By Rebecca B. Perkins, MD, MSc
Associate Professor, Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston
SYNOPSIS: These studies evaluated adherence to national guidelines for exiting from cervical cancer screening at 65 years of age and managing abnormal results on screening with human papillomavirus (HPV) and Pap co-testing and found that the majority of women 64 to 66 years of age do not qualify to discontinue screening, and the majority of women with discordant Pap and HPV test results are managed incorrectly.
SOURCES: Mills JM, Morgan JR, Dhaliwal A, Perkins RB. Eligibility for cervical cancer screening exit: Comparison of a national and safety net cohort. Gynecol Oncol 2021;162:308-314.
Perkins RB, Adcock R, Benard V, et al. Clinical follow-up practices after cervical cancer screening by co-testing: A population-based study of adherence to U.S. guideline recommendations. Prev Med 2021;153:106770.
Cervical cancer screening has decreased rates of invasive cervical cancer by 80%.1 In the 1980s through the 2000s, the annual Pap test was the mainstay of cervical cancer prevention. More recently, the discovery that human papillomavirus (HPV) caused nearly all cervical cancers led to the development of HPV testing.2 In addition, concerns for over-testing and over-treatment led to guidelines recommending longer intervals between screening tests and discontinuation of screening at the age of 65 years in those who fulfilled exit criteria.3-5 However, correct application of these new guidelines requires risk stratification of patients, including knowledge of current management guidelines and past history of screening and abnormal results.6
The study by Mills et al examines the proportion of women 64 to 66 years of age who qualify for screening exit in two cohorts: women receiving care in a safety net setting, the majority of whom have public insurance, and women with employer-based private insurance.7 The authors applied existing screening exit criteria, which include hysterectomy without evidence of cancer or precancer, no history of human immunodeficiency virus (HIV) or cervical cancer ever, no history of cervical precancer in the past 25 years, no abnormal screening test results in the past 10 years, or adequate screening in the past 10 years, defined as three Pap tests alone or two HPV tests, with or without accompanying Pap tests.
Evaluating women from 2016 to 2019, the investigators found that, of the 590,901 women in the national claims database with employer-based private insurance, only 131,059 (22.2%) were eligible to exit. Approximately one in five (20.6%) had adequate negative screening, and a small minority (1.6%) had undergone hysterectomy.
Among 1,544 women from the safety net health center, only 528 (34.2%) were eligible to exit. Approximately one in four (24.9%) had adequate negative screening, and 9.3% had undergone hysterectomy (9.3%). Therefore, the majority of women lacked sufficient screening to fulfill exit criteria: 382,509 (64.7%) in the national database and 875 (56.7%) in the safety net cohort. Even among women with 10 years of continuous private insurance coverage, only 41.5% qualified to discontinue screening.
The Perkins et al study examined management following abnormal results on Pap/HPV co-testing among 164,522 women screened with co-testing in the state of New Mexico between 2015 and 2019.8 Guideline-concordant management was high among those who were both HPV-positive and had abnormal Pap test results (62% to 80%). However, when results were discordant, less than half of women were managed according to guidelines (48% to 49%). Guideline nonadherent follow-up in these scenarios included receiving colposcopy when not indicated after a low-grade abnormal Pap test result with an HPV-negative test or failing to receive colposcopy or follow-up in one year for HPV-positive results accompanied by negative Pap tests.
COMMENTARY
These studies indicate that the potential benefits of newer cervical cancer screening guidelines are not being realized by the majority of women. Guidelines promoting screening cessation at 65 years of age are premised on strict criteria, and these data indicate that only one in three women in this age group fulfill them. The discordance between guidelines and population-level actions may contribute to the finding that approximately 25% of cervical cancers in the United States are diagnosed in women 65 years of age and older, and many of those women had inadequate screening prior to diagnosis.9,10
Most women in the United States currently are screened for cervical cancer with Pap/HPV co-testing.11 Data indicate that one in 10 screening results are abnormal, with the most common abnormal result (40% of all abnormal results) being a positive HPV test with a normal Pap result.12 However, the data mentioned earlier indicate that most women with discordant results are managed incorrectly. This implies that the added benefits of HPV testing in terms of identifying high-risk patients who may be missed by Pap alone are not being realized.13 Failure to identify and closely follow high-risk patients increases their risk for cervical cancer. In fact, an estimated 14,400 cervical cancers will be diagnosed in 2021.14
Evidence-based guidelines have the potential to decrease the number of tests and procedures while maintaining or improving cervical cancer prevention, but only if applied properly.6 These papers indicate a need for improved education and support for guideline-adherent care among patients, individual providers, healthcare systems, laboratories, and insurers, including Medicare and Medicaid, to ensure guideline-adherent care to avoid the development of preventable cervical cancers.
REFERENCES
- Gustafsson L, Pontén J, Zack M, Adami HO. International incidence rates of invasive cervical cancer after introduction of cytological screening. Cancer Causes Control 1997;8:755-763.
- Arbyn M, Sasieni P, Meijer CJLM, et al. Chapter 9: Clinical applications of HPV testing: A summary of meta-analyses. Vaccine 2006;24(Suppl 3):S3/78-89.
- 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.
- 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;137:516-542.
- Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis 2020;24:102-131.
- Mills JM, Morgan JR, Dhaliwal A, Perkins RB. Eligibility for cervical cancer screening exit: Comparison of a national and safety net cohort. Gynecol Oncol 2021;162:308-314.
- Perkins RB, Adcock R, Benard V, et al. Clinical follow-up practices after cervical cancer screening by co-testing: A population-based study of adherence to U.S. guideline recommendations. Prev Med 2021;153:106770.
- Feldman S, Cook E, Davis M, et al. Cervical cancer incidence among elderly women in Massachusetts compared with younger women.
J Low Genit Tract Dis 2018;22:314-317.
- Castañón A, Landy R, Cuzick J, Sasieni P. Cervical screening at age 50-64 years and the risk of cervical cancer at age 65 years and older: Population-based case control study. PLoS Medicine 2014;11:e1001585.
- Cuzick J, Myers O, Hunt WC, et al. Human papillomavirus testing 2007-2012: Co-testing and triage utilization and impact on subsequent clinical management. Int J Cancer 2015;136:2854-2863.
- Egemen D, Cheung LC, Chen X, et al. Risk estimates supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:132-143.
- Castle PE, Glass AG, Rush BB, et al. Clinical human papillomavirus detection forecasts cervical cancer risk in women over 18 years of follow-up. J Clin Oncol 2012;30:3044-3050.
- National Cancer Institute Surveillance, Epidemiology, and End Results Program. Cancer Stat Facts: Cervical Cancer. http://seer.cancer.gov/statfacts/html/cervix.html#incidence-mortality
