LetterLetter

Concern is not based on evidence

Ainsley Moore
Canadian Family Physician September 2016; 62 (9) 712-713;

The Canadian Task Force on Preventive Health Care strongly recommends against routine pelvic examination screening among asymptomatic women for noncervical cancer, pelvic inflammatory disease, or other gynecologic conditions.1 These recommendations are based on moderate-quality evidence that there is no benefit to women from pelvic screening examinations.2 Indeed, the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial involving 78 000 women included pelvic screening for the first 5 years, and dropped the screening when no cancers were identified as a result of this intervention.3 However, there was evidence of harm in other studies, which reported that 1.5% of women received unnecessary surgery (open or laparoscopic) as a result of routine screening pelvic examinations,4 and more than one-third of women report fear, embarrassment, anxiety, pain, or discomfort associated with the pelvic examination.5–19

Dr Ladouceur laments the possibility that family physicians and residents who follow this recommendation will lose their pelvic examination skills.20 He further speculates that this loss of skill will reduce compliance with cervical cancer screening in Canada, ultimately affecting women’s health.

For any busy family physician in an academic or community setting, the need for appropriate pelvic examinations and opportunities for teaching are abundant. As the Canadian Task Force on Preventive Health Care report specifies, pelvic examination is appropriate in other clinical situations, such as diagnosing gynecologic conditions when women present with symptoms or for follow-up of a previously diagnosed condition.1

Concern that these recommendations would lead to declining skills and therefore poor uptake of cervical cancer screening is not based on evidence and seems tenuous at best. Studies on the topic have found that barriers to cervical cancer screening in Canada are related to ethnocultural, language, and socioeconomic factors among indigenous and immigrant women, as well as preference for female health care providers, rather than provider skill.21

Dr Ladouceur appeals for a return to artful care, in which evidence does not interfere with clinical judgment. I remind Dr Ladouceur that evidence-based care occurs at the intersecting triad of clinician judgment, best available evidence, and patient values and preferences, all of which underlie the shared decision-making paradigm.22 In mourning the loss of a pointless and potentially harmful routine examination, despite clear values and preferences expressed by women and evidence that it would harm but not benefit women, Dr Ladouceur is not making the case for clinical judgment versus evidence. Rather he has made a case for his personal judgment, which does not appear to be shared by patients or by guideline panels in Canada and the United States.

