Opting out of cervical cancer screening: physicians who do not perform pap tests

Eligibility for cervical cancer screening exit: Comparison of a national and safety net cohort

OBJECTIVE

To determine eligibility for discontinuation of cervical cancer screening.

METHODS

Women aged 64 with employer-sponsored insurance enrolled in a national database between 2016 and 2018, and those aged 64-66 receiving primary care at a safety net health center in 2019 were included. Patients were evaluated for screening exit eligibility by current guidelines: no evidence of cervical cancer or HIV-positive status and no evidence of cervical precancer in the past 25 years, and had evidence of either hysterectomy with removal of the cervix or evidence of fulfilling screening exit criteria, defined as two HPV screening tests or HPV plus Pap co-tests or three Pap tests within the past 10 years without evidence of an abnormal result.

RESULTS

Of the 590,901 women in the national claims database, 131,059 (22.2%) were eligible to exit due to hysterectomy (1.6%) or negative screening (20.6%). Of the 1544 women from the safety net health center, 528 (34.2%) were eligible to exit due to hysterectomy (9.3%) or negative screening (24.9%). Most women did not have sufficient data available to fulfill exit criteria: 382,509 (64.7%) in the national database and 875 (56.7%) in the safety net hospital system. Even among women with 10 years of insurance claims data, only 41.5% qualified to discontinue screening.

CONCLUSIONS

Examining insurance claims in a national database and electronic medical records at a safety net institution led to remarkably similar findings: two thirds of women fail to qualify for screening exit. Additional steps to ensure eligibility prior to screening exit may be necessary to decrease preventable cervical cancers among women aged >65.

CLINICAL TRIAL REGISTRATION

N/A.

National Data Analysis and Systematic Review for Human Resources for Cervical Cancer Screening in Japan

BACKGROUND

Although cervical cancer screening has been performed as a national program since 1983 in Japan, the participation rate has remained below 20%. Equity of access is a basic requirement for cancer screening. However, taking smears from the cervix has been limited to gynecologists or obstetricians in Japan and it might be a barrier for accessibility. We examined the current access and its available human resources for cervical cancer screening in Japan.

METHODS

We analyzed the number of gynecologists and obstetricians among 47 prefectures based on a national survey. A systematic review was performed to clarify disparity and use of human resources in cervical cancer screening, diagnosis, and treatment for cervical cancers in Japan. Candidate literature was searched using Ovid-MEDLINE and Ichushi-Web until the end of January 2020. Then, a systematic review regarding accessibility to cervical cancer screening was performed. The results of the selected articles were summarized in the tables.

RESULTS

Although the total number of all physicians in Japan increased from 1996 to 2016, the proportion of gynecologists and obstetricians has remained at approximately 5% over the last 2 decades. 43.6% of municipalities have no gynecologists and obstetricians in 2016. Through a systematic review, 4 English articles and 1 Japanese article were selected. From these 5 articles, the association between human resources and participation rates in cervical cancer screening was examined in 2 articles.

CONCLUSIONS

The human resources for taking smears for cervical cancer screening has remained insufficient with a huge disparity among municipalities in Japan. To improve accessibility for cervical cancer screening another option which may be considered could be involving general physicians as potential smear takers.

General practitioners who never perform Pap smear: the medical offer and the socio-economic context around their office could limit their involvement in cervical cancer screening

BACKGROUND

In France, with the growing scarcity of gynecologists and a globally low and socially differentiated coverage of cervical cancer screening (CCS), general practitioners (GPs) are valuable resources to improve screening services for women. Still all GPs do not perform Pap smears. In order to promote this screening among GPs, the characteristics of physicians who never perform CCS should be more precisely specified. Besides already-known individual characteristics, the contextual aspects of the physicians' office, such as gynecologist density in the area, could shape GPs gynecological activities.

METHODS

To analyze county (département) characteristics of GPs' office associated with no performance of CCS, we used a representative sample of 1063 French GPs conducted in 2009 and we constructed mixed models with two levels, GP and county.

RESULTS

Almost 35% (n = 369) of the GPs declared never performing CCS. GPs working in counties with a poor GP-density per inhabitants were more likely to perform CCS (odds ratio (OR) = 0.52 for each increase of density by 1 GP per 10,000 inhabitants, 95% confidence interval (CI) = 0.37-0.74). On the contrary, GPs working in counties with an easier access to a gynecologist were more likely not to perform CCS (OR = 1.06 for each increase of density by 1 gynecologist per 100,000 women, 95%CI = 1.03-1.10 and OR = 2.02 if the first gynecologist is reachable in less than 15 min, 95%CI = 1.20-3.41) as well as GPs working in areas with a poverty rate above the national average (OR = 1.66, 95%CI = 1.09-2.54). These contextual characteristics explain most of the differences between counties concerning rates of not performing CCS.

CONCLUSIONS

Specific programs should be developed for GPs working in contexts unfavorable to their involvement in CCS.

