Cervical Cancer Screening Guidelines Research Articles

Non-use and inadequate use of cervical cancer screening among a representative sample of women in the United States.

Women's adherence to the United States (U.S.) Preventive Services Task Force guidelines for cervical cancer screening was determined by examining predisposing, enabling, and needs factors from Andersen's Behavioral Model of Health Services Use conceptual framework. The outcome was operationalized as cervical cancer screening use, non-use, and inadequate-use. Multinomial logistic regression was conducted on data from the 2019 National Health Interview Survey of 7,331 eligible women aged 21-65. Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Non-Users than those aged 21-29. Hispanic, Asian, and American Indian/Alaska Native (AIAN) women were more likely to be Non-Users than White women. More educated women were less likely to be Non-Users. Foreign-born women <10 years in the U.S. were more likely to be Non-Users than U.S.-born women. Women with financial hardship were less likely to be Non-Users. Poorer women and uninsured women were more likely to be Non-Users. Women with children in their household were less likely to be Non-Users than those without children. Women who had a well-visit in the past year were less likely to be Non-Users. Women with a history of human papillomavirus (HPV) vaccination were less likely to be Non-Users. Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Inadequate-Users. AIAN women were more likely to be Inadequate-Users. Women of other races were less likely to be Inadequate-Users. Employed women were less likely to be Inadequate-Users. Uninsured women were more likely to be Inadequate-Users. Women who had a well-visit within a year were less likely to be Inadequate-Users. Women with past HPV vaccination were more likely to be Inadequate-Users. Smokers were less likely to be Inadequate-Users. Predisposing, enabling, and needs factors are differently associated with non-use and inadequate use of cervical cancer screening. Understanding factors associated with the use, non-use, and inadequate use of cervical cancer screening is crucial to avoid or curb unnecessary tests, increased costs to both society and individuals, and the ill-allocation of limited resources.

Attitudes toward the American Cancer Society's 2020 cervical cancer screening guidelines: A qualitative study of a national sample of US clinicians.

The 2020 American Cancer Society (ACS) guidelines are the most recent national guidelines for cervical cancer screening. These guidelines propose two major changes from current practice: initiating screening at age 25 years and using primary human papillomavirus (HPV) testing. Adoption of guidelines often occurs slowly, and therefore understanding clinician attitudes is important to facilitate practice change. Interviews with a national sample of clinicians who perform cervical cancer screening in a variety of settings explored attitudes toward the two major changes from the 2020 ACS cervical cancer screening guidelines. Clinicians participated in 30- to 60-min interviews exploring their attitudes toward various aspects of cervical cancer screening. Qualitative analysis was performed. Seventy clinicians participated from across the United States. Few respondents were initiating screening at age 25 years, and none were using primary HPV testing. However, over half would be willing to adopt these practices if supported by scientific evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional societies, lack of laboratory availability and insurance coverage, limited autonomy within large health care systems, and concerns related to missed disease. Few clinicians have adopted screening initiation or primary HPV testing, as recommended by the 2020 ACS guidelines, but over half were open to adopting these changes. Implementation may be facilitated via professional organization endorsement, clinician education, and laboratory, health care system, and insurance support. In 2020, the American Cancer Society (ACS) released updated guidelines for cervical cancer screening. The main changes to current practices were to initiate screening at age 25 years instead of age 21 years and to screen using primary human papillomavirus (HPV) testing rather than cytology alone or in combination with HPV testing. We performed in-depth interviews with 70 obstetrics and gynecology, family medicine, and internal medicine physicians and advanced practice providers about their attitudes toward these guidelines. Few clinicians are following the 2020 ACS guidelines, but over half were open to changing practice if the changes were supported by evidence and recommended by professional medicalorganizations. Barriers to adoption included the lack of endorsement by professional medical organizations, logistical issues, and concerns about missed disease.

Enduring Consensus Guidelines for Cervical Cancer Screening and Management: Introduction to the Scope and Process.

