Challenges in cervical cancer prevention: a survey of U.S. obstetrician-gynecologists

Implementation of WHO guidelines for cervical cancer screening, diagnosis and treatment: knowledge and perceptions of health providers from Argentina

BACKGROUND

The 2021 World Health Organization (WHO) guidelines on cervical cancer screening and treatment provide countries with evidence-based recommendations to accelerate disease elimination. However, evidence shows that health providers' adherence to screening guidelines is low. We conducted a study in Argentina to analyze health providers' knowledge and perceptions regarding the 2021 WHO Guidelines.

METHODS

A qualitative study was conducted based on individual, semi-structured interviews with health providers specializing in gynecology (n = 15). The themes explored were selected and analyzed using domains and constructs of the Consolidated Framework for Implementation Research.

RESULTS

Although health providers perceive WHO as a reliable institution, they do not know the 2021 guidelines, its supporting evidence, and its elaboration process. Their clinical practice is mainly guided by local recommendations developed by national professional medical associations (PMAs). For interviewees, WHO guidelines should be disseminated through health authorities and national PMAs, mainly through in-service training. Health providers had a positive assessment regarding WHO Recommendation 1 (screen, triage, and treatment for women aged 30 + with HPV-testing every 5 to 10 years) and perceived a favorable climate for its implementation. HPV-testing followed by triage was considered a low-complexity practice, enabling a better detection of HPV, a better selection of the patients who will need diagnosis and treatment, and a more efficient use of health system resources. However, they suggested adapting this recommendation by removing screening interval beyond 5 years. WHO Recommendation 2 (screen-and-treat approach with HPV-testing for women aged 30 + every 5 to 10 years) was predominantly rejected by interviewees, was considered an algorithm that did not respond to women's needs, and was not adequate for the Argentinean context. Regarding the HPV-test modality, clinician-collected tests were the preferred mode. Health providers considered that HPV self-collection should be used primarily among socially vulnerable women to increase screening coverage.

CONCLUSION

WHO guidelines should be widely disseminated among health providers, especially in settings that could benefit from a screen-and-treat approach. Identifying areas of partnership and collaboration with PMAs in implementing WHO guidelines is essential.

Using electronic health records to evaluate the adherence to cervical cancer prevention guidelines: A cross-sectional study

OBJECTIVE

The fight against cervical cancer requires effective screening together with optimal and on-time treatment along the care continuum. We examined the impact of cervical cancer testing and treatment guidelines on testing practices, and follow-up adherence to guidelines.

METHODS

Data from Estonian electronic health records and healthcare provision claims for 50,702 women was used. The annual rates of PAP tests, HPV tests and colposcopies during two guideline periods (2nd version 2012-2014 vs 3rd version 2016-2019) were compared. To assess the adherence to guidelines, the subjects were classified as adherent, over- or undertested based on the timing of the appropriate follow-up test.

RESULTS

The number of PAP tests decreased and HPV tests increased during the 3rd guideline period (p < 0.01). During the 3rd guideline period, among 21-29-year-old women, the adherence to guidelines ranged from 38.7% (44.4…50.1) for ASC-US to 73.4% (62.6…84.3) for HSIL and among 30-59-year-old from 49.0% (45.9…52.2) for ASC-US to 65.7% (58.8…72.7) for ASCH. The highest rate of undertested women was for ASC-US (21-29y: 25.7%; 30-59y: 21.9%). The rates of over-tested women remained below 12% for all cervical pathologies observed. There were 55.2% (95% CI 49.7…60.8) of 21-24-year-olds and 57.1% (95% CI 53.6…60.6) of 25-29-year-old women who received HPV test not adherent to guidelines.

CONCLUSIONS

Our findings highlighted some shortcomings in guideline adherence, especially among women under 30. The insights gained from this study help to improve the quality of care and, thus, reduce cervical cancer incidence and mortality.

Factors Associated With Guideline-concordant and Excessive Cervical Cancer Screening: A Mixed Methods Study

INTRODUCTION

National guidelines recommend cervical cancer screening with Papanicolaou (Pap) testing at 3-year intervals or with human papillomavirus (HPV) testing alone or HPV/Pap cotesting at 5-year intervals for average-risk individuals aged 30-65 years.

METHODS

We explored factors associated with clinician-reported guideline-concordant screening, as well as facilitators and barriers to appropriate cervical cancer screening.

RESULTS

A national sample of clinicians (N = 1,251) completed surveys; a subset (n = 55) completed interviews. Most (94%) reported that they screened average-risk patients aged 30-65 years with cotesting. Nearly all clinicians who were categorized as nonadherent to national guidelines were overscreening (98%). Guideline concordant screening was reported by 47% and 82% of those using cotesting and HPV testing, respectively (5-year intervals), and by 62% of those using Pap testing only (3-year intervals). Concordant screening was reported more often by clinicians who were aged <40 years, non-Hispanic, and practicing in the West or Midwest, and less often by obstetrician-gynecologists and private practice physicians. Concordant screening was facilitated by beliefs that updated guidelines were evidence-based and reduced harms, health care system dissemination of guidelines, and electronic medical record prompts. Barriers to concordant screening included using outdated guidelines, relying on personal judgment, concern about missing cancers, inappropriate patient risk assessment, and lack of support for guideline adoption through health care systems or electronic medical records.

CONCLUSIONS

Most clinicians screened with Pap/HPV cotesting and approximately one-half endorsed a 5-year screening interval. Clinician knowledge gaps include understanding the evidence underlying 5-year intervals and appropriate risk assessment to determine which patients should be screened more frequently. Education and tracking systems can promote guideline-concordant screening.

Assessment of knowledge and attitude of cervical cancer among the youths in the Rayalaseema region of Andhra Pradesh - India

BACKGROUND

India suffers a quarter of the global burden of cervical cancer (CC) but is controllable by taking some precautions. The major issue is the low amount of participation among women in screening and vaccination for disease. The objective of the research is to evaluate knowledge, attitude, and practice (KAP) regarding CC among college going students residing in the Rayalaseema region of Andhra Pradesh-India.

MATERIAL AND METHODS

A cross-sectional study was conducted on a total of 380 subjects whose ages ranged from 15 to 25 and older. The questionnaires were circulated through google forms. The socio-demographic variables and KAP levels are represented by descriptive statistics. The Chi-square test is used to determine the relationship between sociodemographic factors and KAP levels.

RESULTS

Among 380 subjects, 172 (54.7%) are aware of CC, 71% have poor knowledge, and 20% have good knowledge about CC. More than three-fourths of women 374 (98.4%) are not having regular practice towards CC.

CONCLUSION

The awareness about CC is very low in the population, so prevention of CC relies on routine screening, proper vaccination, and treatment. Awareness programs and promoting knowledge about cervical health in social media are required.

Human Papillomavirus Vaccination in Pediatric, Adolescent, and Young Adult Cancer Survivors-Opportunity to Address Gaps in Cancer Prevention and Survivorship

The risks of secondary cancers associated with human papillomavirus (HPV) infection are as much as three times higher for survivors of pediatric, adolescent, and young adult cancer (PYAC) compared to the general population. Despite this, HPV vaccination rates among PYAC survivors remain low. Whereas pediatric oncology providers endorse HPV vaccination of PYAC survivors, many lack the resources or opportunities to intervene. The responsibility of HPV vaccination, therefore, falls to primary care providers and practices. This article provides an overview of the challenges with HPV vaccination that are distinct to PYAC survivors and discusses potential strategies to increase HPV vaccine coverage in this population.

A cross-sectional survey examining clinician characteristics, practices, and attitudes associated with adoption of the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines

BACKGROUND

The 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) risk-based management consensus guidelines are the most recent national guidelines for the management of abnormal cervical cancer screening tests. These guidelines benefit patients by concentrating testing and treatment in those at highest cervical cancer risk. Adoption of guidelines often occurs slowly, with few studies examining the factors associated with guideline-adherent management of abnormal results.

