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

Impact of management guidelines for abnormal cervical cytology on colposcopy procedure rates among young women

OBJECTIVE

In 2012, updated ASCCP management guidelines for abnormal cervical cytology recommended observation rather than immediate referral to colposcopy for low-grade abnormalities in women ages 21-24. We evaluated the impact of these guidelines on changes in colposcopy procedure rates among young women.

METHODS

We analyzed administrative and claims data from the largest statewide family planning program between July 2011 and June 2015. Using a difference-in-differences approach, we estimated changes in colposcopy procedure rates among women ages 21-24 years before and after the 2012 ASCCP management guidelines, relative to a comparison group of women ages 25-44.

RESULTS

Our analysis included 333,977 women from 216 primary care provider sites. After publication of the 2012 ASCCP management guidelines, colposcopy rates significantly declined from 6.70% (95% CI 6.21-7.19) to 3.94% (95% CI 3.60-4.29) among women ages 21-24 and from 4.35% (95% CI 4.03-4.67) to 3.53% (3.25-3.80) among women over 24 years. These declines correspond to a 1.93 percentage point reduction (95% CI 1.62-2.25; p < 0.001) in colposcopy rate among women 21-24 vs. over 24 years, or a two-fold relative reduction. Among women ages 21-24, colposcopy receipt was associated with speaking primarily English vs. non-English (OR 1.46, 95% CI 1.35-1.57), having a cervical cytology test within the past year vs. not (OR 1.55, 95% CI 1.44-1.66), and receiving care from a public vs. private provider (OR 1.31, 95% CI 1.06-1.62).

CONCLUSIONS

Colposcopy procedure rates among young women significantly declined following publication of the 2012 management guidelines, which has implications for reducing potential harms of overtreatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association Between Clinician Confidence and Making Guideline-Recommended Decisions in the Management of Abnormal Cervical Cancer Screening Results

BACKGROUND

Guidelines for managing abnormal cervical cancer screening results are complex and adherence is challenging for clinicians. Previous studies have identified gaps in knowledge as a possible cause; few have explored the confidence clinicians have in their management decisions. Confidence in decision-making may influence management practices, particularly when guidelines are complex and evolving.

OBJECTIVE

Assess whether confidence in decision-making is associated with making guideline-concordant recommendations for abnormal cervical cancer screening results.

DESIGN

A clinician survey used vignettes to ask clinicians to make a management recommendation for different abnormal results and rate their level of confidence in their response.

PARTICIPANTS

Physicians and advanced practice providers (APPs) at three diverse health systems in Washington, Texas, and Massachusetts.

MAIN MEASURES

Correct response to each vignette based on either the 2012 or 2019 American Colposcopy and Cervical Pathology (ASCCP) management guidelines.

KEY RESULTS

In total, 501 clinicians completed the survey between October and December 2020 (response rate 53.7%). Overall, most clinicians made guideline-recommended management decisions for two vignettes (73.2 and 73.7%), but fewer were confident in their selection (48.3% and 46.6%, respectively). Clinicians who reported high levels of confidence were more often correct than those who reported lower levels of confidence (85.8% vs. 62.2% and 87.5% vs. 60.7%, both p<0.001). After adjusting for clinician and practice characteristics, confidence remained significantly associated with selecting the correct answer.

CONCLUSIONS

Clinician confidence in management decisions for abnormal cervical cancer screening results was significantly associated with knowing guideline-concordant recommendations. Given the complexity of cervical cancer management guidelines, solutions to improve clinician confidence in decision-making are needed.

Assessing Management of Abnormal Cervical Cancer Screening Results and Concordance with Guideline Recommendations in Three US Healthcare Settings

BACKGROUND

Follow-up of abnormal results is essential to cervical cancer screening, but data on adherence to follow-up are limited. We describe patterns of follow-up after screening abnormalities and identify predictors of guideline-concordant follow-up.

METHODS

We identified the index screening abnormality (positive human papillomavirus test or atypical squamous cells of undetermined significance or more severe cytology) among women of ages 25 to 65 years at three US healthcare systems during 2010 to 2019. We estimated the cumulative incidence of surveillance testing, colposcopy, or treatment after the index abnormality and initial colposcopy. Logistic regressions were fit to identify predictors of guideline-concordant follow-up according to contemporaneous guidelines.