The Enduring Consensus Cervical Cancer Screening and Management Guidelines (Enduring Guidelines) effort is a standing committee to continuously evaluate new technologies and approaches to cervical cancer screening, management, and surveillance. The Enduring Guidelines process will selectively incorporate new technologies and approaches with adequate supportive data to more effectively improve cancer prevention for high-risk individuals and decrease unnecessary procedures in low-risk individuals. This manuscript describes the structure, process, and methods of the Enduring Guidelines effort. Using systematic literature reviews and primary data sources, risk of precancer will be estimated and recommendations will be made based on risk estimates in the context of established risk-based clinical action thresholds. The Enduring Guidelines process will consider health equity and health disparities by assuring inclusion of diverse populations in the evidence review and risk assessment and by developing recommendations that provide a choice of well-validated strategies that can be adapted to different settings. The Enduring Guidelines process will allow updating existing cervical cancer screening and management guidelines rapidly when new technologies are approved or new scientific evidence becomes available.

Recommendations for Use of p16/Ki67 Dual Stain for Management of Individuals Testing Positive for Human Papillomavirus.

The Enduring Consensus Cervical Cancer Screening and Management Guidelines Committee developed recommendations for dual stain (DS) testing with CINtec PLUS Cytology for use of DS to triage high-risk human papillomavirus (HPV)-positive results. Risks of cervical intraepithelial neoplasia grade 3 or worse were calculated according to DS results among individuals testing HPV-positive using data from the Kaiser Permanente Northern California cohort and the STudying Risk to Improve DisparitiES study in Mississippi. Management recommendations were based on clinical action thresholds developed for the 2019 American Society for Colposcopy and Cervical Pathology Risk-Based Management Consensus Guidelines. Resource usage metrics were calculated to support decision-making. Risk estimates in relation to clinical action thresholds were reviewed and used as the basis for draft recommendations. After an open comment period, recommendations were finalized and ratified through a vote by the Consensus Stakeholder Group. For triage of positive HPV results from screening with primary HPV testing (with or without genotyping) or with cytology cotesting, colposcopy is recommended for individuals testing DS-positive. One-year follow-up with HPV-based testing is recommended for individuals testing DS-negative, except for HPV16- and HPV18-positive results, or high-grade cytology in cotesting, where immediate colposcopy referral is recommended. Risk estimates were similar between the Kaiser Permanente Northern California and STudying Risk to Improve DisparitiES populations. In general, resource usage metrics suggest that compared with cytology, DS requires fewer colposcopies and detects cervical intraepithelial neoplasia grade 3 or worse earlier. Dual stain testing with CINtec PLUS Cytology is acceptable for triage of HPV-positive test results. Risk estimates are portable across different populations.

Knowledge regarding human papillomavirus and cervical cancer prevention among medical students from Chulalongkorn University in Thailand

BackgroundCervical cancer is one of the leading causes of death among women in Thailand. General practitioners, within their primary healthcare role, play a vital role in the cervical cancer screening program, as they are the healthcare professionals most easily accessible to the general population. This study aims to determine the level of knowledge of cervical cancer and human papillomavirus (HPV) infection, HPV vaccination, and cervical cancer screening among last-year medical students.MethodsA cross-sectional study was conducted among sixth-year medical students using an electronic self-administered questionnaire. The two-part questionnaire comprised demographic data and 12 true/false questions that assessed knowledge regarding HPV infection, HPV vaccination, and cervical cancer screening recommendations. Pilot testing revealed a high Cronbach’s alpha and test–retest reliability coefficient.ResultsA 67% response rate was achieved. Among the 198 respondents, only one (0.5%) student correctly answered over 80% of the questions while most respondents (172, 71.7%) correctly answered less than 60% of the questions. Less than half of the respondents correctly identified crucial aspects such as the primary cause of cervical cancer, recommended vaccination age, cytology sensitivity compared to HPV testing, and the recommended screening frequency for average-risk women.ConclusionsThis study highlights a significant lack of comprehension among Thai medical students concerning HPV infection, vaccination, and cervical cancer screening guidelines. Encouraging educational enhancement, effective communication, and heightened awareness of these crucial topics within the medical school curriculum are imperative.

Implementation of cervical cancer prevention and screening across five tertiary hospitals in Nepal and its policy implications: A mixed-methods study.

