What is the risk of not having a Pap (Papanicolau) smear?

Risks of Not Having a Pap Smear

Not having regular Pap smears significantly increases the risk of developing invasive cervical cancer, as approximately 50% of cervical cancers are diagnosed in women who have never been screened and an additional 10% in women who haven't had a Pap smear in the 5 years before diagnosis. 1

Understanding the Risk

The Pap smear is a highly effective screening tool that has dramatically reduced cervical cancer rates:

• Cervical cancer incidence and mortality have decreased by over 70% in the United States since the introduction of Pap screening 2
• Introduction of screening programs in previously unscreened populations reduces cervical cancer rates by 60-90% within just 3 years 3
• Women who have not been screened by Pap smear have a 2.7 times higher relative risk of invasive cervical cancer compared to those who have been screened 4

Risk Factors for Unscreened Women

Several populations are at particularly high risk when not screened:

• Women attending STD clinics have precursor lesions for cervical cancer about five times more frequently than women attending family planning clinics 3
• Ethnic minorities, particularly Hispanic women and Vietnamese women (who have cervical cancer rates 2.5 times higher than other racial/ethnic groups) 3
• Women with low socioeconomic status, less education, and limited financial resources 3, 5
• Women with risk factors such as:
  • Multiple sexual partners
  • History of HPV or HIV infection
  • History of cervical dysplasia
  • Smoking
  • Immunosuppression 3

Progression of Disease Without Screening

Without regular screening, cervical cancer can progress undetected:

• Early-stage cervical abnormalities are typically asymptomatic and can only be detected through screening
• The progression from precancerous lesions to invasive cancer is generally slow, providing ample opportunity for detection if screened regularly 3
• By the time symptoms appear (abnormal bleeding, pain), the disease has often progressed to more advanced stages that are more difficult to treat

Missed Opportunities for Early Detection

Research shows significant missed opportunities for screening:

• In one study of low-income communities, 73% of unscreened women who developed cervical cancer had received ambulatory medical care in the previous five years 6
• Among women diagnosed with cervical cancer, 56% were unable to report when they last had a Pap smear 1
• Many women who have had a pelvic examination erroneously believe they have had a Pap smear when they actually have not 3

Recommended Screening Schedule

To minimize risk, current guidelines recommend:

• Begin screening at age 21
• Ages 21-29: Cytology alone every 3 years
• Ages 30-65: HPV testing every 5 years (preferred), cotesting (HPV+cytology) every 5 years, or cytology alone every 3 years 2
• Discontinue screening after age 65 only if there have been adequate negative prior screenings (3 consecutive negative cytology tests or 2 consecutive negative cotests within the past 10 years) 2
• Women with risk factors (HIV, immunocompromised, history of cervical cancer or high-grade precancerous lesions) should continue screening beyond age 65 2

Common Barriers to Screening

Understanding why women avoid screening is important:

• Personal factors: fear, embarrassment, anxiety, inadequate knowledge, lack of time, misperception of risk 3
• Cultural factors: provider gender concerns, lack of acculturation, religious beliefs 3
• Systemic factors: lack of insurance, poverty, legal migratory status, geographic isolation, lack of providers 3
• The most frequently reported reason for not having a recent Pap smear is procrastination or not believing it is necessary 5

Key Takeaway

The evidence is clear that regular Pap screening is essential for preventing cervical cancer mortality. Women who remain unscreened face significantly higher risks of developing advanced cervical cancer with worse outcomes. Healthcare providers should emphasize the importance of regular screening according to guidelines and address barriers to ensure all eligible women receive this life-saving preventive service.