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

The impact of social media on guideline-concordant cervical cancer-screening: insights from a national survey

OBJECTIVES

Cervical cancer is one of the leading causes of cancer mortality in women, yet routine screenings lead to early detection and sometimes even prevention. Screening is an effective way to prevent cervical cancer, and it has been implemented in many countries and regions worldwide, especially in developed countries. However, the incidence of cervical cancer remains a public health problem due to screening disparities in the population. Social media engagement and overloading of online health information may be the cause of this disparity.

STUDY DESIGN

Cross-sectional study.

METHODS

Data from the Health Information National Trends Survey (a national survey conducted by the National Cancer Institute) was used to characterise cervical cancer screening into two dimensions; namely, high-frequency screening and guideline-concordant screening. The differences between these two screening frequency behaviours were compared by applying ordered logistic regression and binary logistic regression, and the mechanisms of guideline-concordant screening were explored.

RESULTS

The factors influencing high-frequency screening and guideline-concordant screening were different. Only self-efficacy (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.98, 1.37) had a significant positive association with the high-frequency screening behaviour. Social media engagement (OR = 0.57; 95% CI = 0.33, 0.96) was shown to have a significant negative impact on guideline-concordant screening. A theory-based mechanism of screening behaviour found that traditional health perception factors no longer influence guideline-concordant screening behaviour, whereas environmental factors (e.g., social media) significantly reduce guideline-concordant screening behaviour.

CONCLUSIONS

The results from this study indicate that while the internet has become the main channel through which women acquire health resources, and social media has become a main platform for people to obtain health information, online information cannot guide people to engage in appropriate healthy behaviours. Overloading of online health information and the digital divide may lead to excessive screening. Consequently, it is important to address the screening disparity caused by health behaviours as a result of environmental factors and the digital divide.

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.

Cervical Cancer Screening: Evolution of National Guidelines and Current Recommendations

Cancer of the cervix is preventable through vaccination against human papillomavirus and by screening and treatment of cervical precancers. Cervical cancer screening has evolved since the Pap smear was first discovered in the 1920s. Current guidelines from the US Preventive Services Task Force and the American Cancer Society incorporate the use of cervical cytology and high-risk human papillomavirus tests performed every 3 to 5 years for screening in average-risk asymptomatic patients. Testing should begin at age 21 to 25 years old and stop at 65 years old if sufficient cessation criteria has been met.

Assessing Intersectional Disparities in Cervical Cancer Screening by Disability Status, Race, and Ethnicity

Introduction

Separate bodies of research have studied disparities by disability status and by race or ethnicity in receipt of cervical cancer screening. Much less is known about how these disparities intersect. The purpose of this study was to evaluate disparities in compliance with the U.S. Preventive Services Task Force guidelines for Pap testing in age-eligible women at the intersection of disability and race or ethnicity.

Methods

We conducted cross-sectional analyses of the Medical Expenditure Panel Survey Household Component deidentified public data files pooled for years 2007-2016, using a modified Poisson regression analysis to compute prevalence ratios for being up to date with Pap testing by disability status and race or ethnicity. We also calculated predicted marginal proportions adjusting for demographic and socioeconomic covariates.

Results

The analytic sample included 68,507 women with nonmissing covariates; 15.6% had a disability. Overall, the proportion current with Pap testing was significantly lower among women with disabilities than among those without disabilities (82.1% vs 88.6%, p<0.0001). Furthermore, within each racial and ethnic group, women with disabilities were less likely than those without disabilities to be current with Pap testing. In adjusted analyses, prevalence ratios for White women with disabilities (adjusted prevalence ratio=0.94; 95% CI=0.92, 0.96) and other race women with and without disabilities (adjusted prevalence ratio=0.91; 95% CI=0.86, 0.95 and adjusted prevalence ratio=0.91; 95% CI=0.89, 0.95, respectively) were significantly below those for the reference group of White women without disabilities. Hispanic women with disabilities did not differ significantly from White women without disabilities, and Black women with disabilities had significantly higher adjusted prevalence ratios than White women without disabilities (adjusted prevalence ratio=1.07; 95% CI=1.05, 1.09). When taking covariates into account, the proportion of Black women with disabilities current with screening was only slightly lower than the estimated proportion for Black women without disabilities (92% vs 93%). The gap in screening between White women with and without disabilities narrowed somewhat (from 9 percentage points to 4 percentage points) but remained significant.

