Content Analysis of Continuing Medical Education for Cervical Cancer Screening

Abstract

Background:

Since 2003, newer cervical cancer screening guidelines that include human papillomavirus (HPV) testing with cytology (HPV co-testing) call for extension of screening intervals in women who are cytology normal and HPV negative. Continuing medical education (CME) may help increase knowledge and appropriate adoption of new technologies and guidelines. However, there are concerns that industry support of CME may bias messages favoring newer technologies without emphasizing the updated guidelines, especially less frequent testing recommendations. Our objectives were to assess availability and accuracy of web-based CME activities describing cervical cancer screening guidelines, screening intervals, and HPV testing.

Methods:

We identified 20 web-based CME activities available between 2006 and 2008 and evaluated the content for messages related to HPV and natural history, cervical cancer screening guidelines, management of HPV abnormalities, and counseling tips for patients. In addition to content, we noted funding source, credit offered, and dates available.

Results:

Most activities (80%) discussed the updated screening guidelines with HPV co-testing for eligible women. Twelve activities (60%) referenced professional organization support of the extended screening interval with the HPV co-test, and three (15%) discussed the justification for extension of intervals for eligible women. Eight activities (40%) were funded by industry, seven of which included accurate, updated screening guidelines about extension of screening intervals.

Conclusions:

Web-based CME activities generally support updated guidance for HPV co-testing and extended screening intervals but need more information on counseling patients and acceptability of extending screening intervals.

Introduction

In the United States, regular cervical cancer screening with cytology testing¹ has reduced cervical cancer incidence and mortality over the past 50 years.² Identification of the human papillomavirus (HPV) as the primary etiological agent for cervical cancer³ has broadened our understanding of the natural history of HPV and cervical cancer and resulted in newer screening and detection technologies, such as the HPV DNA test (HPV test). Since 2003, the HPV test has been approved as an adjunct (co-test)⁴ to cytology testing in women ≥30 years of age, greatly improving screening sensitivity and identifying women with current disease and those at greatest risk.⁵ Because of the high negative predictive value⁴ of the HPV co-test, an estimated 80%–90%^6,7 of women will have concurrent negative results (cytology test normal, HPV test negative) and can, therefore, increase cervical screening intervals from annually to triennially, as recommended by American Cancer Society (ACS)⁸ and American College of Obstetricians and Gynecologists (ACOG)⁹ guidelines. With co-testing, however, limited data are available on how to interpret results of women who have a normal cytology test and a positive HPV test and how to counsel these women on their risk of developing cervical cancer.¹⁰

To respond to changes in HPV testing and cancer screening guidelines, web-based continuing medical education (CME) activities may be effective in influencing provider knowledge, perception, and attitudes.^11,12 The popularity of web-based CME activities is steadily increasing because of convenience and low cost. Younger physicians and those who have a heavy patient load have reported a preference for the web-based format.¹³ Industry often plays a large role in provider health education and outreach,¹⁴ and in the United States, commercial funding for CME has raised concerns about the balance and scientific integrity of medical education.¹⁵ Tracking the relationship between source of funding and accuracy of clinical messaging in CME may be necessary for quality control and to understand how clinical medical education about new screening technologies is disseminated and adopted.

Because CME is required of most providers to maintain their clinical license, educational activities focused on updated cervical cancer screening guidelines can meet the continuing education requirements for clinicians while at the same time supporting the application of new technologies to improve clinical practice. The purpose of this study was to review whether free or low-cost, web-based CME activities reflected updated guidelines for cervical cancer screening and HPV testing, including extension of screening intervals for eligible women.

Materials and Methods

Sample selection

From April 2006 through June 2008, we conducted an internet search using the terms, CME sites and CE sites, which identified 14 CME host directories. Among the 14 directories, we used a combination of the search terms, cervical cancer, cervical cancer screening, HPV, and HPV testing, to locate relevant activities. We identified 20 CME activities that met our criteria of (1) having been developed and published in the United States, (2) free or low-cost (≤$20 registration), (3) released online between January 1, 2006, and April 30, 2008, (4) containing the key search terms, HPV and cervical cancer, and (5) written/posted in English. One relevant CME activity that met inclusion criteria was identified after the initial search and was added to this analysis, and one activity was excluded from the sample because it was removed from the host site after identification.

