Annual Cervical Cancer Screening Persists Despite Guidelines

Steven Fox

August 18, 2011

August 18, 2011 — A representative survey of nearly 600 US physicians concludes that the majority continue to recommend annual cervical cancer screening, even for women whom current guidelines say can wait 3 years before being tested again.

Results from the survey were published online today in the American Journal of Obstetrics & Gynecology.

"Our findings suggest a need for continued surveillance and data collection on adherence to cervical screening guidelines, and perhaps an open dialogue on provider, patient, and systems preferences for prevention and management of cervical cancer and abnormalities," write Katherine Roland, MPH, from the Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Centers for Disease Control, and colleagues.

"Appropriate use of cervical cancer screening technologies is essential, now more than ever, if [human papillomavirus (HPV)] co-testing is to be considered a preventive service for women covered by insurance providers," states Ms. Roland in a press release.

The researchers point out that current guidelines published by the American Cancer Society and the American College of Obstetricians and Gynecologists recommend that for women 30 years of age or older, providers use a combination of 2 tests to screen for cervical cancer: the Papanicolaou test and the HPV cotest.

If the results of the 2 tests come back normal, recommendations say the women can wait 3 years before being retested.

However, the results of the current survey indicate that most providers are not following those recommendations.

Roland and colleagues analyzed data on HPV testing and cotesting practices captured in 2006 by the CDC's Cervical Cancer Screening Supplement. The screening supplement is administered as part of the CDC's National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. The data included responses from 376 physicians based in private practice and 216 physicians who worked in hospital outpatient departments.

As part of the survey, physicians who ordered HPV cotests were asked about what sorts of retesting recommendations they would make in 3 types of hypothetical clinical situations. Each situation involved a woman between 30 and 60 years of age with a current normal Papanicolaou test status. The 3 scenarios were as follows:

  • the patient has no current HPV test results and a history of 2 consecutive normal Papanicolaou tests,

  • the patient has a current negative HPV test result and a history of 2 consecutive normal Papanicolaou tests, and

  • the patient has a current negative HPV test result and has never had a Papanicolaou test.

Current guidelines recommend that women in all 3 of those clinical situations be advised they can wait 3 years before returning for retesting.

Even so, the researchers found that for scenario 1, 76.4% of office-based providers (95% confidence interval [CI], 69.3% - 82.3%) and 85.2% of hospital-based providers (95% CI, 72.6% - 92.6%) would recommend the patient be rescreened in 12 months.

For scenario 2, 66.6% of office-based providers (95% CI, 59.1% - 73.4%) and 72.7% of hospital-based providers (95% CI, 57.8% - 83.8%) would recommend a follow-up Papanicolaou test in 12 months.

Notably, the authors write, only 14% of office-based providers (95% CI, 9.2% - 20.6%) would recommend the next Papanicolaou test in 3 or more years, as the current guidelines recommend.

In the case of scenario 3, 73.4% of office-based providers (95% CI, 63.3% - 81.5%) and 73.5% of hospital-based providers (95% CI, 63.1% - 81.8%) would recommend a follow-up Papanicolaou test in 12 months.

The researchers say a large percentage of office-based providers (25.2%; 95% CI, 17.8% - 34.4%) and hospital-based providers (24.9%; 95% CI, 16.6% - 35.6%) would recommend the next Papanicolaou test be scheduled within a 12-month period.

Study limitations include a large percentage of survey completion by "other office staff" and small sample size, which led to a large variance in response to the descriptive clinical vignettes.

Commenting on their findings, the researchers say that establishing patients' history of normal Papanicolaou test results appears to be a critical component to providers making guideline-supported recommendations regarding screening intervals.

"Approximately one-half of providers ordered the HPV co-test for their patients; of those providers, approximately two-thirds ordered the test for women ≥30 years old, which is the only approved use of the HPV co-test," they write.

They conclude: "Understanding discordance between clinical policy and practice, which can result in unnecessary testing costs and burden to the women, should be central to future research initiatives."

The authors have disclosed no relevant financial relationships.

Am J Obstet Gynecol. Published online August 18, 2011.

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