Annual cervical cancer screening persists, despite recommended guidelines

Investigators from the Centers for Disease Control and Prevention (CDC) have determined that the majority of primary care providers continue to recommend annual cervical cancer screening, and less than 15% would extend the screening interval when using the Papanicolaou test and human papillomavirus (HPV) test together, as some guidelines suggest. The results of the study are published online today in the American Journal of Obstetrics & Gynecology (AJOG).

Current cervical cancer screening guidelines, issued by the American Cancer Society in 2002 and the American College of Obstetricians and Gynecologists in 2003, recommend a combination of a Papanicolaou test and an HPV test, known as an HPV co-test, for women 30 years of age and older. Upon screening, if the results of these two tests are normal, women can wait 3 years for their next cervical cancer screening test. However, annual cervical cancer screening continues to be a common recommendation, regardless if a woman has a history of normal Pap tests or normal HPV co-test. Approximately one-half of providers studied ordered the HPV co-test for their patients.

“Use of the HPV co-test and adherence to the extended screening interval with normal test results reduce patient harms that can be caused by over-testing, including pain, inconvenience, morbidity, and unnecessary follow-up procedures and treatments,” commented lead investigator Katherine B. Roland, MPH, a behavioral scientist in CDC's Division of Cancer Prevention and Control. “Appropriate use of cervical cancer screening technologies is essential, now more than ever, if HPV co-testing is to be considered a preventive service for women covered by insurance providers.”

Analyzing nationally representative data collected in 2006 through the CDC's National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, researchers assessed HPV testing and co-testing practices and documented the recommendations for screening intervals given by private office-based providers and hospital outpatient departments (OPDs). The study included responses from 376 private office-based physicians and 216 physicians from hospitals and outpatient facilities.

Providers who ordered the HPV co-test were asked their recommendation for the next Papanicolaou test according to 3 clinical vignettes. The vignettes describe a woman between the ages of 30 and 60 years of age with a current normal Papanicolaou test with: 1) no current HPV test results and history of 2 consecutive normal Papanicolaou test results 2) a current negative HPV test result and a history of 2 consecutive normal Papanicolaou test results, and 3) a current negative HPV test result and no history of Papanicolaou tests. The guidelines support extending the screening interval up to 3 years in each of the vignettes described.

For vignette 1, 76.4% of office-based providers and 85.2% of hospital OPDs would recommend a next screening in 12 months. For vignette 2, 66.6% of office-based providers and 72.7% of hospital OPDs would recommend a next Papanicolaou test in 12 months. Only 14.0% of office-based providers would recommend a next Papanicolaou test in 3 years or more, as guidelines recommend. For vignette 3, 73.4% of office-based providers and 73.5% of hospital OPDs would recommend a next Papanicolaou test in 12 months.

Establishing a history of normal Papanicolaou test results with the patient appears to be a critical component to providers making guideline-supported screening interval recommendations.

Roland added, “Our findings suggest a need for continued surveillance on cervical cancer screening guideline adherence. Evaluating provider screening behaviors, whether they reflect national guidelines and policies, and how those behaviors and policies translate to women's clinical preventive care are vital, especially in an area where science and policy are rapidly evolving.”

The article is “Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States” by Katherine B. Roland, MPH; Ashwini Soman, MBBS, MPH; Vicki B. Benard, PhD; Mona Saraiya, MD, MPH (doi: 10.1016/j.ajog.2011.06.001). It will appear in the American Journal of Obstetrics & Gynecology, Volume 205, Issue 5 (November 2011) published by Elsevier.