Conclusions

Our results extend previous research focused separately on disability or race and ethnicity. Women with disabilities in all racial and ethnic groups fell short of Healthy People 2020 goals for cervical cancer screening.

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

Background

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

Materials and Methods

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

Results

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

Conclusions

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

De-implementation of cervical cancer screening before age 21

In 2012, United States consensus guidelines were modified to recommend that cervical cancer screening not begin before age 21 and, since 2014, the Health Effectiveness Data and Information Set (HEDIS), a health plan quality measurement too, has included a measure for non-recommended cervical cancer screening among females ages 16-20. Our goal was to describe prevalence over time of cervical cancer screening before age 21 following the 2012 guideline change, and provide information to help understand how rapidly new guidelines may be disseminated and implemented into clinical practice. We used longitudinal clinical and administrative data from three diverse healthcare systems in the Population-based Research to Optimize the Screening Process (PROSPR II) consortium to examine annual trends in screening before age 21. We identified 55,316 average-risk, screening-eligible females ages 18-20 between 2011 and 2017. For each calendar year, we estimated the proportion of females who received a Papanicolaou (Pap) test. We observed a steady decline in the proportion of females under age 21 who received a Pap test, from an average of 8.3% in 2011 to <1% in 2017 across the sites. The observed steady decline suggests growing adherence to the 2012 consensus guidelines. This trend was consistent across diverse geographic regions, healthcare systems, and patient populations, strengthening the generalizability of the results; however, since we only had 1-2 years of study data prior to the consensus guidelines, we cannot discern whether screening under age 21 was already in decline. Nonetheless, these results provide data to compare with other guideline changes to de-implement non-recommended screening practices.

Effect of 2 Interventions on Cervical Cancer Screening Guideline Adherence

INTRODUCTION

This study sought to determine whether a provider mobile phone application, used with or without a patient educational tool accessed on a computer tablet, would promote adherence to guidelines for cervical cancer screening and management of abnormal cytology in young women.

METHODS

The study was conducted as a prospective cohort study in which 14 Family Planning, Access, Care, and Treatment provider clinics were randomized to 1 of 2 arms: (1) provider mobile phone application only or (2) provider mobile phone application plus patient educational tool. The provider mobile phone application gave information to providers regarding cervical cancer screening and management of abnormal cytology. The patient educational tool accessed on a computer tablet was a patient-centered educational tool. Each arm was compared with clinic control groups (no intervention) in a 2:1 ratio (control:intervention). Claims data were used to calculate and compare 18-month cytology (Pap) and colposcopy rates before the intervention and during the 18 months using the Poisson mixed-effect regression model. A sensitivity analysis examined the differences in the rate of change between each arm and controls. The study took place between July 2015 and December 2016, and analysis was performed in 2019.

RESULTS

The clinics randomized to the provider mobile phone application plus patient educational tool arm and their control group achieved similar 18-month Pap rates (0.52, 95% CI=0.37, 0.74 and 0.68, 95% CI=0.53, 0.86, respectively) as well as the provider mobile phone application arm and their control group (0.44, 95% CI=0.33, 0.58 and 0.41, 95% CI=0.34, 0.51; p-values >0.1). In the sensitivity analysis, the difference in the rate of change in Pap rates for the provider mobile phone application plus patient educational tool arm and their control group before and during the intervention was -0.22 and -0.09, respectively (p=0.02), but no differences were seen between the provider mobile phone application arm and their control group. No significant changes were observed for colposcopy rates.

CONCLUSIONS

Providing clinicians and patients with information on guidelines had no demonstrable effect on 18-month Pap and colposcopy rates in the regression model; however, results from the sensitivity analysis for the patient educational tool were encouraging.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02270021.