RESULTS

Among 43,007 patients with an index abnormality, the cumulative incidence of any follow-up was 49.6% by 4 years for those with atypical squamous cells of undetermined significance/human papillomavirus-negative and higher for abnormalities warranting immediate colposcopy. The 1-year cumulative incidence of any follow-up after colposcopy was 70% for patients with normal results or cervical intraepithelial neoplasia I and 90% for patients with cervical intraepithelial neoplasia II+. Rates of concordant follow-up after screening and colposcopy were 52% and 47%, respectively. Discordant follow-up was associated with factors including age, race/ethnicity, overweight/obese body mass index, and specific types of public payor coverage or being uninsured.

CONCLUSIONS

Adherence to the recommended follow-up of cytologic and histopathologic abnormalities is inconsistent in clinical practice. Concordance was poor for mild abnormalities and improved, although suboptimal, for more severe abnormalities.

IMPACT

There remain gaps in the cervical cancer screening process in clinical practice. Further study is needed to understand the barriers to the appropriate management of cervical abnormalities.

Variation in cervical cancer screening test utilization and results in a United States-based program

BACKGROUND

Little is known about cervical cancer screening strategy utilization (cytology alone, cytology plus high-risk human papillomavirus [HPV] testing [cotesting], primary HPV testing) and test results in the United States.

METHODS

Data from the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program were analyzed for 199,578 persons aged 21-65 years screened from 2019 to 2020. Screening test utilization and results were stratified by demographic characteristics and geographic region. Age-standardized pooled HPV test positivity and genotyping test positivity were estimated within cytology result categories.

RESULTS

Primary HPV testing was performed in 592 persons (0.3%). Among the remaining 176,290 persons aged 30-65 years, cotesting was utilized in 72.1% (95% confidence interval [CI] 71.9-72.3%), and cytology alone was utilized in 27.9% (95% CI 27.7-28.1%). Utilization of cytology alone varied by geographic region, ranging from 18.3% (95% CI 17.4-19.1%) to 49.0% (95% CI 48.4-49.6%). HPV genotyping test utilization among those with positive pooled HPV test results was 33.9%. In persons aged ≥30 years, variations in age-adjusted test results by region were observed for pooled HPV-positive test results and for HPV genotyping-positive test results.

CONCLUSIONS

Cervical cancer screening strategy utilization and test results vary substantially by geographic region within a national screening program. Variation in utilization may be due to regional differences in screening test availability or the preferences of healthcare systems, screened persons and/or clinicians. Test result variations may reflect differing risk factors for HPV infections by geographic region.

Primary Human Papillomavirus Test Uptake and Cervical Cancer Screening Trends in the Midwest, United States

INTRODUCTION/OBJECTIVES

Despite U.S. Preventive Services Task Force and American Cancer Society endorsement of primary HPV screening, limited published data shows low uptake.

PRIMARY AIM

Assess cervical cancer screening rates over time, particularly primary HPV test uptake, among patients in a midwestern practice.

SECONDARY AIM

Evaluate associations between sociodemographics and screening adherence.

METHODS

Cross-sectional study. Qualifying subjects and type of screening test used were identified by applying ICD-9, ICD-10, lab test, and CPT codes to the Unified Data Platform. Sociodemographics were found through the electronic health record.

RESULTS

Primary HPV uptake represented <1% of annual screening from 1/2017 to 1/2022. On 1/1/2022, only 55% of 21 to 29 year old and 63% of 30 to 65 year old were up to date with screening among the studied population. For 21 to 29 year old, compared with White women, Black women were 28% less likely to be screened [RR = 0.72 (0.66-0.79)]. Compared with never-smokers, current smokers were 9% less likely to be screened [RR = 0.91 (0.87-0.96)], past smokers were 14% more likely [RR = 1.14 (1.09-1.2)]. Among 30 to 65 year old, compared with White women, Black women were 14% less likely to be screened [RR = 0.86 (0.81-0.9)]. Compared with never-smokers, current smokers were 21% less likely to be screened [RR = 0.79 (0.77-0.81)], past smokers were 6% less likely [RR = 0.94 (0.92-0.95)]. Jointly considering race, ethnicity, smoking status, Charlson score, and rurality, findings were similar for 21 to 29 year old; Black women were screened less than White women [RR = 0.73 (0.67-0.79)]; current smokers [RR = 0.9 (0.85-0.94)] and past smokers [RR = 1.12 (1.06-1.17)] were screened less than never smokers. For 30 to 65 year old, Black women were screened less than White women [RR = 0.83 (0.79-0.88)]; current smokers [RR = 0.8 (0.78-0.81)] and past smokers [RR = 0.95 (0.93-0.96)] were screened less than never smokers.

