Screening for cervical cancer: will women accept less?

Factors associated with women's supplemental screening intentions following dense breast notification in an online randomised experimental study

Controversy surrounding recommendations for supplemental screening (ultrasound and magnetic resonance screening) in women with dense breasts exists, as the long-term benefits from these additional modalities may not outweigh the harms. This study aimed to examine factors associated with supplemental screening intentions following a hypothetical breast density notification in a population of women who have not been routinely notified. Australian women of breast screening age participated in an online randomised experimental study where they were presented with one of two breast density notifications (with or without health literacy-sensitive information) and asked their screening intentions. After adjusting for covariates in multivariable analyses, women in both groups (n = 940) who indicated higher levels of breast cancer worry, had private health insurance, had a family history of breast cancer, and had a greater number of times previously attending mammography screening had higher intentions for supplemental screening. Understanding women's supplemental screening intentions following notification of dense breasts has important implications for health systems with breast screening considering the impacts of widespread notification. Personal, clinical and psychological factors should be considered when discussing both the benefits and harms of supplemental screening with women with dense breasts.

Correlates of premature pap test screening, under 25 years old: analysis of data from the CONSTANCES cohort study

Background

Many countries currently recommend that screening for cervical cancer begin at the age of 25 years. Premature screening (before that age) could lead to unnecessary follow-up examinations and procedures that turn out to be useless. Our objective is to ascertain if the use of particular contraceptive methods are associated with premature screening.

Methods

This cross-sectional study based on the CONSTANCES cohort enabled us to include 4297 women younger than 25 years. The factors associated with premature screening were modeled by logistic regression. Missing data were handled by multiple imputations. The multivariate analyses were adjusted for sex life, social and demographic characteristics, and health status.

Results

Nearly half (48.5%) the women younger than 25 years had already undergone premature screening. Women not using contraceptives (aOR 0.3, 95% CI 0.3–0.5) and those using nonmedicalized contraceptives (condom, spermicide, etc.) (aOR 0.5, 95% CI 0.4–0.6) had premature screening less often than women using birth control pills. Higher risks of premature screening were observed in 20-year-old women (aOR 2.7, 95% CI 2.2–3.3) and in those with more than 5 lifetime partners (aOR 2.5, 95% CI 2.0–3.1), compared respectively with women who were younger and those with 5 or fewer lifetime partners.

Conclusion

Young women using contraceptives that require a doctor’s prescription are exposed to premature screening more often than those not using contraception and those with nonmedicalized contraceptives.

Discussing Cervical Cancer Screening Options: Outcomes to Guide Conversations Between Patients and Providers

Purpose. In 2018, the US Preventive Services Task Force (USPSTF) endorsed three strategies for cervical cancer screening in women ages 30 to 65: cytology every 3 years, testing for high-risk types of human papillomavirus (hrHPV) every 5 years, and cytology plus hrHPV testing (co-testing) every 5 years. It further recommended that women discuss with health care providers which testing strategy is best for them. To inform such discussions, we used decision analysis to estimate outcomes of screening strategies recommended for women at age 30. Methods. We constructed a Markov decision model using estimates of the natural history of HPV and cervical neoplasia. We evaluated the three USPSTF-endorsed strategies, hrHPV testing every 3 years and no screening. Outcomes included colposcopies with biopsy, false-positive testing (a colposcopy in which no cervical intraepithelial neoplasia grade 2 or worse was found), treatments, cancers, and cancer mortality expressed per 10,000 women over a shorter-than-lifetime horizon (15-year). Results. All strategies resulted in substantially lower cancer and cancer death rates compared with no screening. Strategies with the lowest likelihood of cancer and cancer death generally had higher likelihood of colposcopy and false-positive testing. Conclusions. The screening strategies we evaluated involved tradeoffs in terms of benefits and harms. Because individual women may place different weights on these projected outcomes, the optimal choice for each woman may best be discerned through shared decision making.

Population preferences for breast cancer screening policies: Discrete choice experiment in Belarus

BACKGROUND

Reaching an acceptable participation rate in screening programs is challenging. With the objective of supporting the Belarus government to implement mammography screening as a single intervention, we analyse the main determinants of breast cancer screening participation.

METHODS

We developed a discrete choice experiment using a mixed research approach, comprising a literature review, in-depth interviews with key informants (n = 23), "think aloud" pilots (n = 10) and quantitative measurement of stated preferences for a representative sample of Belarus women (n = 428, 89% response rate). The choice data were analysed using a latent class logit model with four classes selected based on statistical (consistent Akaike information criterion) and interpretational considerations.

RESULTS

Women in the sample were representative of all six geographic regions, mainly urban (81%), and high-education (31%) characteristics. Preferences of women in all four classes were primarily influenced by the perceived reliability of the test (sensitivity and screening method) and costs. Travel and waiting time were important components in the decision for 34% of women. Most women in Belarus preferred mammography screening to the existing clinical breast examination (90%). However, if the national screening program is restricted in capacity, this proportion of women will drop to 55%. Women in all four classes preferred combined screening (mammography with clinical breast examination) to single mammography. While this preference was stronger if lower test sensitivity was assumed, 28% of women consistently gave more importance to combined screening than to test sensitivity.

CONCLUSION

Women in Belarus were favourable to mammography screening. Population should be informed that there are no benefits of combined screening compared to single mammography. The results of this study are directly relevant to policy makers and help them targeting the screening population.