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.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Cervical Cancer Screening Intervals Preferred by U.S. Women

INTRODUCTION

Many U.S. women continue to be screened annually for cervical cancer, despite current guidelines that recommend 3- or 5-year screening intervals depending on screening modality and patient age.

METHODS

Data from 2012 and 2015 web-based surveys of U.S. adults were analyzed in 2017 to investigate U.S. women's cervical cancer screening preferences. The study was limited to women aged ≥18 years without a hysterectomy or cervical cancer diagnosis (2012 n=1,380, 2015 n=1,339).

RESULTS

Women's preference for 3- or 5-year screening intervals doubled during the study period (2012: 31.2%, 2015: 64.2%, p<0.001). The most preferred screening options in 2015 were co-testing every 3 years with the Pap and human papillomavirus tests (34.0%) and annual Pap testing (30.4%)-neither of which were recommended at that time or currently. Use of 3- and 5-year Pap testing intervals increased during the study period (2012: 6.9%, 2015: 12.9%, p<0.001), whereas annual Pap testing declined (2012: 48.5%, 2015: 35.6%, p<0.001). Among women who were regularly screened and preferred 3- or 5-year screening intervals, the minority reported screening practices that matched this preference (2012: 24.1%, 2015: 29.3%, p=0.71).

CONCLUSIONS

Women's preference for longer cervical cancer screening intervals has increased rapidly and outpaced utilization. At the same time, many women continue to be screened annually. Expanding appropriate screening may require increasing women's and providers' comfort with screening recommendations.

Determinants of Potentially Unnecessary Cervical Cancer Screenings in American Women

Objectives

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

Methods

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

Results

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

Conclusions

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

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

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

Uptake of HPV testing and extended cervical cancer screening intervals following cytology alone and Pap/HPV cotesting in women aged 30-65 years

OBJECTIVE

To evaluate the adoption of HPV testing and recommended extended cervical cancer screening intervals in clinical practice, we described yearly uptake of Pap/HPV cotesting and estimated length of time between normal screens by patient characteristics.

METHODS

We examined 55,575 Pap/HPV records from 27,035 women aged 30-65 years from the Johns Hopkins Hospital Pathology Data System between 2006 and 2013. Cotest uptake and median times to next screening test for cotests and cytology only were calculated. Adjusted hazard ratios were estimated using Cox proportional hazards models, with random effects adjustment for clustering within clinic.

RESULTS

Cotest usage increased from < 10% in 2006 to 78% in 2013. The median time to next screening test following normal cytology alone remained constant around 1.5 years. Screening intervals following a dual-negative cotest increased from 1.5 years in 2006/2007 to 2.5 years in 2010, coincident with increases in the proportion of women cotested. Intervals following a dual negative cotest were longer among Medicare patients (3 years) compared with privately insured women (2.5 years), and shorter among black (2 years) compared with white women (2.8 years).

CONCLUSION

By mid-2013 we observed broad adoption of Pap/HPV cotesting in routine screening in a large academic medical center. Increased screening intervals were observed only among cotested women, while those screened by cytology alone continued to be screened almost annually. The influence of different combinations of race and insurance on screening intervals should be further evaluated to ensure balance of screening risks and benefits in the U.S.

POPULATION

Utilization of Cervical Cancer Screening Among Hispanic Immigrant Women in Coastal South Carolina

OBJECTIVES

This study aims to examine prevalence and correlates of cervical cancer screening utilization and adherence among a growing population of Hispanic immigrant women in coastal South Carolina.

METHODS

We conducted a cross-sectional survey of 196 women to assess recency of screening and hypothesized study predictors (health status, beliefs, self-efficacy, having a regular provider, barriers to screening, and trust in providers). Multiple ordinal logistic regressions identified final covariates which would predict recency of screening.

RESULTS

Approximately 84% of women were up-to-date with their Pap tests and 47% had received a Pap test in the previous year. In the adjusted analyses, having a regular provider and having a chronic medical condition were significantly associated with recency of Pap test.

CONCLUSIONS

Differences in cervical cancer screening for participants were partially explained by psychosocial factors, health status, and individual and structural barriers to healthcare.