METHODS

To elucidate the factors associated with the use of the 2019 ASCCP guidelines among clinicians who perform cervical cancer screening, physicians and advanced practice professionals who perform cervical cancer screening were cross-sectionally surveyed. Clinicians responded to screening vignettes with differing recommendations for management between the 2019 and prior management guidelines. Screening vignette 1 involved reduction of invasive testing on a low-risk patient; screening vignette 2 involved increased surveillance testing on a high-risk patient. Binomial logistic regression models determined the factors associated with the use of the 2019 guidelines.

RESULTS

A total of 1251 clinicians participated from across the United States. For screening vignettes 1 and 2, guideline-adherent responses were given by 28% and 36% of participants, respectively. Management recommendations differed by specialty and were incorrect in different situations: there was inappropriate invasive testing by obstetrics and gynecology physicians (vignette 1) and inappropriate discontinuation of screening by family and internal medicine physicians (vignette 2). Regardless of their chosen response, over half erroneously believed they were guideline adherent.

CONCLUSIONS

Many clinicians who believe they are following appropriate guidelines may not realize their management strategy is inconsistent with the 2019 guidelines. Education initiatives tailored to clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.

PLAIN LANGUAGE SUMMARY

The 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines are the most recent national guidelines for abnormal cervical cancer screening test management. We surveyed over 1200 obstetrics and gynecology (OB/GYN), family medicine, and internal medicine physicians and advanced practice providers about their screening and abnormal results follow-up practices in relation to guidelines. Few clinicians are following the 2019 guidelines. Management recommendations differed by clinician specialty and were incorrect in different situations: there was inappropriate invasive testing by OB/GYN physicians and inappropriate screening discontinuation by family and internal medicine physicians. Education tailored by clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.

Analysis of Cervix Intraepithelial Neoplasia Prevalence in the Kurdistan Region, Iraq

BACKGROUND

 Cervix intraepithelial neoplasia (CIN) refers to abnormal changes in the squamous cells of the cervix, with more significant changes known as high-grade squamous intraepithelial lesions (HSIL) occurring in grades II and III.

AIM

 The study aimed to estimate the prevalence of cervical intraepithelial neoplasia and explore potential risk factors for HSIL among women living in the Kurdistan region, Iraq.

MATERIALS AND METHODS

 The research encompassed a sample size of 1300 female participants whose Papanicolaou (pap) smears were taken in several hospitals located within the Kurdistan region. The objective of the study was to determine the prevalence of cervical infection among these women. This was a multi-centre study conducted from January 2021 to the end of December 2021 for the determination of pap smears and the relationship between CIN and cervical cancer. Only 120 (9.23%) of those 1300 participants suffered from cervical or vaginal problems. A pap smear, also known as a pap test, is a routine screening procedure used to detect abnormal cervical cells that may indicate cervical cancer or precancerous conditions. The procedure involves collecting a sample of cells from the cervix.

RESULTS

 The most important details in this study are the age groups and percentages of women who have undergone a pap smear. There were four women who tested positive for cervical cancer, accounting for 3.33% of the 120 participants with cervical or vaginal problems. However, there were 116 (96.67%) women who tested negative. With regard to the distribution of inflammation rates among the participants with cervical or vaginal problems, there were 114 (95%) women who suffered inflammation, whereas there were six (5%) women without inflammation. In each age group, the numbers of women with and without cervical cancer, as well as the corresponding percentages, were considered. The data suggest that the incidence of cervical cancer tends to increase with age since higher percentages were observed in older age groups. The study highlights the importance of regular screenings and age-specific cervical cancer prevention and detection strategies to ensure early diagnosis and effective medical interventions.

CONCLUSION

 The prevalence of cervical cancer cases was relatively low, with only 0.31% of the total participants diagnosed with cervical cancer. The majority, accounting for 99.69%, did not have cervical cancer. These results highlight the importance of pap smear screenings as a valuable tool for early detection and prevention of cervical cancer. They also highlight the importance of regular screenings, especially for younger women, to detect and treat cervical abnormalities at an early stage.

Disparities in geospatial patterns of cancer care within urban counties and structural inequities in access to oncology care

OBJECTIVE

To examine geospatial patterns of cancer care utilization across diverse populations in New Jersey-a state where most residents live in urban areas.

DATA SOURCES/STUDY SETTING

We used data from the New Jersey State Cancer Registry from 2012 to 2014.

STUDY DESIGN

We examined the location of cancer treatment among patients 20-65 years of age diagnosed with breast, colorectal, or invasive cervical cancer and investigated differences in geospatial patterns of care by individual and area-level (e.g., census tract-level) characteristics.

DATA COLLECTION/EXTRACTION METHODS

Multivariate generalized estimating equation models were used to determine factors associated with receiving cancer treatment within residential counties, residential hospital service areas, and in-state (versus out-of-state) care.

PRINCIPAL FINDINGS

We observed significant differences in geospatial patterns of cancer treatment by race/ethnicity, insurance type, and area-level factors. Even after adjusting for tumor characteristics, insurance type, and other demographic factors, non-Hispanic Black patients had a 5.6% higher likelihood of receiving care within their own residential county compared to non-Hispanic White patients (95% CI: 2.80-8.41). Patients insured with Medicaid and those without insurance had higher likelihoods of receiving care within their residential county compared to privately insured individuals. Patients living in census tracts with the highest quintile of social vulnerability were 4.6% more likely to receive treatment within their residential county (95% CI: 0.00-9.30) and were 2.7% less likely to seek out-of-state care (95% CI: -4.85 to -0.61).

CONCLUSIONS

Urban populations are not homogenous in their geospatial patterns of cancer care utilization, and individuals living in areas with greater social vulnerability may have limited opportunities to access care outside of their immediate residential county. Geographically tailored efforts, along with socioculturally tailored efforts, are needed to help improve equity in cancer care access.

Patterns of cervical cancer screening follow-up in the era of prolonged screening intervals

INTRODUCTION

Little is known as to how prolonged screening recommendations for cervical cancer have affected compliance.

OBJECTIVE

We examined compliance with repeat cervical cancer screening among U.S. women aged 30-64 who underwent index screening between 2013 and 2019.

STUDY DESIGN

The IBM Watson Health MarketScan Database was used to identify commercially-insured women 30-64 years old who underwent cervical cancer screening from 2013 to 2019. The cohort was limited to women with continuous insurance 12 months before and ≥ 2 months after index testing. Patients with prior hysterectomy, more frequent surveillance needs, or a history of abnormal cytology, histology, or HPV test were excluded. Index screening included cytology, co-testing, or primary HPV testing. Cumulative incidence curves described screening intervals. Compliance was considered if repeat screening occurred 2.5-4 years after index cytology and 4.5-6 years after index co-testing. Cause-specific hazard models examined factors associated with compliance.

RESULTS

Of 5,368,713 patients identified, co-testing was performed in 2,873,070 (53.5%), cytology in 2,422,480 (45.1%), and primary HPV testing in 73,163 (1.4%). The cumulative incidence of repeat screening among all women by seven years was 81.9%. Of those who underwent repeat screening, 85.7% with index cytology and 96.6% with index co-testing were rescreened early. Only, 12.2% with index cytology had appropriate rescreening and 2.1% had delayed rescreening. Among the index co-testing group, 3.2% had appropriate rescreening and 0.3% had delayed rescreening.

CONCLUSION

Appropriate cervical cancer follow-up screening is highly variable. The cumulative incidence rate of repeat screening was 81.9% and among women rescreened, the vast majority are tested earlier than recommended by current guidelines.

Underscreening, overscreening, and guideline-adherent cervical cancer screening in a national cohort

OBJECTIVE

To explore rates of under- and overscreening for cervical cancer among a national cohort.

METHODS

The MarketScan database, a national administrative database of employee-sponsored insurance, was queried for elements relevant to cervical cancer screening among women aged 21-65 with 6 years of continuous enrollment (2015-2019). Average-risk women were defined as those without high-risk medical conditions or abnormal screening histories, and without evidence of hysterectomy with removal of the cervix for benign indications. Average-risk women were considered adequately screened if they had Pap tests alone at 2.5-3.5 year intervals, or HPV tests or co-tests at 4.5-5.5 year intervals. Logistic regressions were used to predict the odds of receiving guideline-adherent screening, underscreening, and overscreening.