Footnotes

  • Competing interests

    None declared

References

  1. 1.↵
    1. Tonelli M,
    2. Connor Gorber S,
    3. Moore A,
    4. Thombs BD,
    5. Canadian Task Force on Preventive Health Care
    . Recommendations on routine screening pelvic examination. Canadian Task Force on Preventive Health Care adoption of the American College of Physicians guideline. Can Fam Physician 2016;62:211-4. (Eng), e117–21 (Fr).
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Qaseem A,
    2. Humphrey LL,
    3. Harris R,
    4. Starkey M,
    5. Denberg TD,
    6. Clinical Guidelines Committee of the American College of Physicians
    . Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014;161(1):67-72.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Buys SS,
    2. Partridge E,
    3. Black A,
    4. Johnson CC,
    5. Lamerato L,
    6. Isaacs C,
    7. et al
    . Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening randomized controlled trial. JAMA 2011;305(22):2295-303.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Adonakis GL,
    2. Paraskevaidis E,
    3. Tsiga S,
    4. Seferiadis K,
    5. Lolis DE
    . A combined approach for the early detection of ovarian cancer in asymptomatic women. Eur J Obstet Gynecol Reprod Biol 1996;65(2):221-5.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Golomb D
    . Attitudes toward pelvic examinations in two primary care settings. R I Med J 1983;66(7):281-4.
    OpenUrlPubMed
  6. 6.
    1. Harper C,
    2. Balistreri E,
    3. Boggess J,
    4. Leon K,
    5. Darney P
    . Provision of hormonal contraceptives without a mandatory pelvic examination: the first stop demonstration project. Fam Plann Perspect 2001;33(1):13-8.
    OpenUrlCrossRefPubMed
  7. 7.
    1. Bourne PA,
    2. Charles CA,
    3. Francis CG,
    4. South-Bourne N,
    5. Peters R
    . Perception, attitude and practices of women towards pelvic examination and Pap smear in Jamaica. N Am J Med Sci 2010;2(10):478-86.
    OpenUrlPubMed
  8. 8.
    1. Hesselius I,
    2. Lisper HO,
    3. Nordström A,
    4. Anshelm-Olson B,
    5. Odlund B
    . Comparison between participants and non-participants at a gynaecological mass screening. Scand J Soc Med 1975;3(3):129-38.
    OpenUrlPubMed
  9. 9.
    1. Wijma B,
    2. Gullberg M,
    3. Kjessler B
    . Attitudes towards pelvic examination in a random sample of Swedish women. Acta Obstet Gynecol Scand 1998;77(4):422-8.
    OpenUrlPubMed
  10. 10.
    1. Armstrong L,
    2. Zabel E,
    3. Beydoun HA
    . Evaluation of the usefulness of the “hormones with optional pelvic exam” programme offered at a family planning clinic. Eur J Contracept Reprod Health Care 2012;17(4):307-13. Epub 2012 Apr 23.
    OpenUrlPubMed
  11. 11.
    1. Osofsky HJ
    . Women’s reactions to pelvic examination. Obstet Gynecol 1967;30(1):146-51.
    OpenUrlPubMed
  12. 12.
    1. Hoyo C,
    2. Yarnall KS,
    3. Skinner CS,
    4. Moorman PG,
    5. Sellers D,
    6. Reid L
    . Pain predicts non-adherence to Pap smear screening among middle-aged African American women. Prev Med 2005;41(2):439-45.
    OpenUrlCrossRefPubMed
  13. 13.
    1. Taylor VM,
    2. Yasui Y,
    3. Burke N,
    4. Nguyen T,
    5. Acorda E,
    6. Thai H,
    7. et al
    . Pap testing adherence among Vietnamese American women. Cancer Epidemiol Biomarkers Prev 2004;13(4):613-9.
    OpenUrlAbstract/FREE Full Text
  14. 14.
    1. Fiddes P,
    2. Scott A,
    3. Fletcher J,
    4. Glasier A
    . Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception 2003;67(4):313-7.
    OpenUrlPubMed
  15. 15.
    1. Yu CK,
    2. Rymer J
    . Women’s attitudes to and awareness of smear testing and cervical cancer. Br J Fam Plann 1998;23(4):127-33.
    OpenUrlPubMed
  16. 16.
    1. Broadmore J,
    2. Carr-Gregg M,
    3. Hutton JD
    . Vaginal examinations: women’s experiences and preferences. N Z Med J 1986;99(794):8-10.
    OpenUrlPubMed
  17. 17.
    1. Haar E,
    2. Halitsky V,
    3. Stricker G
    . Patients’ attitudes toward gynecologic examination and to gynecologists. Med Care 1977;15(9):787-95.
    OpenUrlPubMed
  18. 18.
    1. Petravage JB,
    2. Reynolds LJ,
    3. Gardner HJ,
    4. Reading JC
    . Attitudes of women toward the gynecologic examination. J Fam Pract 1979;9(6):1039-45.
    OpenUrlPubMed
  19. 19.↵
    1. Kahn JA,
    2. Goodman E,
    3. Huang B,
    4. Slap GB,
    5. Emans SJ
    . Predictors of Papanicolaou smear return in a hospital-based adolescent and young adult clinic. Obstet Gynecol 2003;101(3):490-9.
    OpenUrlCrossRefPubMed
  20. 20.↵
    1. Ladouceur R
    . Recommendations for the routine screening pelvic examination. Could they have a negative effect on physician competence? Can Fam Physician 2016;62:460. (Eng), 461 (Fr).
    OpenUrlFREE Full Text
  21. 21.↵
    1. Redwood-Campbell L,
    2. Fowler N,
    3. Laryea S,
    4. Howard M,
    5. Kaczorowski J
    . “Before you teach me, I cannot know”: immigrant women’s barriers and enablers with regard to cervical cancer screening among different ethnolinguistic groups in Canada. Can J Public Health 2011;102(3):230-4.
    OpenUrlPubMed
  22. 22.↵
    1. Sackett DL,
    2. Rosenberg WM,
    3. Gray JA,
    4. Haynes RB,
    5. Richardson WS
    . Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(7023):71-2.
    OpenUrlFREE Full Text
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Concern is not based on evidence
Ainsley Moore
Canadian Family Physician Sep 2016, 62 (9) 712-713;
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