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.

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.

Changes in Knowledge and Beliefs About Human Papillomavirus and Cervical Cancer Screening Intervals in Low-Income Women After an Educational Intervention

INTRODUCTION

Women have been reluctant to adopt longer than annual intervals for cervical cancer screening, despite guidelines recommending screening every 3 to 5 years. Our study assessed patient knowledge and beliefs about human papillomavirus (HPV) and cervical cancer screening after exposure to an educational intervention, and whether there was a change in time regarding knowledge and beliefs among all study participants in an underserved population.

METHOD

The study was conducted in 15 clinics associated with 6 Federally Qualified Health Centers in Illinois, USA. Cervical cancer screening patients (n = 644) completed a baseline and postintervention follow-up survey. The intervention included an HPV test and an educational pamphlet. Significance testing of changes in knowledge and beliefs was conducted with multilevel, mixed-effects models adjusting for repeated measures of patients and clustering within clinics.

RESULTS

No significant differences in study outcomes were found between the intervention and control groups. Among all women, knowledge of HPV significantly improved over time. At follow-up, fewer women reported that having a co-test is good, wise, will give you peace of mind, will tell you whether you need to worry if Pap is abnormal, is something your doctor thinks you should have, and will give you the best care available. More women said it would be bad, useless, or worrying to wait 3 years for a Pap test at follow-up.

CONCLUSION

HPV knowledge improved over time, but the educational intervention utilized in this study was not successful in improving attitudes and beliefs about co-testing and longer screening intervals, and beliefs about HPV co-testing and 3-year screening intervals were less favorable. Having health care providers discuss the consequences of overscreening and the natural history of HPV and cervical cancer with their patients may help increase adherence to longer screening intervals. Further examination of the essential components for educational intervention in this population is warranted.

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 in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians

DESCRIPTION

The purpose of this best practice advice article is to describe the indications for screening for cervical cancer in asymptomatic, average-risk women aged 21 years or older.

METHODS

The evidence reviewed in this work is a distillation of relevant publications (including systematic reviews) used to support current guidelines.

BEST PRACTICE ADVICE 1

Clinicians should not screen average-risk women younger than 21 years for cervical cancer.

BEST PRACTICE ADVICE 2

Clinicians should start screening average-risk women for cervical cancer at age 21 years once every 3 years with cytology (cytologic tests without human papillomavirus [HPV] tests).

BEST PRACTICE ADVICE 3

Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years.

BEST PRACTICE ADVICE 4

Clinicians may use a combination of cytology and HPV testing once every 5 years in average-risk women aged 30 years or older who prefer screening less often than every 3 years.

BEST PRACTICE ADVICE 5

Clinicians should not perform HPV testing in average-risk women younger than 30 years.

BEST PRACTICE ADVICE 6

Clinicians should stop screening average-risk women older than 65 years for cervical cancer if they have had 3 consecutive negative cytology results or 2 consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years.

BEST PRACTICE ADVICE 7

Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.

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.

Adherence to the 2012 national cervical cancer screening guidelines: a pilot study

OBJECTIVE

The goal of this pilot study was to evaluate adherence to the 2012 cervical cancer screening guidelines among health care providers in a large health maintenance organization.

STUDY DESIGN

A cross-sectional survey evaluating knowledge, reported practices, and views of the 2012 cervical cancer screening guidelines was distributed to 325 health care providers within HealthPartners. The survey was divided into 3 sections: (1) provider demographics; (2) knowledge of the 2012 age-specific cancer screening guidelines; and (3) provider practice. Comparisons based on appropriate knowledge and practice of the guidelines were made using Fisher exact tests.

RESULTS

The response rate was 42%. Of 124 respondents, 15 (12.1%) reported they were not aware of the 2012 guideline changes. Only 7 (5.7%) respondents answered all the knowledge questions correctly. A majority of respondents reported correct screening practices in the 21-29 year patient age group (65.8%) and in the >65 year patient age group (74.3%). Correct screening intervals in the 30-65 year patient age group varied by modality, with 89.3% correctly screening every 3 years with Pap smear alone, but only 57.4% correctly screening every 5 years with Pap smear + human papillomavirus cotesting. The most frequently cited reasons for not adhering were lack of knowledge of the guidelines and patient demand for a different screening interval.

CONCLUSION

Adherence to the 2012 cervical cancer screening guidelines is poor due, in part, to a lack of knowledge of the guidelines. Efforts should focus on improved provider and patient education, and methods that facilitate adherence to the guidelines such as electronic health record order sets.

Women's intentions to receive cervical cancer screening with primary human papillomavirus testing

We explored the potential impact of human papillomavirus (HPV) testing on women's intentions to be screened for cervical cancer in a cohort of Canadian women. Participants aged 25-65 years from an ongoing trial were sent a questionnaire to assess women's intentions to be screened for cervical cancer with HPV testing instead of Pap smears and to be screened every 4 years or after 25 years of age. We created scales for attitudes about HPV testing, perceived behavioral control, and direct and indirect subjective norms. Demographic data and scales that were significantly different (p < 0.1) between women who intended to be screened with HPV and those who did not intend were included in a stepwise logistic regression model. Of the 2,016 invitations emailed, 1,538 were received, and 981 completed surveys for a response rate of 63% (981/1,538). Eighty-four percent of women (826/981) responded that they intended to attend for HPV-based cervical cancer screening, which decreased to 54.2% when the screening interval was extended, and decreased further to 51.4% when screening start was delayed to age of 25. Predictors of intentions to undergo screening were attitudes (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.15, 1.30), indirect subjective norms (OR: 1.02; 95% CI: 1.01, 1.03) and perceived behavioral control (OR: 1.16; 95% CI: 1.10; 1.22). Intentions to be screened for cervical cancer with HPV testing decreased substantially when the screening interval was extended and screening started at age of 25. Use of primary HPV testing may optimize the screening paradigm, but programs should ensure robust planning and education to mitigate any negative impact on screening attendance rates.