RESULTS

Among 1,872,809 eligible patients, 1,471,063 (78.5%) qualified for routine screening. Of these, only 18.1% received guideline-adherent screening, and 25.4% were unscreened during the 6-year period. Younger women (aged 21-39) were more likely to be overscreened [OR 1.46]. Older women (aged 50-64) were more likely to be underscreened or unscreened during the study period [OR 2.54]. Guideline-adherent screening was highest with HPV testing alone (80%) followed by co-testing (44%), and lowest with cytology alone (15%). A total of 329,062 women in this general population sample (18%) met high-risk criteria that required increased frequency of screening.

CONCLUSIONS

High rates of both underscreening and overscreening indicate a need for additional strategies to improve guideline-adherent care.

CLINICAL TRIAL REGISTRATION

N/A.

Changing Preferences for a Cervical Cancer Screening Strategy: Moving Away from Annual Testing

Background

While annual cytology has not been recommended for many years, it remains many patients' preferred screening strategy for cervical cancer. Patient education and provider recommendations have been found effective in aligning professional society guidelines with patient preferences. We assessed whether an educational video with value elicitation exercises (utility assessments) changed screening strategy preferences among patients who had an initial preference for annual screening.

Materials and Methods

We conducted an interventional study of English- or Spanish-speaking women 21-65 years of age, recruited from two women's health clinics in San Francisco, California (n = 262). Participants were asked about their preferred method of screening before viewing a 7-minute educational video and using a computerized tool that elicited values for 23 different health states related to cervical cancer screening. Directly afterward, they were again asked about their preferred screening strategy. Multivariable regression analysis was utilized to identify independent predictors of changing preferences.

Results

Of 246 enrollees, 62.6% (154/246) had an initial preference for annual cytology; after viewing the video and completing the values elicitation exercises, about half (72/154, 47%) preferred a strategy other than annual screening. Having attended college and being screened every 3 to 5 years in the recent past were independent predictors of changing preferences away from annual screening. In sensitivity analyses, 53.2% of average-risk participants changed preferences away from annual cytology (p < 0.01).

Conclusions

Viewing an educational video and conducting a series of value elicitation exercises were associated with a substantially decreased likelihood of preferring annual screening. These findings underscore the importance of patient-centered education to help support informed patient preferences.

Unindicated cervical cancer screening in adolescent females within a large healthcare system in the United States

BACKGROUND

Current consensus recommendations are to not initiate cervical cancer screening for immunocompetent adolescent females before 21 years of age. This is in part because of the very low rate of 0.8 per 100,000 new cervical cancer cases diagnosed among women aged between 20 to 24 years. Timely human papillomavirus vaccination further decreases the incidence of cervical cancer to 4 cases per 100,000 persons by the age of 28 years. Screening before 21 years of age has demonstrated no clear benefit in cancer risk reduction or outcomes. In addition, unindicated screening among adolescents can lead to patient harm and increasing costs to the healthcare system.

OBJECTIVE

It is important to assess the rates of overutilization of cervical cancer screening and to identify areas where improvements have occurred and where further opportunities exist. This study aimed to assess the trends over time and the practice and provider factors associated with unindicated cervical cancer screening tests in adolescent females within the largest healthcare system in the state.

STUDY DESIGN

Cross-sectional data from patients aged 13 to 20 years who underwent cervical cancer screening between January 1, 2012, and December 31, 2018, across a large multihospital health system were reviewed. All cervical cancer screening results were included. The incidence rate of unindicated screening was analyzed over 6-month intervals using the Poisson regression analysis.

RESULTS

The study included data from 118 providers and 794 women. Among the 900 screening results, most (90%) were unindicated: 87% with unindicated cytology testing alone and 14% with unindicated human papillomavirus testing. Screening tests were collected from patients aged 13 to 20 years, many of whom had multiple unindicated cytology tests, with 25 patients having ≥3 tests before the age of 21 years. Most results of cytology testing were negative for intraepithelial lesion or malignancy (77%). Moreover, 52 invasive diagnostic or therapeutic procedures (49 colposcopies and 3 conizations) were performed, of which 45 (87%) followed an unindicated screening test. Between 2012 and 2018, the incidence rate of unindicated cytology decreased by 33% (12.6 to 8.5 unindicated cytology per 1000 encounters). The incidence rate of unindicated screening was lower in the academic setting than in the community setting (incidence rate ratio, 0.43; P<.01). Even with decreases in the overall rates of unindicated screening throughout the study period, there were still 58 unindicated screening tests performed in the final year of this study.

CONCLUSION

Despite substantial reductions in unindicated screening for women aged <21 years, there remained areas for improvement. Our data reflected practices of guideline nonadherence up to 7 years after the 2012 guideline. Now, with a new series of changes to the guidelines, which may be even more challenging for patients and providers, it is more important than ever to utilize evidence-based strategies to improve guideline dissemination and adherence.

The ASCCP Cervical Cancer Screening Task Force Endorsement and Opinion on the American Cancer Society Updated Cervical Cancer Screening Guidelines

ABSTRACT

The American Cancer Society (ACS) released updated cervical cancer screening guidelines in 2020 that endorse a shift in practice to primary human papillomavirus (HPV) screening in people with a cervix, beginning at ages of 25-65 years. When access to US Food and Drug Administration-approved primary HPV testing is not available, the ACS offers cotesting or cytology as acceptable alternative strategies but suggests that these testing modalities may be excluded from future iterations of the guidelines. The ASCCP recognizes the benefits and risks of primary HPV cervical cancer screening while acknowledging the barriers to widespread adoption, including implementation issues, the impact of limited HPV vaccination in the United States, and inclusion of populations who may not be well represented on primary HPV screening trials, such as underrepresented minorities. The ASCCP endorses the 2018 US Preventive Services Task Force Recommendation Statement and supports the ACS cervical cancer screening guidelines. Most importantly, the ASCCP endorses any cervical cancer screening for secondary prevention of cervical cancer and recommends interventions that improve screening for those who are underscreened or unscreened.

Clair CM, Hou JY, Khoury-Collado F, Gockley A, Accordino M, Hershman DL. Overuse of Cervical Cancer Screening Tests Among Women With Average Risk in the United States From 2013 to 2014

IMPORTANCE

While cervical cancer screening with cytologic and human papillomavirus (HPV) testing has reduced mortality from cervical cancer, overuse of these tests is associated with downstream psychological and medical consequences, as well as significant costs. Guidelines now recommend less frequent testing, although adherence to these recommendations is uncertain.

OBJECTIVE

To determine the frequency of overuse of cervical cancer screening tests.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 2 299 177 women aged 30 to 65 years recorded in the MarketScan database who underwent cervical cancer screening with cervical cytologic testing, cotesting, or primary HPV testing in 2013 through 2014. Women were followed-up for 3 years, and use of repeat testing during this period was noted. Clinical and demographic characteristics associated with overuse of screening and the association between screening and performance of routine gynecologic examinations were recorded. Data were analyzed from June 15 to September 15, 2020.

MAIN OUTCOMES AND MEASURES

Cumulative performance of overuse of cervical cancer screening with repeat cytologic or HPV testing within 36 months of the index screening test.