Cervical Cancer Screening

Cervical cancer screening in the United States has accompanied profound decreases in cancer incidence and mortality over the last half century. Two screening strategies are currently endorsed by US-based guideline groups: (1) triennial cytology for women aged 21 to 65 years, and (2) triennial cytology for women aged 21 to 29 years followed by cytology plus testing for high-risk human papillomavirus types every 5 years for women aged 30 years and older. Providing women with affordable, easily accessible screening, follow-up of abnormal tests, and timely treatment will result in the greatest impact of screening on cervical cancer incidence and mortality.

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.

Roles of Health Care Providers and Patients in Initiation of Unnecessary Papanicolaou Testing After Total Hysterectomy

OBJECTIVES

To assess Papanicolaou (Pap) testing use among US adult women with a history of a total hysterectomy for a benign condition and the roles of health care providers and patients in the initiation of screening Pap tests.

METHODS

We used 2000 to 2013 data from the National Health Interview Survey on women aged 20 years or older who had undergone a hysterectomy (n = 11 616) to estimate unnecessary Pap test use.

RESULTS

The percentage of self-reported Pap testing in the preceding 3 years among women who had undergone a hysterectomy decreased from 72.2% in 2000 to 53.3% in 2013. In 2013, 42.4% of women who had undergone a hysterectomy reported receiving recommendations for screening from a health care provider in the past year (32% of which were unnecessary), and 32.1% reported undergoing Pap tests in the preceding year (22.1% of which were unnecessary). Although the majority of Pap tests were performed at a clinician's recommendation, approximately one fourth were initiated by patients without clinician recommendations.

CONCLUSIONS

Health care providers should advise women who have had a total hysterectomy for a benign condition on appropriate use of screening services.

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

Opportunities and challenges for the use of large-scale surveys in public health research: a comparison of the assessment of cancer screening behaviors

Large-scale surveys that assess cancer prevention and control behaviors are a readily available, rich resource for public health researchers. Although these data are used by a subset of researchers who are familiar with them, their potential is not fully realized by the research community for reasons including lack of awareness of the data and limited understanding of their content, methodology, and utility. Until now, no comprehensive resource existed to describe and facilitate use of these data. To address this gap and maximize use of these data, we catalogued the characteristics and content of four surveys that assessed cancer screening behaviors in 2005, the most recent year with concurrent periods of data collection: the National Health Interview Survey, Health Information National Trends Survey, Behavioral Risk Factor Surveillance System, and California Health Interview Survey. We documented each survey's characteristics, measures of cancer screening, and relevant correlates; examined how published studies (n = 78) have used the surveys' cancer screening data; and reviewed new cancer screening constructs measured in recent years. This information can guide researchers in deciding how to capitalize on the opportunities presented by these data resources.

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.

Physicians' beliefs about effectiveness of cancer screening tests: a national survey of family physicians, general internists, and obstetrician-gynecologists

OBJECTIVE

To study physicians' beliefs about the effectiveness of different tests for cancer screening.

METHODS

Data were examined from the Women's Health Survey of 1574 Family Medicine, Internal Medicine, and Obstetrics-Gynecology physicians to questions about their level of agreement about the clinical effectiveness of different tests for breast, cervical, ovarian, and colorectal cancer screening among average risk women. Data were weighted to the U.S. physician population based on the American Medical Association Masterfile. Multivariable logistic regression identified physician and practice characteristics significantly associated with physicians' beliefs.

RESULTS

There were 1574 respondents, representing a 62% response rate. The majority of physicians agreed with the effectiveness of mammography for women aged 50-69years, Pap tests for women aged 21-65years, and colonoscopy for individuals aged ≥50years. A substantial proportion of physicians believed that non-recommended tests were effective for screening (e.g., 34.4% for breast MRI and 69.1% for annual pelvic exam). Physicians typically listed their respective specialty organizations as a top influential organization for screening recommendations.

CONCLUSIONS

There were several substantial inconsistencies between physician beliefs in the effectiveness of cancer screening tests and the actual evidence of these tests' effectiveness which can lead both to underuse and overuse of cancer screening tests.