Primary Care Clinicians' Willingness to Care for Transgender Patients

Transgender patients report negative experiences in health care settings, but little is known about clinicians' willingness to see transgender patients. We surveyed 308 primary care clinicians in an integrated Midwest health system and 53% responded. Most respondents were willing to provide routine care to transgender patients (85.7%) and Papanicolaou (Pap) tests (78.6%) to transgender men. Willingness to provide routine care decreased with age; willingness to provide Pap tests was higher among family physicians, those who had met a transgender person, and those with lower transphobia. Medical education should address professional and personal factors related to caring for the transgender population to increase access.

Determinants of Potentially Unnecessary Cervical Cancer Screenings in American Women

Objectives

To identify factors responsible for potentially clinically unnecessary cervical cancer screenings in women with prior hysterectomy.

Methods

A retrospective cross-sectional study was conducted using the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS). This study targeted adult women and examined whether they received a both a Papanicolaou (Pap) test and undergone a hysterectomy in the last three years. We conducted multivariate analyses, including weighted proportions and odds ratios (ORs), based on the modified BRFSS weighting method (raking). The inclusion criteria were adult women (>18 years old) who reported having received a Pap test within the last 3 years.

Results

Of all women (n=252 391), 72 366 had received a Pap test, and 32 935 of those women (45%, or 12.5 million, weighted) had a prior hysterectomy. We found that age, race/ethnicity, marital status, family income, health status, time since last routine checkup, and health insurance coverage were all significant predictors. Black, non-Hispanic women were 2.23 times more likely to receive Pap testing after a hysterectomy than white women (OR, 2.23; 95% confidence interval [CI], 1.99 to 2.50). Similarly, the odds for Hispanic women were 2.34 times higher (OR, 2.34; 95% CI, 1.97 to 2.80). The odds were also higher for those who were married (OR, 1.17; 95% CI, 1.08 to 1.27), healthier (OR, 1.24; 95% CI, 1.14 to 1.35), and had health insurance (OR, 1.54; 95% CI, 1.28 to 1.84), after controlling for confounders.

Conclusions

We conclude that women may potentially receive Pap tests even if they are not at risk for cervical cancer, and may not be adequately informed about the need for screenings. We recommend strategies to disseminate recommendations and information to patients, their families, and care providers.

Cervical Cancer Screening and Prevention in 78 Sexually Transmitted Disease Clinics-United States, 2014-2015

BACKGROUND

Human papillomavirus (HPV) infections cause approximately 30,700 cancers annually among US men and women, cervical cancer being the most common. Human papillomavirus vaccination is recommended routinely for US girls and boys at age 11 to 12 years, and for those not previously vaccinated, through age 26 and 21 years for women and men, respectively. Our objective was to assess current cervical cancer screening and HPV vaccination practices among sexually transmitted disease (STD) clinics in the United States.

METHODS

We surveyed a geographically diverse convenience sample of US STD clinics identified by members of the National Coalition of STD Directors within 65 state, territorial, and local jurisdictions. An online multiple-choice survey about clinical services was administered to clinic directors or designees during October 2014 to February 2015.

RESULTS

Survey respondents included 78 clinics from 46 states and territories. Of these clinics, 31 (39.7%) offered both cervical cancer screening and HPV vaccination, 6 (7.7%) offered cervical cancer screening only, 21 (26.9%) offered HPV vaccination only, and 20 (25.6%) offered neither cervical cancer prevention service. Among those not offering the service, the most commonly reported barrier to cervical cancer screening was time constraints (25/41, 61.0%); for HPV vaccination it was reimbursement (11/26, 42.3%).

CONCLUSIONS

By early 2015, in a geographically diverse group of 78 STD clinics, 39.7% provided nationally recommended HPV vaccination and cervical cancer screening, whereas 25.6% provided neither. Further research could identify strategies for STD clinics to reduce HPV-associated cancers by increasing provision of HPV vaccination and cervical cancer screening services, particularly among medically underserved populations.

Primary HPV testing recommendations of US providers, 2015

OBJECTIVE

To investigate the HPV testing recommendations of US physicians who perform cervical cancer screening.

METHODS

Data from the 2015 DocStyles survey of U.S. health care providers were analyzed using multivariate logistic regression to identify provider characteristics associated with routine recommendation of primary HPV testing for average-risk, asymptomatic women ≥30years old. The analysis was limited to primary care physicians and obstetrician-gynecologists who performed cervical cancer screening (N=843).

RESULTS

Primary HPV testing for average-risk, asymptomatic women ≥30years old was recommended by 40.8% of physicians who performed cervical cancer screening, and 90.1% of these providers recommended primary HPV testing for women of all ages. The screening intervals most commonly recommended for primary HPV testing with average-risk, asymptomatic women ≥30years old were every 3years (35.5%) and annually (30.2%). Physicians who reported that patient HPV vaccination status influenced their cervical cancer screening practices were almost four times more likely to recommend primary HPV testing for average-risk, asymptomatic women ≥30years old than other providers (Adj OR=3.96, 95% CI=2.82-5.57).

CONCLUSION

Many US physicians recommended primary HPV testing for women of all ages, contrary to guidelines which limit this screening approach to women ≥25years old. The association between provider recommendation of primary HPV testing and patient HPV vaccination status may be due to anticipated reductions in the most oncogenic HPV types among vaccinated women.