Dont discount doing a pap smear

A patient said to me last week “I do believe you saved my life for the second time Dr. Tuakli” And I thought Wow! You know what, she is right. People thank me for saving their lives from time to time and not to sound cavalier but I often think that it is nice to hear but I was just doing my job. Any qualified physician could have been credited with doing the same thing. But this time was different and very stark. This 50 something year old lady has been in my practice for perhaps 3 or 4 years. She has a variety of medical issues that we have been working on and from time to time I would suggest she have a pap. She had told me previously that she had been told that she didn’t need one because she had had a hysterectomy. Interestingly enough whenever I probed further she never seemed sure about exactly what had been done. Was the uterus completely gone including the cervix? How about the ovaries? Why was the surgery done in the first place? It never ceases to amaze me how many times I ask those questions and the answer is “I don’t know”, particularly in over 40 year old women. I eventually convinced her that it would be a good idea to just do a routine check up even though she had no symptoms and so I did a pap. As soon as I started her pap I knew from the look of the lesion in her vagina that it was cancerous. Putting cells on a slide and sending it to the lab quite frankly was a formality and I had her schedule an appointment with a gynecology oncologist pending the results. She told me when she came in last week that the specialist walked into the room and the first thing he said to her was “What is a women your age doing still getting pap smears?!” (I wont be referring any more patients to him). The arrogance dissolved when he saw the cytology report and the patient has since had the appropriate surgery. So why do I tell this cautionary tale? Well, for one thing, the current guidelines imply that she did not need a pap smear, simply based on her age. Secondly, I think that many women are walking around thinking that because they have had a hysterectomy they are immune to genital cancers. Thirdly, standard recommendations are just that, written for the common good but not by someone who knows you. Do not take them as gospel. You could argue that this is the exception to the rule and that is probably true but it also means that someone’s mother and sister will still be alive 3 years from now and she also managed to avoid the trauma of cancer therapy that would have resulted had she found it later. In medicine it is not always easy to argue with “official recommendations” and specialists who don’t know the patients. I believe that I taught myself something with this case, not everything has to be rational, and care must be individualized regardless. I am a strong believer in learning from past experience even if its not written anywhere. I derive no satisfaction from my patient being diagnosed with cancer but I am sure glad I followed my gut. When in doubt get a pap, it sure beats the alternative!