Doctors in U.S. Overuse Pap Smears

Release Date: March 20, 2012 | By Milly Dawson, Contributing Writer
Research Source: The Milbank Quarterly


  • In the U.S., women received three to four times the number of Pap smears over a period of three decades as women in the Netherlands, yet the two countries’ cervical cancer mortality rates were similar.
  • The Netherlands follows a model of screening based on governmental guidelines; the U.S. has traditionally followed a model based on decisions by individual physicians, insurance plans and guidelines from medical organizations.
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A new study finds U.S. physicians are performing Pap smears far more often than needed to prevent cervical cancer. The study, published in The Milbank Quarterly, examines Pap smear usage alongside cervical cancer mortality data in the U.S. and the Netherlands between 1970 and 2007. While American doctors performed about three or four times as many Pap smears as Dutch doctors did, the rates at which women developed or died from cervical cancer were roughly equal for the two nations.

“This strongly suggests that the Dutch approach to cervical cancer screening is much more efficient than the U.S. approach. We did detect some potential shortcomings in the Dutch approach, but the evidence suggests that the U.S. could move substantially in the direction of the Dutch program, at considerable economic savings, without sacrificing health benefits,” said co-author Martin L. Brown, Ph.D., of the National Cancer Institute.

The Netherlands has long treated cancer screening as a national public health endeavor carried out by doctors who generally follow National Ministry of Health guidelines, the study reports. Meanwhile, the U.S. follows a medical model: individual doctors choose who to screen and how often. U.S. doctors select from or ignore guidelines from various organizations and from the government’s U.S. Public Health Service.

Overall, in the Netherlands, cancer screenings adhere to the most recent evidence. There, a woman generally undergoes a lifetime total of 7 Pap smears between ages 30 and 60. Doctors typically screen patients every five years, depending on their age and risk level.

“In the U.S., actual medical practice lags behind and diverges strongly from evidence-based guidelines,” says Brown. Screening guidelines U.S. doctors adopt from highly influential medical societies vary widely, calling for anywhere from 20 to 33 Pap smears. Screenings often take place annually, without regard for a woman’s age or risk.

While the study discussed only cervical cancer evidence, the authors did note that its themes might apply to differences in screening for many preventable diseases.

Darcy Phelan, DrPH with the Johns Hopkins Bloomberg School of Public Health, hopes that policy makers will consider these findings as they address ways of preventing cervical cancer that are more efficient. “These findings suggest that broad adoption of a policy to extend the Pap screening interval will protect patient safety while reducing costs. This will be especially important as prevention costs escalate in the context of human papillomavirus (HPV) vaccination among girls and young women.” Both experts noted that the U.S. Preventive Services Task Force included extension of the interval in its recently updated cervical cancer screening guidelines.

Phelan added that the study confirms the importance of screening all women, as most cervical cancers occur among those never screened or not screened within the recommended interval. Screening all women has great potential to reduce persistent racial and ethnic disparities in cervical cancer in the U.S., she says.

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For More Information:

Reach the Health Behavior News Service, part of the Center for Advancing Health, at or (202) 387-2829.

The Milbank Quarterly: Heidi Bresnahan, director of publications, at (212) 355-8400 or

Habbema, D., de Kok, I.M.C.M., Brown, M.L., (2012). Cervical Cancer Screening in the United States and the Netherlands: A Tale of Two Countries. The Milbank Quarterly, 90: 5-37.

Tags for this article:
Reproductive Health/Contraception   Disease Screening   Women's Health  

Comments on this article
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Elizabeth (Aust) says
August 26, 2012 at 6:07 AM

I think pap tests have been used by doctors in the States and Australia to create a vast and hugely profitable industry in the over-treatment of CIN...a rare cancer has been turned into a major problem with most women now having some "treatment" on the cervix, almost all is unnecessary, due to false positives, made worse by serious over-screening. An American woman in her 60s is likely to have had an absurd 40 or more pap tests and this may go on until she's in advanced old age, an Australian woman over 25 and two yearly testing will continue until she's 70...this should amount to medical misconduct...reckless screening that risks the health of your patients.
The Finns and Dutch are the ones to watch here, both have evidence based programs that put what's best for women first. The Dutch will shortly replace their 7 pap test program, 5 yearly from 30 to 60, with 5 hrHPV primary triage tests offered at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are positive and at risk will be offered a 5 yearly pap test. Most women are HPV negative, not at risk and cannot benefit from pap testing...they will be offered the HPV primary testing program. Those HPV negative and confidently monogamous or no longer sexually active can forget all further testing. This will save more lives, save money and spare huge numbers of not-at-risk women from a lifetime of pointless pap testing and the risk of over-treatment. (which also means fewer women with damage to the cervix and fewer premature babies, c-sections, miscarriages etc)
Countries like Australia and the States are unlikely to ever offer evidence based programs, harmful and expensive excess
is firmly in place...very little real information is released to women so few women can make an informed decision about testing and protect themselves from excess. There is no respect for informed consent for women or for their bodily privacy. Men are not treated in this way, it seems paternalistic attitudes still control women's healthcare in some countries. The Dutch are also using a reliable HPV self test option, the Delphi Screener, also being used in Singapore, Italy and elsewhere. Self-test options are rarely offered in countries that practice excess, the first priority is protecting the excessive women are provided with no other option, just over-screening with population pap testing.
The States pile up tests, more harmful excess...they do pap tests AND HPV tests on all women over 30, this wastes money, is unhelpful and leads to confusion and over-investigation. The HPV test should stand alone, it gives women important info...positive and you may benefit from a pap test, negative and you're not at risk.
Hopefully, more women will become informed and demand something that is in their best interest. As a low risk woman, I rejected pap testing thirty years risk of cc is near zero, the risks were too high for me. So much avoidable damage with screening in ethical and responsible hands.