In Nepal, cervical cancer is the most common cancer among women despite the existing policies. This study intends to assess the implementation of cervical cancer prevention and screening through service utilization by women, knowledge and attitude among health professionals, and the perceptions of stakeholders in Nepal. This mixed-methods study was conducted in 2022 across five tertiary hospitals in Kathmandu, Nepal. The quantitative study comprised the health professionals and women attending gynecology outpatient clinics from the selected hospitals. The qualitative study comprised stakeholders including service providers and experts on cervical cancer from selected hospitals, civil societies, and the Ministry of Health and Population. The utilization of screening through pap smear among 657 women across five hospitals was 22.2% and HPV vaccination was 1.5%. The utilization of cervical cancer screening was associated with older age [adjusted odds ratio (AOR) = 1.09, CI: 1.07, 8.19], married (AOR = 3.024, CI: 1.12, 8.19), higher education (AOR = 3.024, CI:1.12, 8.42), oral contraceptives use (AOR = 2.49, CI: 1.36, 4.39), and ever heard of cervical cancer screening (AOR = 13.28, CI: 6.85, 25.73). Among 254 health professionals, the knowledge score was positively associated with them ever having a training [Standardized Beta (β) = 0.20, CI: 0.44, 2.43)] and having outreach activities in their hospital (β = 0.19 CI: 0.89, 9.53) regarding cervical cancer screening. The female as compared to male health professionals (β = 0.16, CI: 0.41, 8.16, P = 0.03) and having a cervical cancer screening guideline as compared to none (β = 0.19 CI: 0.89, 9.53, P = 0.026) were more likely to have a better attitude for screening. The qualitative findings among 23 stakeholders reflected implementation challenges in policy, supply, service delivery, providers, and community. This study showed low utilization of prevention and services by women and implementation gaps on cervical cancer prevention and screening services across five tertiary hospitals in Kathmandu, Nepal. The findings could help designing more focused interventions.

Underestimated Cervical Cancer among Women over 65 Years Old: Is It Time to Revise the Screening Target Age Group?

To compare cytological and histological results from women > 64 years old who followed the Brazilian national cervical cancer screening guidelines with those who did not. The present observational retrospective study analyzed 207 abnormal cervical smear results from women > 64 years old in a mid-sized city in Brazil over 14 years. All results were reported according to the Bethesda System. The women were divided into those who followed the screening guidelines and those who did not. Atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion cytology results were found in 128 (62.2%) cases. Of these, 112 (87.5%) had repeated cytology with positive results. The other 79 (38.1%) with abnormal results should have been referred to colposcopy and biopsy. Out of 41 (51.9%) biopsied women, 23 (29.1%) had a confirmed diagnosis of neoplasia or precursor lesion. In contrast, among the 78 (37.7%) biopsied patients, 40 (51.3%) followed the guideline recommendations, with 9 (22.5%) positive biopsies. Of the 38 (48.7%) women who did not follow the guidelines, there were 24 (63.1%) positive results. Women who did not follow the guidelines demonstrated higher chances of cancer and precursor lesions (odds ratio [OR]: 5.904; 95% confidence interval [CI]: 2.188-15.932; p = 0.0002). Women > 64 years old who did not follow the national screening protocol showed significant differences in the frequency of abnormal results and severity of diagnosis compared with those who followed the protocol.

Government Housing Assistance and Cancer Screening Among Adults With Low Income

Access to affordable housing may support cancer control for adults with low income by alleviating financial barriers to preventive care. This study examines relationships between cancer screening and receipt of government housing assistance among adults with low income. Data are from the 2019 and 2021 National Health Interview Survey. Eligible respondents were classified as up-to-date or not with breast cancer (BC), cervical cancer (CVC) and colorectal cancer (CRC) screening guidelines. Multivariable logistic regression was used to model guideline-concordant screening by receipt of government housing assistance, overall and stratified by urban-rural status, race/ethnicity, and age. Analyses were performed in 2023. Analyses for BC, CVC and CRC screening included 2,258, 3,132, and 3,233 respondents, respectively. There was no difference in CVC screening by housing assistance status, but screening for BC and CRC was higher among those who received assistance compared to those who did not (59.7% vs. 50.8%, p<0.01 for BC; 57.1% vs. 44.1%, p<0.01 for CRC). In models adjusted for sociodemographic characteristics, health status and insurance, these differences were not statistically significant for either BC or CRC screening. In stratified adjusted models, housing assistance was statistically significantly associated with increased BC screening in urban areas (aOR=1.35, 95% CI=1.00-1.82) and among Hispanic women (aOR=2.20, 95% CI=1.01-4.78) and women 45-54 years of age (aOR=2.10, 95% CI=1.17-3.75). Policies that address housing affordability may enhance access to BC screening for some subgroups, including women in urban areas, Hispanic women, and younger women. More research on the mechanisms that link housing assistance to BC screening is needed.

