Single Health System Adherence to 2012 Cervical Cancer Screening Guidelines at Extremes of Age and Posthysterectomy

Cervical Cancer Screening in Patients with Total Hysterectomy in a Diagnostic Center at Mexico City

BACKGROUND

The aim of this study was to outline the Pap smears rate done in women with total hysterectomy, sent to an urban diagnostic center that attends Mexican Government workers in the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE: State´s Employees´ Social Security and Social Services Institute) at Mexico City.

METHODS

It was a retrospective study on Pap smear reports taken in 2017. The reports came from users of four family medicine clinics and a general hospital´s gynecology service. Demographic facts, instruments for collection, kind of insurance (ISSSTE-insurance or non-insurance), and total hysterectomy history were evaluated.

RESULTS

From 4989 reports, 600 (12%) had a total hysterectomy history. In the patients with ISSSTE-insurance, 586 of 4618 (12.68%) had a Pap smear whereas in the patients with non-insurance, only 14 of 371 (3.7%) had it, and this difference was significant (P < 0.00001; OR 3.7, 95% IC 2.15-6.36).

CONCLUSIONS

Although Pap smear is not indicated in women with total hysterectomy, this study is still carried out frequently.

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.

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.

Assessing Physician Adherence to Guidelines for Cervical Cancer Screening and Management of Abnormal Screening Results

OBJECTIVE

The aim of the study was to survey obstetrician-gynecologists' cervical cancer screening practices and management of cervical abnormalities to ascertain adherence to guidelines.

METHODS

From January to July 2019, obstetrician-gynecologists at 5 St. Louis area hospitals were surveyed online about cervical cancer screening and management practices through 13 clinical vignettes. Survey scores and the American Society of Colposcopy and Cervical Pathology (ASCCP) app use were compared using Mann-Whitney tests.

RESULTS

When screening 30- to 65-year-old participants, 114 (98%) of the 116 total participants used co-testing, but only 71 (61%) screened at 5-year intervals. None used primary human papillomavirus (HPV) testing. For 21- to 29-year-old participants, 17 (15%) screened with annual cytology, whereas 14 (12%) used annual or every 3-year co-testing. Forty eight (41%) screened younger than 21 years, regardless of risk factors or only if immunocompromised. Eleven (9%) continued screening after total hysterectomy for benign indications. Only 2 (2%) responded to all clinical vignettes in adherence to guidelines. More than 30% of participants would pursue unnecessary HPV testing and/or loop electrosurgical excision procedure for persistent low-grade cytology. Fifty eight (48%) incorrectly reported hysterectomy as management for adenocarcinoma in situ on biopsy. Participants would undertreat young women with high-grade abnormalities including high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 3 (48, 41%) and high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 1 (65, 56%). Forty one (35%) reported exiting women from screening prematurely. The median score for participants using the ASCCP app was significantly greater than those who did not (79% vs 71%, p = .002).

CONCLUSIONS

Midwestern obstetrician-gynecologists' adherence to the guidelines for cervical cancer screening and management of abnormal results is suboptimal. Although co-testing for women aged 30-65 years has been broadly adopted, primary HPV testing has not. Physicians overscreen, overtreat low-grade lesions, and undertreat high-grade lesions in young women.

Prevalence of Cervical Cancer Overscreening: Review of a Wellness Registry

Appropriately matching preventive health services and screenings with patient risk is an important quality indicator. Adherence by both providers and patients to cervical cancer screening guidelines has been inconsistent, resulting in overscreening and increased costs. This study examined the prevalence of cervical cancer overscreening following changes in screening guidelines in a wellness registry database. Cervical cancer overscreening after guideline implementation decreased for 18- to 20-year-old patients from 26.8% to 24.8% (P < .001) and increased for those aged 65 years and older from 11.1% to 12.5% (P = .0005). Black race, Hispanic ethnicity, Medicaid insurance, and the presence of a personal health record were associated with overscreening. Reliability and accuracy of data are a concern when data intended for one purpose, such as clinical care, are used for research. Correctly identifying screening tests in the electronic health record is important so that appropriate screening can be reliably assessed. In this study on the prevalence of cervical cancer overscreening, we used a focused chart review to identify whether screening Pap tests were accurately identified in the electronic medical record. Pap tests were correctly identified as screening in 85% of those aged 18 to 20, and in 74% of those aged 65 and older.

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.

Trends Over Time in Pap and Pap-HPV Cotesting for Cervical Cancer Screening

BACKGROUND

In 2012, updated cervical cancer screening recommendations were released with consensus on Papanicolaou (Pap) testing every 3 years for women age 21-65 years or Pap-human papillomavirus (HPV) cotesting at 5-year intervals for women age 30-65 years. Primary study aims: Assess current use of Pap-HPV cotesting and describe local population trends over time in Pap and Pap-HPV cotesting. Secondary aim: Assess sociodemographic factors correlating with screening.

