Changing Cervical Cancer Screening Guidelines: Patient Attitudes and Clinical Practice
Silver, Michelle I.
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Objectives: Cervical cancer screening guidelines have been revised, and now emphasize evidence-based medicine, resulting in recommendations for less frequent screening; however, these changes have been met with concern by both patients and providers. Understanding the patterns of acceptance versus reticence to accept these guidelines by health systems, providers, and patients is critical to developing successful strategies for translating policy change into routine practice. Here we fill some of these knowledge gaps by incorporating both actual cervical cancer screening practice data and patient perspectives towards HPV testing and screening interval changes through the following specific aims: 1a) describe the uptake of co-testing and examine the correlates of receiving an HPV co-test, 1b) estimate the length of time until the next screening test following either a negative Pap smear alone or a dual negative co-test, and 2) investigate the correlates of reluctance to adhere to revised guidelines, which recommend the addition of HPV testing along with less frequent cervical cancer screening. Methods: Using cervical cancer screening records from the Pathology Data Systems (PDS) at Johns Hopkins Hospital, we estimate temporal trends in choice of screening strategy (cytology alone or with HPV DNA testing) and the interval between successive screening tests in routine clinical practice. We then incorporate the patient perspective by using data collected in the HPV in Perimenopause (HIP) natural history study of women age 35-60 years, we will compare women who indicate willingness versus reluctance to accept alternative screening strategies such as HPV testing and a longer interval between cervical cancer screening tests. Results: In clinical practice, we saw a significant increase in use of HPV co-testing over the last 10 years, reaching almost 80% of screening tests. We also saw a significant increase in time between screening tests following a dual-negative co-test to almost 3 years, but essentially no change in time to next screening test following a normal Pap smear, remaining near 1.5 years. Among patients, we found a majority of study participants indicated a willingness to adopt a cervical cancer screening strategy of cytology alone or Pap-HPV co-testing every 3 years if recommended by their physician, but remain concerned about primary HPV testing and co-testing with 5-year screening intervals. Conclusion: HPV testing was incorporated into screening with an assumption of less frequent screening due to its greater sensitivity and negative predictive value. While intervals have increased following a co-test, more time will be needed to see whether they reach 5 years as recommended. We also found evidence of continued reticence to accepting newer HPV-based screening algorithms among routinely screened women over age 35, highlighting a need for more patient education regarding the use and meaning of HPV testing.