Epigenome-wide methylation and progression to high-grade cervical intraepithelial neoplasia (CIN2+): a prospective cohort study in the United States

BackgroundMethylation levels may be associated with and serve as markers to predict risk of progression of precancerous cervical lesions. We conducted an epigenome-wide association study (EWAS) of CpG methylation and progression to high-grade cervical intraepithelial neoplasia (CIN2 +) following an abnormal screening test.MethodsA prospective US cohort of 289 colposcopy patients with normal or CIN1 enrollment histology was assessed. Baseline cervical sample DNA was analyzed using Illumina HumanMethylation 450K (n = 76) or EPIC 850K (n = 213) arrays. Participants returned at provider-recommended intervals and were followed up to 5 years via medical records. We assessed continuous CpG M values for 9 cervical cancer-associated genes and time-to-progression to CIN2+. We estimated CpG-specific time-to-event ratios (TTER) and hazard ratios using adjusted, interval-censored Weibull accelerated failure time models. We also conducted an exploratory EWAS to identify novel CpGs with false discovery rate (FDR) < 0.05.ResultsAt enrollment, median age was 29.2 years; 64.0% were high-risk HPV-positive, and 54.3% were non-white. During follow-up (median 24.4 months), 15 participants progressed to CIN2+. Greater methylation levels were associated with a shorter time-to-CIN2+ for CADM1 cg03505501 (TTER = 0.28; 95%CI 0.12, 0.63; FDR = 0.03) and RARB Cluster 1 (TTER = 0.46; 95% CI 0.29, 0.71; FDR = 0.01). There was evidence of similar trends for DAPK1 cg14286732, PAX1 cg07213060, and PAX1 Cluster 1. The EWAS detected 336 novel progression-associated CpGs, including those located in CpG islands associated with genes FGF22, TOX, COL18A1, GPM6A, XAB2, TIMP2, GSPT1, NR4A2, and APBB1IP.ConclusionsUsing prospective time-to-event data, we detected associations between CADM1-, DAPK1-, PAX1-, and RARB-related CpGs and cervical disease progression, and we identified novel progression-associated CpGs.ImpactMethylation levels at novel CpG sites may help identify individuals with ≤CIN1 histology at higher risk of progression to CIN2+ and inform risk-based cervical cancer screening guidelines.

Women's perceptions and preferences for cervical cancer screening in light of updated guidelines.

Updated risk-based guidelines for cervical cancer screening (CCS) allow for individualized screening that minimizes unnecessary testing. However, these guidelines are complex and may not be easily understandable to patients. To describe women's perceptions and preferences about CCS in light of recent guideline changes. This qualitative study conducted in February 2020 used online, text-based focus groups with a sample of US women (n = 49) ages 27-45. After participants completed a short demographic survey, an experienced moderator used a semistructured guide to solicit participants' perceptions of routine gynecologic care and CCS. We summarized survey data using descriptive statistics. Two authors analyzed transcripts using conventional content analysis and met with other team members to resolve discrepancies and determine final themes. Most participants were non-Hispanic White (65%), had health insurance (90%), and reported having a routine gynecologic examination in the past year (70%). We identified four common themes: (1) low perceived risk of human papillomavirus (HPV) coupled with low knowledge about HPV as a causative factor for cervical cancer, (2) confusion about-and mistrust of-recent individual risk-based guidelines that determine the indicated timing and type of CCS test (Pap or HPV testing), (3) mixed opinions about performing a self-swab for HPV testing, and (4) conflicting perceptions of trust toward providers and the health care industry. Findings highlight women's uncertainty and hesitancy about updated CCS guidelines. Provider-patient communication strategies should consider women's gaps in knowledge about HPV, include the rationale for guidelines and types of tests, and build trust between patients and providers.

Understanding over- and under-screening of cervical cancer among a national sample of commercially insured women: Implications for health equity.