Content assessment abstraction form

The authors developed an abstraction tool to assess the content of the 20 CME activities. Forty-one messages identified as valuable to provider education^16
–18 were organized in the abstraction tool according to four content themes: (1) natural history and epidemiology of HPV and cervical cancer, (2) cervical cancer screening and extended intervals (based on guidelines at time of study), (3) management of HPV infections and cervical abnormalities, and (4) counseling tips for patients. Each activity was reviewed to assess the presence or absence of those messages. The abstraction tool enabled the reviewers to record CME title, host site/source, dates available, credit offered, and funding source. Table 1 lists the 20 CME activities according to learning format (e.g., research articles, webinars, modules, or audiocasts) and their ranking according to the average percentage of all messages present within each learning format. Authors (T.L.L. and K.B.R.) independently reviewed and within each learning format analyzed the content of each CME.

Table 1.

Characteristics and Content of 20 Continuing Medical Education (CME) Activities Reviewed

						% of messages in each theme
						Themes ^b
Organization presenting CME Title of CME activity	Website/source	Dates available	CME hours available	Industry sponsorship ^a	Extended screening interval message	1	2	3	4	Average ^c
Research articles (n = 7)
University of Cincinnati College of Medicine Family Practice Recertification	Family Practice Recertification Vol. 29 No. 1 January 2007	01/01/07–01/31/09	1.0 AMA PRA Category 1	No	Yes	86	69	60	17	58
Screening for Cervical Cancer: The Current Approach
American Cancer Society
Cancer Screening in the United States, 2008: A Review of Current American Cancer Society Guidelines and Cancer Screening Issues	CA Cancer J Clin 2008;58:161–179	05/01/08–05/01/10	1.0 AMA PRA	No	Yes	14	50	20	0	21
American Cancer Society
Cervical Cancer Screening Rates in the United States and the Potential Impact of Implementation of Screening Guidelines	CA Cancer J Clin 2007;57:105–111	03/01/07–03/01/08	0.5 AMA PRA	No	Yes	0	50	20	0	18
American Cancer Society
Cancer Screening in the United States, 2007: A Review of Current Guidelines, Practices, and Prospects	CA Cancer J Clin 2007;57:90–104	03/01/07–03/01/08	1.0 AMA PRA	No	Yes	7	56	0	0	16
Medscape
HPV Testing a Promising New Option in Cervical Cancer Screening	cme.medscape.com/viewarticle/564591	10/22/07–10/22/08	0.25 AMA PRA	No	No	7	13	20	0	10
MedPage Today
DNA Tests for HPV Improve Cervical Cancer Screening	www.medpagetoday.com/HematologyOncology/OtherCancers/6872	10/04/07–10/04/08	0.25 AMA PRA	No	No	0	13	0	0	3
Medscape
HPV DNA Testing in Cervical Screening May Lead to Earlier Detection of Lesions	cme.medscape.com/viewarticle/563801	10/22/07–10/22/08	0.25 AMA PRA	No	No	0	13	0	0	3
Modules (n = 3)
Modern Medicine/ American College of Physicians. Physicians' Information and Education Resource	pier.acponline.org/physicians/diseases/d1011/d1011.html	07/01/07–6/10/08^d	1.0 AMA PRA	No	Yes	71	63	80	33	62
Human Papillomavirus PIER
Modern Medicine/American College of Physicians. Physicians' Information and Education Resource	pier.acponline.org/physicians/diseases/d643/d643.html	07/01/07–6/10/08^d	1.0 AMA PRA	No	Yes	50	31	60	17	39