Patient knowledge and beliefs as barriers to extending cervical cancer screening intervals in Federally Qualified Health Centers

OBJECTIVE

Despite guidelines recommending cervical cancer screening intervals be extended beyond one year, clinical practice has been slow to change. Patient preferences are a potential barrier. In the Centers for Disease Control's Cervical Cancer (Cx3) Study at Federally Qualified Health Centers (FQHCs) across Illinois, we surveyed patients about screening practices, and assessed beliefs regarding lengthening screening intervals.

METHOD

We analyzed data from 984 low income women in the Cx3 Study (2009-2011). Participants completed a survey assessing health history, knowledge about Pap testing, beliefs and intentions about extending screening intervals, and demographics.

RESULTS

The majority reported annual Pap testing (61%), while only 24% reported a 2-3 year screening interval (recommendation at time of survey). Misunderstandings about the Pap test were prevalent, with over half believing it screened for vaginal, yeast, and sexually transmitted infections (58%-72%). Unfavorable beliefs about extending screening intervals were common. The majority (57%) indicated that they would not wait 3 years to be screened if their physician recommended it, and intentions were associated with knowledge about Pap testing.

CONCLUSION

Most women reported annual cervical cancer screening, and intended to resist longer screening intervals. Patients' lack of knowledge and unfavorable beliefs may serve as barriers to extending screening intervals.

Primary care provider practices and beliefs related to cervical cancer screening with the HPV test in Federally Qualified Health Centers

OBJECTIVE

Cervical cancer screening using the human papillomavirus (HPV) test and Pap test together (co-testing) is an option for average-risk women ≥ 30 years of age. With normal co-test results, screening intervals can be extended. The study objective is to assess primary care provider practices, beliefs, facilitators and barriers to using the co-test and extending screening intervals among low-income women.

METHOD

Data were collected from 98 providers in 15 Federally Qualified Health Center (FQHC) clinics in Illinois between August 2009 and March 2010 using a cross-sectional survey.

RESULTS

39% of providers reported using the co-test, and 25% would recommend a three-year screening interval for women with normal co-test results. Providers perceived greater encouragement for co-testing than for extending screening intervals with a normal co-test result. Barriers to extending screening intervals included concerns about patients not returning annually for other screening tests (77%), patient concerns about missing cancer (62%), and liability (52%).

CONCLUSION

Among FQHC providers in Illinois, few administered the co-test for screening and recommended appropriate intervals, possibly due to concerns over loss to follow-up and liability. Education regarding harms of too-frequent screening and false positives may be necessary to balance barriers to extending screening intervals.

Cervical cancer screening among young adult women in the United States

BACKGROUND

Cervical cancer screening guidelines have evolved significantly in the last decade for young adult women, with current recommendations promoting later initiation and longer intervals.

METHODS

Using self-reported cross-sectional National Health Interview Survey (NHIS) 2000-2010 data, trends in Papanicolaou (Pap) testing among women ages 18-29 years were examined. NHIS 2010 data were used to investigate age at first Pap test (N = 2,198), time since most recent Pap test (n = 1,622), and predictors of Pap testing within the last 12 months (n = 1,622).

RESULTS

The percentage of 18-year-olds who reported ever having a Pap test significantly decreased from 49.9% in 2000 to 37.9% in 2010. Mean age at first Pap test in 2010 was significantly younger for non-Hispanic black women (16.9 years), women < high school education (16.9 years), women who received the HPV vaccine (17.1 years), and women who have ever given birth (17.3 years). The majority reported their last Pap test within the previous 12 months (73.1%). Usual source of healthcare (OR, 2.31) and current birth control use (OR, 1.64) significantly increased chances of having a Pap test within the previous 12 months.

CONCLUSIONS

From 2000 to 2010, there was a gradual decline in Pap test initiation among 18-year-olds; however, in 2010, many women reported ≤12 months since last screening. Evidence-based guidelines should be promoted, as screening young adult women for cervical cancer more frequently than recommended can cause considerable harms.

IMPACT

A baseline of cervical cancer screening among young adult women in the United States to assess adherence to evidence-based screening guidelines.

Physicians' intentions to change pap smear frequency following human papillomavirus vaccination

STUDY OBJECTIVE

We evaluated factors associated with physicians' intentions to perform Pap smears in human papillomavirus-vaccinated women.

DESIGN

Physicians were mailed a survey asking about intentions to change cervical cancer screening based on patients' human papillomavirus vaccination status.

PARTICIPANTS

A national sample of 1,738 Family Physicians, Internal Medicine Physicians, Pediatricians, and Obstetricians and Gynecologists was selected from the American Medical Association Physician Masterfile. Completed surveys were received from 1,118 physicians, of which 791 were included in the analyses.

