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U.S. physicians cling to annual Pap testing.


Introduction of the human papillomavirus cotest for cervical screening in 2003 failed to make a dent in the tendency of U.S. physicians to overuse Pap tests, according to data collected in a 2006 national survey.

In 2006, at least two-thirds of the office-based physicians surveyed said that they would use Pap tests annually even in women aged 30-60 years who had a current negative human papillomavirus (HPV) test result, a current normal Pap test, and two consecutive previous normal Pap results in the past 5 years, even though U.S. recommendations at the time (and currently) called for a retesting interval of at least 3 years, Katherine B. Roland and her associates reported in an article published online in the American Journal of Obstetrics and Gynecology (2011 Aug. 18 [doi:10.1016/j.ajog.2011.06.001]).

'Annual screening [with Pap tests] is persistent regardless of a woman's screening history or HPV test results," said Ms. Roland, a behavioral scientist in the division of cancer prevention and control at the Centers for Disease Control and Prevention in Atlanta. "For a number of years prior to 2006, an extended screening interval had been recommended [for women aged 30 years or older and a history of normal Pap test results], yet we still found annual testing." Divergence from the recommendations for a longer screening interval in these women produces unnecessary testing costs and risks, she said in an interview.

"The annual Pap test is deeply ingrained in the American psyche of both physicians and patients. It takes a long time for health care providers to change their practice habits," Dr. Alan Waxman, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, said in an interview.

The study used data collected in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. These annual surveys run by the CDC began in 2006 to include the Cervical Cancer Screening Supplement. Data from this supplement came from 376 randomly selected, U.S. office-based providers--27% ob.gyns., 46% general and family practice physicians, 24% internists, and 3% midlevel providers--and from 216 hospital outpatient department physicians, split evenly between ob.gyns. and general and family practice physicians. Physicians were asked about their use of cervical HPV testing, and their use of Pap testing in three clinical vignettes. Each vignette was designed to have a correct answer of "no need for immediate Pap testing," according to existing U.S. recommendations from the American Cancer Society (CA Cancer J. Clin. 2002;52:342-62) and from the American College of Obstetricians and Gynecologists (Int. J. Gynaecol. Obstet. 2003;83:237-47).

In 2006, 51% of the office-based providers said that they order or collect the HPV cotest for at least some of their patients, including 56% of the ob.gyns. and 48% of all other physicians. Among the hospital-based physicians, the rate was also 51%. Among the providers who said they ordered HPV cotests for at least some patients, 64% of the office-based physicians (62% of hospital-based) said that they limited the orders to women aged 30 or older, as is recommended, indicating that a significant minority of about one-third also ordered the test for younger women, against 2006 and current guidelines.

When answering the vignettes, two-thirds of all office-based physicians (73% of hospital-based) said they would order an annual Pap retest for a woman aged 30-60 years who is currently Pap test normal, has a current negative HPV test result, and had two prior normal Pap test results during the prior 5 years. A Pap retest for a woman who fit this profile received endorsement from 78% of the office-based ob.gyns. surveyed and from 60% of the other office-based physicians.

'A lot of education needs to take place regarding HPV testing," Dr. Mona Saraiya, who works in the same division of the CDC and is a coauthor of the report, said in an interview. "There are many anecdotal reports of HPV testing done annually."

"It's a failure in the appropriate use of the HPV test," said Ms. Roland. Current evidence suggests that a woman who is at least 30 years old and is both normal on a single Pap test and HPV test negative can safely wait at least 3 years until her next Pap test. In Europe, public policies call for a 6-year delay in the next Pap test, she noted. A history of three consecutive normal Pap test results in women in this age group also identifies a woman who can safely wait at least 3 years to her next test.

To decrease the discrepancy between the testing guidelines and actual U.S. practice "we need to figure out why this is happening," Ms Roland said. "We need to try to find out why there is a disconnect because it is obvious there is a disconnect. If the guidelines stay as they are but screening is done annually, then a conversation needs to happen" among providers, and between providers and their patients, she said.

Ms. Roland, Dr. Waxman, and Dr. Saraiya said that they had no relevant financial disclosures.


Change Needs Concerted Action

I am not surprised by these results, but I am disappointed to see how prevalent over testing for cervical cancer has been. There is no reason to think that U.S. screening rates have decreased since the survey was done in 2006.

Some medical groups and health delivery systems such as Kaiser Per-manente have initiatives to reduce overscreening for cervical cancer. Family PACT, the family planning program run by California (and where I work) has seen a progressive reduction in the number of cervical cytology tests done following provider education programs, including widely distributed clinical practice guidelines and webinars.

Given the aggressive and direct-to-consumer marketing of HPV cotest-ing, it is reasonable to think that even more physicians now use HPV testing than the 51% in 2006. But results from this study and others indicate that physicians are using HPV cotest-ing incorrectly. Study findings also show that most clinicians start cervical cytology screening too early, continue too late, and screen too often.

Women either do not know the recommendations on testing intervals or they believe they are primarily financially motivated. Women have been educated since the 1940s regarding the need for an annual Pap test. There has not been a public health campaign to inform women about the new guidelines.

Providers are too quick to comply with patients' requests for testing, regardless of the real need.

Providers also are fearful of being sued if a woman was to develop an interval cancer. They fear that women will skip their annual well visits without the need for a Pap test to bring them into the office. Even time constraints work against deferred testing because it is quicker to perform a cervical cytology test than to explain why it isn't being done. And there is concern that if testing is not given to a woman who asks for it she may leave for a different physician.

The public must be educated and persuaded that the public health message of the 20th century regarding the need for annual Pap testing in all women has been significantly changed for the purpose of improving the quality of care. In addition, providers must be convinced that the guidelines are based on the best evidence, and they must be held accountable for following the guidelines. They should receive periodic reports that compare their adherence to the guidelines with that of their peers. And Medicaid, health plans, and other payers must stop paying for cervical testing that falls outside of consensus recommendations.

Michael S. Policar, M.D., is a clinical professor of obstetrics and gynecology and reproductive sciences at the University of California, San Francisco. He is medical director at UCSF's Family PACT Evaluation and Bixby Center for Global Reproductive Health. He said he had no relevant financial disclosures.


Major Finding: In 2006, 51% of office-based U.S. providers offered human papillomavirus cervical testing to their patients. In addition, at that time, about two-thirds of providers said that they would recommend annual Pap retesting for women aged 30-60 years who were negative for the HPV test, and normal on a current and two consecutive Pap tests during the prior 5 years.

Data Source: The Cervical Cancer Screening Supplement to the 2006 National Hospital Ambulatory Medical Care Survey run by the Centers for Disease Control and Prevention. In 2006, the supplement was completed by 376 office-based providers and by 216 providers in hospital outpatient departments.

Disclosures: Ms. Roland, Dr. Waxman, and Dr. Saraiya said that they had no relevant financial disclosures.
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Title Annotation:WOMEN'S HEALTH
Author:Zoler, Mitchel L.
Publication:Internal Medicine News
Date:Sep 15, 2011
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