Skepchick Quickies 2.28


Amanda works in healthcare, is a loudmouthed feminist, and proud supporter of the Oxford comma.

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  1. Current American Cancer Society Guidelines:
    • Screening for cervical cancer should begin at age 21
    years. Women aged 21 to 29 years should receive cytology
    screening (with either conventional cervical cytology
    smears or liquid-based cytology) every 3 years.
    HPV testing should not be used for women in this age
    group. Women aged younger than 21 years should not
    be screened, regardless of their age of sexual initiation.
    • For women aged 30 to 65 years, the preferred approach
    is to be screened every 5 years with the combination of
    HPV testing and cytology (‘‘cotesting’’). It is also
    acceptable for women to continue to be screened every
    3 years with cytology alone.
    • Women should discontinue screening after age 65 years
    if they have had 3 consecutive negative cytology tests or
    2 consecutive negative cotest results within the 10-year
    period prior to ceasing screening, with the most recent
    test occurring within the last 5 years.
    • Women at any age should NOT be screened annually
    by any screening method.

    Cancer Screening in the United States, 2013
    A Review of Current American Cancer Society Guidelines, Current
    Issues in Cancer Screening, and New Guidance on Cervical Cancer
    Screening and Lung Cancer Screening

    Based on this, isn’t the Ontario Ministry of Health following evidence based guidelines?

    1. This wasn’t about the occurance of pap smears, but rather the COST of them. It used to be covered; now, women need to pay (I think) $20 per screening.

      Is that just like a co-pay and does that include everything, including labs? I only had a chance to browse the article; I’ll read it in full later.

      1. (The title even says “Ontario women pay for annual Pap tests under new rules ” So I’m not sure how you missed that…?)

        1. Marilove, from the article: “The Ontario Health Insurance Program (OHIP) previously covered one Papanicolaou (Pap) stain a year, but in an effort to cut costs the province now only covers the cost of a test once every three years. The change saves the government $1.5 million for 2012/13 and $6.1 million for 2013/14.” This means that women who want pap smears more often than indicated by the guidelines can have them, but will have to pay a fee. This is what ragdish presumably means, and it seems a reasonable policy position for the government in this case.

          1. OH! I misunderstood a few things, it appears! I was just about to read it in full now that I’m not on my cell phone. I was clearly confused, haha. Thanks, Dan! Now Radish’s comment makes more sense. :D

        2. And no, it only includes labs. Physicians may also charge a fee since the government would not be reimbursing them either.

          1. And I wonder if it includes exceptions for women who have to get yearly exams? Most women don’t, but some do.

          2. @Marilove: It’s a bit deeper in the article, but apparently the screening is still free if the woman has abnormal results or a recommendation from a doctor to get a pap smear.

            In short, this is not a case of the government refusing to provide women with needed healthcare. It’s a case of the government refusing to pay for screening above and beyond their recommendations (which have recently changed). You can get a pap smear every week if you want to; you just can’t expect the government to pay for it (unless a doctor says it’s necessary).

          3. Thanks, Infophile. My only question is if the $20 fee will be the ONLY fee. Dan seems to imply that it might/probably won’t be. Is this different from the coverage from before? I don’t live in Canada obviously so I’m not so familiar with this.

            At the same time, ugh, at least it’s covered, right? Pap smears here in Arizona, even at Planned Parenthood, are nuts. PP doesn’t get much in the way of federal funds.

          4. The way the article is written, I can’t honestly say whether or not it’ll cost more. It says: “If women want a Pap test more frequently than every three years, they’ll have to pay for the lab analysis, which costs about $20, Weir said, adding most physicians will likely charge the fee to perform the test.” If I were reading that very literally, I would read “the fee” as referring to the $20 fee (the implication being that some physicians might choose to do it for free), but it could also be a bit awkwardly-phrased and mean that the analysis costs $20, and physicians will also charge a fee for it.

            I’d think it’s the former (just $20), though I can’t be sure. My reasoning for this comes down to how healthcare works in Canada. Unlike in the US, physicians, doctors, pharmaceutical companies, and hospitals aren’t perfectly free to set their own prices. For most healthcare, Health Canada (the government agency) determines what will be covered, and how much they’ll pay for it, and then patients get it for free (this doesn’t apply to prescription drugs or dental care, which are usually covered by benefits plans attached to jobs, somewhat like the US system, but a lot cheaper overall). So what I’m reading here is that $20 is the cost Health Canada has determined is appropriate reimbursement for performing a pap smear (accounting for materials used and labour), and so that’s what patients will have to pay themselves if they choose to have it more often then recommended.

