Screening Guidelines Don’t Necessarily Translate to Practice

Posted by The Evidence Blog on July 10, 2013

Recent breakthroughs in cervical cancer prevention have resulted in new vaccination and cervical cancer screening guidelines. Vaccination against HPV has been recommended for women aged 11–26 years since 2006. For decades, women between the ages of 21 and 69 were advised to get annual screening exams for cervical cancer. In 2009, however, accumulating scientific evidence led major guideline groups to agree on a new recommendation that women be screened less frequently based on their age and health status.

Recommendations do not always translate into practice, however.

Results of a newly published survey suggest that among OB-GYNs, clinical guidelines and screening recommendations do not translate into practice. According to a survey published in the American Journal of Preventive Medicine, less than one third of obstetrician-gynecologists vaccinate their eligible patients against the human papilloma virus (HPV), and only half adhere to ACOG cervical cancer prevention guidelines recommending that women be screened every 3 years, rather than annually.

The survey was sent to 1,000 OB-GYNs, all members of ACOG, about their screening and vaccination practices, as well as barriers that prevented them from following the 2009 ACOG guidelines regarding the frequency of Pap smears. A total of 366 responses were analyzed.

The investigators found that although 92% of respondents offered HPV vaccination to patients, only 27% estimated that most eligible patients received vaccination. The most commonly cited barriers to HPV vaccination were parent and patient refusals.

Approximately half of the respondents followed guidelines to begin cervical cancer screening at age 21, discontinue screening at age 70 or after hysterectomy, and to utilize Pap and HPV cotesting appropriately. However, most physicians continued to recommend annual Pap test screening (74% ages 21-29, 53% ages 30 and above). Solo practitioners were less likely to follow both vaccination and screening guidelines than those in group practices. Only 16 physicians (4%) reported adherence to all ACOG 2009 guidelines for cervical cancer screening.

Annual Pap tests produce more abnormal results leading to additional, invasive testing such as colposcopy that itself bring risks. The authors recognize the important benefit of screening for cervical and other cancers, but “screening every three years [for cervical cancer] retains about 95% of the benefit of annual screening, but reduces harms by roughly two-thirds."

Screening for cervical cancer and other cancers such as breast and prostate, has clear potential for harms as well as benefits. While Pap tests do identify cervical cancers, annual testing produces more abnormal results leading to additional, invasive testing that itself bring risks. Less-frequent screening also reduces costs significantly in terms of patient and physician time and laboratory testing supplies and other resources.

Do you have any thoughts about how to promote adherence to guidelines without compromising patient outcomes?

Perkins RB, Anderson BL, Gorin S, Schulkin J. Challenges in cervical cancer prevention. A survey of U.S. obstetrician-gynecologists. Am J Prev Med 2013;July 9.

Topics: Hayes Blog

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