Cervical Cancer PIER
Modern Medicine/American College of Physicians. Physicians' Information and Education Resource	pier.acponline.org/physicians/procedures/physpro1016/physpro1016.html	07/01/07–6/10/08^d	1.0 AMA PRA	No	Yes	14	56	40	0	28
Papanicolaou Smear PIER
Webinars (n = 8)
Association of Reproductive Health Professionals	www.arhp.org/professional-education/medical-education-opportunities/archived-webinars	11/15/07 and 12/05/07	1.0 AMA PRA Category 1	Yes	Yes	93	69	100	50	78
Managing HPV: A New Era in Patient Care
Discovery Health CME
HPV and Cervical Cancer: Managing the Risk	discoveryhealthcme.discovery.com/hpv/program/program.html	NA–09/24/08	1.0 AMA PRA Category 1	Yes	Yes	79	81	20	67	62
Postgraduate Institute for Medicine	cme.medscape.com/viewprogram/5804;	10/31/06–10/31/07	2.0 AMA PRA	Yes	Yes	57	81	60	50	62
Different Perspectives: Case Studies in HPV Management	www.hpvresource.org/activity.php?activityID=40
University at Albany (SUNY)
Cancer Screening and Prevention-Eliminating Deaths from Cervical Cancer (ACOG-NY)	www.albany.edu/sph/coned/whgracogcancer.htm	3/27/08–12/1/08	1.0 AMA PRA	No	Yes	71	63	80	0	54
Postgraduate Institute for Medicine
AHC Media LLC HPV Vaccination and Cervical Screening: A Synergistic Approach to Cervical Cancer Prevention	www.scimedny.com/activity_details/interactive_activity.php?activityID=sgo-acog-einsert	02/15/08–02/15/09	1.5 AMA PRA Category 1	Yes	Yes	29	50	100	17	49
Postgraduate Institute for Medicine
Oncogenic HPV and Its Link to Cervical Cancer: A Primary Care Perspective	www.hpvresource.org/activity.php?activityID=41	10/31/06–10/31/07	2.0 AMA PRA	Yes	Yes	86	44	20	17	42
Postgraduate Institute for Medicine
Human Papillomavirus: What You Need to Know	www.hpvresource.org/article.php?articleID=32	05/12/06–05/12/07	1.25 AMA PRA	Yes	No	93	6	20	17	34
Postgraduate Institute for Medicine
Emerging Strategies for the Prevention of HPV and Cervical Cancer	www.hpvresource.org/article.php?articleID=33	05/12/06–05/12/07	1.0 AMA PRA	Yes	Yes	14	69	40	0	31
Audiocasts (n = 2)
California Family Health Council, Inc.^e
Exploring the Link Between HPV and Cervical Cancer	healthed.org/Training/HPV.htm	05/01/07–05/01/08	1.0 AMA PRA 1.2 NP	Yes	Yes	71	56	40	0	42
Primary Care Education Network, Inc
Recent Advances in Preventing HPV-Related Diseases	www.primarycareed.com/Online_CME.html	02/14/07–02/14/09	1.25 AMA PRA	No	Yes	64	31	40	17	38

Defined as whether industry sponsored or funded the educational activity. Does not account for whether the speaker has a financial relationship with industry.

Theme 1: Natural history and epidemiology of HPV and cervical cancer. Total messages = 14. Theme 2: Cervical cancer screening and extended intervals. Total messages = 16. Theme 3: Management of HPV infections and cervical abnormalities. Total messages = 5. Theme 4: Counseling tips for patients. Total messages = 6.

Assuming no preference among the four themes.

CME updated by the organization content editor and now available until June 30, 2010.

$20 registration fee.

AMA, American Medical Association; CME, continuing medical education; HPV, human papillomavirus; PRA, Physicians Recognition Award; NP, nurse practitioner.