RESULTS

A total of 2 299 177 women with a median (interquartile range) age of 47 (39-54) years were identified. Initial cervical cancer screening consisted of cytologic testing alone in 1 286 179 women (55.9%), cotesting in 991 583 women (43.1%) and HPV testing in 21 415 women (0.9%). The cumulative incidence of repeat cervical cancer screening was 17.7% (95% CI, 17.6%-17.7%) at 12 months, 51.1% (95% CI, 51.0%-51.2%) at 24 months and 65.8% (65.7%-65.8%) at 36 months. Repeat screening was less common in older women (32 198 women [60.2%] aged 60-64 years vs 194 665 women [67.8%] aged 30-39 years; P < .001), women with medical comorbidities (125 197 women [64.1%] with ≥2 comorbidities vs 423 012 women [64.7%] with no comorbidities; P < .001), women screened in 2014 (176 734 women [53.4%] in 2014 vs 555 767 women [69.4%] in 2013; P < .001), and those screened with cotesting (277 032 women [56.9%] for cotesting vs 450 438 [71.2%] for cytologic testing; P < .001). In contrast, overuse of testing was more common in the Northeastern US (143 916 women [68.1%] in the Northeast vs 81 552 women [51.6%] in the West; P < .001), in women with more frequent outpatient visits (238 510 women [71.1%] with ≥6 visits vs 279 412 [58.7%] with ≤2 visits; P < .001). Women with a sexually transmitted infection after their index testing were also more likely to undergo repeat testing (adjusted odds ratio, 1.42 [95% CI, 1.21-1.68]). Women who did not undergo repeat screening were significantly less likely to undergo a gynecological exam after the index screening test: during year 2 of follow-up, 657 749 women (96.7%) who underwent repeating screening had a gynecological examination compared with 203 566 women (26.2%) who did not undergo a gynecological examination.

CONCLUSIONS AND RELEVANCE

These findings suggest that among commercially insured women with average risk, cervical cancer screening tests were frequently overused.

Group practice impacts on patients, physicians and healthcare systems: a scoping review

OBJECTIVE

To identify the advantages and disadvantages that group practices have on patients, physicians and healthcare systems.

STUDY DESIGN

A scoping review was performed based on the methodology proposed by Arksey and O'Malley, and refined by Levac et al. Titles and abstracts were screened by two reviewers. A quantitative analysis was performed to assess the type, year and region of publication, as well as the population studied. A qualitative descriptive analysis was performed to identify common themes.

STUDY SETTING

MEDLINE, EMBASE and Cochrane databases were searched from database inception to October 2018 for papers which assessed outcomes relevant to the research question.

RESULTS

Our search strategy returned 2408 papers and 98 were included in the final analysis. Most papers were from the USA, were surveys and assessed physician outcomes. Advantages of group practices for patients included improved satisfaction and quality of care. Studies of physicians reported improved quality of life and income, while disadvantages included increased stress due to poor interpersonal relationships. Studies of healthcare systems reported improved efficiency and better utilisation of resources.

CONCLUSIONS

Group practices have many benefits for patients and physicians. However, further work needs to be done assessing patient outcomes and establishing the elements that make a group practice successful.

Incorporating Stakeholder Feedback in Guidelines Development for the Management of Abnormal Cervical Cancer Screening Tests

OBJECTIVE

The 2019 ASCCP Risk-Based Management Consensus Guidelines present a paradigm shift from results- to risk-based management. Patient and provider factors can affect guideline adoption. We sought feedback from stakeholders to inform guideline development.

MATERIALS AND METHODS

To solicit provider feedback, we surveyed attendees at the 2019 ASCCP annual meeting regarding readiness to adopt proposed changes and used a web-based public comment period to gauge agreement/disagreement with preliminary guidelines. We elicited patient feedback via a brief survey on preferences around proposed recommendations for treatment without biopsy. Surveys and public comment included both closed-ended and free-text items. Quantitative results were analyzed using descriptive statistics; qualitative results were analyzed using content analysis. Results were incorporated into guideline development in real time.

RESULTS

Surveys indicated that 98% of providers currently evaluate their patients' past results to determine management; 88% felt formally incorporating history into management would represent an improvement in care. Most providers supported expedited treatment without biopsy: 22% currently perform expedited treatment and 60% were willing to do so. Among patients, 41% preferred expedited treatment, 32% preferred biopsy before treatment, and the remainder were undecided. Responses from the public comment period included agreement/disagreement with preliminary guidelines, reasons for disagreement, and suggestions for improvement.

CONCLUSIONS

Stakeholder feedback was incorporated into the development of the 2019 ASCCP Risk-Based Management Consensus Guidelines. Proposed recommendations with less than two-thirds agreement in the public comment period were considered for revision. Findings underscore the importance of stakeholder feedback in developing guidelines that meet the needs of patients and providers.

Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society

The American Cancer Society (ACS) recommends that individuals with a cervix initiate cervical cancer screening at age 25 years and undergo primary human papillomavirus (HPV) testing every 5 years through age 65 years (preferred); if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable) (strong recommendation). The ACS recommends that individuals aged >65 years who have no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years, and who have documented adequate negative prior screening in the prior 10 years, discontinue all cervical cancer screening (qualified recommendation). These new screening recommendations differ in 4 important respects compared with the 2012 recommendations: 1) The preferred screening strategy is primary HPV testing every 5 years, with cotesting and cytology alone acceptable where access to US Food and Drug Administration-approved primary HPV testing is not yet available; 2) the recommended age to start screening is 25 years rather than 21 years; 3) primary HPV testing, as well as cotesting or cytology alone when primary testing is not available, is recommended starting at age 25 years rather than age 30 years; and 4) the guideline is transitional, ie, options for screening with cotesting or cytology alone are provided but should be phased out once full access to primary HPV testing for cervical cancer screening is available without barriers. Evidence related to other relevant issues was reviewed, and no changes were made to recommendations for screening intervals, age or criteria for screening cessation, screening based on vaccination status, or screening after hysterectomy. Follow-up for individuals who screen positive for HPV and/or cytology should be in accordance with the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors.

Midwives' practices related to cervical cancer screening during pregnancy: A vignette-based study

OBJECTIVE

To describe midwives' practices related to cervical cancer screening and women's eligibility for screening during pregnancy.

STUDY DESIGN

Cross-sectional vignette-based study of French midwives during February-May 2018.

MAIN OUTCOME MEASURES

Participants were asked to complete an internet-based questionnaire: a clinical case-vignette about a woman eligible for cervical cancer screening during pregnancy and a short self-administered questionnaire.

RESULTS

We obtained 273 complete questionnaires from eligible midwives. Of those responding, 15% reported that they never screened for cervical cancer during pregnancy, 63.7% did so for women 25 years or older, and 51% adhered to the recommended intervals between tests. Overall, 110 (40%) midwives adhered to the complete screening protocol (age at initiation and interval). In this clinical case vignette of a woman meeting the criteria for screening, only 29% of midwives reported they would perform a Pap test at 25 weeks of gestation, while 91% would at 10 weeks.

CONCLUSION

Midwives' practices of cervical cancer screening and their determination of women's eligibility during pregnancy vary, especially according to gestational age; Nevertheless, pregnancy is an appropriate time to screen women who meet the criteria for cervical cancer screening, especially if they are not receiving regular gynaecological care.

Implementing changes to cervical screening: A qualitative study with health professionals

BACKGROUND

Profound changes were made to the Australian National Cervical Screening Program in December 2017, which included a reduction in the frequency of screening and a new cervical screening test.

AIM

To explore the attitudes and experiences of health professionals practising in Australia since implementation of these changes.

MATERIALS AND METHODS

Thirty-one semi-structured interviews were conducted with general practitioners, obstetricians and gynaecologists, pathologists and nurses involved in cervical screening Australia-wide. Data were analysed using Framework Analysis.

RESULTS

Overall, health professionals had positive attitudes toward the changes but described many challenges associated with their implementation. Participants discussed practical system challenges, communication and education, finding ways around the guidelines and other perceived 'collateral'. Practical system challenges included increased colposcopy referrals, limited access to the National Cancer Screening Register, a complex primary screening approach, and issues with self-collection. In terms of communication and education, limited public education was recognised, in addition to challenges with particular age groups of women. Finding ways around the guidelines were described, for example over-referring women for co-testing by stating symptoms, which could lead to overtreatment. Other perceived collateral were demonstrated through reduced opportunistic screening opportunities due to less frequent primary care presentations, and concern over the potential for further underscreening in already under-screened populations.

CONCLUSIONS

These findings provide insight into the challenges health professionals face with renewing programs, in terms of practical issues and unexpected downstream effects which need to be addressed to ensure future implementation of the program is streamlined.

