Holly B. Fontenot

Women's perceptions and preferences for cervical cancer screening in light of updated guidelines

ABSTRACT Background: Updated risk-based guidelines for cervical cancer screening (CCS) allow for individualized screening that minimizes unnecessary testing. However, these guidelines are complex and may not be easily understandable to patients. Purpose: To describe women's perceptions and preferences about CCS in light of recent guideline changes. Methodology: This qualitative study conducted in February 2020 used online, text-based focus groups with a sample of US women (n = 49) ages 27–45. After participants completed a short demographic survey, an experienced moderator used a semistructured guide to solicit participants' perceptions of routine gynecologic care and CCS. We summarized survey data using descriptive statistics. Two authors analyzed transcripts using conventional content analysis and met with other team members to resolve discrepancies and determine final themes. Results: Most participants were non-Hispanic White (65%), had health insurance (90%), and reported having a routine gynecologic examination in the past year (70%). We identified four common themes: (1) low perceived risk of human papillomavirus (HPV) coupled with low knowledge about HPV as a causative factor for cervical cancer, (2) confusion about—and mistrust of—recent individual risk-based guidelines that determine the indicated timing and type of CCS test (Pap or HPV testing), (3) mixed opinions about performing a self-swab for HPV testing, and (4) conflicting perceptions of trust toward providers and the health care industry. Conclusions: Findings highlight women's uncertainty and hesitancy about updated CCS guidelines. Implications: Provider–patient communication strategies should consider women's gaps in knowledge about HPV, include the rationale for guidelines and types of tests, and build trust between patients and providers.

Health Care Provider Willingness to Recommend Self-collected Tests for Human Papillomavirus: A Mixed Methods Examination of Associated Factors

Cervical cancer disproportionately affects those who are underscreened. Human papillomavirus self-collection is a promising tool to expand screening. Study objectives were to examine 1) factors (provider characteristics and practice type) associated with and 2) attitudes (perceived benefits and concerns) toward using human papillomavirus self-collection for cervical cancer screening in clinical practice. This study had a mixed method design; prior to regulatory approval of self-collection, we conducted a national survey and interviews of health care providers who perform cervical cancer screening. Quantitative measures included provider and practice characteristics, willingness to recommend, and preferences related to self-collection. Qualitative interviews further elucidated provider perspectives. A total of 1,251 providers completed surveys, and 56 completed interviews. Among survey respondents, 33.4% reported they were likely to offer self-collection, 28.6% were unsure, and 38.0% reported they were unlikely. Most would offer self-collection either in the clinic or at home per patient preference. Male participants, advanced practice providers, internal and family physicians, and those practicing in academic medical center, hospital, or community health settings were more likely than female participants, obstetrician-gynecologist physicians, and those in private practice to indicate they were likely to offer self-collection. Concerns expressed in both surveys and interviews included the adequacy of sample collection and the ability to follow up. Respondents felt that self-collection would be particularly beneficial for those who did not have access to clinician-collected screening, as well as for patients who may have difficulty with pelvic examinations for any reason. Providers considered human papillomavirus self-collection to be a way to expand access for patients with health care barriers and pelvic examination difficulties. They had concerns related to sample adequacy and follow-up after abnormal results.

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

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

Factors Associated With Guideline-Concordant Cervical Cancer Screening Exit: A Mixed Methods Study

More than 20% of cervical cancers are diagnosed in women older than 65 years. Guidelines recommend screening exit at age 65 for average-risk patients only if certain criteria are met, yet most women aged 64-66 years in the United States are inadequately screened. In this mixed methods study, we explored clinician knowledge of exit criteria. We explored factors associated with clinician-reported guideline-concordant screening exit, as well as facilitators and barriers to appropriate cervical cancer screening exit. Guideline concordance required that clinicians be aware that patients can exit screening if they have received a hysterectomy for benign reasons or had either three consecutive negative Pap tests or two consecutive negative human papilloma virus tests-and that they should not exit screening if they have a history of precancer treatment in the prior 25 years. In 2021, a national sample of 1,251 clinicians completed surveys; a subset (n = 55) completed qualitative interviews. Although most (>70%) correctly identified criteria related to hysterectomy and prior negative screening requirements, only 35% of participants (n = 434) responded correctly to all screening exit items. In logistic regression models, male clinicians, OB/GYNs, and those in academic or hospital-based practices were more likely to respond correctly. Interview responses indicated variable understanding of the nuances of exit criteria. Those who continued screening patients past age 65 cited concerns related to new sexual partners and missing cancers. Several providers noted difficulty accessing adequate records. Clinicians who routinely perform cervical cancer screening have knowledge gaps around exit criteria and also describe difficulty applying the criteria in practice. As fewer women undergo hysterectomy and life expectancy increases, the number of individuals older than 65 at risk for cervical cancer will continue to rise. Adjusting guidelines to decrease the complexity of exit criteria should be considered.

In-Clinic Self-swab for Human Papillomavirus Offers New Option for Cervical Cancer Screening.

Despite widespread availability of cervical cancer screening to prevent cervical cancer, approximately 14,000 women and people with cervixes in the United States are diagnosed as having invasive cervical cancer each year. At highest risk are those who have never been screened or who are overdue for screening. In May 2024, the Food and Drug Administration approved a self-test for human papillomavirus (HPV) for use in clinical settings. An HPV self-test, collected by patients themselves as a vaginal swab, offers a new option for cervical cancer screening that reduces barriers by eliminating the need for a pelvic examination by a health care provider. We present specifications of two tests and discuss factors to consider in preparing for clinical practice implementation once HPV self-tests are integrated into cervical cancer screening guidelines.