Demographic factors associated with overuse of Pap testing

BACKGROUND

Since 2003, U.S. Preventive Services Task Force guidelines recommend against Pap testing for women without a cervix following a hysterectomy and those aged >65 years. Few population-based studies have investigated factors associated with overuse of Pap testing in the U.S.

PURPOSE

To evaluate patient characteristics associated with overuse of Pap testing.

METHODS

A cross-sectional study was conducted using data from the 2010 National Health Interview Survey (NHIS) for women aged ≥30 years. NHIS is a nationally representative survey that employs a random, stratified, multi-stage cluster sampling design. In 2010, the NHIS administered a Cancer Control Supplement with questions on cervical cancer screening and hysterectomy status. Conducted in 2011-2013, all analyses account for the stratification and clustering of data within the complex NHIS survey design. Multivariate logistic regression models were used in all analyses.

RESULTS

Among women who have undergone a hysterectomy, younger age, Hispanic and black race/ethnicity, exceeding 400% of poverty level, and private health insurance coverage were significantly associated with receipt of a recent Pap test since hysterectomy. Among women aged >65 years, non-Hispanic white ethnicity, higher education level, exceeding 400% of poverty level, and no hysterectomy were significantly associated with receipt of a recent Pap test.

CONCLUSIONS

Targeted efforts to reduce unnecessary testing among older women and women with a hysterectomy in compliance with clinical recommendations for cervical cancer prevention are needed. Specific attention should be paid to privately insured women with incomes above 400% of the federal poverty level.

The Possible Effects on Socio-Economic Inequalities of Introducing HPV Testing as Primary Test in Cervical Cancer Screening Programs

Background: Screening with HPV is more effective than Pap test in preventing cervical cancer. HPV as primary test will imply longer intervals and a triage test for HPV positive women. It will also permit the development of self-sampling devices. These innovations may affect population coverage, participation, and compliance to protocols, and likely in a different way for less educated, poorer, and disadvantaged women.

Aim: To describe the impact on inequalities, actual or presumed, of the introduction of HPV-based screening.

Methods: The putative HPV-based screening algorithm has been analyzed to identify critical points for inequalities. A systematic review of the literature has been conducted searching PubMed on HPV screening coverage, participation, and compliance. Results were summarized in a narrative synthesis.

Results: Knowledge about HPV and cervical cancer was lower in women with low socio-economic status and in disadvantaged groups. A correct communication can reduce differences. Longer intervals will make it easier to achieve high-population coverage, but higher cost of the test in private providers could reduce the use of opportunistic screening by disadvantaged women. There are some evidences that inviting for HPV test instead of Pap increases participation, but there are no data on social differences. Self-sampling devices are effective in increasing participation and coverage. Some studies showed that the acceptability of self-sampling is higher in more educated women, but there is also an effect on hard-to-reach women. Communication of HPV positivity may increase anxiety and impact on sexual behaviors, the effect is stronger in low educated and disadvantaged women. Finally, many studies found indirect evidence that unvaccinated women are or will be more probably under-screened.

Conclusion: The introduction of HPV test may increase population coverage, but non-compliance to protocols and interaction with opportunistic screening can increase the existing inequalities.

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.

Does a 30-min quality improvement clinical practice meeting reviewing the recommended Papanicolaou test guidelines for adolescents improve provider adherence to guidelines in a pediatric primary care office?

PURPOSE

The purpose of this quality improvement project was to evaluate adherence to Papanicolaou (Pap) test guidelines 6 months prior to and 6 months following a 30-min educational clinical practice meeting in a pediatric primary care office. Guidelines for Pap tests have been revised in recent years by the American Academy of Obstetrics and Gynecology, the American Cancer Society, and the U.S. Preventive Task Force, but providers often do not adhere to the guidelines.

DATA SOURCES

A total of 777 charts from a pediatric primary care office were reviewed. Eighty-four percent (652) met criteria for inclusion.