CONCLUSIONS

Screening rates remained below the Healthy People 2030 goal of 79.2% over time, particularly for younger Black women and current smokers, with minimal use of primary HPV screening.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PLAIN LANGUAGE SUMMARY

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

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

INTRODUCTION

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Clinician practices, knowledge, and attitudes regarding primary human papillomavirus testing for cervical cancer screening: A mixed-methods study in Indiana

Primary human papillomavirus (HPV) testing, in which a high-risk HPV test is administered without cytology, was first included in 2018 US cervical cancer screening guidelines. Subsequent guidelines endorsed primary HPV testing as the preferred method for cervical cancer screening following evidence of its clinical and economic benefits, although many sources still indicate it as an option along with cytology and HPV/Pap co-testing. Primary HPV testing could be key to improving the declining cervical cancer screening rates in the US; however its adoption has been slow as clinicians are hesitant to make the change. Indiana ranks in the top ten states for cervical cancer mortality, with marked race-ethnic disparities in cervical cancer screening and low HPV vaccination rates. To examine clinician practices, knowledge, and attitudes regarding primary HPV testing, in 2021 we conducted an online cross-sectional survey (n = 224) and in-depth interviews (n = 20) with Indiana clinicians practicing cervical cancer screening. Only 3 % reported using primary HPV testing for eligible patients, and only 50 % were willing to adopt it as the preferred cervical cancer screening method for the recommended patient group. In a multivariable logistic regression model, knowledge of the effectiveness (aOR 2.58 [1.41-4.72]) and perceived benefit (aOR 7.35 [3.65-14.81]) of primary HPV testing predicted willingness to adopt. In-depth interviews revealed knowledge gaps, uncertainty, and perceived limitations of this method as the reasons for limited uptake of primary HPV testing. Targeted messages about the benefits and effectiveness may enhance clinician knowledge, acceptance, and adoption.

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.

National Trends in Cervical Cancer Screening in Adolescents

STUDY OBJECTIVE

To characterize patterns of cervical cancer screening among adolescents ages 14-20 years before and after the 2009 American College of Obstetrics and Gynecology recommendations.

DESIGN

Retrospective cohort study.

SETTING

National Ambulatory Medical Care Survey 2005-2016 data.

PARTICIPANTS

Female adolescents and young women ages 14-26 years.

INTERVENTIONS

Multivariable logistic regression models identified independent predictors of unindicated cervical cancer screening at office-based visits among adolescents ages 14-20 years.

MAIN OUTCOME MEASURES

Cervical cancer screening in women ages 14-20 and 21-26 years in 2 time periods: 2005-2008 and 2009-2016.

RESULTS

Between 2005 and 2016, 11,768 office visits were among adolescents ages 14-20 years. Overall, the cervical cancer screening rate for young women ages 14-20 years was 4.0%, which decreased from 4.5% to 0.4% (P = .008) during the study period. Adolescents who received cervical cancer screening during an office visit were older (18-20 years: 24.1% vs 14-17 years: 8.2%; P < .001), had a preventive care visit (preventive care: 79.7% vs other visit types: 20.3%; P < .001), and saw an obstetrician/gynecologist (obstetrician/gynecologist: 74.81% vs other specialties: 25.1%; P < .001). After adjusting for age, year, period, insurance status, region, and provider type, screening for cervical cancer was associated with living in the Southern region of the United States (adjusted odds ratio, 1.88; 95% confidence interval, 1.09-3.25; P = .02) and public insurance (adjusted odds ratio, 0.47, 95% confidence interval, 0.34-0.64; P < .001).

CONCLUSION

Despite recommendations, cervical cancer screening continued to occur in the adolescent population-especially older adolescents-creating unnecessary costs and potential harms. These findings show a slow uptake of guidelines nationally and the need for initiatives that encourage implementation of performance measures for providers, including ongoing provider and patient education.

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

ABSTRACT

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