MAIN OUTCOME MEASURES

Bivariate analyses compared physician, practice, and patient characteristics by intention change screening frequency. Significant variables were included in a multivariable logistic regression model.

RESULTS

Overall, 81.8% (n = 647) of physicians reported not planning to change Pap smear frequency for vaccinated women. Internal Medicine physicians were significantly more likely than Obstetrician/Gynecologists to report intentions to change frequency for vaccinated patients. Other factors significantly associated with the intention to change frequency were self-identification as a late adopter of new vaccines, a solo practice, and practicing primarily in a clinic or hospital-based setting.

CONCLUSIONS

Although it appears most clinicians understand that human papillomavirus vaccination should not alter current screening practices, there is a need to develop and evaluate interventions for physicians who are likely to change their screening pattern based on human papillomavirus vaccination receipt.

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from six working groups, and a recent symposium co-sponsored by the ACS, American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP), which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (e.g., management of screen positives and screening interval for screen negatives) of women after screening, age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16/18 infections.

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from 6 working groups, and a recent symposium cosponsored by the ACS, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (eg, the management of screen positives and screening intervals for screen negatives) of women after screening, the age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16 and HPV18 infections.

Recency of Pap testing and future testing plans among women aged 18-64: analysis of the 2007 Health Information National Trends Survey

BACKGROUND

Cervical cancer incidence has declined as a result of Papanicolaou (Pap) test use. Current guidelines recommend increasing screening intervals for women of average risk. The objective of this study is to examine current screening intervals, factors associated with recency of Pap testing, and future testing plans.

METHODS

We analyzed data from 2915 female respondents, aged 18-64, using the 2007 Health Information National Trends Survey (HINTS), a biennial national survey of access and use of cancer information in the United States. We divided time since last Pap test into ≤1 year (n=1960), >1 to ≤3 years (n=512), >3 years/never had Pap test (n=443). We performed univariate analyses and multivariate logistic regression, using proportional odds model with cumulative logit link.

RESULTS

Sixty-five percent of women had their most recent Pap test within 1 year. Most expected to be screened again within 1 year (81%). This expectation was highest among women who were tested within the previous year (90.9%). Having had a test within 1 year was positively associated with age groups 31-45 vs. 46-64 years; with being non-Hispanic black vs. non-Hispanic white; with being a college graduate vs. having less education; with being married, divorced, or separated vs. widowed; with having at least one visit to a healthcare provider in the past year; and with being aware of the human papillomavirus (HPV).

CONCLUSIONS

Most women currently are tested and anticipate future testing at annual intervals. To implement guidelines, increased communication and systematic or policy changes may be needed to reduce overtesting.

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from 6 working groups, and a recent symposium cosponsored by the ACS, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (eg, the management of screen positives and screening intervals for screen negatives) of women after screening, the age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16 and HPV18 infections.

Attitudes toward preventive services and lifestyle: the views of primary care patients in Europe. the EUROPREVIEW patient study

BACKGROUND

For preventive interventions in general practice to succeed, patients' points of view must be taken into account in addition to those of GPs.

OBJECTIVE

To explore patients' views and beliefs about the importance of lifestyle and preventive interventions, to assess their readiness to make changes to their lifestyle and their willingness to receive support from GPs.

METHODS

Cross-sectional survey conducted by EUROPREV in primary care practices in 22 European countries. Patients were consecutively selected and interviewed from September 2008 to September 2009.

RESULTS

Seven thousand nine hundred and forty-seven participants, 52.2% females. Only 30.5% of risky drinkers think they need to change, as opposed to 64% of smokers, 73.5% of patients with unhealthy eating habits and 73% with lack of physical activity. Risky drinkers reported that GPs initiated a discussion on alcohol consumption less often (42%) than on smoking (63%), eating habits (59%) or physical activity (55%). Seventy-five per cent, 66% and 63% of patients without hypertension, diabetes or hypercholesterolaemia, respectively, think blood pressure, blood sugar and serum cholesterol should be checked yearly. Women (80%) think they should be screened with the cervical smear test and 72.8% of women aged 30-49 years with mammography, yearly or every 2 years.

CONCLUSIONS

A high proportion of patients attending primary care with unhealthy lifestyles (especially risky drinkers) do not perceive the need to change their habits, and about half the patients reported not having had any discussion on healthy lifestyles with their GPs. Patients overestimate their need to be screened for cardiovascular risk factors and for cancer.

Beliefs about cervical cancer screening among Turkish married women

Cervical cancer can be prevented by having a Pap test aiming for early screening. This study was planned to determine the beliefs of women about cervical cancer and the influencing factors. The cross-sectional study was conducted in Sarıyer, one of the most densely populated districts of Istanbul, which is the most crowded city in Turkey. This study sample included 300 women receiving training at public education centers. The data for the study were collected with "HBM-based scale" developed by Bryd et al. upon the basis of health belief model. The mean of the women's ages was determined as 33.9 ± 10.6. Considering the beliefs of the women who haven't had a Pap test about cervical cancer, it was determined that 75.7% of the women participating in the survey thought "I am not at risk for cervical cancer". Logistic regression analysis was carried out in order to find out the most decisive variable among the reasons for not having a Pap test, and it was determined that the factors stated as "I don't know where I could go if I wanted a Pap test" was a four times factor. This study demonstrated that the main determinant factor affecting CCS behaviors of married women is beliefs. It is considered that the results from this study could be basic data for cervical cancer early screening and educational programs.

