Factors Associated With Guideline-concordant and Excessive Cervical Cancer Screening: A Mixed Methods Study

Abstract

Introduction

National guidelines recommend cervical cancer screening with Papanicolaou (Pap) testing at 3-year intervals or with human papillomavirus (HPV) testing alone or HPV/Pap cotesting at 5-year intervals for average-risk individuals aged 30–65 years.

Methods

We explored factors associated with clinician-reported guideline-concordant screening, as well as facilitators and barriers to appropriate cervical cancer screening.

Results

A national sample of clinicians (N = 1,251) completed surveys; a subset (n = 55) completed interviews. Most (94%) reported that they screened average-risk patients aged 30–65 years with cotesting. Nearly all clinicians who were categorized as nonadherent to national guidelines were overscreening (98%). Guideline concordant screening was reported by 47% and 82% of those using cotesting and HPV testing, respectively (5-year intervals), and by 62% of those using Pap testing only (3-year intervals). Concordant screening was reported more often by clinicians who were aged <40 years, non-Hispanic, and practicing in the West or Midwest, and less often by obstetrician–gynecologists and private practice physicians. Concordant screening was facilitated by beliefs that updated guidelines were evidence-based and reduced harms, health care system dissemination of guidelines, and electronic medical record prompts. Barriers to concordant screening included using outdated guidelines, relying on personal judgment, concern about missing cancers, inappropriate patient risk assessment, and lack of support for guideline adoption through health care systems or electronic medical records.

Conclusions

Most clinicians screened with Pap/HPV cotesting and approximately one-half endorsed a 5-year screening interval. Clinician knowledge gaps include understanding the evidence underlying 5-year intervals and appropriate risk assessment to determine which patients should be screened more frequently. Education and tracking systems can promote guideline-concordant screening.