-cancer and cervical cancer. The test may also detect infections and abnormalities in the endocervix and endometrium.
It is generally recommended that females who have had sex seek regular Pap smear testing. Guidelines on frequency vary, from annually to every five years. If results are abnormal, and depending on the nature of the abnormality, the test may need to be repeated in three to twelve months. If the abnormality requires closer scrutiny, the patient may be referred for detailed inspection of the cervix by colposcopy. The patient may also be referred for HPV DNA testing, which can serve as an adjunct to Pap testing.
Whom to screen
The guidance on whom to screen varies from country to country. In general, screening starts at age 20 or 25 and continues until about age 50 or 60. There is probably no benefit screening women aged 60 or over, whose previous tests have been negative.
In the United States, most Pap results are normal, however about 2-3 million abnormal Pap smear results are found each year. Most abnormal results are mildly abnormal (ASC-US (typically 2-5% of Pap results) or LSIL which stands for low-grade squamous intraepithelial lesion (about 2% of results)), indicating HPV infection. Although most low grade cervical dysplasias spontaneously regress without ever leading to cervical cancer, dysplasia can serve as an indication that increased vigilance is needed. Endocervical and endometrial abnormalities can also be detected, as can a number of infectious processes, including yeast and Trichomonas vaginalis. A small proportion of abnormalities are reported as of "uncertain significance".
Typically about 0.5% of Pap results are high-grade SIL (HSIL), and less than 0.5% of results indicate cancer; typically 0.2 to 0.8% of results indicate ASCUS.
Abnormal results are reported according to the Bethesda system. They include:
- Atypical glandular cells (AGC)
- Atypical squamous cells of undetermined significance (ASCUS)
- Atypical squamous cells of undetermined significance (ASCUS)
- Atypical squamous cells - cannot exclude HSIL (ASC-H)
- Low grade squamous intraepithelial lesion (LGSIL or LSIL)
- High grade squamous intraepithelial lesion (HGSIL or HSIL)
Prior to the introduction of the Pap test, carcinoma of the cervix was a leading cause of death in women. Since the introduction of the Pap test, deaths caused by carcinoma of the cervix have been reduced by up to 99% in some populations where women are screened regularly.
Failure of prevention of cancer by the Pap test can occur for many reasons, including not getting regular screening, lack of appropriate follow up of abnormal results, and sampling and interpretation errors. Adenocarcinoma of the cervix has not been shown to be prevented by Pap tests. In the UK, which has a Pap smear screening program, Adenocarcinoma accounts for about 15% of all cervical cancers
Estimates of the effectiveness of the United Kingdom's call and recall system vary widely, but it may prevent about 700 deaths per year in the UK. A medical practitioner performing 200 tests each year would prevent a death once in 38 years, while seeing 152 women with abnormal results, referring 79 for investigation, obtaining 53 abnormal biopsy results, and seeing 17 persisting abnormalities lasting longer than two years. At least one woman during the 38 years would die from cervical cancer despite being screened. HPV vaccine may offer better prospects in the long term.
Samples are collected from the outer opening or os of the cervix using an Aylesbury spatula and an endocervical brush, or (more frequently with the advent of liquid-based cytology) a plastic-fronded broom. The broom is not as good a collection device, since it is much less effective at collecting endocervical material than the spatula and brush. The cells are placed on a glass slide and checked for abnormalities in the laboratory.
The sample is stained using the Papanicolaou technique, in which tinctorial dyes and acids are selectively retained by cells. Unstained cells cannot be visualized with light microscopy. The stains chosen by Papanicolaou were selected to highlight cytoplasmic keratinization, which actually has almost nothing to do with the nuclear features used to make diagnoses now.
The sample is then screened by a specially trained and qualified cytotechnologist using a light microscope. The terminology for who screens the sample varies according the country; in the UK, the personnel are known as Cytoscreeners, Biomedical scientists (BMS), Advanced Practitioners and Pathologists. The latter two take responsibility for reporting the abnormal sample which may require further investigation.