What Australian women want and when they want it: cervical screening testing preferences, decision-making styles and information needs

BACKGROUND

New testing technologies and human papillomavirus (HPV) vaccines have recently brought changes to cervical cancer screening. In 2006, the Australian government also changed the protocol for managing abnormal Pap smears. Australian women's attitudes and preferences to these changes are largely unknown. Quantitative data on information needs and community attitudes to informed decision making in screening in Australia are also limited.

OBJECTIVE

This national study measures women's preferences for testing and management of abnormal screening results, preferred decision-making styles and information needs for cervical cancer screening.

DESIGN

A randomly selected sample of Australian women aged 18-70 participated in a structured telephone questionnaire, exploring testing preferences, information and decision-making needs.

RESULTS

A total of 1279, of 1571 eligible women, participated in the study with an overall response rate of 81.4%. Half of the women (n = 637) preferred having their Pap smears at least annually, and 85% wanted concurrent HPV testing. A large proportion of women preferred to be involved in decision making for both routine Pap smears (87%) and follow-up for abnormal results (89%). The majority of women wanted information on screening risks (70%) and benefits (77%); of these 81 (85%) wanted this information before screening. However, 63% of women only wanted information about follow-up examinations if they had an abnormal Pap test result.

CONCLUSION

Australian women want to be involved in decision making for cervical cancer screening and require information on the risks and benefits of Pap testing prior to undergoing any screening.

US physicians' intentions regarding impact of human papillomavirus vaccine on cervical cancer screening

BACKGROUND

US cervical cancer screening recommendations have not changed since the human papillomavirus (HPV) vaccine introduction in 2006, but epidemiological and cost-effectiveness studies indicate that recommendations will need to change for fully vaccinated women. We evaluated physician intentions regarding HPV vaccine's impact on future screening.

METHODS

A nationally representative sample of 1212 primary care physicians was surveyed in 2006-2007 (response rate: 67.5%). Our study included 1114 physicians who provided Pap testing. Questions covered Pap test screening practices and intentions regarding HPV vaccine's impact on screening. Distribution differences were assessed using chi(2) statistics; multivariate analyses were performed.

RESULTS

Overall, 40.7% (95% confidence interval (CI): 37.6-43.8%) of physicians agreed that the HPV vaccine will affect screening initiation, and 38.2% (35.0-41.5%) agreed that vaccination will affect screening frequency. Significant differences in responses were found by specialty; internists were more likely to agree that vaccination would impact screening than other specialties. Belief in the effectiveness of new screening technologies was associated with intention to change screening initiation (odds ratio (OR) = 1.66 (1.20-2.31)) and frequency (OR = 1.99 (1.40-2.83)). Adherence to current Pap test screening interval guidelines was associated with intention to change screening frequency (OR = 1.39 (1.01-1.91)).

CONCLUSIONS

Many providers anticipate adjusting screening for vaccinated women, but a significant group believes nothing will change or are unsure. The present study provides important baseline data on intentions in the period preceding widespread vaccine diffusion and may help explain current and future trends in practice patterns.

How does public policy impact cervical screening and vaccination strategies?

OBJECTIVES

To examine the current approaches to cervical screening and points to consider for improving HPV vaccination acceptance and uptake in the US.

METHODS

An expert forum was conducted September 12-13, 2008, by the Society of Gynecologic Oncologists including 56 experts in cervical cancer and titled "Future Strategies of Cervical Cancer Prevention: What Do We Need to Do Now to Prepare?".

RESULTS

Cervical cancer prevention has primarily relied on screening paradigms but vaccination against human papillomavirus (HPV), the cause of the disease, is a primary preventative measure that has been recommended by all cervical cancer screening stakeholders. Guidelines for vaccination are developed by national advisory groups, but successful implementation requires a supportive infrastructure and the cooperation of providers, clinicians, and patients. HPV vaccination has been available in the United States (US) since 2006 and screening practices have been updated to also include HPV genotyping. However, many clinicians fail to adhere to the guidelines for HPV testing (and HPV co-testing) as part of cervical cancer screening, and vaccination coverage has been poor among females aged 11 and 12, the group for which vaccination is recommended by all organizations.

CONCLUSIONS

The data reviewed and presented in this session of the "Future Strategies of Cervical Cancer Prevention. What Do We Need to do Now to Prepare?". The Forum suggests that the policies influencing HPV vaccination and screening need to be reassessed at multiple levels in order to achieve more effective implementation and regular use.

Too much of a good thing? Physician practices and patient willingness for less frequent pap test screening intervals

BACKGROUND

Recent guidelines recommend longer Pap test intervals. However, physicians and patients may not be adopting these recommendations.

OBJECTIVES

Identify (1) physician and practice characteristics associated with recommending a less frequent interval, and (2) characteristics associated with women's willingness to adhere to a 3-year interval.

RESEARCH DESIGN

We used 2 national surveys: (1) a 2006/2007 National Survey of Primary Care Physicians for physician cervical cancer screening practices (N = 1114), and (2) the 2005 Health Information Trends Survey for women's acceptance of longer Pap intervals (N = 2206). MEASURES AND METHODS: Physician recommendation regarding Pap intervals was measured using a clinical vignette involving a 35-year-old with no new sexual partners and 3 consecutive negative Pap tests; associations with independent variables were evaluated with logistic regression. In parallel models, we evaluated women's willingness to follow a 3-year Pap test interval.