Statistical analysis

To determine which of the 20 activities included the greatest proportion of selected key messages, we calculated the percentage of messages present in each of the four content themes for each CME. We then calculated the average percentage over the four content themes (assuming no preference among the four themes) (Table 1). We also recorded how often each of the selected 41 messages appeared within the 20 CME activities according to theme (Table 2). We used a kappa coefficient to determine the intercoder reliability between the two reviewers and the Wilcoxon signed test for paired data to determine whether the rankings of the two coders were significantly different. The two reviewers agreed on 85.1% of the message content. The overall kappa coefficient was 0.69 (95% CI 0.64-0.74), indicating good reliability.¹⁹ The Wilcoxon test statistic [W = min (76.5, 133.5) >52] indicated no statistical difference between the rankings of the two authors (p > 0.2).

Table 2.

Frequency of Continuing Medical Education (CME) Activities That Include the Message According to Theme

Message (n = 41)	No. of CME activities that include the message^ (%)*
Theme 1. Natural history and epidemiology of HPV and cervical cancer (14 messages)
HPV is a common sexually transmitted infection.	13 (65)
Most genital HPV infections clear without intervention.	13 (65)
Most genital HPV infections are transient and asymptomatic.	11 (55)
Approximately 13–15 high-risk HPV subtypes (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82) are associated with invasive cancers.	11 (55)
Persistence of HPV infection is the most important risk factor for cervical cancer development (CIN 2 or less).	11 (55)
Multiple sexual partners can be a risk factor for HPV.	10 (50)
Use of condoms to prevent HPV.	10 (50)
Smoking is a risk factor for HPV.	9 (45)
Overall cervical cancer incidence and mortality have significantly declined in the United States due to conventional cytology. However, disparities exist among certain populations.	9 (45)
HPV is transmitted through genital to genital/oral to genital contact.	8 (40)
Early age of first sexual activity is a risk factor for HPV.	6 (30)
Background on the classification of cervical cytology (Bethesda categories).	6 (30)
Young age as a risk factor for HPV.	6 (30)
Having a male partner who has had multiple partners is a risk factor for HPV.	3 (15)
Theme 2. Cervical cancer screening and extended intervals (16 messages)
Age to begin screening.^**	17 (85)
Screening intervals.	16 (80)
Women ≥30 years with normal cytology and negative HPV test should undergo next routine screening in 3 years or beyond.	16 (80)
Women ≥30 years of age with 3 normal cytology test results may extend the screening interval to 2–3 years.	14 (70)
HPV testing is now approved by the FDA for use as an adjunct/co-test to cervical cytology for screening in women ≥30 years of age.	13 (65)
Age to discontinue screening.	12 (60)
Discontinue screening post-hysterectomy (with no history of CIN).	12 (60)
Promotion of the HPV co-test by professional organizations (American Cancer Society and American College of Obstetricians and Gynecologists).	12 (60)
HPV testing detects 13 high-risk HPV subtypes of the HPV.	10 (50)
HPV co-testing is not recommended for younger women because of their high rate of HPV infections.	9 (45)
HPV co-testing can be done with conventional or liquid-based cytology.	9 (45)
Mentioned using LBC only with HPV co-testing	6
Mentioned using either LBC or conventional cytology for HPV co-testing	2
Mentioned using conventional cytology only for HPV co-testing	1
For general screening, there are two cytology tests: conventional and LBC.	7 (35)
Provided rationale for use/support of LBC over conventional cytology	6
Factors that influence the extension of screening interval with HPV co-testing.	3 (15)
Screening during pregnancy.	1 (5)
HPV test recommended as screening tool for sexually transmitted infections (without conventional cytology) (which guidelines do not recommend).	1 (5)
Risk of developing CIN 2 or greater in the next 3 years (among women who are cytology normal and HPV negative).	0 (0)
Theme 3. Management of HPV infections and cervical abnormalities (5 messages)
HPV reflex testing as a management tool for ASC-US.	14 (70)
Colposcopic evaluation is the appropriate follow-up for those women with cytological abnormalities greater than ASC-US.	9 (45)
HPV testing as a management tool for other abnormalities besides ASC-US. (which guidelines do not recommend)	9 (45)
HPV-positive patients with normal cytology repeat screening of both test cytology and HPV testing in 6 or 12 months.	7 (35)
HPV test as a management tool for postcolposcopy surveillance.	2 (10)
Theme 4. Counseling tips for patients (6 messages)
Importance of well-woman visit (i.e., pelvic examination, frequency).	6 (30)
HPV positivity does not mean your partner was unfaithful; it is impossible to know which partner gave a person HPV.	5 (25)
How to counsel HPV-positive women (partners and future sexual activity).	3 (15)
Cervical cancer risk is low when HPV negative, even with abnormal cytology.	2 (10)
Women need reassurance even with cytology normal, HPV negative results.	2 (10)
Receiving patient's consent for HPV testing.	0 (0)

