Ask the Flight Surgeon / By MAJ Abigail K. Vargo, MD: Q: I’ve had an “abnormal, but not concerning” Pap result in the past and I just turned RED for cervical cancer screening in MEDPROS. I am worried that this is going to ground me. What does this test result mean?
FS: Before I give some guidance on how to interpret such results and the possible impact on flight status, let me take a moment to explain why screening tests like the Pap are performed.
The US Preventive Services Task Force (USPSTF) makes evidence-based recommendations concerning clinical preventive health services such as tests that screen for diseases. This well-respected, independent, volunteer panel is composed of national experts in disease prevention who seek to improve the health of the Nation through the rigorous review of the medical literature. When it comes to screenings, such as for Pap smears and HPV testing for cervical cancer screening, the goal is the early detection of disease, even before you notice the symptoms. In general, the earlier a condition is caught, the easier it is to treat. The process that the USPSTF uses to make recommendations also considers possible harms that screening might cause. The USPSTF weighs the benefits and against the harms to determine the best population of people to screen, how often to perform the screenings and how to interpret the results.
Cervical cancer screening has been shown to save lives. The screening identifies people with early and pre-stages of the disease, when it is most treatable, and reduces both the number of cervical cancer diagnoses and related deaths. However, there are potential negatives that can result from the follow-on testing that is indicated for a positive result. These potential negatives include cervical bleeding, pain, infection, and pregnancy complications. However, the recognized potential life-saving benefits outweigh the low frequency of possible harms. Regular screening for cervical cancer was given a Grade A (i.e., the highest) recommendation by the USPSTF for females ages 21-65 years old. Note that some women, as in those who have had a hysterectomy, may not have a cervix and do not need to be screened for cervical cancer. I support the Army’s screening requirements as it is an important aspect of taking care of female soldiers. In my opinion, making it a MEDPROS (the database that tracks individual and unit medical readiness) requirement is a great way to get the command team to reinforce the need for this screening.
Now, what leads to an “abnormal” test result? The most common cause of cervical cancer is an infection with one, or more, of several types of the Human Papilloma Virus (HPV). This viral infection does not cause pain or itching or discharge, but rather causes changes at the cellular level. Infected cells look different than normal cells, which is what the pathologists look for and report as Pap test results. Abnormal results describe the degree of changes in the cell appearance. Changes can range from mildly abnormal cells that will likely resolve and not progress to anything worse, to seriously abnormal cells concerning for an association with, or presence of, precancer or cancer.
Recommendations for follow-up testing for an abnormal result depend on: the age of the patient, the pathologist’s description of the cellular changes, and the patient’s previous test results. Some follow-up testing involves repeating the Pap test and/or “co-testing” (Pap test plus a test for high-risk types of HPV). More invasive follow-up testing is known as colposcopy – direct visualization of the cervix, a sample of tissue may be selected and sent to a pathologist for examination.
If abnormal cells are identified in samples taken during colposcopy, abnormal cells are either removed with an excisional procedure (LEEP or conization) or an ablative treatment (cryo- or laser therapy).
In AR 40-501, Standards of Medical Fitness, moderate or severe cell changes may limit deployability location and/or duration, to ensure adequate follow-up evaluation for further testing or treatment. The Army’s Aeromedical Policy Letters (APLs) state that in the Army flight community, those with abnormal test results that are serious enough to require follow-up testing will be given a down slip, but only until satisfactorily treated. If a diagnosis of cervical cancer is determined, the process of returning to flight status can get more complicated, depending on the stage and spread of the disease and what treatments are required. Treatment must be completed, and a disease-free state achieved, prior to application for a waiver. In your case, the “abnormal, but not concerning” result may trigger the need for a repeat Pap test in six months (with no down-slip during this time period) or further testing for HPV as directed by your aeromedical provider.
If you have further questions, don’t hesitate to talk with your flight surgeon or gynecologist.
Fly Safe! Dr. Vargo
MAJ (Dr.) Abigail K. Vargo is a flight surgeon at the U.S. Army School of Aviation Medicine, Fort Rucker, AL.