451 Background: Cervical cancer screening guidelines have changed frequently in recent years. Different adherence patterns by screening modalities (e.g., cytology-only, HPV testing-only, co-testing) could lead to overuse and underuse of care. It is unclear if receipt of guideline adherent screening varies among racial/ethnic minorities and those with low socioeconomic status (SES), which can exacerbate existing disparities. Methods: Optum Clinformatics Data Mart from 2013-2021 was used to identify women aged 30-65 to examine over- and under-screening to understand national patterns of guideline adherence. Average-risk women with continuous enrollment for 6 years for years starting in 2012-2016 and at least one claim were included. Those with history of hysterectomy and cervical cancer were excluded. According to the 2012 U.S. Preventive Services Task Force guideline, adherence was defined as screening interval of 4.5-5.5 years for co-testing/HPV testing as the index screening modality and 2.5-3.5 years for cytology-only, and over-screening as &lt;4.5 years and &lt;2.5 years, and under-screening as &gt; 5.5 years and &gt; 3.5 years including lack of subsequent screening, respectively. We compared distribution of screening adherence by screening modality, race, education level, and household net worth using chi-squared test. Results: A total of 1,422,258 individuals ages 30-65 were included. Among the eligible sample, 1,016,067 women received at least one cervical cancer screening from 2013-2017. Of these, 830,549 (81.7%) were considered average-risk. About half (48.4%) received an index screening with cytology-only, 51.0% with co-testing and 0.6% with HPV testing. Overall, 7.4% were guideline adherent, 62.1% were over-screened and 30.5% were under-screened. 12.7% of the women screened with cytology-only were adherent compared to 2.5% of those screened with co-testing, 59.2% vs. 64.9% were over-screened, and 28.1% vs. 32.6% were under-screened, respectively. Unadjusted differences in the distribution of adherence were statistically significant by race, education level, and household net worth (p &lt; 0.01). Conclusions: The study identified high rates of over-screening and under-screening among a national cohort of commercially insured women, signaling the need for interventions to improve guideline adherent screening. Furthermore, over- and under-screening varied by screening modalities, race and SES factors, which highlights the need to study specific patterns of adherence among subpopulations to address cervical cancer inequities.

Barriers to Cervical Cancer Screening among Sub-Saharan African Immigrant Women in the United States: A Qualitative Report

Objective: Cervical cancer screening can prevent women across all age groups from developing cervical cancer (CC). However, Sub-Saharan African immigrant women (SAIW) sparsely engage in routine CC screening. Thus, developing prevention strategies to improve SAIW’s adherence to recommended CC screening guidelines is critical. To ensure that such strategies are successful, they must meet the needs of the target population. By conducting qualitative interviews with SAIW (N = 15), we aimed to get a deeper understanding of barriers to CC screening receipt. Methods: We asked SAIW about barriers to CC screening and possible ideas to facilitate their future screening behavior. Results: Our findings revealed that SAIW are especially affected by several major barriers: lack of awareness of CC guidelines, fear/fatalism, lack of resources (eg, a lack of time due to job and family commitment), other resource-related barriers (eg, unreliable mode of transport, and no health insurance), modesty, and overt bias. Participants indicated a preference for female healthcare providers for CC screening and suggested spousal involvement in CC intervention development to foster support. Conclusion: The identification of multi-level barriers indicates that multiple strategies are needed to improve the uptake of CC screening among SAIW.

The Association of Cervical Cancer Screening With Disability Type Among U.S. Women (Aged 25–64 Years)