*Total number of CME activities = 20

**This study was conducted prior to the 2009 ACOG guideline update (ACOG Practice Bulletin No. 109 Cervical Cytology Screening, December 2009) and therefore messages to start screening were evaluated based on prior guidelines.

ASC-US, atypical squamous cells of undetermined significance; CIN, cervical intraepithelial neoplasia; CME, continuing medical education; HPV, human papillomavirus; LBC, liquid-based cytology.

Results

Characteristics and content of each CME activity

Our review of the 20 CME activities yielded 7 research articles, 3 modules (multiple CME activities within one file), 8 webinars, and 2 audiocasts (Table 1). Eight of the 20 activities (40%) disclosed relationships or support from industry. Six CME activities (30%) contained at least half of the 41 total messages from the four content themes. The majority of the activities were active for 12 months and credited for at least 1.0 hour continuing education.

Frequency of each message according to theme content

Theme 1: Natural history and epidemiology of HPV and cervical cancer

Of the 41 messages, 14 pertained to the natural history and epidemiology of HPV and cervical cancer (Table 2). The two most common messages in the 20 CME activities in this theme were that HPV is a very common infection (65%) and that HPV usually clears without medical intervention (65%). Messages about the use of condoms for HPV prevention and multiple sexual partners as a risk factor for HPV acquisition were included in half of the CME activities (50%). Eleven (55%) of the activities included messages that persistent HPV infection is the most important risk factor for cervical cancer development. Nine (45%) mentioned that smoking is a risk factor for HPV and increases a woman's chance for developing cervical cancer.

Theme 2: Cervical cancer screening and extended intervals

Sixteen of the 41 messages related to cervical cancer screening and extended intervals (Table 2). Of significance is that 80% of the CME activities included recommendations for extending next routine screening to at least 3 years among women ≥30 years of age with a normal cytology test and a negative HPV test; 70% of the activities referenced an extended screening interval for women ≥30 years of age with three negative cytology tests (without an HPV test). The most common message in this theme was guidance on the age to begin screening. Seventeen (85%) of the activities listed time to begin cervical cancer screening 3 years after the onset of sexual activity but no later than age 21. Messages about the age to stop screening, referenced in 12 materials (60%), varied by professional medical organization guidelines cited. Nine activities (45%) discussed that HPV co-testing could occur with either conventional or liquid-based cytology (LBC) testing. Seven activities (35%) mentioned that there were two types of cytology testing for general screening, LBC and conventional. Six of those seven activities provided rationale for use of LBC over conventional cytology testing. Three CME activities (15%) discussed what factors the physician may consider (such as whether the patient has a new sexual partner) when deciding to extend the screening interval.

Theme 3: Management of HPV infections and cervical abnormalities

Five key messages addressed the management of HPV and cervical abnormalities (Table 2). Fourteen (70%) CME activities reported that the preferred management of women who have atypical squamous cells of undetermined significance (ASC-US) cytology is reflex HPV testing. Nine activities (45%) mentioned that HPV testing could be used as a management tool for other abnormalities besides ASC-US. Seven (35%) of the activities mentioned that patients with normal cytology who are HPV positive should repeat both tests in 6–12 months. Only two (10%) CME activities discussed using the HPV test as a follow-up management tool for postcolposcopy surveillance.