Studies of the accuracy of conventional cytology report:
- sensitivity 72%
- specificity 94%
Liquid based monolayer cytology
Since the mid-1990s, techniques based around placing the sample into a vial containing a liquid medium which preserves the cells have been increasingly used. The media are primarily ethanol based. Two of the types are Sure-Path (TriPath Imaging) and Thin-Prep (Cytyc Corp). Once placed into the vial, the sample is processed at the laboratory into a cell thin-layer, stained, and examined by light microscopy. The liquid sample has the advantage of being suitable for low and high risk HPV testing and reduced unsatisfactory specimens from 4.1% to 2.6%. Proper sample acquisition is crucial to the accuracy of the test; clearly, a cell that is not in the sample cannot be evaluated.
Studies of the accuracy of liquid based monolayer cytology report:
Human papillomavirus testing
The presence of HPV indicates that the person has been infected; the majority of women who get infected will successfully clear the infection within 18 months. It is those who have an infection of prolonged duration with high risk types (e.g. types 16,18,31,45) that are more likely to develop Cervical Intraepithelial Neoplasia due to the effects that HPV has on DNA. Studies of the accuracy of HPV testing report:
- sensitivity 88% to 91% (for detecting CIN 3 or higher) to 97% (for detecting CIN2+)
- specificity 73% to 79% (for detecting CIN 3 or higher) to 93% (for detecting CIN2+)
By adding the more sensitive HPV Test, the specificity may decline. However, the drop in specificity is not definite.  If the specificity does decline, this results in increased numbers of false positive tests and many women who did not have disease having colposcopy and treatment. A worthwhile screening test requires a balance between the sensitivity and specificity to ensure that those having a disease are correctly identified as having it and equally importantly those without the disease are not identified as having it. Due to the liquid based pap smears having a false negative rate of 15-35%, the American College of Obstetricians and Gynecologists and American Society for Colposcopy and Cervical Pathology have recommended the use of HPV testing in addition to the pap smear in all women over the age of 30.
Regarding the role of HPV testing, randomized controlled trials have compared HPV to colposcopy. HPV testing appears as sensitive as immediate colposcopy while reducing the number of colposcopies needed. Randomized controlled trial have suggested that HPV testing could follow abnormal cytology or could precede cervical cytology examination.
A study published in April 2007 suggested the act of performing a Pap smear produces an inflammatory cytokine response, which may initiate immunologic clearance of HPV, therefore reducing the risk of cervical cancer. Women who had even a single Pap smear in their history had a lower incidence of cancer. "A statistically significant decline in the HPV positivity rate correlated with the lifetime number of Pap smears received."
In the last decade there have been successful attempts to develop automated, computer image analysis systems for screening. Although, on the available evidence automated cervical screening could not be recommended for implementation into a national screening program, a recent NHS Health technology appraisal concluded that the 'general case for automated image analysis ha(d) probably been made' . Automation may improve sensitivity and reduce unsatisfactory specimens. One of these has been FDA approved and functions in high volume reference laboratories, with human oversight.
The physician or operator collecting a sample for the test inserts a speculum into the patient's vagina, to obtain a cell sample from the cervix. Pap smears can be performed during a woman's menstrual period, especially if the physician is using a liquid-based test; if bleeding is extremely heavy, endometrial cells can obscure cervical cells, and it is therefore inadvisable to have a pap smear if bleeding is excessive. The patient's perception of the procedure ranges from no discomfort at all to severe discomfort (especially in women with cervical stenosis). Many women experience spotting or mild cramping afterward.
The endocervix may be partially sampled with the device used to obtain the ectocervical sample, but due to the anatomy of this area, consistent and reliable sampling cannot be guaranteed. As abnormal endocervical cells may be sampled, those examining them are taught to recognize them.
The endometrium is not directly sampled with the device used to sample the ectocervix. Cells may exfoliate onto the cervix and be collected from there, so as with endocervical cells, abnormal cells can be recognised if present but the Pap Test should not be used as a screening tool for endometrial malignancy.
- Strander B (2009). "At what age should cervical screening stop?". Brit Med J 338. doi:10.1136/bmj.b809.
- Saiseni P, Adams J, Cuzick J (2003). "Benefit of cervical screening at different ages: evidence from the UK audit of screening histories". Br J Cancer 89: 88–93. doi:10.1038/sj.bjc.6600974.
- Pap Smear. Retrieved on 2008-12-27.
- DeMay, M. (2007). Practical principles of cytopathology. Revised edition.. Chicago, IL: American Society for Clinical Pathology Press. ISBN 978-0-89189-549-7.
- Cancer Research UK website. Retrieved on 2009-01-03.