CONCLUSIONS

Among sexually active adolescents, there was a statistically significant relationship between rates of Pap tests following the clinical practice meeting (χ(2) (1) = 13.5, p = .001). Prior to the meeting there were 29 Pap tests recorded, whereas after there were two Pap tests done. After the focused clinical practice meeting, providers performed far fewer Pap tests, which is in accordance with the guidelines for this population.

IMPLICATIONS FOR PRACTICE

Providers may not always practice in accordance with recommended clinical practice guidelines for various reasons. Focused, in-office educational interventions via clinical practice meetings may be an effective way of discussing recommended guidelines to improve provider adherence.

A Conceptual Framework for Understanding and Reducing Overuse by Primary Care Providers

Primary care providers frequently recommend, administer, or prescribe health care services that are unlikely to benefit their patients. Yet little is known about how to reduce provider overuse behavior. In the absence of a theoretically grounded causal framework, it is difficult to predict the contexts under which different types of interventions to reduce provider overuse will succeed and under which they will fail. In this article, we present a framework based on the theory of planned behavior that is designed to guide overuse research and intervention development. We describe categories of primary care provider beliefs that lead to the formation of intentions to assess the appropriateness of services, and propose factors that may affect whether the presence of assessment intentions results in an appropriate recommendation. Interventions that have been commonly used to address provider overuse behavior are reviewed within the context of the framework.

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

BACKGROUND

Current cervical cancer prevention recommendations include human papillomavirus (HPV) vaccination, Pap and HPV co-testing, and Pap testing at 3- to 5-year intervals.

PURPOSE

To examine attitudes, practice patterns, and barriers related to HPV vaccination and cervical cancer screening guidelines among U.S. obstetrician-gynecologists.

METHODS

In 2011-2012, a national sample of members of the American Congress of Obstetricians and Gynecologists responded to a 15-item (some with multiple parts) questionnaire assessing sociodemographic characteristics, clinical practices, and perceived barriers to HPV vaccination and cervical cancer screening. Multivariate logistic regression was used to identify factors associated with guideline adherence. Analyses were conducted in 2012.

RESULTS

A total of 366 obstetrician-gynecologists participated. Ninety-two percent of respondents offered HPV vaccination to patients, but only 27% estimated that most eligible patients received vaccination. Parent and patient refusals were commonly cited barriers to HPV vaccination. Approximately half of respondents followed guidelines to begin cervical cancer screening at age 21 years, discontinue screening at age 70 years or after hysterectomy, and appropriately utilize Pap and HPV co-testing. Most physicians continued to recommend annual Paps (74% aged 21-29 years, 53% aged ≥30 years). Physicians felt that patients were uncomfortable with extended screening intervals and were concerned that patients would not come for annual exams without concurrent Paps. Solo practitioners were less likely to follow both vaccination and screening guidelines than those in group practices.

CONCLUSIONS

This survey of obstetrician-gynecologists indicates persistent barriers to the adoption of HPV vaccination and cervical cancer screening guidelines. Interventions to promote guideline adherence may help improve the quality of cervical cancer prevention.

Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening

Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, current ACS cancer screening guidelines are summarized, as are updated guidelines on cervical cancer screening and lung cancer screening with low-dose helical computed tomography. The latest data on the use of cancer screening from the National Health Interview Survey also are described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act of 2010.

Adherence to conservative management recommendations for abnormal pap test results in adolescents

OBJECTIVE

To investigate whether the 2006 American Society for Colposcopy and Cervical Pathology guidelines for conservative management of minimally abnormal Pap test results (atypical squamous cells of undetermined significance, human papillomavirus-positive, and low-grade squamous intraepithelial lesions) and moderate dysplasia (cervical intraepithelial neoplasia 2) in adolescents 1) resulted in fewer colposcopies and loop electrosurgical excision procedures (LEEPs) in adolescents or 2) resulted in unintended treatment changes in older age groups.

