Go Schmear Yourself
Self-Collected HPV Tests Get FDA Approval
There’s a lot to celebrate in our house this month. One kid has just gone to the senior prom, walked through the halls of her elementary school in her cap and gown, and had a party with a handful of friends from pre-school who all still know each other. Tonight, she graduates from high school, and in less than two months (as she mercilessly reminds us), she’s off to college.
As for the other kid, yesterday was the 8th grade dinner dance, and tomorrow she officially bids farewell to middle school. When we dropped her off on the first day of 6th grade, I looked at my husband and said, “She’s going to be okay, right?” He answered, “It’s middle school, a thousand heartbreaks await her.” His calculations were off by an order of magnitude, but she made it through, and I have faith that high school is going to be better. Feel free to question our parenting, but we’re getting her a cake that says, “f**k off, middle school” for after graduation.
There are other things to celebrate even as the world’s dumpster fire continues. A local issue involving the principal of our high school has been settled. We may even get him back by graduation. And while it might not change the election results one iota, I’m still celebrating Trump’s 34-count felony conviction if only because I know it’s making him miserable.
I’m not, however, celebrating the Supreme Court’s mifepristone decision from last week. The court did the bare minimum by ruling that the doctors who brought the case did not have standing. As you’ll read below, however, some experts think Brett Kavanaugh used the unanimous opinion of the court to set up future anti-abortion victories.
Okay, I’m not not celebrating. The court could have decided to roll back Biden Administration rules, which would have made it harder to get mifepristone even in states where abortion is still legal. That could still be coming, but it didn’t happen yet. So, yes, this decision deserves a collective sigh of relief, but it does not warrant a cake (other than possibly one that says, “Keep f**king off Brett).
Mifepristone Stays, For Now
The case in question was brought by the Alliance for Hippocratic Medicine, a loose affiliation of anti-abortion doctors who sued the FDA over mifepristone because someday maybe they might have to treat a patient who had taken the medication to induce an abortion and was suffering from complications.
Had they not chosen Judge Matthew Kacsmaryk (and I say chosen because bizarre administrative procedures in Texas essentially guarantee conservative groups will come in front of their buddy Matt if they file in the right place), the case may well have been thrown out for lack of standing in early stages. The Supreme Court has ruled in the past that plaintiffs in federal lawsuits must show they’ve been injured by a law or that injury is imminent. It is not enough for such injury to be “conjectural” or “hypothetical.”
These docs never claimed to have already been injured by the FDA’s approval of mifepristone that they sought to overturn, and it was a stretch to argue such injury was imminent because mifepristone has been around for 20+ years and has been shown to be uncommonly safe (safer than Tylenol or Viagra). Moreover, the docs were covered by federal conscience clauses that allow them to take a pass on any case that conflicts with their personal morals.
But Kacsmaryk was put on the bench precisely because he would ignore the easy outs and send conservative decisions up the federal pipeline. Despite being equally nutty-pants, the Fifth Circuit overturned some of the extra-crazy parts of Kacsmaryk decision (like saying the original FDA approval should be thrown out two decades later). However, it also did not dismiss the case on standing. So, SCOTUS had to.
Writing for the majority, Justice Brett Kavanaugh said, “… citizens and doctors do not have standing to sue simply because others are allowed to engage in certain activities.” His decision explained that there was no rule of “doctor standing” and said the court refused “to create such a novel rule out of whole cloth.” Kavanaugh then offered a number of examples of why this would be a problem that had nothing to do with abortion such as a doctor suing the EPA for relaxing air pollution rules because he had to treat more asthma patients.
The reasoning is sound (impressive for Brett), but I bring it up mostly to point out that the decision in this case has very little to do with abortion and headlines suggesting the court “ruled in favor of abortion” were greatly exaggerated.
This decision temporarily protects the rules around mifepristone and means that the medication can still be accessed through the mail and can be prescribed through 10 weeks of pregnancy. This is great for now, but the case isn’t entirely dead. Kacsmaryk granted Idaho, Oklahoma, and Missouri permission to intervene in the case, and we all know that states have standing in cases about abortion rules because they have to “protect” their women. This case could end up back in front of Kacsmaryk, or we could get another one. You can bet that conservative groups are currently shopping around for a better plaintiff if they have start over.