- Raffle AE, Alden B, Quinn M, Babb PJ, Brett MT (2003). "Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths prevented". BMJ 326 (7395): 901. doi:10.1136/bmj.326.7395.901. PMID 12714468.
- Martin-Hirsch P, Lilford R, Jarvis G, Kitchener HC. (1999). "Efficacy of cervical-smear collection devices: a systematic review and meta-analysis". Lancet 354 (9192): 1763â€“1770. doi:10.1016/S0140-6736(99)02353-3. PMID 10577637.
- Coste J, Cochand-Priollet B, de Cremoux P, et al. (2003). "Cross sectional study of conventional cervical smear, monolayer cytology, and human papillomavirus DNA testing for cervical cancer screening". BMJ 326 (7392): 733. doi:10.1136/bmj.326.7392.733. PMID 12676841. ACP Journal Club
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- Kulasingam SL, Hughes JP, Kiviat NB, et al. (2002). "Evaluation of human papillomavirus testing in primary screening for cervical abnormalities: comparison of sensitivity, specificity, and frequency of referral". JAMA 288 (14): 1749â€“57. doi:10.1001/jama.288.14.1749. PMID 12365959.
- Cuschieri KS, Cubie HA, Whitley MW, et al. (2005). "Persistent high risk HPV infection associated with development of cervical neoplasia in a prospective population study". J. Clin. Pathol. 58 (9): 946â€“50. doi:10.1136/jcp.2004.022863. PMID 16126875.
- Cuzick J, Szarewski A, Cubie H, et al. (2003). "Management of women who test positive for high-risk types of human papillomavirus: the HART study". Lancet 362 (9399): 1871â€“6. doi:10.1016/S0140-6736(03)14955-0. PMID 14667741.
- Arbyn M, Buntinx F, Van Ranst M, Paraskevaidis E, Martin-Hirsch P, Dillner J (2004). "Virologic versus cytologic triage of women with equivocal Pap smears: a meta-analysis of the accuracy to detect high-grade intraepithelial neoplasia". J. Natl. Cancer Inst. 96 (4): 280â€“93. PMID 14970277.
- Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginner's Manual
- Wright TC, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ (2002). "2001 Consensus Guidelines for the management of women with cervical cytological abnormalities". JAMA 287 (16): 2120â€“9. doi:10.1001/jama.287.16.2120. PMID 11966387.
- ASCUS-LSIL Traige Study (ALTS) Group. (2003). "Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance". Am. J. Obstet. Gynecol. 188 (6): 1383â€“92. PMID 12824967.
- , J Inflamm 2007;4.
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- Willis BH, Barton P, Pearmain P, Bryan S, Hyde C, "Cervical screening programmes: can automation help? Evidence from systematic reviews, an economic analysis and a simulation modelling exercise applied to the UK". Health Technol Assess 2005 9(13).
- Davey E, d'Assuncao J, Irwig L, et al. (2007). "Accuracy of reading liquid based cytology slides using the ThinPrep Imager compared with conventional cytology: prospective study". BMJ 335: 31. doi:10.1136/bmj.39219.645475.55. PMID 17604301.
- Jo's Trust - UK's leading cervical cancer charity.
- Imaginis - Pap Smear information
- International Agency for Research on Cancer - Resource about screening, including that of Cervical Cancer. There are digital atlases of coloscopy, histology and cytology, the rationale of screening and setting up of a screening programme.
- The Pap Test: Questions and Answers â€” National Cancer Institute â€” from the U.S.'s National Cancer Institute
- Pap Smear â€” from eMedicineHealth
- MedlinePlus: Cervical Cancer Prevention/Screening â€” from MedlinePlus
- The Bethesda 2001 Workshop, held April 30 - May 2, 2001, reviewed issues regarding terminology and reporting of cervical cytology
- NCI Bethesda System Web Atlas, with 349 images of different Pap smear morphologic findings â€” from the American Society of Cytopathology
- Canadian Guidelines for Cervical Cancer Screening - Society of Obstetricians and Gynaecologists of Canada
- The UK's National Association of Cytologists
- British Society for Clinical Cytology
- IBMS â€” The Institute of Biomedical Science on cellular pathology
- NHS Cervical Screening Programme â€” from the UK's National Health Service
- EngenderHealth- Cervical Cancer Screening
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