            Aside: One of the big benefits of a single-payer healthcare system is that you can’t be gouged on prices. The government will get the lowest prices it possibly can, and so everyone in the healthcare supply chain is forced to have thin profit margins. In the US, on the other hand, it’s a negotiation between the providers and patients, where patients don’t have the power to refuse, so the providers can and do gouge people for all they’re worth. I’d suspect that if companies in the US all had more reasonable profit margins, the cost of a pap smear would be a ton cheaper (I’m not referring to PP here, who isn’t one of the gougers, but rather the companies that manufacture and supply the medical equipment and materials needed for the tests).

          5. Thanks for the information and Canadian perspective, Infophile! This is what I had come to conclude as well, so I think Dan wasn’t quite correct. But you’re right, it’s not perfectly clear. Still, I think you’re correct.

            It seems fair, to me.

          6. Infophile, you are incorrect in describing the way health care works in Canada. Health Canada does not mandate the costs of procedures at the federal level. Rather each province has its own medicare plan, and these differ from one another in what they cover and to how much they pay for different procedures. Doctors bill the provincial plans directly for covered services, based on negotiated prices that take into account differences in operating costs in different areas (this works in a way similar to Medicare in the US). Doctors who take public money are prohibited from directly charging patients extra fees for covered procedures, but can and do charge patients for procedures not covered by the plan (this is why there is also supplementary private coverage in Canada). There are, however, entirely private clinics that do not take public money and charge patients directly.

            I did originally read “charge the fee” as “charge a fee,” which would have more clearly implied something extra. It is unclear whether the writer of the article intended this, or meant that some doctors would refrain from billing patients despite being unable to bill OHIP (Ontario’s plan) for the cost. My original point came from the assumption that OHIP may decline to cover the doctor’s fee for actually doing the procedure in addition to declining to pay the lab fee, and doctors may pass this fee on to patients. However I do not live in Ontario and I am not sure if that part might be covered under the fee for the visit itself.

  2. OK so if you want the full story from the Aussie POV check this out
    Not that I recommend reading in full, but the relevant section is 6.11
    Cervical cancer is a rare disease incidence 15/100,000
    PAP smear picks up 5000/100,000 abnormalities (ie HPV infection etc.)
    Treatment of these abnormalities causes significant problems for the patient, not only fear and stress but actual physical damage such as haemorrahge or infection in 6% of cases (about 300 out of the 5000)

    So the problem is not only money, but that there is a real downside of treating women who mostly would not progress to cancer anyway..
    Table 6.5 shows the screening frequency used in several Western countries, usually 3-5 years, Australia is 2 years.

    1. I feel like 5 years is way too long! Especially if there are any big changes, both life and hormonal. For me, for example, things were WAY different for me between say, 17 or 18 years old and by the time I was 23. My cycle completely changed in two years. And if you’re not married very young, then you may have more than one partner, and you should be getting pap smears more than every 5 years in that case, for sure.

      I think every 2-3 years is what should be aimed for.

      1. Sure. I guess the point though is, on a population basis, we would be better off putting more resources into things like improving the treatments or into HPV vaccinations rather than increasing the frequency of screening and creating even more false positives.

  3. Yes the new guidelines do recognize that some women would require more frequent screenings and allows for that.

    The thing that struck me about this was how many of my female friends were sharing this story while nobody was sharing the same story from a different (and larger) news source.

    Guidelines recommend less frequent cervical cancer screenings

    It seemed like fear mongering to me and what little research I did seem to support that (including the fact that cervical cancer rates were declining in Ontario over the last decade). But I’m a dude, and while I feel I’m good with women’s issues there are things I can miss. And many of you are also far more scientifically literate than me so I thought I’d see what you folks had to say about this.

    Thanks for the input.

    1. It feels like fear mongering to me, too. These new changes seem perfectly reasonable, as long as there are provisions for extra needed paps, etc. At the same time, considering how freakin’ awful women’s healthcare is treated the world over, I am not really surprised nor do I necessarily blame them. Sometimes it starts to feel as if you’re being attacked from all sides, all because you have a vagina.

  4. Oh and yes the Province is also providing HPV vaccinations to all girls. Hopefully they will do the same for boys before my son reaches that age.

    1. Yeah, I was mostly just reiterating your implied feelings on the matter! :)

      The HPV vaccinations part is fantastic, though, and I agree — hopefully boys are included soon as well.

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