Recent changes in cervical cancer screening guidelines: U.S. women's willingness for HPV testing instead of Pap testing

Cervical cancer screening guidelines in the United States were revised in 2018 to include the option of primary human papillomavirus (HPV) testing. The transition to this screening method may face difficulties as Pap testing has been the primary screening modality in the United States. The objective of this study is to assess information, motivation, and behavioral skills associated with willingness to receive an HPV test instead of a Pap test among women. The sample included U.S. 812 women, ages 30 to 65 years. Participants completed an online survey in 2018. The Information, Motivation, and Behavioral Skills (IMB) model was used to measure predictors of willingness for HPV testing. The outcome variables were willingness to receive the HPV test instead of the Pap test, with and without time interval details. Logistic regression modeling was used with SAS 9.4. Over half of the sample (55%) were willing to receive the HPV test. For the information domain, HPV knowledge was significantly associated with willingness for HPV testing (OR = 1.08, 95%CI 1.04-1.13). Significant motivating factors included: positive attitudes, social norms, perceived benefits, worry about cervical cancer, and worry about abnormal HPV tests. For behavioral skills, women were significantly more willing to get the HPV test if a provider recommended it (OR = 2.43, 95%CI 1.53-3.87) and currently up-to-date on cervical cancer screening guidelines (OR = 1.52, 95%CI 1.52-2.26). Addressing barriers and facilitators to willingness to transition to primary HPV testing over Pap testing is needed as the United States has updated guidelines for cervical cancer screening.

Effect of an Electronic Health Record Decision Support Alert to Decrease Excess Cervical Cancer Screening

OBJECTIVE

Cervical cancer screening is often conducted in excess of current screening guidelines. The objective of this study was to evaluate the effect of an electronic health record (EHR) clinical decision support alert to decrease guideline-nonadherent cervical cancer screening beyond the age limits of screening or posthysterectomy.

MATERIALS AND METHODS

The proportion of guideline-nonadherent Pap tests in women younger than 21 years or older than 65 years or posthysterectomy were compared 4 months before and 3 months after implementation of an EHR clinical decision support alert warning providers that a Pap test is not indicated. Providers could cancel the Pap test or override the alert and place the order. Provider characteristics and Pap test indications were summarized by preintervention/postintervention period using descriptive statistics. The proportions of nonindicated Pap tests were compared by intervention period and provider characteristics using generalized estimating equation models.

RESULTS

In women beyond the screening age limits or posthysterectomy, a total of 388 Pap tests were ordered before intervention, and 313 tests were ordered after intervention. Proportion of guideline-nonadherent tests was similar before (62%) and after intervention (63%); thus, implementation of the clinical decision support alert did not change the proportion of guideline-nonadherent Pap tests ordered (OR = 1.08, 95% CI = 0.77-1.52). It is notable that 52% of guideline-nonadherent tests were ordered by 11 providers. Even when controlling for providers who ordered more than 1 test during the study period, multivariate analysis showed that male providers were more likely to order guideline-nonadherent Pap tests (OR = 2.30, 95% CI = 1.36-3.89); no other differences by provider characteristics were observed.

CONCLUSIONS

An EHR clinical decision support alert does not decrease guideline-nonadherent cervical cancer screening. These data suggest efforts to optimize clinical decision support should be focused on other aspects of cervical cancer prevention.

A Thematic Analysis of Attitudes Toward Changes to Cervical Screening in Australia

Background

In December 2017, the Australian National Cervical Screening Program (NCSP) was changed to encompass a 5-yearly human papillomavirus (HPV) primary test for women aged 25 to 74 years. Public concerns about changes to screening programs has been demonstrated in other countries previously.

Objective

The aim of the study was to explore in depth women’s understanding of and concerns about the specific changes to the Australian NCSP implemented in December 2017.

Methods

A Web-based petition (Change.org) opposing the changes received over 70,000 signatures and nearly 20,000 comments from February to March 2017. Of 19,633 comments, a random sample of 10% (2000/19,633) were analyzed using content analysis (reported elsewhere). Comments relating directly to the specific changes to the program were further analyzed using qualitative thematic analysis.

Results

Around one-third (34.55%; 691/2000) of the total comments were related to concerns about specific changes to the program. The greatest concern was that screening intervals would be too long and that cancer may not be detected in time for successful treatment. Missing cancer in younger women (aged <25 years) was also an important concern, perceiving younger women to remain at significant risk. Notably, concern was rarely expressed about the new test (the HPV test).

Conclusions

Gaps in knowledge and understanding about changes to the program and the rationale behind these have caused health concerns among women. Worry about the extended screening interval indicates little understanding of the slow progression of the HPV infection to cervical cancer or the high rates of regression. Identification of these knowledge gaps can inform both deintensification of other cancer screening programs and practitioners, so that they are able to address these concerns with their patients.

Clinician offering is a key factor associated with HPV vaccine uptake among Mexican mothers in the USA and Mexico: a cross-sectional study

OBJECTIVE

To compare the knowledge, beliefs, and practices regarding HPV vaccination among mothers of vaccine-eligible girls in Mexico and the USA.

METHODS

Similar samples of Mexican mothers with vaccine-eligible daughters were surveyed at two clinics in Cuernavaca, Morelos, from July to October 2012 (n = 200) and at two clinics in Oxnard, California, from August to November 2013 (n = 200).

RESULTS

Although mothers in the USA had less knowledge and more negative attitudes toward the vaccine than their counterparts in Mexico, vaccine uptake rates were higher in the USA (49% vs. 40%). US mothers were more likely to have discussed and been offered the HPV vaccine by a clinician than mothers in Mexico. In multivariate analyses, having been offered the HPV vaccine was the most important predictor of vaccine uptake.

CONCLUSIONS

Our results suggest that healthcare access or other system, clinic, or provider factors are the main drivers of vaccine receipt in this binational sample of Mexican mothers. Interventions and programs that encourage clinicians to offer the HPV vaccine should be developed to increase vaccine uptake in both countries.

Reducing overuse of cervical cancer screening: A systematic review

Overuse of clinical preventive services increases healthcare costs and may deprive underserved patients of necessary care. Up to 45% of cervical cancer screening is overuse. We conducted a systematic review of correlates of overuse of cervical cancer screening and interventions to reduce overuse. The search identified 25 studies (20 observational; 5 intervention). Correlates varied by the type of overuse measured (i.e., too frequent, before/after recommended age to start or stop screening, after hysterectomy), the most common correlates of overuse related to patient age (n = 7), OBGYN practice or provider (n = 5), location (n = 4), and marital status (n = 4). Six observational studies reported a decrease in overuse over time. Screening overuse decreased in all intervention studies, which used before-after designs with no control or comparison groups. Observational studies suggest potential targets for de-escalating overuse. Randomized clinical trials are needed to establish best practices for reducing overuse.

Improving Knowledge and Awareness of Human Papillomavirus-Associated Gynecologic Cancers: Results from the National Comprehensive Cancer Control Program/Inside Knowledge Collaboration

BACKGROUND

Over 16,000 women are diagnosed with a human papillomavirus (HPV)-associated gynecologic cancer every year. Because most of these cancers are preventable, correct and appropriate information about the HPV vaccine and cervical cancer screening can help reduce incidence.

MATERIALS AND METHODS

The Centers for Disease Control and Prevention created Inside Knowledge: Get the Facts About Gynecologic Cancer campaign materials, which were used by seven National Comprehensive Cancer Control Program recipients in tailored educational sessions on gynecologic cancer with women and healthcare providers in the community setting. Session participants completed presession and postsession questionnaires. Differences in knowledge and intentions were assessed using chi-square tests for women in the general public, obstetricians/gynecologists (OB/GYNs), primary care physicians (PCPs), and other healthcare providers.