Theme 4: Counseling tips for patients

Six of the 41 key messages related to counseling tips for patients (Table 2). Six activities (30%) communicated information about the importance of a regular preventive visit (i.e., well-woman visit). The impact HPV positivity can have on a relationship and respective partners was discussed in five activities (25%). Only three activities (15%) mentioned how to counsel women who test positive for HPV. Two activities (10%) contained messages that women who test negative for HPV are at low risk for developing cervical cancer even if they have abnormal cytology. None of the 20 activities contained counseling messages about obtaining patient consent before HPV testing.

Discussion

We found that overall, clinically accurate, web-based CME activities were available between 2006 and 2008 regarding cervical cancer screening guidelines, focusing on updated screening intervals both with cytology testing alone and with the HPV co-test strategy. We also assessed the presence of messages from four content themes within the CME activities and found commonly cited content about the natural history of HPV and the management of infections and cervical abnormalities.

Largely absent were explanations of why it would be appropriate and beneficial to extend the interval with the HPV co-test for eligible women, such as the high negative predictive value⁴ and improved sensitivity⁵ of the test, leading to fewer unnecessary testing and follow-up procedures²⁰ and decreased psychological consequence to the patient.²¹ Additional content absent from many activities included the risk factors for HPV acquisition, receiving patient consent for HPV testing, and counseling messages that could assuage the fears of the patient.

In addition to content reviewed, we found commercial support for 8 of the 20 activities, 7 of which contained clinically accurate messages about extension of screening intervals with the HPV co-test. Pharmaceutical companies often play a large role in patient and provider health education and outreach,^14,22 and this relationship has raised questions about scientific integrity and balance in medical education.¹⁵ Industry's role in CME presents a potential conflict of interest,^23,24 and independence from commercial influence on content is an ongoing concern. Developing unbiased, evidence-based, effective professional education should continue to be central when promoting clinical guidelines and screening technologies.

Although the primary findings of this review highlight the inclusion of updated cervical cancer screening guidelines and information about HPV co-testing in web-based activities, the mere presence of these guidelines and other content associated with cervical cancer and HPV may not be enough to change behavior and clinical practice. Previous research has identified misuse of the HPV test and resistance to extending screening intervals for eligible women with the HPV co-test.^25
–27 Cited provider barriers to adopt newer cervical cancer screening guidelines, such as controversial recommendations, unknown patient cytology history, and knowledge about the techniques used, are contributors to these findings.²⁸ Future CME activities regarding cervical cancer screening guidelines may need to concentrate on how to counsel patients, system interventions to improve screening behaviors, and the impact new guidelines have on physician liability and malpractice cases. If more information on counseling patients and reasoning for extending the screening interval were present, perhaps this would help providers to make the changes necessary to appropriately implement updated screening guidelines. Web-based CME activities disseminate information that can produce objectively measured changes in behavior,²⁹ thereby potentially improving patient outcomes.³⁰ This review identified the availability of easily accessible CME activities that incorporate updated cervical cancer screening guidelines into their content, and the need to more effectively bridge the gap between CME and clinical practice.

One limitation is that this review may not represent an exhaustive list of CME activities available for HPV testing and cervical cancer screening between 2006 and 2008. Also, this review noted only the presence or absence of messages in CME activities and not the context or emphasis of the message. Few articles have been published about updated cervical cancer screening guidelines and the impact on application of screening intervals in practice. To our knowledge, this project is the first content assessment of web-based CME activities that examines the availability of cervical cancer screening guidelines with HPV co-testing messages. The relationship between industry and CME sponsorship is a novel component of this review. This information could be relevant to establish a baseline for web-based cervical cancer screening CME activities. As guidelines evolve, continued evaluation of professional education and provider screening behaviors may be valuable.

Conclusions

Between 2006 and 2008, low-cost, web-based CME containing accurate messages on HPV testing and cervical cancer screening was available. A majority of activities contained accurate and up-to-date screening guidelines supporting screening interval extension with HPV co-testing. It may be useful to continue to track content of CME activities about cancer screening, as well as provider screening behaviors, to assess how access to and content of CME activities are translated into clinical practice.

Footnotes

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Disclosure Statement

No competing financial interests exist.

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