Cervical cancer screens overused in some groups
EXECUTIVE SUMMARY
A review of 10 years of national data indicates that clinicians have been performing unnecessary Pap tests for cervical cancer screening in certain groups of women: those who have undergone hysterectomies and those older than age 65 with no cervical cancer history.
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In 2012, guidance from three leading medical organizations fell in line in recommending against screening women ages 65 and older with an adequate history of prior screening, defined as three consecutive negative cytology results or two consecutive negative human papillomavirus results within 10 years before cessation of screening, with the most recent test occurring within five years.
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All three organizations also now recommend against cervical cancer screening in women who have had a hysterectomy with removal of the cervix and who don't have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia grade 2 or 3) or cervical cancer.
A review of 10 years of national data indicates that clinicians across the United States have been performing unnecessary Pap tests for cervical cancer screening in certain groups of women: those who have undergone hysterectomy and those over age 65 with no cervical cancer history.1
In 2012, guidance from the U.S. Preventive Services Task Force (USPSTF), the American Cancer Society, and the American College of Obstetricians and Gynecologists fell in line in recommending against screening women ages 65 and older with an adequate history of prior screening,2-4 says Deanna Kepka, PhD, MPH, assistant professor in the College of Nursing at the University of Utah and an investigator with the university's Huntsman Cancer Institute. Adequate prior screening history in this age group is defined as three consecutive negative cytology results or two consecutive negative human papillomavirus (HPV) results within 10 years before cessation of screening, with the most recent test occurring within five years.2
All three organizations also now recommend against cervical cancer screening in women who have had a hysterectomy with removal of the cervix and who don't have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer.2-4
Kepka and fellow researchers performed the current data analysis to serve as a benchmark for future assessments of overuse of Pap testing following the 2012 guidance. (To review the guidance, see the Contraceptive Technology Update articles "Guidance issued on cervical cancer screening: Update your practice now," June 2012, p. 61, and "Most women should wait 3-5 years between Pap tests, says ACOG," January 2013, p. 1.)
Look at the analysis
The decision not to screen the two groups of women is not new. For more than a decade, the USPSTF has recommended that women discontinue Pap testing if they have received a total hysterectomy and have no history of cervical cancer or if they are older than age 65 and have ongoing and recent normal Pap test results.
To perform the current analysis, researchers examined data from the 2010 National Health Interview Survey, an annual health survey conducted since 1957 of representative samples of the U.S. population. The 2010 survey includes the most recent cancer control supplement, which is performed every three to five years.
The analysis indicates that in 2010, nearly two-thirds (64.5%) of women reported a Pap test since their hysterectomy and roughly one-half (50.4%) of women older than age 65 years reported similar Pap testing in the last three years.1 These statistics represent 14 million women in the United States receiving an unnecessary procedure, Kepka notes.
What women older than age 65 qualify for screening? According to information presented by Ina Park, MD, MS, medical director of the California STD/HIV-Prevention Training Center in San Francisco and chief of the Office of Medical and Scientific Affairs at the California Department of Public Health STD Control Branch in Richmond, CA at the 2013 Contraceptive Technology conference in San Francisco, this group includes women who:
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have never been screened;
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have received inadequate screening (less than three cytologies in 10 years; unknown/undocumented history, limited history);
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have history of cervical or endometrial cancer;
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have CIN2+ in the last 20 years;
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are immunocompromised (HIV, post-transplant, etc.); and
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have been exposed to diethylstilbestrol in utero.5 (The American Society for Colposcopy and Cervical Pathology in Frederick, MD, has developed a comprehensive, user-friendly mobile app for working with abnormal readings; see the resource box at the end of this story.)
Will ACA make impact?
"Misuse of Papanicolaou testing continues despite USPSTF recommendations, and health care resources could be spent better elsewhere," the researchers note. "Targeted efforts are needed to reduce unnecessary testing among older women and women without a cervix in compliance with clinical recommendations for cervical cancer prevention."1
The implementation of the federal Affordable Care Act (ACA) might make an impact, say the researchers. With its focus on the use of electronic medical records, healthcare provider reminder systems, decision support, and new strategies to improve quality of care, the federal legislation might enhance clinicians' awareness and adherence to the screening guidelines, the researchers note.
For many non-grandfathered private health plans, the Affordable Care Act in 2010 eliminated cost-sharing requirements for preventive services that are graded A or B by the USPSTF, notes Kepka. This includes Pap testing and human papillomavirus vaccination for cervical cancer prevention and control in specified populations. Cost-sharing for cervical cancer screening that is not recommended by USPSTF might deter Pap testing overuse, she states.
Also, the ACA has created incentives for healthcare providers to coordinate Medicare to better serve individual patients across multiple settings such as providers' offices, hospitals, and long-term care facilities using a system of coordinated care and communication through the establishment of accountable care organizations (ACOs), says Kepka. These organizations aim to improve patient knowledge about their own care through innovative systems such as patient information portals. Such improved patient and provider communication and information systems might lessen Pap testing overuse among Medicare beneficiaries, she states.
REFERENCES
- Kepka D, Breen N, King JB, et al. Overuse of Papanicolaou testing among older women and among women without a cervix. JAMA Intern Med 2013; doi:10.1001/jamainternmed.2013.12607.
- Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol 2012; 137(4):516-542.
- Moyer VA, U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012; 156(12):880-891, W312.
- Committee on Practice Bulletins — Gynecology. Screening for cervical cancer. Obstet Gynecol 2012; 120:1,222-1,238.
- Park I. Getting up to speed on cervical cancer prevention. Presented at the 2013 Contraceptive Technology conference. San Francisco; March 2013.
RESOURCE
- What if Pap testing yields an abnormal reading? The American Society for Colposcopy and Cervical Pathology in Frederick, MD, has developed a comprehensive, user-friendly mobile app for its Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and Cancer Precursors. Simple to use, the app allows clinicians to view recommendations and algorithms following a few keystrokes. Available for IPhone, IPad, and Android, information on purchasing the app is available at http://bit.ly/1dmk9VZ.
