Physicians slow to implement HPV vaccination and cervical cancer screening guidelines
Recent breakthroughs in cervical cancer prevention have resulted in new vaccination and cervical cancer screening guidelines. Recommendations do not always translate into practice, however. Less than one third of obstetrician-gynecologists vaccinate their eligible patients against the human papilloma virus (HPV), and only half adhere to cervical cancer prevention guidelines published three years previously, according to a survey published this month in the American Journal of Preventive Medicine.
Vaccination against HPV has been recommended for women aged 11–26 years since 2006. In 2009, the American Congress of Obstetricians and Gynecologists (ACOG) issued guidelines recommending the initiation of Pap tests for 21 year-old women, decreasing the frequency of screening to biennial screening between ages 21 and 29 years, triennial screening for women aged 30 years or more with either prior normal Paps or negative concurrent HPV co-testing, and discontinuation of screening at age ?70 years or after hysterectomy for benign indications.
The investigators found that patient and physician interactions may pose important barriers to guideline implementation. "In the current survey and others, providers stated that the largest barrier to HPV vaccination was patients and parents declining to receive the vaccine. However, studies indicate that most patients support HPV vaccination, and that a strong physician recommendation is the most important determinant of vaccine uptake in young women," says lead investigator Rebecca B. Perkins, MD, MSc, of the Boston University School of Medicine.
Investigators queried 1,000 obstetrician-gynecologists, all members of ACOG, about their screening and vaccination practices, as well as barriers that prevented physicians from following the 2009 ACOG guidelines. A total of 366 responses were analyzed.
The investigators found low rates of HPV vaccination. 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. Most practitioners (96%) would recommend HPV vaccination to a hypothetical 13 year-old patient, but only 73% said they would recommend vaccination to an 11 year-old patient.
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 co-testing appropriately.
Most physicians continued to recommend annual Pap test screening (74% ages 21-29, 53% ages 30 and above). Although the respondents were personally comfortable with extended screening intervals, they felt that patients were uncomfortable with extended screening intervals and were concerned that patients would not come for annual exams if a Pap were not offered. Solo practitioners were less likely to follow both vaccination and screening guidelines than those in group practices.
About 45% of practitioners offered Pap and HPV co-testing to women aged 30 years upwards, 21% offered this only if requested by the patient, 11% screened all women with both tests, and 23% did not offer HPV testing.
Only 16 physicians (4%) reported adherence to all ACOG 2009 guidelines for cervical cancer screening.
Since this survey was completed, new guidelines have been issued in 2012 by the US Preventive Services Task Force, American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology, which have subsequently been endorsed by the American Congress of Obstetricians and Gynecologists, recommending triennial Paps for women aged 21–29 years and co-testing with Pap and HPV tests at five-year intervals for women aged 30–65 years, regardless of whether they have received HPV vaccination.
"Our survey which was conducted prior to the new 2012 guidelines reveals limited implementation of HPV vaccination and cervical cancer screening guidelines six and three years, respectively, after these guidelines were published. It may portend very slow uptake of these guidelines unless efforts are made to hasten implementation," comments Dr. Perkins. "In the light of persistently low HPV vaccination rates, and new guidelines recommending Pap and HPV co-testing at five-year intervals, programs to educate physicians and patients on the evidence behind universal HPV vaccination, and extended-interval cervical cancer screening with Pap and HPV co-testing could help improve the quality of cervical cancer prevention."
In an Editorial in the same issue, Russell Harris, MD, MPH, and Stacey Sheridan, MD, MPH, from the Department of Medicine, Division of General Medicine and Clinical Epidemiology, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, observe that the US Preventive Services Task Force (USPSTF), sometimes joined by other professional and advocacy groups, has continued to recommend less screening for breast, colorectal, prostate, and cervical cancer, and that there has been a growing chorus of voices that suggest a coming change in the attitudes of the public and the profession towards screening.
"The new message boils down to this: Screening is not the unqualified good that we have advertised it to be. It has clear potential harms as well as benefits, and these must be carefully weighed before a rational decision about screening can be made. Sometimes screening does more good than harm, but at other times it does more harm than good," they write.
"As shown by Perkins et al., many gynecologists continue to report starting cervical cancer screening before age 21 and not stopping at age 65; continuing to screen after hysterectomy for benign indications; and screening annually rather than every three years. This finding is in agreement with other studies of both physicians and the public. We have not yet reached a tipping point of professional or public opinion; we are only witnessing increased discussion and open dissent with prior policies. The battle for the hearts and minds of the profession and the public is ongoing," Harris and Sheridan conclude.
"The Times They (May) Be A-Changin': Too Much Screening Is a Health Problem," by Russell Harris, MD, MPH; Stacey Sheridan, MD, MPH (DOI: 10.1016/j.amepre.2013.05.002).
Both articles appear in the American Journal of Preventive Medicine, Volume 45, Issue 2 (August 2013)