RESULTS

Women's knowledge improved significantly presession to postsession that HPV causes vaginal (39%-65%, p < 0.001) and vulvar cancers (26%-60%, p < 0.001), but postsession few women correctly identified all HPV-associated gynecologic cancers (15%). From presession to postsession, more women were able to correctly identify recommended age groups for whom the HPV vaccine is recommended (15%-30%, p < 0.001), and that the Pap test only screens for cervical cancer (58%-73%, p < 0.001). Among providers, OB/GYNs had more baseline knowledge of HPV-associated gynecologic cancers than other providers. Postsession, PCPs and other providers increased their knowledge of HPV vaccine recommended age groups (33%-71% and 23%-61%, respectively), and the 3-year recommended screening interval for the Pap test (73%-91% and 63%-85%, respectively). HPV vaccine knowledge did not show significant improvement among OB/GYNs postsessions.

CONCLUSIONS

Women and healthcare providers who attended the Inside Knowledge sessions significantly improved their knowledge of HPV-associated gynecologic cancers. Additional educational activities during the sessions that support distinguishing between HPV-associated versus other gynecologic cancers and clarify HPV vaccine recommendations may help with further increases in knowledge.

Adherence patterns to extended cervical screening intervals in women undergoing human papillomavirus (HPV) and cytology cotesting

Although guidelines have recommended extended interval cervical screening using concurrent human papillomavirus (HPV) and cytology ("cotesting") for over a decade, little is known about its adoption into routine care. Using longitudinal medical record data (2003-2015) from Kaiser Permanente Northern California (KPNC), which adopted triennial cotesting in 2003, we examined adherence to extended interval screening. We analyzed predictors of screening intervals among 491,588 women undergoing routine screening, categorizing interval length into early (<2.5years), adherent (2.5<3.5years), or late (3.5<6.0years). We also examined repeated early screening in a subgroup of 50,691 women. Predictors examined included: cohort year (defined by baseline cotest, 2003-2009), race/ethnicity, and baseline age. Compared to the 2003 cohort, women in the 2009 cohort were significantly less likely to screen early (aOR=0.22, 95% CI=0.21, 0.23) or late (aOR=0.47, 95% CI=0.45, 0.49). African American (AA) and Hispanic women were less adherent overall than Non-Hispanic White women, with increased early [(AA: aOR=1.21, 95%CI=1.17, 1.25) (Hispanic: aOR=1.08, 95%CI=1.06, 1.11)] and late screening [(AA: aOR=1.23, 95%CI=1.19, 1.27) (Hispanic: aOR=1.06, 95%CI=1.03, 1.08)]. Asian women were slightly more likely to screen early (aOR=1.03, 95%CI=1.01, 1.05), and less likely to screen late (aOR=0.92, 95% CI=0.90, 0.94). Women aged 60-64years were most likely to screen early for two consecutive intervals (aOR=2.09, 95%CI=1.91, 2.29). Our study found that widespread and rapid adoption of extended interval cervical cancer screening is possible, at least in this managed care setting. Further research examining multilevel drivers promoting or restricting extended interval screening across diverse healthcare settings is needed.

US Health Care Clinicians' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Vaccination: A Qualitative Systematic Review

Clinicians' recommendation for the human papillomavirus (HPV) vaccine appears to be an important driver of parental decisions about vaccination. Our aim was to synthesize the best available evidence exploring the perceptions and experiences regarding HPV vaccination, from the perspective of the US clinician. We conducted a comprehensive literature search of Academic Search Complete, CINAHL Plus, Communication & Mass Media Complete, Consumer Health Complete (EBSCOhost), ERIC, Health and Psychosocial Instruments, MEDLINE with full text, and PsycINFO databases. We identified 60 eligible articles: 48 quantitative and 12 qualitative. We extracted the following information: study purpose, use of theory, location, inclusion criteria, and health care provider classification. Results were organized into 5 categories: 1) clinicians' knowledge and beliefs about HPV and the HPV vaccine, 2) clinicians' attitudes and beliefs about recommending HPV vaccines, 3) clinicians' intention to recommend HPV vaccines, 4) clinicians' professional practices regarding HPV vaccination, and 5) patient HPV vaccination rates. Although clinicians were generally supportive of HPV vaccination, there was a discrepancy between clinicians' intentions, recommendation practices, and patient vaccination rates. Studies reported that clinicians tended not to provide strong, consistent recommendations, and were more likely to recommend HPV vaccines to girls versus boys and to older versus younger adolescents. Analyses revealed a number of facilitating factors and barriers to HPV vaccination at the clinician, parent/patient, and systems levels, including clinician knowledge, clinician beliefs, and office procedures that promote vaccination. This review provides an evidence base for multilevel interventions to improve clinician HPV vaccine recommendations and vaccination rates.

E6/E7 proteins are potential markers for the screening and diagnosis of cervical pre-cancerous lesions and cervical cancer in a Chinese population

The present prospective study aimed to evaluate the effects of E6/E7 protein detection by western blotting on cervical cancer (CC) early screening compared with detection by Hybrid Capture 2 (HC2) test and ThinPrep cytological test (TCT) in a Chinese population. A total of 450 cases of cervical intraepithelial neoplasia (CIN) suspected samples (positive in ≥1 indicator of TCT and HC2 test) were recruited from women who were treated at the International Peace Maternity and Child Health Hospital (Shanghai, China) from March 2014 to February 2015. Each sample was analyzed by cytological test. In addition, human papillomavirus (HPV) DNA examination by Hybrid Capture Tube test and E6/E7 protein expression detection by western blotting were performed in all samples, as well as histologic diagnosis to determine the stage of CIN. The results revealed that, for the diagnosis of CIN2⁺, although the sensitivity of E6/E7 protein detection was lower than that of HC2 test (71.3 vs. 96.6%, respectively), the specificity was markedly improved (67.6 vs. 5.9%, respectively). Compared with that of TCT, the sensitivity of E6/E7 protein detection was much higher (36.2 vs. 71.3%, respectively), but the specificity was lower (88.2 vs. 67.6%, respectively). In the present study, HPV E6/E7 protein expression was evaluated as a potential new biomarker for CC, with satisfactory diagnostic values for HPV types 16 and 18. The relative diagnostic value may be further improved by combination of E6/E7 messenger RNA detection.

Describing knowledge encounters in healthcare: a mixed studies systematic review and development of a classification

Background

Implementation science seeks to promote the uptake of research and other evidence-based findings into practice, but for healthcare professionals, this is complex as practice draws on, in addition to scientific principles, rules of thumb and a store of practical wisdom acquired from a range of informational and experiential sources. The aims of this review were to identify sources of information and professional experiences encountered by healthcare workers and from this to build a classification system, for use in future observational studies, that describes influences on how healthcare professionals acquire and use information in their clinical practice.

Methods

This was a mixed studies systematic review of observational studies. DATA SOURCES: OVID MEDLINE and Embase and Google Scholar were searched using terms around information, knowledge or evidence and sharing, searching and utilisation combined with terms relating to healthcare groups. ELIGIBILITY: Studies were eligible if one of the intentions was to identify information or experiential encounters by healthcare workers. DATA EXTRACTION: Data was extracted by one author after piloting with another. STUDY APPRAISAL: Studies were assessed using the Mixed Methods Appraisal Tool (MMAT). PRIMARY OUTCOME: The primary outcome extracted was the information source or professional experience encounter. ANALYSIS: Similar encounters were grouped together as single constructs. Our synthesis involved a mixed approach using the top-down logic of the Bliss Bibliographic Classification System (BC2) to generate classification categories and a bottom-up approach to develop descriptive codes (or “facets”) for each category, from the data. The generic terms of BC2 were customised by an iterative process of thematic content analysis. Facets were developed by using available theory and keeping in mind the pragmatic end use of the classification.

Results

Eighty studies were included from which 178 discreet knowledge encounters were extracted. Six classification categories were developed: what information or experience was encountered; how was the information or experience encountered; what was the mode of encounter; from whom did the information originate or with whom was the experience; how many participants were there; and where did the encounter take place. For each of these categories, relevant descriptive facets were identified.

Conclusions

We have sought to identify and classify all knowledge encounters, and we have developed a faceted description of key categories which will support richer descriptions and interrogations of knowledge encounters in healthcare research.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0564-1) contains supplementary material, which is available to authorized users.

