More than 3 years after the release of new cervical cancer screening guidelines, patients remain largely unaware of substantial changes in screening, and many physicians remain confused about or resistant to those changes.
The confusion is a matter of education, said Dr. Owen Montgomery, chairman of the department of obstetrics and gynecology at Drexel University, Philadelphia. As for the resistance, that’s less a reflection of concern about the science and more about the emotional and sociological processes involved in change, he said.
“It’s really good science,” Dr. Montgomery said of the data that formed the basis for the guidelines. “I was on the executive board of the [American College of Obstetricians and Gynecologists] when we signed off on the new recommendations. The science is valid.”
Two sets of guidelines were released in 2012, one by the U.S. Preventive Services Task Force (USPSTF) and one by the American Cancer Society (ACS) in conjunction with the American Society for Clinical Pathology (ASCP) and the American Society for Colposcopy and Cervical Pathology (ASCCP). Although the two guidelines differ in some respects, both recommend against a longstanding tradition: routine yearly Pap testing. The guidelines now call for screening intervals of 3-5 years depending on patient age and other factors, and recommend against screening those under age 21 years and over age 65 years in the absence of risk factors.
Knowledge gaps
Despite the widespread organizational support for the guidelines, data suggest that knowledge of them may be lacking among both patients and physicians. For instance, about 85% of 249 adult women who participated in a recent survey answered incorrectly when asked how often low-risk women aged 21-29 should be screened, and nearly 95% answered incorrectly when asked about the recommended frequency of screening in low-risk women over age 30 years.
According to Dr. Katherine O’Flynn O’Brien and her colleagues at George Washington University, Washington, who presented the results earlier this year at the American College of Obstetricians and Gynecologists annual scientific meeting, the findings suggest “that providers should focus more on educating women about changes to screening practices.”
But another survey presented at the same ACOG meeting showed that many providers may be unaware of the guideline changes or hesitant about embracing those changes.
Using a convenience sample of 165 medical and osteopathic physicians, physician assistants, and nurse practitioners, the investigators found that, in contrast with the current guidelines, about half do not perform cotesting in women aged 30-65 years every 5 years, and nearly 57% do not screen women aged 21-29 years with cytology alone every 3 years. More than 40% reported that they do not perform cytology screening in women aged 30-65 years every 3 years.
Addressing the ‘what ifs’
Confusion about the guidelines, and hesitation about implementing them, is not surprising as the changes – particularly the 3- to 5-year screening interval changes – are some of the most dramatic in recent memory, according to Dr. Constance Bohon, an ob.gyn. in Washington, D.C., and assistant clinical professor of ob.gyn. at George Washington University.
Certainly the guidelines have evolved with the science over the years, and some changes, such as screening only those over age 21 years, have been embraced, she said.
“But some changes are easier to accept than others,” she added, noting that “doing a Pap with cotesting in women after age 30 and repeating it again in 5 years is very difficult for many clinicians to accept … part of the issue is that fine line in medicine between using the data and relying on clinical sense, clinical expertise.”
There is concern about the exceptions and the “what ifs,” she said.
What if a patient has a new partner? What if she develops an illness that results in a shift in immunity?
These concerns are valid, agreed Dr. Jill Rabin, professor of obstetrics and gynecology and cochief of the division of ambulatory care, Women’s Health Programs–PCAP Services at North Shore–Long Island Jewish Health System, New Hyde Park, N.Y.
But she stressed in an interview that the guidelines are just that – guidelines. “They aren’t written in stone,” she said, adding that the recommendations are based on good science, and that a careful reading shows there is plenty of room for clinical judgment.
“Guidelines evolve and we have to keep an open mind and make sure that we don’t use a one-size-fits-all model. That doesn’t really help our patients,” said Dr. Rabin, who also is head of the urogynecology department at Long Island Jewish Medical Center.
Patient expectations
Another hurdle to embracing the guidelines is that of patient expectations. One of the big misunderstandings among patients of all ages is that they will skip all visits for 3 years because of the interval in Pap testing, Dr. Montgomery said. It is important to stress that “the Pap is just one of the services done during the visit, and a relatively small one when you look at all the other thing that are part of a comprehensive well woman visit,” he said.
He further noted that both patient and physician age may be an important factor in acceptance of the guidelines and the changes in screening frequency.
As a physician with a large population of patients in their postreproductive years, and as one who trains young residents, he has noticed a generational difference: Younger patients and physicians are more accepting of the changes, but women who have spent 30 or 40 years coming in for an annual Pap smear equate that with health; they feel that they have done their part in staying healthy, and they have a greater sense of the value of the visit, he said.
Dr. Bohon predicted that both the advancing science and the concerns of patients and physicians will be considered when new guidelines are developed.
“My hope is that we have a realistic view of what the Pap can do,” Dr. Bohon said, adding that she expects that human papillomavirus (HPV) testing will get more and more reliable, and that clinicians will gain experience with following the HPV test and using that as a determining factor in patient care.
Guidelines at a glance
The USPSTF guidelines recommend screening with cytology every 3 years in women aged 21-29 years, and either screening with cytology every 3 years or cotesting using cytology and HPV testing every 5 years in those aged 30-65.
They also recommend against screening after hysterectomy with removal of the cervix in women with no history of high-grade precancer or cervical cancer, and against screening with HPV testing in women younger than age 30, either alone or with cytology.
The ACS/ASCP/ASCCP guidelines recommend a Pap test every 3 years in women aged 21-29 years, with HPV testing only if needed after an abnormal Pap test result. Those aged 30-65 years should have both a Pap test and an HPV test every 5 years, although a Pap test alone every 3 years is also acceptable. Women over age 65 years who have been screened regularly with normal results do not require screening, but those over age 65 years who are diagnosed with cervical precancer should continue to be screened, the guidelines say.
In April, the American College of Physicians in April released its own set of guidelines for screening average-risk women; these guidelines adhere closely to the USPSTF guidelines, and have been endorsed by the American Congress of Obstetricians and Gynecologists and the ASCP (Ann Intern Med. 2015;162[12]:851-9).