Despite a gradual decline in cervical cancer mortality because of greater use of screening, including Pap and human papillomavirus (HPV) tests, disparities in screening among adult women by disability type have not been examined. This study aims to assess the odds of cervical cancer screening using HPV tests by disability type among U.S. women aged 25-64 years. This study was analyzed in 2022 using pooled data from 2018 and the 2020 Behavioral Risk Factor and Surveillance System. The analytic sample included 189,795 women aged 25-64 years. Disability was defined as having any sensory disability, cognitive disability, physical disability, ≥2 disabilities, or no disability adapted from a standardized questionnaire. Descriptive analyses were used to estimate the proportion of HPV tests on the basis of 2020 American Cancer Society guidelines, which recommend testing within five years for all women aged 25-65 years. Multivariable analyses were conducted to estimate AORs of cervical cancer screening by disability type. Overall, 53.8% of women met recommended 2020 American Cancer Society guidelines for cervical cancer screening using HPV tests. The proportion of HPV tests was higher in women with a cognitive disability (55.9%) and lower in those with sensory (49.7%), physical (48.2%), and ≥2 disabilities (47.8%) than in those without disabilities (54.8%). In adjusted analyses, women with any disability (AOR=0.95, 95% CI=0.88, 0.97), physical disability (AOR=0.96, 95% CI=0.80, 0.98), and ≥2 disabilities (AOR=0.88, 95% CI=0.78, 0.97) had lower odds of receiving cervical cancer screening with HPV testing than women without disabilities. Disparities in screening with HPV tests among women with physical and ≥2 disabilities suggest the need for a targeted approach to improve prevention screening awareness, access, and availability in this population.

Unindicated Cervical Cancer Screening in Adolescent Females Within a Large Healthcare System in the United States

ABSTRACT The increasingly complicated nature of screening guidelines for cervical cancer includes multiple component tests (cytology, genotyping, and high-risk human papilloma virus [HPV] testing) and evolving recommendations. The aim of this study was assessing single-large-healthcare-system trends over time associated with adolescent females and unindicated cervical cancer screening tests. This repeated cross-sectional study analyzed electronic medical records of provider- and patient-specific variables from the Yale New Haven Health System. Included in the study were all 13- to 20-year-old Yale New Haven Health System patients who underwent screening for cervical cancer via either HPV testing or cytology between January 1, 2012 and December 31, 2018. Age, medical histories, surgical histories, self-reported race and ethnicity, and prescribed medications were all patient-specific variables. Provider-specific variables included clinical practice affiliation, clinical degree, and adolescent patient volume (number of medical visits completed by a patient less than 21 every 6 months). In terms of this study, definition of practice setting was either academic (low-income teaching hospitals) or community-based (private practice setting with primarily insured women). Cytologies were categorized as either unindicated or indicated, based on cervical cancer screening guidelines from 2012 (recorded as unindicated for index specimens collected before the 21st birthday in patients lacking immunocompromised conditions). Should an HPV test be performed, any results other than “atypical squamous cells of undetermined significance” received an unindicated status. The final sample size in the study included 794 women from 118 providers (53% community setting and 47% academic setting). Results from analysis of 900 cervical cancer screenings demonstrated that unindicated tests made up the majority of tests (90%), with 87% of these being unindicated cytology testing only and 14% with unindicated HPV testing as well. Reasons for obtaining unindicated tests as recorded in the original clinical history were lacking, as 62% had no justification listed for testing, and those with reasons failed current guideline compliance. The incidence rate (IR) of adolescent unindicated tests decreased by 33% between 2012 and 2018. Although a significantly lower IR of unindicated screening existed in the academic setting, the rate of decline in the IR of unindicated screening during this period was significantly greater in the community than in the academic setting by 11%. A strength of the study included its ability to calculate IRs in all encounters, including sexually transmitted infection or contraception screenings. Limitations included utilization of hospital system cytology reports for obtaining data, thereby hindering any access to data necessary for validation of screening or surveillance indications from previously performed antecedent cytology. Furthermore, the study failed to collect information regarding another guideline-adherence marker: number of indicated index cervical cancer screenings for patients beginning at 21 years. According to an examination by Becerra-Culqui of women having an encounter at the age of 21 years or beyond, 65% missed opportunities for screening. Finally, the authors were unable to comment on both immunocompromised women and eligible young women who missed indicated screening due to collection of data via pathology reports rather than well-woman examinations. Although unindicated screening for women ages 21 and younger experienced significant reductions, areas for improvement remained. As recent guidelines updates may present greater provider and patient challenges, evidence-based strategies are more important than ever in terms of guideline adherence and dissemination.

Association Between Cervical Cancer Screening Guidelines and Preterm Delivery Among Females Aged 18 to 24 Years

Association Between Cervical Cancer Screening Guidelines and Preterm Delivery Among Females Aged 18 to 24 Years

Changes over time in papanicolaou cytology test and HPV test in a large women's academic center laboratory.

