Key takeaways:
- Adherence to US cervical cancer screening guidelines was under 10% among commercially insured patients.
- Screening modality was strongly associated with nonadherence, influencing both overscreening and underscreening rates.
- Overscreening was more common than underscreening and occurred most frequently with cotesting.
- Socioeconomic status, comorbidity burden, age, and education level were linked to screening patterns, while racial and ethnic differences were minimal overall.
- Federally qualified health centers may play a key role in improving adherence through team-based care, patient navigation, and education.
Data published in JAMA Network Open has identified an adherence rate to cervical cancer guidelines of under 10%, with a significant link between screening modality and nonadherence.1
Significant advancements in cervical cancer screening guidelines have been reported, such as the additions of quintennial contesting and primary human papillomavirus (HPV) testing in 2012 and 2018, respectively. Data has indicated increased nonadherence because of guideline confusion about factors such as overscreening and underscreening.
“However, the impact of these US guideline changes on adherence across modalities and populations remains understudied, raising concerns about widening gaps in care,” wrote investigators.
Key variables and modalities assessed
The cohort study was conducted to determine adherence to cervical cancer screening guidelines in commercially insured US patients, alongside factors linked to nonadherence such as race, ethnicity, and modality. Data between 2013 and 2021 was obtained from the Optum Clinformatics, which includes the medical, laboratory, and procedure records from approximately 13 million patients.
Modality, race and ethnicity, age, Charlson Comorbidity Index (CCI), and socioeconomic status (SES) variables were included as relevant factors. Since primary HPV testing was not officially recommended until 2018, it was excluded from modalities.
The adjusted predicted probabilities (PPs) of overscreening and underscreening were determined through multivariable logistic regression. The interaction between race and ethnicity with adherence were tested using Wald χ2 test, with covariates including age, education, household net worth (HHN), and CCI.
Factors associated with overscreening
There were 670,003 patients eligible for inclusion, 47.1% of whom were only given cytology and 52.9% were given cotesting. Overscreening was reported in 61.6%, with an overall adjusted PP of 89.4%. For underscreening, these rates were 31.1% and 81%, respectively. PPs for overscreening and underscreening did not significantly differ between racial and ethnic groups.
Patients with cotesting more often experienced overscreening, with a rate of 96.2% vs 82.4% for cytrology only. Additional factors linked to increased rates of overscreening included:
- Non-Hispanic Black race
- Younger age
- High CCI
- High SES
In non-Hispanic Black patients, the PP for overscreening was 91%, alongside 90.1% for a baccalaureate degree or greater and 89.9% for an HHN of $500,000 or greater. For underscreening, an increased PP of 93.1% was reported for patients receiving cytology only vs 68.7% for contesting.
Factors associated with underscreening
Asian patients, those with less than a baccalaureate degree, and those with an HHN under $250,000 also had increased PPs of 82.7%, 81.3%, and 82.8%, respectively. High CCI and low SES were also linked to increased odds of underscreening.
The links between methodology and overscreening vs underscreening were observed across all racial and ethnic groups. Overall, the results highlighted a correlation between screening modality and nonadherence, with an adherence rate of less than 10%.
“Targeted strategies are needed to improve adherence, de-implement unnecessary care, and address disparities in adoption of evolving screening guidelines,” wrote investigators.
Expanding cervical cancer screening
To improve cervical cancer screening adherence, Trisha Amboree, PhD, has highlighted the role of federally qualified health centers (FQHCs).2 According to Amboree, only 50% to 55% of FQHC patients are up to date on cervical cancer screening. These centers server more than 7 million patients, indicating potential to make a significant impact on screening rates.
To accomplish this, Amboree recommended a team-based approach in which physicians, advanced practice providers, nurses, and support staff all play an active role in encouraging screening among patients. Additionally, patient navigation and educational initiatives are vital for improving screening adherence.
“If we can really focus on improving and targeting resources towards FQHCs to really focus on implementing evidence-based strategies that have been shown to improve cervical cancer screening, then I really believe that we can really help push this in the right direction,” said Amboree.