RESULTS

A minority of physicians (32%) have adopted-but more than half of women are willing to adopt-3-year Pap test intervals. In adjusted models, physician factors associated with less frequent screening were: serving a higher proportion of Medicaid patients, white, non-Hispanic race, fewer years since medical school graduation, and US Preventive Services Task Force being very influential in physician clinical practice. Women were more willing to follow a 3-year interval if they were older, but less willing if they had personal or family experiences with cancer or followed an annual Pap test schedule.

CONCLUSIONS

Many women are accepting of a 3-year interval for Pap tests, although most primary care physicians continue to recommend shorter intervals.

Overuse of mammography during the first round of an organized breast cancer screening programme

OBJECTIVES

We examined the frequency of mammography screening among women who had had a screening mammogram recently and therefore generally did not need to repeat the examination.

METHODS

A population-based sample of 50- to 69-year-old women were surveyed immediately before and 8 months after they received an invitation to participate in the first round of screening of the newly organized mammography screening programme in Geneva, Switzerland. These women also received a booklet that included the recommendation to have screening mammograms at 2-year intervals.

RESULTS

The baseline survey identified 660 women who had had a mammogram within the previous 12 months. Of these, 23.2% [95% confidence interval (CI), 20.0-26.6] had an opportunistic mammogram and 4.1% (95% CI, 2.7-5.9) had an organized mammogram during follow-up. Women who had had their last mammogram 6-12 months prior to baseline (vs. more recently), intended to have a mammogram within the next 6 months, wished to receive more information on mammography screening, and had a history of surgical breast biopsy were more likely to have an unnecessary screening mammogram (either organized or opportunistic) during follow-up. Compared with women who had an opportunistic mammogram, women who had an organized mammogram were more likely to be of lower socioeconomic status, to have made their own screening decision and to have anticipated the date of their next mammogram by no more than a few months.

CONCLUSIONS

Opportunistic mammography screening in excess of recommendation is common, and persists despite explicit advice about recommended screening frequency.

The impact of human papillomavirus vaccination on cervical cancer prevention efforts

OBJECTIVES

To review concepts, information, obstacles, and approaches to cervical cancer screening and prevention as vaccination against human papillomavirus (HPV) types 16 and 18 is adopted.

METHODS

Expert forum, conducted September 12-13, 2008, hosted by the Society of Gynecologic Oncologists, including 56 experts in cervical cancer and titled Future Strategies of Cervical Cancer Prevention: What Do We Need to Do Now to Prepare?

RESULTS

The current approach to cervical cancer screening in the U.S. is limited by its opportunistic nature. If given to women before exposure, a vaccine against HPV 16,18 can decrease cervical cancer risk by up to 70%. The impact on abnormal cytology and cervical intraepithelial neoplasia (CIN) will be less but still substantial. As the prevalence of high-grade CIN falls, fewer women with positive screening tests will have truly preinvasive disease. To minimize harm from false positive tests in women who are at low risk for cancer because of early vaccination, later initiation of and longer intervals between screenings are ideal. However, the vaccine is less effective when administered after first intercourse, and delivering and documenting HPV vaccination to girls at optimal ages may prove difficult.

CONCLUSIONS

Until population-based data on the performance of cytology, HPV testing, and alternate screening or triage interventions become available, modifying current screening guidelines is premature. Current recommendations to initiate screening as late as age 21 and to screen less often than annually are appropriate for young women known to have been vaccinated before first intercourse.

Ending cervical cancer screening: attitudes and beliefs from ethnically diverse older women

OBJECTIVE

Guidelines support ending cervical cancer screening in women aged 65-70 years and older with previous normal testing, but little is known about older women's attitudes and beliefs about ending screening.

STUDY DESIGN

We conducted face-to-face interviews with 199 women aged 65 and older in English, Spanish, Cantonese, or Mandarin.

RESULTS

Most interviewees were nonwhite (44.7% Asian, 18.1% Latina, and 11.6% African American). Most (68%) thought lifelong screening was either important or very important, a belief held more strongly by African American (77%) and Latina (83%) women compared with women in other ethnic groups (P < .01). Most (77%) had no plans to discontinue screening or had ever thought of discontinuing (69%). When asked if they would end screening if recommended by their physician, 68% responded "yes."

CONCLUSION

The majority of these women believe that lifelong cervical cancer screening is important. Many women, however, reported that they would end screening if recommended by their physician.

Does patient health and hysterectomy status influence cervical cancer screening in older women?

BACKGROUND

Decisions to screen older patients for cancer are complicated by the fact that aging populations are heterogeneous with respect to life expectancy.

OBJECTIVE

To examine national trends in the association between cervical cancer screening and age, health and hysterectomy status.

DESIGN AND PARTICIPANTS

Cross-sectional data from the 1993, 1998, 2000, and 2005 National Health Interview Surveys (NHIS) were used to examine trends in screening for women age 35-64 and 65+ years of age. We investigated whether health is associated with Pap testing among older women using the 2005 NHIS (N = 3,073). We excluded women with a history of cervical cancer or who had their last Pap because of a problem.