In the past 2 decades, cervical cancer screening guidelines in the United States have undergone numerous revisions with recent greater emphasis on primary high-risk human papillomavirus (hrHPV) testing. We examine the trends of Papanicolaou test and hrHPV testing at our large academic center across 4 years (2006, 2011, 2016, and 2021) over a 15-year period. The number of ThinPrep Papanicolaou and hrHPV tests, as well as the triggers for HPV testing, were retrospectively analyzed. A total of 308,355 Papanicolaou tests and 117,477 hrHPV tests were reported across the 4 years. The number of Papanicolaou tests performed decreased nearly 3-fold over the study period, with only 43,230 Papanicolaou tests performed in 2021. The HPV test to Papanicolaou test ratio increased: 17% of Papanicolaou tests had an associated HPV test in 2006, whereas 72% of Papanicolaou tests ordered in 2021 had a companion hrHPV. The use of co-testing also increased. Overall, 73% were co-tests and 27% were reflexively ordered in the 4 one-year time periods. Co-tests constituted only 46% of HPV tests in 2006, but this increased to 93% in 2021. The percentage of positive hrHPV results decreased; in 2006, 18.3% of cases were positive, dropping to 8.6% in 2021 due to the marked increase in co-testing. Stratifying by diagnostic category, hrHPV results have remained relatively constant. With the numerous recent revisions of cervical screening guidelines, screening strategies at our institution reflected these changes in clinical practice. Papanicolaou and HPV co-testing became the most common screening method for women 30 to 65 years of age in our cohort.

HPV self-sampling versus healthcare provider collection on the effect of cervical cancer screening uptake and costs in LMIC: a systematic review and meta-analysis

BackgroundCervical cancer is a major global health issue, with 89% of cases occurring in low- and middle-income countries (LMICs). Human papillomavirus (HPV) self-sampling tests have been suggested as an innovative way to improve cervical cancer screening uptake and reduce the burden of disease. The objective of this review was to examine the effect of HPV self-sampling on screening uptake compared to any healthcare provider sampling in LMICs. The secondary objective was to estimate the associated costs of the various screening methods.MethodStudies were retrieved from PubMed, Embase, CINAHL, CENTRAL (by Cochrane), Web of Science, and ClinicalTrials.gov up until April 14, 2022, and a total of six trials were included in the review.Meta-analyses were performed mainly using the inverse variance method, by pooling effect estimates of the proportion of women who accepted the screening method offered. Subgroup analyses were done comparing low- and middle-income countries, as well as low- and high-risk bias studies. Heterogeneity of the data was assessed using I2. Cost data was collected for analysis from articles and correspondence with authors.ResultsWe found a small but significant difference in screening uptake in our primary analysis: RR 1.11 (95% CI: 1.10–1.11; I2 = 97%; 6 trials; 29,018 participants). Our sensitivity analysis, which excluded one trial that measured screening uptake differently than the other trials, resulted in a clearer effect in screening uptake: RR: 1.82 (95% CI: 1.67–1.99; I2 = 42%; 5 trials; 9590 participants). Two trials reported costs; thus, it was not possible to make a direct comparison of costs. One found self-sampling more cost-effective than the provider-required visual inspection with acetic acid method, despite the test and running costs being higher for HPV self-sampling.ConclusionOur review indicates that self-sampling improves screening uptake, particularly in low-income countries; however, to this date, there remain few trials and associated cost data. We recommend further studies with proper cost data be conducted to guide the incorporation of HPV self-sampling into national cervical cancer screening guidelines in low- and middle-income countries.Systematic review registrationPROSPERO CRD42020218504.

Factors associated with shorter-interval cervical cancer screening for young women in three United States healthcare systems