Understanding women's hesitancy to undergo less frequent cervical cancer screening

Inappropriate cervical cancer screening (e.g., screening too often) can result in unnecessary medical procedures, treatment, and psychological distress. To balance the benefits and harms, cervical cancer screening guidelines were recently modified in favor of less frequent screening (i.e., every 3 to 5 years). This study investigated women's acceptance of less frequent cervical cancer screening and their primary concerns about extending the screening interval beyond one year. A national sample of 376 U.S. women ages 21-65 completed an online survey in 2014. Predictors of willingness to get a Pap test every 3 to 5 years were identified using logistic regression. We also examined perceived consequences of less frequent screening. Over two thirds were willing to undergo less frequent screening if it was recommended by their healthcare provider. Nevertheless, nearly 20% expressed discomfort with less frequent screening and 45% were either in opposition or unsure whether they would be comfortable replacing Pap testing with primary HPV testing. Women whose most recent Pap test was (vs. was not) within the past year and women who ever (vs. never) had an abnormal Pap test were less willing to extend the screening interval. Additionally, women who typically saw an obstetrician/gynecologist or nurse practitioner for their Pap test (vs. a family physician) were less accepting of the guidelines. Hesitancy about the longer screening interval appears to stem from concern about developing cancer between screenings. Findings contribute to the growing body of research on cancer overscreening and may inform interventions for improving adherence to cancer screening guidelines.

Facilitators and barriers to the use of standing orders for vaccination in obstetrics and gynecology settings

BACKGROUND

Many young and middle-aged women receive their primary health care from their obstetrician-gynecologists. A recent change to vaccination recommendations during pregnancy has forced the integration of new clinical processes at obstetrician-gynecology practices. Evidence-based best practices for vaccination delivery include the establishment of vaccination standing orders.

OBJECTIVES

As part of an intervention to increase adoption of evidence-based vaccination strategies for women in safety-net and private obstetrician-gynecology settings, we conducted a qualitative study to identify the facilitators and barriers experienced by obstetrician-gynecology sites when establishing vaccination standing orders.

STUDY DESIGN

At 6 safety-net and private obstetrician-gynecology practices, 51 semistructured interviews were completed by trained qualitative researchers over 2 years with clinical staff and vaccination program personnel. Standardized qualitative research methods were used during data collection and team-based data analysis to identify major themes and subthemes within the interview data.

RESULTS

All study practices achieved partial to full implementation of vaccine standing orders for human papillomavirus, tetanus diphtheria pertussis, and influenza vaccines. Facilitating factors for vaccine standing order adoption included process standardization, acceptance of a continual modification process, and staff training. Barriers to vaccine standing order adoption included practice- and staff-level competing demands, pregnant women's preference for medical providers to discuss vaccine information with them, and staff hesitation in determining HPV vaccine eligibility.

CONCLUSIONS

With guidance and commitment to integration of new processes, obstetrician-gynecology practices are able to establish vaccine standing orders for pregnant and nonpregnant women. Attention to certain process barriers can aid the adoption of processes to support the delivery of vaccinations in obstetrician-gynecology practice setting, and provide access to preventive health care for many women.

Provider communication about HPV vaccination: A systematic review

BACKGROUND

Improving HPV vaccination coverage in the US will require healthcare providers to recommend the vaccine more effectively. To inform quality improvement efforts, we systematically reviewed studies of provider communication about HPV vaccination.

METHODS

We searched MEDLINE, CINAHL, EMBASE, and POPLINE in August 2015 to identify studies of provider communication about HPV vaccination.

RESULTS

We identified 101 qualitative and quantitative studies. Providers less often recommended HPV vaccine if they were uncomfortable discussing sex, perceived parents as hesitant, or believed patients to be low risk. Patients less often received recommendations if they were younger, male, or from racial/ethnic minorities. Despite parents' preference for unambiguous recommendations, providers often sent mixed messages by failing to endorse HPV vaccine strongly, differentiating it from other vaccines, and presenting it as an "optional" vaccine that could be delayed.

CONCLUSION

Interventions are needed to help providers deliver effective recommendations in the complex communication environment surrounding HPV vaccination.

Correlates of women's intentions to be screened for human papillomavirus for cervical cancer screening with an extended interval

Background

High-risk HPV DNA testing has been proposed as a primary tool for cervical cancer screening (HPV-CCS) as an alternative to the Papanicolaou cytology- method. This study describes factors associated with women’s intentions to attend cervical cancer screening if high-risk HPV DNA testing (HPV-CCS) was implemented as a primary screening tool, and if screening were conducted every 4 years starting after age 25.

Methods

This online survey was designed using the Theory of Planned Behaviour to assess factors that impact women’s intentions to attend HPV-CCS among women aged 25–69 upon exit of the HPV FOCAL trial. Univariate and regression analyses were performed to compare the demographic, sexual history, and smoking characteristics between women willing and unwilling to screen, and scales for intention to attend HPV-CCS. A qualitative analysis was performed by compiling and coding the comments section of the survey.

Results

Of the 981 women who completed the survey in full, only 51.4 % responded that they intended to attend HPV-CCS with a delayed start age and extended screening interval. Women who intended to screen were more likely to have higher education (AOR 0.59, 95 % CI [0.37, 0.93]), while both positive attitudes (AOR 1.26, 95 % CI [1.23, 1.30]) and perceived behavior control (AOR 1.06, 95 % CI [1.02, 1.10]) were significant predictors of intention to screen. Among women who provided comments in the survey, a large number of women expressed fears about not being checked more than every 4 years, but 12 % stated that these fears may be alleviated by having more information.

Conclusions

Acceptability of increased screening intervals and starting age could be improved through enhanced education of benefits. Program planners should consider measures to assess and improve women’s knowledge, attitudes and beliefs prior to the implementation of new screening programs to avoid unintended consequences.

Acceptable and Preferred Cervical Cancer Screening Intervals Among U.S. Women

INTRODUCTION

Current U.S. cervical cancer screening guidelines recommend a 3- or 5-year screening interval depending on age and screening modality. However, many women continue to be screened annually. The purpose of this study is to investigate U.S. women's self-reported frequency of cervical cancer screening, acceptance of an extended screening interval (once every 3-5 years), and preferred screening options.

METHODS

Data from a 2012 web-based survey of U.S. women aged ≥18 years who had not undergone a hysterectomy or been diagnosed with cervical cancer (N=1,380) were analyzed in 2014. Logistic regression models of extended screening interval use, acceptance, and preference were developed.

RESULTS

Annual Pap testing was the most widely used (48.5%), accepted (61.0%), and preferred (51.1%) screening option. More than one third of respondents (34.4%) indicated that an extended screening interval would be acceptable, but only 6.3% reported that they were currently screened on an extended interval. Women who preferred an extended screening interval (32.9% of those willing to accept regular screening) were more likely to report no primary care visits during the last 12 months (AOR=2.05, p<0.003), no history of abnormal Pap test results (AOR=1.71, p=0.013), and that their last Pap test was performed by an internist/family practitioner rather than an obstetrician-gynecologist (AOR=2.03, p<0.001).

CONCLUSIONS

U.S. women's acceptance of and preference for an extended cervical cancer screening interval appears to be more widespread than utilization. Strategies to educate women about the reasoning behind recommendations for less-than-annual testing and to foster informed preferences should be devised and evaluated.

Cervical cancer screening among women ≥70 years of age in the United States-A referral problem or patient choice

OBJECTIVE

Clinical guidelines recommend that women with a history of adequate screening and not otherwise at high risk may discontinue cervical cancer screening after 65 years of age. However, screening remains common among US women over 65 years old. This study was conducted to examine whether overutilization was attributable to provider's recommendation or patient choice.

METHOD

This cross-sectional study used data from 1752 female participants (70+ years) from the 2013 National Health Interview Survey (NHIS). We quantitatively assessed the proportions of provider-recommended and patient self-initiated Pap smears.