MEASUREMENTS

The dependent variable was having a Pap test within the past 3 years. Independent variables included three measures of respondent health (the Charlson comorbidity index (CCI), general health status and having a chronic disability), hysterectomy status and sociodemographic factors.

MAIN RESULTS

NHIS data showed a consistent pattern of lower Pap use among older women (65+) compared to younger women regardless of hysterectomy status. Screening also was lower among older women who reported being in fair/poor health, having a chronic disability, or a higher CCI score (4+). Multivariate models showed that over 50% of older women reporting poor health status or a chronic disability and 47% with a hysterectomy still had a recent Pap.

CONCLUSIONS

Though age, health and hysterectomy status appear to influence Pap test use, current national data suggest that there still may be overutilization and inappropriate screening of older women.

Older patients perceptions of "unnecessary" tests and referrals: a national survey of Medicare beneficiaries

CONTEXT

Unnecessary exposure to medical interventions can harm patients. Many hope that generalist physicians can limit such unnecessary exposure.

OBJECTIVE

To assess older Americans' perceptions of the need for tests and referrals that their personal physician deemed unnecessary.

DESIGN

Telephone survey with mail follow-up in English and Spanish, conducted from May to September 2005 (overall response rate 62%).

STUDY PARTICIPANTS

Nationally representative sample of 2,847 community-dwelling Medicare beneficiaries. Main analyses focus on the 2,319 who had a personal doctor ("one you would see for a check-up or advice if you were sick") whom they described as a generalist ("doctor who treats many different kinds of problems").

MAIN OUTCOME MEASURE

Proportion of respondents wanting a test or referral that their generalist suggested was not necessary using 2 clinical vignettes (cough persisting 1 week after other flu symptoms; mild but definite chest pain lasting 1 week).

RESULTS

Eighty-two percent of Medicare beneficiaries had a generalist physician; almost all (97%) saw their generalist at least once in the past year. Among those with a generalist, 79% believed that it is "better for a patient to have one general doctor who manages most of their medical problems" than to have each problem cared for by a specialist. Nevertheless, when faced with new symptoms, many would want tests and referrals that their doctor did not think necessary. For a cough persisting 1 week after flu symptoms, 34% would want to see a lung specialist even if their generalist told them they "probably did not need to see a specialist but could if they wanted to." For 1 week of mild but definite chest pain when walking up stairs, 55% would want to see a heart specialist even if their generalist did not think it necessary. In these same scenarios, even higher proportions would want diagnostic testing; 57% would want a chest x-ray for the cough, and 74% would want "special tests" for the chest pain.

CONCLUSIONS

When faced with new symptoms, many older patients report that they would want a diagnostic test or specialty referral that their generalist thought was unnecessary. Generalists striving to provide patient-centered care while at the same time limiting exposure to unnecessary medical interventions will need to address their patients' perceptions regarding the need for these services.

Preferences for human papillomavirus testing with routine cervical cancer screening in diverse older women

BACKGROUND

Human papillomavirus (HPV) testing is increasingly being used to determine the optimal cervical cancer screening interval in older women. Little is known about women's attitudes toward HPV testing or how these attitudes may influence medical discussions about cervical cancer screening.

METHODS

Preferences for HPV and concomitant Papanicolaou (Pap) testing were assessed through in-person interviews with diverse women aged 50 to 80 years recruited from community and university-based practices.

RESULTS

Eight hundred and sixty-five women (257 White, 87 African American, 149 Latina, and 372 Asian) were interviewed. Approximately 60% of participants wanted to be tested for HPV and another 15% would undergo testing if recommended by their physician. Among those wanting HPV testing, 94% would want more frequent than annual Pap tests if they had a positive HPV test and a normal Pap test. Two thirds of those under age 65 would be willing to switch to triennial Pap testing, and half of those aged 65 and older would be willing to discontinue Pap testing, if they had a negative HPV test and normal Pap test. Preferences for testing varied by ethnicity, age, place of birth, and cancer history.

CONCLUSIONS

The majority of older women were willing to use HPV testing to make decisions about frequency and duration of cervical cancer screening, but up to one third would want at least annual, ongoing screening regardless of HPV test results. Efforts should be made to ensure that HPV testing is used to reinforce appropriate utilization of screening tests.

Lessons from cost-effectiveness research for United States public health policy

The application of cost-effectiveness analysis to health care has been the subject of previous reviews. We address the use of economic evaluation methods in public health, including case studies of population-level policies, e.g., environmental regulations, injury prevention, tobacco control, folic acid fortification, and blood product safety, and the public health promotion of clinical preventive services, e.g., newborn screening, cancer screening, and childhood immunizations. We review the methods used in cost-effectiveness analysis, the implications for cost-effectiveness findings, and the extent to which economic studies have influenced policy and program decisions. We discuss reasons for the relatively limited impact to date of economic evaluation in public health. Finally, we address the vexing question of how to decide which interventions are cost effective and worthy of funding. Policy makers have funded certain interventions with rather high cost-effectiveness ratios, notably nucleic acid testing for blood product safety. Cost-effectiveness estimates are a decision aid, not a decision rule.

Why do women participate in the English cervical cancer screening programme?

The vast majority of women in England attend for cervical cancer screening. Conventional economic theorising fails to explain why and its predictions are inconsistent with the evidence. Using questionnaire data, we analyse directly motivations for screening attendance. We conclude that regular attendance at screening is driven primarily by a search for reassurance, a sense of duty and herd signalling. It is evident that recognisable sub-groups of attenders exist, in which the configurations of motivational factors differ. Being motivated to attend by physicians is less significant that is widely supposed and is more frequently associated with irregular attendance.

