Is a Pap smear (Papanicolaou test) necessary after a hysterectomy in a patient with a history of endometrial cancer?

From the Guidelines

After a hysterectomy for endometrial cancer, Pap tests are generally not needed if the cervix was removed, but vaginal cytology may be recommended as part of cancer surveillance. The recommendation depends on the type of hysterectomy performed. If a supracervical hysterectomy was performed where the cervix remains, routine Pap testing should continue 1. For women who had a total hysterectomy with removal of the cervix, vaginal cytology (similar to a Pap but sampling the vaginal cuff) may be recommended as part of cancer surveillance, particularly in the first few years after surgery, as stated in the 2018 American Cancer Society guidelines for cancer screening 1. Some key points to consider include:

• The frequency of these follow-up examinations should be determined by the oncologist based on the patient's specific cancer characteristics, stage, and risk of recurrence.
• Vaginal cytology tests look for abnormal cells at the surgical site where the cervix was attached to the vagina, as rare recurrences can occur there.
• The oncologist will include these tests as part of a comprehensive follow-up plan that may also include physical examinations, imaging studies, and blood tests to monitor for any cancer recurrence. It's essential to follow the guidelines and recommendations provided by the American Cancer Society and other reputable organizations, such as those outlined in the 2009 and 2018 guidelines for cancer screening 1. However, the most recent and highest quality study, which is the 2018 American Cancer Society guidelines for cancer screening 1, should be prioritized when making a definitive recommendation. Therefore, Pap tests are not necessary after a total hysterectomy for endometrial cancer, but vaginal cytology may be recommended as part of cancer surveillance.

From the Research

Necessity of Pap Smear after Hysterectomy in Patients with Endometrial Cancer History

• The practice of vaginal smears after total hysterectomy should be discussed according to the indication for hysterectomy 2.
• In the case of endometrial cancer, the practice of vaginal smears can be abandoned, as the interest of vaginal smears drops drastically after the first 5 years of follow-up 2.
• A study found that no recurrent endometrial cancers were diagnosed on the basis of isolated abnormal cytology, and the sensitivity, specificity, and positive and negative predictive values of an abnormal Pap test result in detecting a local recurrence are 40%, 87.9%, 7.3%, and 98.4%, respectively 3.
• Another study suggested that vaginal vault cytology should continue to be performed if high-risk factors, such as history of lower genital tract neoplasia, are present 4.
• The value and cost evaluation of routine follow-up for patients with clinical stage I/II endometrial cancer found that the follow-up based on routine Pap smears and systematic radiography does not permit earlier detection of recurrences 5.

Specific Considerations

• The risk of vaginal recurrence of HPV-induced pathology fully justifies an annual monitoring after hysterectomy for cervical intraepithelial neoplasia (CIN) 2.
• Colposcopy is not needed after a Pap test result read as atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion (LSIL) 3.
• Primary vaginal cancer is uncommon, and after hysterectomy, vaginal vault cytology should continue to be performed if high-risk factors are present 4.

Surveillance and Follow-up

• The follow-up of patients treated for endometrial cancer should simply include a clinical examination whose frequency should be based on prognostic factors 5.
• The interest of vaginal smears drops drastically after the first 5 years of follow-up, and the follow-up is mainly clinical 2.