RESULTS

Among female respondents, 40.8% had a Pap smear within the past 3 years, 19.4% had a Pap smear in the last year, and 39.7% reported receiving a recommendation for a Pap smear from their provider in the past year. Among women who received a recommendation to obtain a Pap smear, 39.8% did so within the past 12 months compared to 5.9% of women who did not receive a recommendation (adjusted odds ratio 10.5, 95% confidence interval 7.39-15.0). About 70% of women who visited an obstetrician/gynecologist and reported receiving a recommendation to have a Pap smear did so in the past year, while 32.3% of women who visited an obstetrician/gynecologist but did not receive a recommendation obtained one.

CONCLUSION

Pap smears were common among women ≥70 years of age. Health care providers may need additional education on current guidelines regarding indications for Pap smears in this age group to help reduce screening of patients who may not benefit.

Results of a Health Education Message Intervention on HPV Knowledge and Receipt of Follow-up Care among Latinas Infected with High-risk Human Papillomavirus

A clinic-based intervention study was conducted among high-risk human papillomavirus (HPV)-infected Latinas aged 18-64 years between April 2006 and May 2008 on the Texas-Mexico border. Women were randomly assigned to receive a printed material intervention (n=186) or usual care (n=187) and were followed at three months, six months, and 12 months through telephone surveys and review of medical records. The HPV knowledge of nearly all women had increased greatly, but only two-thirds of women reported they had received follow-up care within one year of diagnosis regardless of additional health education messaging. Our findings suggest that, regardless of type of health education messaging, Latinas living on the Texas-Mexico border are aware that follow-up care is recommended, but they may not receive this care. Individual, familial and medical care barriers to receipt of follow-up care may partially account for the higher rates of cervical cancer mortality in this region.

An update on barriers to adolescent human papillomavirus vaccination in the USA

Human papillomavirus is the most common sexually transmitted infection in the USA. It is the primary cause of almost all cervical cancers as well as several other cancers that affect both men and women. Adolescents of both genders can now prevent transmission of the most common oncogenic strains of human papillomavirus by obtaining a safe, three-dose vaccine series. However, despite its potential to save lives and reduce severe morbidity, many US adolescents have not been vaccinated. This is in contrast to other countries where high rates of vaccination are already reducing rates of cervical intra-epithelial neoplasia and genital warts. This article describes barriers recently reported among families in the USA and concludes with suggestions for improving uptake.

Screening for Cervical, Prostate, and Breast Cancer: Interpreting the Evidence

Cancer screening is an important component of prevention and early detection in public health and clinical medicine. The evidence for cancer screening, however, is often contentious. A description and explanation of disagreements over the evidence for cervical, breast, and prostate screening may assist physicians, policymakers, and citizens faced with screening decisions and suggest directions for future screening research. There are particular issues to be aware of in the evidence base for each form of screening, which are summarized in this paper. Five tensions explain existing conflicts over the evidence: (1) data from differing contexts may not be comparable; (2) screening technologies affect evidence quality, and thus evidence must evolve with changing technologies; (3) the quality of evidence of benefit varies, and the implications are contested; (4) evidence about harm is relatively new, there are gaps in that evidence, and there is disagreement over what it means; and (5) evidence about outcomes is often poorly communicated. The following principles will assist people to evaluate and use the evidence: (1) attend closely to transferability; (2) consider the influence of technologies on the evidence base; (3) query the design of meta-analyses; (4) ensure harms are defined and measured; and (5) improve risk communication practices. More fundamentally, there is a need to question the purpose of cancer screening and the values that inform that purpose, recognizing that different stakeholders may value different things. If implemented, these strategies will improve the production and interpretation of the methodologically challenging and always-growing evidence for and against cancer screening.

The significantly lower risk of cervical cancer at and after the recommended age to begin and end screening compared to breast and colorectal cancer

OBJECTIVE

We compare risk of cervical, colorectal, and breast cancer (and two pre-cancers: cervical intraepithelial neoplasia (CIN) grade 2-3 and colorectal adenomas) at and after the recommended ages to begin and end screening in the United States.

METHODS

Surveillance, Epidemiology, and End Results data were used with Monte Carlo simulations to estimate risk at and after the ages to screen.

RESULTS

At the age to begin screening, absolute risk of breast and colorectal cancer was 381 and 53 times higher, respectively, than cervical cancer (0.0122, 95% CI: 0.0089-0.0162 and 0.0017, 95% CI: 0.0012-0.0023 vs. 3.2e(-5), 95% CI: 2.3e(-5)-4.3e(-5)). Risk of colorectal adenomas and breast cancer was 45 and 2.4 times higher than CIN 2-3 (0.2319, 95% CI: 0.1287-0.3624 and 0.0122, 95% CI: 0.0089-0.0017 vs. 0.0051, 95% CI: 0.0029-0.0081). After the age to end screening, breast and colorectal cancer risk was 17 and 11 times higher, respectively, than cervical cancer.

CONCLUSIONS

Risk of cervical cancer at and after the recommended ages for screening is significantly lower than that of breast and colorectal cancer. Differences may become more pronounced in the era of HPV vaccines. Comparison of risk between cancers provides a novel perspective to inform future guideline development.

HPV and Cervical Dysplasia in Adolescents: A Progressive March Toward Prevention

Cervical cancer caused by infection with the human papillomavirus is the second most common malignancy among women worldwide. Over the course of the past century our understanding of the virus and the disease has expanded exponentially through landmark studies and pioneers of academic medicine. It has all led to the current evidence-based guidelines for prevention of cervical dysplasia and invasive carcinoma in adolescent females that will significantly lessen morbidity and mortality and may eradicate the disease completely. Unfortunately, the greatest challenge to this may be overcoming common misunderstandings and other barriers to compliance with these guidelines among practitioners, patients, and the general public.

Patient concerns about human papillomavirus testing and 5-year intervals in routine cervical cancer screening

OBJECTIVE

To explore attitudes toward new cervical cancer screening options and understand factors associated with those beliefs among women in routine gynecologic care.

METHODS

We used an interviewer-administered survey of 551 women aged 36-62 years enrolled in the HPV in Perimenopause Study. Poisson regression with robust error variance was used to estimate prevalence ratios and 95% confidence intervals (CIs) to compare women's preferences for cervical cancer screening methods and frequency.

RESULTS

A majority of women (55.6%, 95% CI 51.4-59.8%) were aware that screening recommendations had changed, yet 74.1% (95% CI 70.3-77.7%) still believed women should be screened annually. If recommended by their doctor, 68.4% (95% CI 64.4-72.2%) were willing to extend screening to every 3 years, but only 25.2% (95% CI 21.9-29.2%) would extend screening to 5 years. Most women (60.7%, 95% CI 56.5-65.7%) expressed a strong preference for Pap testing, and 41.4% (95% CI 37.4-45.6%) expressed at least moderate concern over having a human papillomavirus (HPV) test without a Pap test. A desire for more frequent care, higher degree of worry and perceived risk, and abnormal screening history were all associated with reduced willingness to accept HPV testing and longer screening intervals.

CONCLUSION

A majority of routinely screened women indicated a willingness to adopt a cervical cancer screening strategy of cytology alone or Pap-HPV cotesting every 3 years if recommended by their physician. However, they remain concerned about HPV testing and extension of screening intervals to once every 5 years. Our results suggest continued reticence to accepting newer HPV-based screening algorithms among routinely screened women older than age 35 years.

Current Cervical Carcinoma Screening Guidelines

A formidable threat to the health of women, cervical carcinoma can be prevented in many cases with adequate screening. The current guidelines for cervical carcinoma screening were created as joint recommendations of the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP) and the American Society for Clinical Pathology (ASCP) in 2012, and later accepted and promoted by the American Congress of Obstetricians and Gynecologists (ACOG). The 2012 recommendations underscore the utility of molecular testing as an adjunct to cytology screening for certain women and provide guidance to clinicians based on different risk-benefit considerations for different ages. This manuscript will review screening techniques and current recommendations for cervical cancer screening and human papilloma virus (HPV) testing, as well as possible future screening strategies.