By Alexandra Samborski, MD
Adjunct Instructor, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY
SYNOPSIS: Less than 20% of average-risk women receive guideline-adherent cervical cancer screening, and guideline-adherent screening was highest for primary human papillomavirus testing.
SOURCE: Lee YW, Morgan JR, Fiascone S, Perkins RB. Underscreening, overscreening, and guideline-adherent cervical cancer screening in a national cohort. Gynecol Oncol 2022; Sep 20. doi: 10.1016/j.ygyno.2022.09.012. [Online ahead of print].
Cervical cancer screening programs are designed to decrease the incidence and mortality from cervical cancer, although screening guidelines have changed numerous times over the past years. Screening recommendations have varied by frequency of screening and by method (cytology, co-testing, or primary human papillomavirus [HPV] testing). Recommendations also vary by patient risk factors, such as immunosuppressed status or prior abnormal screening results.
In addition to both patient and clinician knowledge regarding up-to-date screening recommendations, patients’ ability to access care, insurance status, and healthcare disparities likely play a role in whether patients receive the appropriate screening. This study aimed to identify high-risk patients meeting criteria for more frequent screening and to assess the rates of guideline-adherent screening of average-risk women over a six-year period.
For this study, data were obtained from the IBM MarketScan Commercial Claims and Encounters Database, which contains claims information for nearly half of all commercial U.S. insurance plans. The population included all women aged 21-64 years enrolled continuously for six years from 2014 to 2019. Claims data were queried for information regarding cervical cancer screening, as well as for high-risk medical conditions, prior diagnostic or treatment procedures, or prior hysterectomy for benign indications. Patients without high-risk conditions and without an indication for cessation of screening were included in the average-risk group who meet criteria for screening per U.S. Preventive Services Task Force guidelines. If screened with a Pap test only, a subsequent screen within 2.5 to 3.5 years was defined as guideline-adherent, and for those screened with HPV testing or co-testing, a subsequent test within 4.5 to 5.5 years was defined as guideline-adherent.
After the number of average-risk women and their screening frequency was determined, a logistic regression was used to assess the relationship between demographic (age, geographic location, urbanicity, relationship to insurance holder) and clinical characteristics (comorbidity burden, use of preventative healthcare) and the odds of receiving guideline-adherent screening. Logistic regressions also were used to assess the odds of being underscreened or overscreened during the study period.
More than 1.8 million women were identified and included in the study cohort. Of these, 22% did not meet criteria for routine screening — 4% were appropriate for discontinuation of screening and 18% were considered high-risk and required more frequent screening. A total of 1,471,063 met criteria for routine or average risk screening. Of these, 18% received guideline-concordant screening and 25% had no record of cervical cancer screening during the six-year study period. Cytology alone was performed for 19% of the average-risk women, and of these only 15% received guideline-adherent screening (44% were underscreened and 41% were overscreened).
HPV tests alone were performed for 0.3% of women who qualified for routine screening, and of these, 80% were guideline-adherent (11% were underscreened and 9% were overscreened). HPV + Pap co-testing was performed for 33% of the patients undergoing routine screening; of these, 44% were guideline-adherent (5% were underscreened and 51% were overscreened). Rates of overscreening decreased with age from 60% in the 20- to 29-year-old age group to 38% in the 50- to 64-year-old age group. Rates of no screening conversely increased from 12% in the 20- to 29-year-old age group to 35% in the 50- to 64-year-old age group.
Using the logistic regression, women aged 30-39 years were more likely to receive guideline-adherent screening, as were women with more medical comorbidities. There also were differences based on location of residence; for example, guideline-adherent screening was more common in the Northeast than in the South. Additional preventive care visits were associated with high rates of guideline-adherent screening (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.05-1.06), while each additional gynecologic visit decreased the likelihood of guideline-adherent screening (OR, 0.78; 95% CI, 0.78-0.78) as the result of overscreening.
