By Rebecca H. Allen, MD, MPH, Editor
In this study of provider attitudes toward the American Cancer Society 2020 cervical cancer screening guidelines that recommend deferring screening until age 25 years and using human papilloma virus alone as the primary screening, most providers had not adopted the guidelines and were waiting for endorsement by other professional societies, such as the American College of Obstetricians and Gynecologists and the American Society for Colposcopy and Cervical Pathology.
Michel AD, Fontenot HB, Fuzzell L, et al. Attitudes toward the American Cancer Society’s 2020 cervical cancer screening guidelines: A qualitative study of a national sample of US clinicians. Cancer 2024;Mar 4. doi: 10.1002/cncr.35269. [Online ahead of print].
In 2020, the American Cancer Society (ACS) issued new cervical cancer screening guidelines.1 The guidelines were novel in that they recommended delaying screening initiation until age 25 years (previously age 21 years) and also advised using human papilloma virus (HPV) alone as the screening test. Given that other organizations such as the American Society for Colposcopy and Cervical Pathology (ASCCP), the US Preventive Services Task Force (USPSTF), and the American College of Obstetricians and Gynecologists (ACOG) also issue and endorse cervical cancer screening guidelines, the authors of this study sought to determine whether any clinicians had adopted the new ACS guidelines.2
This study reports on data from two previous survey studies on cervical cancer screening practices. One study sampled clinicians nationally via email from March 2021 to August 2021 and the second targeted those who worked in federally qualified health centers from October 2021 to July 2022. Participants had to be licensed as a physician or advanced practice provider and practicing in internal medicine, family medicine, women’s health, or obstetrics and gynecology (OB/GYN) and perform cervical cancer screening for patients. Respondents who completed the online survey and were interested in participating in a qualitative interview were randomly selected for invitation. Interviews were conducted via video conference between June 2021 and June 2022. Questions focused on perspectives related to initiating cervical cancer screening at age 25 years and screening with primary HPV testing.
There were 70 participants in the interviews (61.4% physicians and 38.6% advanced practice providers). The most common specialty was family medicine (44.3%), followed by OB/GYN (25.7%), and women’s health (20%). There were equal numbers practicing in a private practice setting vs. a community health setting. Most participants still were screening at age 21 years and not using primary HPV testing alone for screening. Facilitators for starting screening at age 25 years included the idea that screening between ages 21 and 24 years was unnecessary, and that screening later would reduce overtreatment.
On the other hand, barriers included concerns regarding high-risk populations who need screening or who are undervaccinated for HPV, the risk of missing a precancer or cancer, the lack of provider and patient knowledge about the new guidelines, the lack of other societies endorsing the new ACS guidelines, and not having regular visits with younger women if they did not need cervical cancer screening. In terms of screening with primary HPV testing alone, none of the participants were using this method. Participants were more likely to adopt this method if there was consensus among professional societies, availability at their laboratory, and insurance coverage was guaranteed.
Barriers to adopting HPV testing alone for screening included a lack of autonomy in choosing testing when working in a large healthcare organization, limited provider knowledge, concerns about the efficacy of testing for HPV alone in detecting precancers and cancers, belief that cytology provided valuable information, and financial concerns.
COMMENTARY
This was a qualitative study to explore if providers had adopted the new ACS cervical cancer screening guidelines and what the barriers and facilitators would be to their adoption. Although the par-ticipants were randomly sampled, the original study was an online survey that may or may not have been generalizable to all providers in the United States. Most of the sample was white, female, and non-Hispanic. Nevertheless, the authors gleaned important insights.
The current cervical cancer screening protocols that the vast majority of providers follow are those that were created by the USPSTF in 2018 and endorsed by the ASCCP (the professional society that specializes in anogenital disorders and HPV-related diseases) and ACOG.2 Current recommendations are to initiate cervical cancer screening in the general population at age 21 years, with cytology only between ages 21 and 29 years every three years, and a preference for co-testing with cytology and high-risk HPV testing every five years from age 30 to 65 years. The United States is unique in that there are several organizations that promote national health screening recommendations that sometimes conflict, compared to other countries that have a more centralized approach.
This study demonstrates that most providers follow the 2018 guidelines regardless of the newer 2020 ACS guidelines. While primary HPV screening is an alternative option listed in the 2018 guidelines, this study confirms that most clinicians are not using it. This is likely because of, as the study mentioned, ordering the test that your healthcare system uses and not having laboratory support for primary HPV screening. The Pap smear/cytology companies are entrenched in laboratories across the United States, and it will be difficult to demote cytology to a reflex test for primary HPV screening. Nevertheless, primary HPV testing alone for screening most likely is the wave of the future and has the advantage that it can be self-collected by patients, potentially reaching populations that are underscreened.
Delaying screening to age 25 years probably is the most radical change proposed by the ACS, and many providers in this study were uncomfortable with the idea. However, it also takes time — decades even — for new guidelines to be universally adopted by practicing providers. My practice currently is using the USPSTF/ASCCP/ACOG 2018 guidelines and will not change unless these are updated.
REFERENCES
- Fontham ETH, Wolf AMD, Church TR, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin 2020;70:321-346.
- US Preventive Services Task Force; Curry SJ, Krist AH, Owens DK, et al. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. JAMA 2018;320:674-686.