METHODS

We analyzed data from 1,806 women aged 18 years and older attending one of six community health centers who were diagnosed with abnormal Pap test results between January 1, 2004, and December 31, 2008. We used multivariable logistic regression to examine treatment differences in women with minimally abnormal Pap test results before and after guideline changes. Variables included date of abnormality, site of care, race or ethnicity, language, and insurance type. We used Fisher exact tests to examine rates of LEEP in patients with moderate dysplasia before and after guideline publication.

RESULTS

Among 206 women aged 18-20 years, rates of colposcopy after a minimally abnormal Pap test result decreased from 78% (n=102) to 45% (n=34) after guideline changes (P<.001). Colposcopy among women over age 21 (n=1,542) remained unchanged (greater than 90%). Multivariable logistic regression indicated that both date of abnormality and site of care were associated with colposcopy referral. After guideline changes, management of moderate dysplasia with LEEP in women aged 18-23 decreased from 55% to 18% (P=.04); rates remained stable in women ages 24 and older (70% compared with 74%; P=.72).

CONCLUSION

Health care providers quickly adopted new conservative management guidelines for low-income, minority adolescents, which may reduce preterm deliveries in these high-risk populations.

LEVEL OF EVIDENCE

II.

Cancer screening in the United States, 2012: A review of current American Cancer Society guidelines and current issues in cancer screening

Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, current ACS cancer screening guidelines are summarized, as are the latest data on the use of cancer screening from the National Health Interview Survey.

Use of electronic health record data to evaluate overuse of cervical cancer screening

BACKGROUND

National organizations historically focused on increasing use of effective services are now attempting to identify and discourage use of low-value services. Electronic health records (EHRs) could be used to measure use of low-value services, but few studies have examined this. The aim of the study was to: (1) determine if EHR data can be used to identify women eligible for an extended Pap testing interval; (2) determine the proportion of these women who received a Pap test sooner than recommended; and (3) assess the consequences of these low-value Pap tests.

METHODS

Electronic query of EHR data identified women aged 30-65 years old who were at low-risk of cervical cancer and therefore eligible for an extended Pap testing interval of 3 years (as per professional society guidelines). Manual chart review assessed query accuracy. The use of low-value Pap tests (ie, those performed sooner than recommended) was measured, and adverse consequences of low-value Pap tests (ie, colposcopies performed as a result of low-value Pap tests) were identified.

RESULTS

Manual chart review confirmed query accuracy. Two-thirds (1120/1705) of low-risk women received a Pap test sooner than recommended, and 21 colposcopies were performed as a result of this low-value Pap testing.

CONCLUSION

Secondary analysis of EHR data can accurately measure the use of low-value services such as Pap testing performed sooner than recommended in women at low risk of cervical cancer. Similar application of our methodology could facilitate efforts to simultaneously improve quality and decrease costs, maximizing value in the US healthcare system.

Young women's beliefs regarding human papillomavirus

OBJECTIVE

To describe young women's perceptions of human papillomavirus (HPV) using the Common Sense Model and examine whether perceptions differ based on history of HPV diagnosis or sexually transmitted disease (STD) testing.

DESIGN

Cross-sectional, survey data.

SETTING

Four women's health clinics and one university classroom.

PARTICIPANTS

Three hundred and two women ages 18-24.

METHODS

Young women's beliefs regarding HPV were measured using the HPV Representations of Sexually Transmitted Diseases (RoSTD) survey.

RESULTS

Most survey respondents believed HPV diagnosis was likely to result in cancer and death. Negative beliefs about the psychosocial consequences of HPV diagnosis were common. Compared to those who had not been diagnosed with HPV (or had never received STD testing), young women with a history of HPV diagnosis or STD testing had less serious and more accurate beliefs about HPV.

CONCLUSION

Young women tend to have misconceptions about HPV in addition to noteworthy concerns about the psychosocial consequences of HPV diagnosis. Clinical attention to young women's beliefs about HPV may provide direction for improving the delivery of patient-centered education and counseling about this exceedingly common illness.

Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States

OBJECTIVE

Guidelines recommend when the human papillomavirus (HPV) and Papanicolaou tests are used together (HPV co-test) for routine cervical cancer screening, screening intervals can be extended to 3 years. We assessed HPV test practices and Papanicolaou test screening interval recommendations of US providers.