COMMENTARY
This article highlights the unfortunate reality that, even in a developed country, only 1 in 5 average-risk women received cervical cancer screening in accordance with the current guidelines. Since this cohort of patients was from a database of those who were privately insured continuously for six years, these patients should have had adequate access to healthcare. Thus, the rates of appropriate screening for the general population, particularly those with public or no insurance, is likely to be even lower. Even in this privately insured cohort, there still were discrepancies in screening rates based upon age or living in a rural area. This likely contributes to the known disparities in incidence and mortality for patients with cervical cancer.1
Patients diagnosed with cervical cancer are less likely to have been screened in the preceding years, and screening has been shown to decrease the rates of and mortality from cervical cancer.2,3 Thus, underscreening or not screening patients can have significant consequences. Similarly, there are risks with overscreening as well, including performing excess diagnostic procedures, increased cost, patient anxiety, and adverse pregnancy outcomes.4-6
As the screening guidelines have changed to less frequent screening, overscreening may become more common if patients or providers are not up to date on the most recent guidelines, do not have memory or records available for the most recent screening tests, or are uncomfortable going longer between screening tests. The recent changes in screening recommendations, including changes in screening intervals and the use of HPV testing, may make it difficult for providers whose primary focus is not women’s healthcare to stay up to date on and follow current guidelines. Interestingly, this study showed that patients receiving primary HPV testing had the highest rates of guideline-adherent screening, likely because providers following this recommendation would need to be aware of these recent changes.
It also is important to note that the timing of this study was prior to multiple guideline changes, including the U.S. Preventive Services Task Force cervical cancer screening recommendations in 2018, the American Cancer Society (ACS) screening recommendations in 2020, and the American Society of Colposcopy and Cervical Pathology (ASCCP) risk-based management guidelines.7-9 Rates of guideline-adherent screening may change after implementation of these new screening and management recommendations. Additionally, this study was performed prior to the COVID-19 pandemic and the increase in telemedicine, both of which also could affect the rates of cervical cancer screening.
Another important factor noted in this study is that nearly 1 in 5 patients met criteria for increased screening frequency because of high-risk medical comorbidities or prior screening abnormalities. Providers who are performing cervical cancer screening need to be thorough in the medical, surgical, and gynecologic history-taking to be sure these patients are identified and, thus, screened appropriately. This may include obtaining prior cervical cancer screening records to assess for any abnormal results if the patient cannot remember. Additionally, educating these patients about their need for increased screening may be a helpful way to engage them in their care and increase the likelihood that they will receive the appropriate screening.
In concordance with the HPV vaccine, appropriate screening and follow-up is a powerful tool for providers to use to decrease the risks from cervical cancer and affect the long-term health of their patients. Continued work toward increasing access to screening and accurate implementation of screening and management guidelines is crucial to decreasing the incidence and mortality of cervical cancer.
REFERENCES
- Collins Y, Holcomb K, Chapman-Davis E, et al. Gynecologic cancer disparities: A report from the Health Disparities Taskforce of the Society of Gynecologic Oncology. Gynecol Oncol 2014;133:353-361.
- Landy R, Pesola F, Castañón A, Sasieni P. Impact of cervical screening on cervical cancer mortality: Estimation using stage-specific results from a nested case-control study. Br J Cancer 2016;115:1140-1146.
- Benard VB, Jackson JE, Greek A, et al. A population study of screening history and diagnostic outcomes of women with invasive cervical cancer. Cancer Med 2021;10:4127-4137.
- Habbema D, Weinmann S, Arbyn M, et al. Harms of cervical cancer screening in the United States and the Netherlands. Int J Cancer 2017;140:1215-1222.
- Teoh D, Hultman G, DeKam M, et al. Excess cost of cervical cancer screening beyond recommended screening ages or after hysterectomy in a single institution. J Low Genit Tract Dis 2018;22:184-188.
- Heinonen A, Gissler M, Riska A, et al. Loop electrosurgical excision procedure and the risk for preterm delivery. Obstet Gynecol 2013;121:1063-1068.
- 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.
- 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.
- U.S. 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.