Again, nothing about this decision should be considered a victory for abortion rights on their merits. The court decision, for example, didn’t touch on the Kacsmaryk’s Comstock reasoning which could become the basis for a national abortion ban or bans on contraceptive. If anything, the decision Brett wrote proves the court’s anti-abortion leaning. Instead of focusing the lack of standing discussion on how unlikely it is that these doctors would ever have to treat a patient harmed by mifepristone, Kavanagh focused on the federal conscience clause that already protect providers. As Dahlia Lhitwick and Mark Joseph Stern explain in Slate:
It’s a clever move: In this so-called victory for medication abortion, Kavanaugh slipped in a wildly expansive reading of the conscience clause that was, up until now, very much in dispute. He turned this case into an opportunity to expand conscience protections for anti-abortion providers.
This doesn’t bode well for the other abortion decision of the season which focuses on the Biden Administration’s interpretation of the Emergency Medical Treatment and Labor Act.
Because last week’s decision was unanimous, I have this funny image of John Roberts gathering all of the conservatives in his office for a stern lecture: “Our credibility is shot guys, they think we’re partisan hacks. This is a gimme. Don’t f**k it up.”
They didn’t, but they certainly set the stage for f**king up the next one.
This Year, You Can Give Yourself a Pap Smear
The FDA recently approved HPV testing using self-collected samples. These tests must still be done in a health care provider’s office and sent to a lab for analysis, but those of us with cervixes may now be able to control the giant q-tip ourselves. While this isn’t a home test, experts hope it will help increase screening rates. (To be fair, this also isn’t a Pap smear, and we don’t even do Pap smears anymore, but the headline was too fun to pass up.)
Cervical cancer screening is a real public health success story. The Pap smear was named after Dr. Georgios Papanikolao who invented it in 1928. It began being used widely in 1941 when research proved it effective in detecting precancerous changes to the cervix. Because cervical cancer grows slowly, early detection allows health care providers to treat abnormal cells and prevent them from ever becoming cancer. Widespread uptake of the Pap smear helped bring down cervical cancer rates around the world. In the US, both the incidence of cervical cancer and deaths from it dropped over 50% between 1975 and 2017.
Of course, screening has evolved in that time period. Scientists developed better procedures for collection and analysis. We stopped calling it a Pap smear, for example, when a new test meant providers no longer had to smear cells onto a glass slide. (Smear, especially when said the Yiddish way—schmear—is practically onomatopoetic.) Instead, the cells are placed in a vial of solution. While Dr. P. still gets credit, we call this version a Pap test or just a Pap.
Screening also evolved because we continued to grow our understanding of the connection to HPV which is estimated to cause 90% of cervical cancer. There are hundreds of types of HPV, and we now know that two of them—16 and 18—cause most cervical cancer. In 2003, a screening test was developed that looked for the genetic material of high-risk types of HPV. A few years later, we got a genotyping test that was able to look specifically for types 16 and 18. (We also invented a vaccine that prevents nine high risk types of HPV.)
These improvements have been amazing, though they have complicated the screening recommendations which used to be as simple as “get a Pap smear every year.” (It even rhymed.) The CDC’s recommendations of which test(s) to get and how often to get them are now based on age and prior test results, and one needs a detailed flow chart to fully comprehend them. The gist of it is that people under 30 should get a Pap test every three years, and people over 30 should get either a Pap test or an HPV test or both every three to five years. If any of these tests come back with abnormal results, however, you will probably be told to screen more often. After 65, you might not need to screen at all, or you might depending on your history. As I said, a little confusing, so ask your health care provider what tests they’ve done and which ones they recommend going forward.
Both Pap tests and HPV tests are usually done as part of a pelvic exam, and providers often use a speculum (which simultaneously looks like a duck bill and a medieval instrument of torture) to hold the vagina open while they collect the cells. The new self-collection tests mean some people can avoid this part. These HPV tests have to be ordered by a provider who gives instruction, sends the sample to the lab, and receives the results, but no examination is required. A person can simply be given the kit and a private space to swab their own cervix. (Come on, how many times have you stuck a q-tip up your nose to check for Covid? You can stick one up your vadge to check for cancer once every few years.)
This opens up more possibilities for cervical cancer screening. People will now be able to get screened at their primary care provider’s office, an urgent care clinic, a mobile clinic, or even in some pharmacies. This could be particularly helpful for people who don’t have access to a gynecologist, or those who don’t feel comfortable with vaginal exams.
The FDA approval of self-collection is based on years of research that found the results are as accurate as those from physician-collected samples. Some experts are hoping that this is the just the first step and that a screening test you can do entirely at home is coming soon. Others are worried that home tests will mean people stop going to their gynecologists on a regular basis and lose out on other sexual health screening, but that’s a debate for another day.
I have to admit that Pap tests and pelvic exams never really bothered me. I’ve joked many times that I’d volunteer to have one weekly if I never had to go to the dentist. Unfortunately, I doubt we’re going to get self-directed dental checkups anytime soon.