Women's experiences of repeated HPV testing in the context of cervical cancer screening: a qualitative study

OBJECTIVE

To evaluate the psychosocial impact of taking part in repeated testing for human papillomavirus (HPV) in the context of cervical cancer screening.

METHODS

In-depth interviews were carried out with 30 women who were HPV positive with normal cytology at trial baseline, and attended for a repeat HPV test 12 months later. Interview transcripts were analysed qualitatively using Framework Analysis to identify emergent themes.

RESULTS

Although women often experienced serious negative emotional consequences at the time of their first positive result, these did not generally last during the year between tests once questions about HPV had been resolved. The emotional impact of testing positive a second time was greater for many women, sometimes causing them to overcome their embarrassment about having a sexually transmitted infection in order to disclose their result and seek support. Among the women interviewed there was an overwhelming preference for immediate colposcopy rather than continued surveillance for persistent HPV. This was associated with the desire for a speedy resolution, and fears about progression to cancer.

CONCLUSIONS

Although most women did not appear to suffer on-going anxiety while waiting for a second HPV test, this seemed contingent on their information needs being met. Women appeared to be more distressed by a second HPV positive result than a single one, and expressed a clear preference for immediate colposcopy over continued surveillance. This finding might have implications for the way in which HPV testing could be used in cervical cancer screening programmes.

Cost is a barrier to widespread use of liquid-based cytology for cervical cancer screening in Korea

This study aimed to document current cervical cancer screening practices of physicians in Korea. Questionnaires were distributed to 852 Korean obstetricians and gynecologists, who attended the 91st Conference of the Korean Society of Obstetrics and Gynecology held during May, 2005. Questionnaires were returned by 30.6% (260/852) of the recipients and 254 of these were eligible for analysis. Sixty-seven percent started cervical cancer screening women at age 20, and 65% replied that they would continue annual screening in a 35-yr-old woman with three consecutive normal cytologic tests. Over 65% of respondents preferred conventional cytologic screening to liquid-based cytology. The cost was a major determinant for selecting screening method. Fifty-three percent used the human papillomavirus DNA test as a triage for atypical squamous cells of undetermined significance. Our findings suggest that majority of Korean obstetricians and gynecologists in hospital prefer annual conventional cytologic testing to liquid-based cytology for financial reason.

Cervical cancer screening, abnormal cytology management, and counseling practices in the United States

OBJECTIVE

We assessed clinician knowledge and practices since the marketing of tests for sexually transmitted human papillomavirus (HPV) and the release of HPV testing guidelines for two indications: 1) as an adjunct to cytologic screening and 2) to guide colposcopic triage of patients with atypical squamous cells of undetermined significance (ASC-US) cytology results.

METHODS

In mid-2004, we surveyed nationally representative, random samples of clinicians practicing specialties that provide cytologic screening. Mail surveys addressed HPV-related knowledge, screening, abnormal cytology management, HPV testing, and counseling practices.

RESULTS

The overall adjusted response rate was 82%. Of the 2,980 (89%) clinicians providing cytologic screening, 99% knew that HPV infection increases cervical cancer risk, and 91% were aware of HPV tests. Of the 21% who reported ever using HPV tests as an adjunct to cytology, more reported usually testing patients aged less than 30 years (which guidelines do not recommend) than older patients (which guidelines do recommend). Of the 63% of clinicians who ever ordered HPV tests for abnormal cytology results, 84% usually ordered tests for ASC-US results and preferentially advised colposcopy if HPV tests were positive, as guidelines recommend. However, more than 60% usually ordered HPV tests for higher-grade abnormalities, which is not recommended for colposcopy triage. Although few sought HPV test consent, most discussed sexually transmitted HPV with patients with abnormal cytology or positive HPV tests despite potentially negative psychosocial consequences.

CONCLUSION

New HPV tests and testing guidelines have transformed screening, abnormal cytology management, and counseling practices. Although many U.S. clinicians reported using HPV tests according to guidelines, many also reported inappropriate use.

Report from the CDC. Pap test intervals used by physicians serving low-income women through the National Breast and Cervical Cancer Early Detection Program

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), administered by the Centers for Disease Control and Prevention (CDC), provides breast and cervical cancer screening to low-income women who are uninsured or underinsured. For women with three consecutive annual Pap tests with normal findings, the NBCCEDP supports extending the screening interval to every 3 years. Thirteen telephone focus groups were conducted with physician providers in 17 states and the District of Columbia to investigate familiarity with NBCCEDP's triennial Pap test policy, the Pap test intervals actually used, and the factors influencing screening interval selection. No participants were familiar with NBCCEDP's triennial Pap test policy, and none reported routinely extending the screening interval after three consecutive annual Pap tests with normal findings. Two patterns of screening interval use were reported: annual screeners continued performing yearly Pap tests, and selective extended screeners offered an extended interval to select patients. Annual and selective extended screeners reported that both unique and common factors influenced the screening intervals they used. The NBCCEDP has established its cancer screening priorities to focus limited resources on the goal of providing services to eligible women who have rarely or never been screened. Increased efforts are needed to educate physicians about the science supporting an extended Pap screening interval and overcome the barriers associated with its adoption.