Concern is not based on evidence

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.