METHODS

We assessed Rochester Epidemiology Project data for Pap and Pap-HPV cotesting among women age 16 years and older living in Olmsted County, Minnesota, yearly from 2005 (study population n = 47,203) through 2016 (study population n = 49,510). We calculated 3-year (Pap) and 5-year (Pap-HPV) moving prevalence rates of screening as proportion of eligible population. Multivariable logistic regression was used to assess factors potentially associated with screening.

RESULTS

In 2016, 64.6% of 27,418 eligible 30- to 65-year-old women were up to date with cervical cancer screening; 60.8% had received Pap-HPV cotest screening. Significant declines in Pap completion rates over time were observed in all age groups, including an unexpected decline in 21- to 29-year-old women. Coincident with decreasing Pap screening rates, Pap-HPV cotesting significantly increased among women age 30-65 years, from 10.0% in 2007 to 60.8% in 2016.

CONCLUSIONS

This suggests increasing adoption of 2012 screening recommendations in the 30- to 65-year-old population. However, decline in Pap screening among 21- to 29-year-old women is concerning. Disparities by race, ethnicity, smoking status, and comorbidity level were observed. Results suggest need for multilevel patient and clinician interventions to increase cervical cancer screening adherence.

Excess Cost of Cervical Cancer Screening Beyond Recommended Screening Ages or After Hysterectomy in a Single Institution

OBJECTIVE

The aim of the study was to estimate the excess cost of guideline nonadherent cervical cancer screening in women beyond the recommended screening ages or posthysterectomy in a single healthcare system.

MATERIALS AND METHODS

All Pap tests performed between September 1, 2012, and August 31, 2014, in women younger than 21 years, older than 65 years, or after hysterectomy, were coded as guideline adherent or nonadherent per the 2012 America Society of Colposcopy and Clinical Pathology guidelines. We assumed management of abnormal results per the 2013 America Society of Colposcopy and Clinical Pathology management guidelines. Costs were obtained from a literature review and Center for Medicare and Medicaid Services data and applied to nonadherent screening and subsequent diagnostic tests.

RESULTS

During this period, 1,398 guideline nonadherent Pap tests were performed (257 in women <21 years, 536 in women >65 years, and 605 after hysterectomy), with 88 abnormal results: 35 (13.5%) in women younger than 21 years, 14 (2.6%) in women older than 65 years, and 39 (6.5%) in women after hysterectomy. The excess cost for initial screening, diagnostic tests, and follow-up was US $35,337 for 2 years in women younger than 21 years, US $54,378 for 5 years in women older than 65 years, and US $77,340 for 5 years in women after hysterectomy, resulting in a total excess cost of US $166,100 for 5 years. Of the 1,398 women who underwent guideline nonadherent screening, there were only 2 (0.1%) diagnoses of high-grade dysplasia (VaIN3).

CONCLUSIONS

Guideline nonadherent cervical cancer screening in women beyond the recommended screening ages and posthysterectomy resulted in costs exceeding US $160,000 for screening, diagnostic tests, and follow-up with minimal improvement in detection of high-grade dysplasia.

Ending Cervical Cancer Screening in Low-Risk Women After Age 65: Understanding Barriers to Adherence With Evidence-Based Guidelines Among Primary Care Providers

Background:

Current evidence-based cervical cancer testing guidelines recommend that screening of low-risk women ceases after age 65. Despite this, research suggests that continued testing by primary care providers remains common and represents unnecessary patient discomfort, cost, and consumption of valuable primary care resources.

Objective:

To understand why primary care providers might knowingly ignore consensus evidence-based screening guidelines for cervical cancer in low-risk women of this age-group and to identify barriers to adherence with best practice recommendations.

Methods:

A survey tool to identify barriers to adherence with current guidelines for cervical cancer screening in low-risk women older than age 65 was mailed to 4929 randomly selected primary care providers throughout California. Providers were asked to indicate the predominant reason(s) they might knowingly continue cervical cancer screening in women older than 65 years, despite evidence-based recommendations to the contrary.

Results:

Qualified surveys were received from 1259 (25.5%) of those surveyed, representing primary care providers of all types, practicing in areas of vastly different demographics. Despite published reassurance to the contrary, many providers retain fear that discontinuation of testing in low-risk women after age 65 may result in missed invasive cervical cancer. Even among health-care providers who agree that cessation of screening is safe, other circumstances prompt their recommendation to continue cervical screening.

Conclusion:

Although the data from this study suggest areas of policy intervention to lessen unnecessary cervical cancer screening, the broader implication is that advancement of evidence-based medicine will be of little value in improving the quality and cost of health care if barriers to guideline adherence are poorly understood and addressed.