Frequently changing cervical cancer screening guidelines over the past two decades have been inconsistently adopted in the United States. Current guidelines set the recommended screening interval to three years for average-risk women aged 21–29 years. Few studies have evaluated how patient and provider factors are associated with implementation of cervical cancer screening intervals among younger women. This study evaluated multilevel factors associated with screening interval length among 69,939 women aged 21–29 years with an initial negative Pap screen between 2010 and 2015 across three large health systems in the U.S. Shorter-interval screening was defined as a second screening Pap within 2.5 years of an initial negative Pap. Mixed-effects logistic regression was performed for each site to identify provider and patient characteristics associated with shorter-interval screening. The odds of shorter-interval screening decreased over the study period across all sites, though the proportion of patients screened within 2.5 years remained between 7.5% and 20.7% across sites in 2014–2015. Patient factors including insurance, race/ethnicity, and pregnancy were associated with shorter-interval screening, though the patterns differed across sites. At one site, the variation in shorter-interval screening explained by the provider was 10.6%, whereas at the other two sites, the provider accounted for < 2% of the variation in shorter-interval screening. Our results highlight the heterogeneity in factors driving cervical cancer screening interval across health systems and point to the need for tailored approaches targeted to both providers and patients to improve guideline-concordant screening.

An RCT of Two Interventions to Usual Care For Increasing Cervical Cancer Screening

Purpose: Rural women have increased incidence and mortality from cervical cancer (CC) compared to urban women indicating a lack of cervical cancer screening (CCS), an important component of CC control. The objective of this study was to examine the comparative effectiveness of a mailed DVD vs. DVD plus telephonic patient navigation (PN) vs. Usual Care (UC) for increasing the percentage of rural Midwestern women up to date (UTD) with 2018 United States Preventive Services Task Force CCS guidelines. Methods: As part of a larger study, 553 women (aged 50–74) who were not UTD for CCS were consented and randomized to one of the three study arms, DVD, DVD+PN, UC. Participants were assessed for baseline characteristics including sociodemographics, health status, and CCS beliefs by self-reported survey. Baseline and 12-month screening status were assessed by medical record review. Results: The mean age of participants was 59.8 years. When controlling for covariates in a logistic regression model, women had 4.52 (95% Confidence Interval [CI] = 2.09, 10.7, P &amp;lt; 0.001) greater odds of being UTD with CCS in the DVD + PN group vs. UC and 2.93 (95% CI = 1.63, 5.25, P &amp;lt; 0.001) greater odds of being UTD in the DVD + PN vs. DVD group. Other significant covariates included having higher odds (Odds Ratio [OR] = 4.76; 95% CI = 1.27, .33.33; P = 0.045) of becoming UTD if on private vs. public insurance; being normal (OR = 2.71; 95% CI = 1.14, 6.37; P = 0.022) or underweight (OR = 2.38; 95% CI = 1.12, 5.09; P = 0.024) vs. obese; and planning to have a Papanicolaou (Pap) test within the next six months (contemplation) (OR = 2.25; 95% CI = 1.23, 4.08; P = 0.008). Conclusions: A PN plus an interactive DVD intervention significantly improved the proportion of Midwestern rural women who became UTD with CCS compared to UC. Certain groups of women may be more at risk for not obtaining a CCS such as those who are on public insurance, obese, and not planning CCS. Future interventions should focus on women with these characteristics to increase CCS rates. A limitation of this study is that behavioral variables, such as contemplation, were measured in relation to Pap testing and did not include human papillomavirus (HPV) testing. As HPV testing/co-testing becomes more widely used, future interventions should examine behaviors specific to this screening.

An audit of adherence to cervical cancer screening guidelines in a tertiary-level HIV clinic.

Cervical cancer is the most common malignancy affecting South African women aged 15-44 years, with a higher prevalence among women living with HIV (WLWH). Despite recommendations for a screening target of 70%, the reported rate of cervical cancer screening in South Africa is 19.3%. To investigate the adherence of healthcare workers to cervical cancer screening guidelines in a tertiary-level HIV clinic. A retrospective cross-sectional record audit of women attending the Charlotte Maxeke Johannesburg Academic Hospital HIV Clinic over a 1-month period. Out of 403 WLWH who attended the clinic, 180 (44.7%) were screened for cervical cancer in the 3 years prior to the index consultation. Only 115 (51.6%) of those women with no record of prior screening were subsequently referred for screening. Women who had undergone screening in the previous 3 years were significantly older (47 years vs 44 years, P = 0.046) and had a longer time since diagnosis of their HIV (12 years vs 10 years, P = 0.001) compared to women who had not undergone screening. There was no significant difference in CD4 count or viral suppression between women who had and had not undergone screening. The rate of cervical cancer screening in our institution is below that recommended by the World Health Organization and the South African National Department of Health.