Pap Smear, Pelvic Exam, Breast Exam

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[edit] Pap Smear, Pelvic Exam, Breast Exam

Knowing the facts about growth behavior regarding cancer of the cervix helps in being proactive about cancer screening with the yearly Pap smear. This test was introduced on a larger scale in the 1950's and 1960's. It consists of two parts: a Pap smear and a bimanual pelvic exam. With breast cancer being so frequent physicians have added a third part, namely a breast exam, to rule out early breast cancer. This is good cancer prevention.

The Pap test (or Pap smear) is done in the "lithotomy position"where the woman lies on her back and has her legs supported in stir-ups. The cervix is visualized by the physician by entering a metal or plastic "speculum" into the vagina.

The speculum consists of two elongated blades that are spread apart so that the vaginal walls are held apart thus enabling the physician to inspect the surface of the cervix. The physician will then touch the surface of the cervix with a slim wooden spatula and gently remove some of the surface cells of the cervix and smear them onto a small rectangular glass slide. Another sample of cells is then taken with a cotton swab from the cervical canal in order to screen for a hidden cancer that might hide inside the cervix. Another smear is made of that either on the same slide, if it is divided, or else on a second glass slide. The two smears are sent to the clinical pathology lab for analysis. It might take several weeks before the results come back (unless it is rushed in highly suspicious cases).

Here is the terminology that has been used and the one that should be used:

Classification of Pap smear
Original Pap smear:	WHO system:
(terms used in the past)	(terms that should be used)
class I	normal
class II	atypical
class III	mild dysplasia
	moderate dysplasia
	severe dysplasia
class IV	carcinoma in situ
class V	invasive carcinoma

In the past there was another popular classification system used in the U.S., the Bethesda system. However, the terminology was misleading in view of the world wide accepted World Health Organization system depicted here as the same term suddenly meant a class III cancer in the old Pap terminology. On the other hand, there was not enough differentiation among the critical class III Pap group, which simply was either called "low grade" or"high grade". Some physicians still use the old Pap terminology, but add in class lII the remark: "with mild dysplasia" etc.

The second part of the Pap test is, as I indicated above, a bimanual examination. With the patient still in the lithotomy position the physician will ask the woman to relax her pelvic and abdominal muscles while he/she examines with two fingers of the one gloved hand through the vagina and at the same time with the other hand through the abdomen. The objective of this bimanual examination is to determine the size and consistency of the cervix, the uterus and both ovaries in rapid succession. The physician will also attempt to feel pelvic lymph glands in the case of established cancer. Gynecologists also always do a rectal examination at the end. This should be done to rule out any cancer in this region or to detect any cancerous pelvic lymph glands or an abnormal uterus that is bent backwards towards the rectum. Not many general practitioners tend to do the rectal examination as it can be uncomfortable for the woman.

The bimanual pelvic examination done on at least a yearly basis is the only prevention for ovarian cancer. Expressed more pointedly, it may be the only step between prevention and death for a woman who develops ovarian cancer (see chapter on Ovarian cancer). If a lump of the ovary is detected by the Pap test (part 2, bimanual exam), the physician can refer her to a gynecologist and the ovary can be removed. This woman in all likelihood will live (95% 5-year survival for stage I cancer of the ovary). If it is deferred and the cancerous lump in the ovary sheds cancer cells into the abdominal cavity, the window of opportunity to save a life will have been lost (only 10% to 30% live for 5-years).

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References:

1. Cancer: Principles &Practice of Oncology.4th edition. Edited by Vincent T. DeVita, Jr. et al. Lippincott, Philadelphia,PA, 1993. Chapter on gynecological tumors.
2. Cancer: Principles&Practice of Oncology. 5th edition, volume 1. Edited by Vincent T. DeVita, Jr. et al. Lippincott-Raven Publ., Philadelphia,PA, 1997. Chapter on gynecological tumors.

3. WG Quint et al. J Pathol 2001 May;194(1):51-58.

4. A Duenas-Gonzalez et al. Am J Clin Oncol 2001 Apr;24(2):201-203.

5. BD Kavanagh et al. Am J Clin Oncol 2001 Apr;24(2):113-119.

6. K Nakanishi et al. Skeletal Radiol 2001 Mar;30(3):132-137.

7. M Follen et al. Cancer 2001 May 1;91(9):1758-1776.