Of all medical decisions, those regarding clinician-initiated tests and treatments in asymptomatic individuals require the most thoughtful consideration: as clinicians, we are careful to "do no harm" to healthy people. Population-based preventive interventions fall in this category and include decisions about screening women older than 65 years for cervical cancer. As women age it becomes increasingly important to consider the benefits and harms that can be expected. With advancing age, the balance between benefit and harm continually changes: greater benefits and fewer harms can be expected in younger, healthy, at-risk women who have never been screened; older, infirmed women with prior normal test results and short life expectancies can expect fewer benefits and greater harms. Assessing where individual women reside at any one time on the balance provides the objective foundation of informed decision making regarding screening. Armed with the best quantitative information, clinicians can then incorporate individual women's preferences to craft a screening strategy that is rational, safe, acceptable, and effective.
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George F. Sawaya, MD
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