A New Era in Cervical Cancer Screening: Balancing the Risks and Benefits of Screening

Since the introduction of cervical cancer screening with the Papanicolaou (Pap) test in the 1950s, the mortality from cervical cancer in the United States has decreased by 70%. ^1,2 Since the sensitivity of the Pap test alone is only 60%–80%, ³ the reduction in mortality has been achieved through annual testing starting at an early age and continuing indefinitely. However, the downside of annual testing is an increase in the number of false-positive tests. The subsequent discovery that the human papillomavirus (HPV) is a necessary cause of cervical cancer and the introduction of an HPV test in 2002 significantly improved the sensitivity of cervical cancer screening. ^{4 –6} Although persistent HPV infection is fundamental to the development of cervical dysplasia and cancer, ^7,8 90% of HPV infections spontaneously resolve within 1–2 years. ^9,10

False-positive test results lead to evaluation with colposcopy and biopsies and may result in unnecessary excisional procedures to evaluate discrepant cytology and biopsy results, or to treat lesions which are unlikely to progress to cancer. These procedures increase patient stress and discomfort ¹¹ and increase healthcare costs. There is also the potential for physical harm, including scarring and distortion of the cervix, which can make subsequent evaluations more difficult and which increase the risk of preterm delivery in future pregnancies. ^12,13 For women who undergo a hysterectomy, their risk of pelvic organ prolapse and stress urinary incontinence is doubled. ¹⁴

In 2012, the American Society for Colposcopy and Cervical Pathology (ASCCP), American Cancer Society (ACS), and American Society for Clinical Pathology (ASCP) published unified cervical cancer screening guidelines, ¹⁵ which were consistent with the newly published US Preventive Services Task Force (USPSTF) guidelines ¹⁶ and endorsed by the American College of Obstetrics and Gynecology (ACOG). ¹⁷ The new guidelines sought to balance the benefits of screening with the potential harms of overscreening. The guidelines reinforced the 2006 recommendation against screening in populations for whom risk of cervical cancer is sufficiently low (age <21 years and >65 years or posthysterectomy) and significantly lengthened the screening interval for women aged 21–29 years (Pap test every 3 years) and aged 30–65 years (Pap test alone every 3 years or Pap + HPV cotest every 5 years). Despite these efforts, multiple survey studies have demonstrated that healthcare providers continue to screen at shorter than recommended intervals and in populations for whom screening is not indicated. ^{17 –19} In one study, the most cited reasons for not adhering to the guidelines were lack of knowledge of the guidelines (20%) and a desire to meet patient expectations (22%) ¹⁹ ; however, the reasons for guideline nonadherence have not been studied in depth.

The study by Boone et al., “Discontent and confusion: Primary care providers' opinions and understanding of current cervical cancer screening recommendations,” in this edition of the Journal of Women's Health begins to fill this knowledge gap. Their survey, which included 1268 qualified respondents, evaluated healthcare providers' sources of cervical cancer screening information, their screening practices, and personal beliefs about the screening recommendations. Their findings reinforce previous study findings that lack of knowledge of the guidelines is a significant contributor to nonadherence; 15% of providers who felt the 2012 cervical cancer screening guidelines were reliable and appropriate were unable to correctly identify the correct screening recommendation for all patients. More problematic was the fact that one third of providers overall (35%) and over half of the gynecologists surveyed (59%) did not feel that the 2012 screening guidelines were reliable or clinically appropriate. These providers expressed concerns that less frequent screening is risky and that these decisions were made to save money rather than to improve patient outcomes. Additionally, many respondents reported inadequate time or resources to explain the guideline changes to their patients and worried that patients would equate less frequent screening with provider unwillingness to provide care. Finally, some providers expressed concern about their financial future, especially when a large portion of their practice was comprised of well-woman exams.

While this study lacks the details, which can be gained through qualitative research methodologies, it identifies key barriers that need to be overcome to improve adherence to the 2012 cervical cancer screening guidelines and decrease the harms associated with overscreening and overdiagnosis.