Naomi C. Brownstein

Clinician Characteristics Associated With Adoption of Updated National Colposcopy Guidelines

Objective To evaluate adherence to the 2019 ASCCP risk-based management consensus guidelines for management of patients following colpscopic cervical biopsy among US colposcopists. Methods To elucidate factors associated with utilization of the 2019 guidelines for patients undergoing colposcopic cervical biopsy, the authors cross-sectionally surveyed physicians and advanced practice professionals who perform colposcopy. Clinicians responded to clinical vignettes describing scenarios for which management recommendations differed between 2019 and prior management guidelines. Vignette 1 involved deferral of repeat colposcopy for patients with a low-risk biopsy, HPV, and cytology results. Vignette 2 involved deferral of excisional treatment on a patient with repeated low-grade biopsy results. Binomial logistic regression models determined factors associated with utilization of 2019 guidelines. Results A total of 670 colposcopists participated from across the United States. For Vignettes 1 and 2, guideline-adherent responses were given by 30.5% and 66.1% of participants, respectively. Colpsocopists practicing in community health centers were more likely to perform guideline-concordant care for Vignettes 1 and 2. Hispanic compared to non-Hispanic colposcopists and Internal or Family medicine compared to OB-GYN colposcopists are less likely to perform guideline-concordant care in Vignette 2. Irrespective of their chosen response, most believed they were guideline-adherent. Conclusions Many colposcopists may not realize their current management strategies are inconsistent with 2019 guidelines. Tailored education initiatives could address knowledge gaps, maximize patient benefits, and minimize harms.

A Mixed-Methods Study Examining Guideline-Concordant Colposcopy Practices Among a National Cohort of US Colposcopists

Objectives The 2017 ASCCP Colposcopy Standards guidelines were designed to maximize the diagnostic yield of colposcopy. However, guideline adoption is often slow, and few studies have examined management of patients undergoing colposcopy. Methods To elucidate factors associated with utilization of the 2017 ASCCP Colposcopy Standards guidelines for patients undergoing colposcopic cervical biopsy, the authors cross-sectionally surveyed and interviewed physicians and advanced practice providers who perform colposcopy. Clinicians responded to a clinical vignette describing a common colposcopy scenario. Clinicians were asked to describe where they would biopsy and why. Binomial logistic regression models determined factors associated with guideline concordance. Qualitative interviews further explored practice patterns. Results A total of 671 colposcopists participated from across the United States. A total of 541 (81%) participants reported colposcopy practice concordant with the 2017 ASCCP Colposcopy Standards guidelines. A total of 490 (73%) participants reported that they were using the 2017 ASCCP Colposcopy Standards guidelines. Male colposcopists and those who were internal and family medicine clinicians were less likely to report guideline-concordant management than females and obstetrician-gynecologists. Colposcopists discussed the rationale behind guideline-concordant aspects of care, including taking targeted biopsies and using excisional rather than ablation procedures. Conclusions Most colposcopists perform biopsies and treatment consistent with the 2017 ASCCP Colposcopy Standards guidelines and understand the rationale behind multiple targeted biopsies.

Attitudes toward the American Cancer Society’s 2020 cervical cancer screening guidelines: A qualitative study of a national sample of US clinicians

AbstractBackgroundThe 2020 American Cancer Society (ACS) guidelines are the most recent national guidelines for cervical cancer screening. These guidelines propose two major changes from current practice: initiating screening at age 25 years and using primary human papillomavirus (HPV) testing. Adoption of guidelines often occurs slowly, and therefore understanding clinician attitudes is important to facilitate practice change.MethodsInterviews with a national sample of clinicians who perform cervical cancer screening in a variety of settings explored attitudes toward the two major changes from the 2020 ACS cervical cancer screening guidelines. Clinicians participated in 30‐ to 60‐min interviews exploring their attitudes toward various aspects of cervical cancer screening. Qualitative analysis was performed.ResultsSeventy clinicians participated from across the United States. Few respondents were initiating screening at age 25 years, and none were using primary HPV testing. However, over half would be willing to adopt these practices if supported by scientific evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional societies, lack of laboratory availability and insurance coverage, limited autonomy within large health care systems, and concerns related to missed disease.ConclusionsFew clinicians have adopted screening initiation or primary HPV testing, as recommended by the 2020 ACS guidelines, but over half were open to adopting these changes. Implementation may be facilitated via professional organization endorsement, clinician education, and laboratory, health care system, and insurance support.Plain Language Summary In 2020, the American Cancer Society (ACS) released updated guidelines for cervical cancer screening. The main changes to current practices were to initiate screening at age 25 years instead of age 21 years and to screen using primary human papillomavirus (HPV) testing rather than cytology alone or in combination with HPV testing. We performed in‐depth interviews with 70 obstetrics and gynecology, family medicine, and internal medicine physicians and advanced practice providers about their attitudes toward these guidelines. Few clinicians are following the 2020 ACS guidelines, but over half were open to changing practice if the changes were supported by evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional medical organizations, logistical issues, and concerns about missed disease.

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.