Because she was a new patient to me, I asked for more information. I found out from her and her reliable caretakers that she had never actually been sexually active. You can imagine her relief when I told her that she did not need Pap tests because research indicates that only women who have had sexual intercourse are at significant risk for developing cancer of the cervix.

So who needs to have Pap tests done, and who doesn’t? The US Preventive Services Taskforce sums it up well:

Pap tests are strongly recommended for all women who have been sexually active and have a cervix (the part of the uterus that is tested with a Pap) .

· When should you start having Paps? Start at age 21, or three years after starting sexual activity, which ever comes first.

· How often should you have Paps? Every 3 years appears to be just as beneficial as having them every year.

· When can you stop? Since cervical cancer is less likely after middle age, stopping Pap tests at age 65 makes sense if recent tests have been done and were normal.

Check with your doctor or nurse practitioner to see if Pap tests are right for you. Visit Proven Health Ways for more information about Pap tests and other prevention activities.

• Prior recommendation: Routine mammograms every 1-2 years for women 40 years and older
• New recommendation: Age 40-49: Consider mammograms every 2 years on an individual basis, taking into account patient values and risk factors, but don’t just do it routinely for everyone. Age 50-74: Routine mammograms every 2 years.  Age 75 and over: Whether or not mammograms are helpful is unknown

These new recommendations have made quite a stir, and led to more than a little confusion among patients as well as health care providers. So how do we make sense out of a group like the USPSTF, which I have found to be more objective and thorough than most, making such recommendations like these that not everyone agrees with?

First, it is important to understand that there is no absolute right or wrong here; it is a matter of balancing the possible benefits and harms, and making a judgment. For example, I do not think anyone reading this would recommend that all women have mammograms every month starting at age 21. But why not? Wouldn’t it save more lives from breast cancer, compared to screening less often or waiting until age 40 or 50? Of course it would. But the cost of doing monthly mammograms at these young ages would be relatively high in terms of radiation exposure, biopsies for false positive tests, and money, and the benefit would be relatively small because breast cancer is very rare at younger ages.

So where do you draw the line? When should we health care providers start recommending that women have mammograms? Again, there is no right or wrong answer to this, and professional organizations have different ways of deciding what they are going to recommend. I would say that talking about it with our female patients age 40-49, rather than routinely recommending it, is a rational approach based on good research. It also involves some degree of judgment, and therefore is a position that reasonable people could reasonably disagree on.

Finally, this guideline, like all guidelines, can and should be used thoughtfully and skillfully by primary care providers in consideration of their patients’ needs and preferences. Remember, guidelines are written for populations, but applied to individuals.

As a practicing family physician, I have often heard from women that mammography, in which the breasts are compressed in order to x-ray, is uncomfortable. Occasionally, women have actually declined to get this life-saving measure due to this discomfort. This experience is not universal, however, and many women have told me that while not a pleasant experience, mammography is not painful, and the benefit is clearly worth it.

Many strong research studies have shown that mammography saves lives in women 40 and over; about a third fewer deaths from breast cancer over seven years on average. In some of these studies, mammograms were done along with breast exams by healthcare providers, called “clinical breast exams,” and these studies showed a benefit as well. I have to qualify this next statement by saying that I am not a woman and have never had a clinical breast exam or a mammogram, but I would guess that in most if not all cases, clinical breast exams would be more comfortable than mammograms.

So an obvious question would be “Are clinical breast exams effective by themselves in reducing deaths from breast cancer?” Unfortunately, the research on this question does not provide strong evidence one way or the other, so we just don’t know. Similarly, we do not know one way or the other if breast self exams by women are effective in reducing deaths from breast cancer.

Another possible screening test for breast cancer is magnetic resonance imaging, or MRI. The MRI is more comfortable than a mammogram because the breast is not sandwiched in between two plates, but it is also more expensive (about 20 times more) and produces more tests that are positive when there is no cancer present (false positives) than mammograms do. MRI’s are therefore not recommended routinely for screening, although some recommend them in addition to mammograms as being worth the cost in women at very high risk.

In summary, mammograms, while uncomfortable for many and very uncomfortable for some, are still the best way to screen for breast cancer. If they are very uncomfortable for you, you will just need to decide if they are worth the decreased risk of this potentially deadly disease.

One final note that may be good news is that getting mammograms done every two years seems to be as effective as doing them every year in most women.