STUDY DESIGN

Using a multistage probability design, we analyzed nationally representative data that were collected in 2006 through the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.

RESULTS

Approximately 51% of providers ordered the HPV co-test; however, clinical vignettes found that <15% of providers who ordered the HPV test recommend the next Papanicolaou test in 3 years for women with concurrent normal HPV co-test results and a documented normal screening history.

CONCLUSION

Overall, annual cervical cancer screening continues to be a common recommendation, regardless of whether a screening history has been established or an HPV test has been ordered.

Reported referral for genetic counseling or BRCA 1/2 testing among United States physicians: a vignette-based study

BACKGROUND

Genetic counseling and testing is recommended for women at high but not average risk of ovarian cancer. National estimates of physician adherence to genetic counseling and testing recommendations are lacking.

METHODS

Using a vignette-based study, we surveyed 3200 United States family physicians, general internists, and obstetrician/gynecologists and received 1878 (62%) responses. The questionnaire included an annual examination vignette asking about genetic counseling and testing. The vignette varied patient age, race, insurance status, and ovarian cancer risk. Estimates of physician adherence to genetic counseling and testing recommendations were weighted to the United States primary care physician population. Multivariable logistic regression identified independent patient and physician predictors of adherence.

RESULTS

For average-risk women, 71% of physicians self-reported adhering to recommendations against genetic counseling or testing. In multivariable modeling, predictors of adherence against referral/testing included black versus white race (relative risk [RR], 1.16; 95% confidence interval [CI], 1.03-1.31), Medicaid versus private insurance (RR, 1.15; 95% CI, 1.02-1.29), and rural versus urban location. Among high-risk women, 41% of physicians self-reported adhering to recommendations to refer for genetic counseling or testing. Predictors of adherence for referral/testing were younger patient age [35 vs 51 years [RR, 1.78; 95% CI, 1.41-2.24]), physician sex (female vs male [RR, 1.30; 95% CI, 1.07-1.64]), and obstetrician/gynecologist versus family medicine specialty (RR, 1.64; 95% CI, 1.31-2.05). For both average-risk and high-risk women, physician-estimated ovarian cancer risk was the most powerful predictor of recommendation adherence.

CONCLUSION

Physicians reported that they would refer many average-risk women and would not refer many high-risk women for genetic counseling/testing. Intervention efforts, including promotion of accurate risk assessment, are needed.

Knowledge and intention to participate in cervical cancer screening after the human papillomavirus vaccine

BACKGROUND

If women who receive the human papillomavirus (HPV) vaccine are unduly reassured about the cancer prevention benefits of vaccination, they may choose not to participate in screening, thereby increasing their risk for cervical cancer. This study assesses adult women's knowledge of the need to continue cervical cancer screening after HPV vaccination, describes Pap test intentions of vaccinated young adult women, and evaluates whether knowledge and intentions differ across groups at greatest risk for cervical cancer.

METHODS

Data were from the 2008 Health Information National Trends Survey (HINTS) and the 2008 National Health Interview Survey (NHIS), which initiated data collection approximately 18 months after the first FDA approval of an HPV vaccine. We calculated associations between independent variables and the outcomes using chi-square tests.

RESULTS

Of 1586 female HINTS respondents ages 18 through 74, 95.6% knew that HPV-vaccinated women should continue to receive Pap tests. This knowledge did not vary significantly by race/ethnicity, education, income, or healthcare access. Among 1101 female NHIS respondents ages 18-26 who had ever received a Pap test, the proportion (12.7%; n=139) who reported receipt of the HPV vaccine were more likely than those not vaccinated to plan to receive a Pap test within three years (98.1% vs. 92.5%, p<0.001).

CONCLUSIONS

US adult women possess high knowledge and intention to participate in Pap testing after HPV vaccination. The vast majority of young adult women who received the HPV vaccine within its first two years on the market intend to participate in cervical cancer screening in the near future. Future studies are needed to examine whether those vaccinated in adolescence will become aware of, and adhere to, screening guidelines as they become eligible.

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.