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Given the threat of cervical cancer to women’s health, guidelines for cervical cancer screening by the American College of Obstetricians and Gynecologists recommend screening with the Pap test and human papillomavirus (HPV) test together every 5 years for women age 30 to 65 years and cytologic testing alone every 3 years for women age 21 to 29 years.1 A wealth of data—including a recently published longitudinal Quest Diagnostics Health Trends™ study—affirm cotesting as the most effective screening strategy for women age 30 to 65 years.2 But to what extent do obstetrician/gynecologists (ob/gyns) agree with and follow guidelines, and how do they differ or deviate from women’s healthcare providers (HCPs) as a whole?
Through a survey of ob/gyns, nurse practitioners, and primary care physicians conducted by the National Association of Nurse Practitioners in Women’s Health (NPWH) and HealthyWomen, we find Ob/gyns, as well as all of these HCPs combined, are unified in their support for and continued use of the Pap test and cotesting for cervical cancer screening.3 We found similar support was noted from patients, which is important to consider when providing them care. There are differences, however, in perception of the effect of guidelines on women’s health, preferences for screening frequency, report of patient screening practice, and perceived patient knowledge about cervical cancer by ob/gyn experience.
Ob/gyns more likely to use Pap test compared to all HCPs
Ob/gyns recognize the value of the Pap test in screening for cervical cancer (94% ob/gyns, 95% all HCPs combined). Additionally, 94% of ob/gyns and 92% of all HCPs combined say the Pap test is an effective tool for managing the risk of cervical cancer (Figure 1). As well, 87% of ob/gyns say the Pap test itself is a primary reason their patients receive annual health checkups. Moreover, ob/gyns are more concerned that eliminating the Pap test from frontline cervical cancer screening will have a negative impact on women’s health (66% vs 61%).
Less than 1% of HCPs screen using HPV alone, demonstrating nearly universal agreement across all types of HCPs that screening with HPV alone is less effective than use of the Pap test and/or cotesting. In considering risks associated with HPV only testing without a Pap test, ob/gyns are most fearful about a positive diagnosis with no treatment options offered to patients (58%), more recommendations for colposcopies (57%), and higher rates of missed diagnoses (52%). These concerns are not surprising given previous research showing that screening with HPV alone could miss up to 1 in 5 cervical cancer cases.4 Considering the high prevalence of HPV, particularly among women younger than age 30 years, it is critical to discern which cases are most likely to progress to invasive disease to avoid unnecessary treatment. All of these concerns culminate in ob/gyns saying they are more likely (88% vs 82%) to continue using the Pap test as part of their cervical screening practices for the foreseeable future (Figure 1).
Ob/gyn and combined HCP support for the Pap test mirrors that of their patients. It was found that 84% of women are familiar with the Pap test and 90% believe the Pap test is important to managing their overall health and well-being. Women value the Pap test and believe it’s an important preventive health tool warranting regular visits with their ob/gyn.
Ob/gyns strongly support cotesting
Like the Pap test, both ob/gyns and all HCPs combined agree that cotesting has positive effects on women’s health. The extent to which HCPs trust and value the role of cotesting has increased to an even higher level since they were last surveyed by us 5 years ago. Ob/gyns are particularly strong in their support for the value of cotesting. Overwhelmingly, 91% of ob/gyns and 89% of combined HCPs believe cotesting is valuable for their patients’ health (Figure 2). These findings demonstrate clear agreement that cotesting remains the best way to protect women’s health.
Ob/gyns are also more likely to use cotesting than all HCPs combined and are taking the lead on what is considered standard practice in the United States. For patients who are age 30 to 65 years, more than 8 in 10 ob/gyns (81%) are likely to use cotesting for screening (compared to 74% of all HCPs combined). Moreover, ob/gyns are more likely to believe that cotesting provides the most assurance that a patient is not at risk for cervical cancer (83% vs 74% among HCPs) (Figure 2). Confidence in cotesting is inversely related to the experience with newer practitioners who are quick to adopt it. Ob/gyns with 10 years or less of experience are most confident in cotesting (93%), compared to those with 11 to 19 years of experience (80%) and those with 20 or more years of experience (79%).
Familiarity with guidelines does not equate to total compliance
Compared to all combined HCPs, ob/gyns are more familiar with consensus screening guidelines as you may expect. In fact, 87% of ob/gyns are familiar with these guidelines, as compared with only 69% of combined HCPs. However, less than half of ob/gyns (42%) believe the consensus guidelines have had a positive effect on overall women’s health compared to 55% among all HCPs combined (Figure 3). This lack of support may be due to the lengthening of screening intervals, given the overwhelming support for screening strategies involving the Pap test.
Divergence exists between ob/gyn preferences for screening frequency and patient practice
Regardless of personal perceptions of screening guidelines, ob/gyns and all HCPs combined most often recommend that their patients age 30 to 65 years be tested every 5 years after an initial test (44% of ob/gyns, 43% of HCPs).
Patients seem to prefer more frequent testing, with only 19% of patients tested every 5 years. However, 81% of patients are tested more frequently, with 1% tested every 4 years, 27% tested every 3 years, 12% tested every 2 years, 38% tested annually, 1% tested every 6 months, and 2% tested at some other frequency (Figure 4). Ob/gyns are more likely to report their patients being concerned about less frequent screenings (81%) than all HCPs combined (71%).
Ob/gyn confidence in patients’ awareness about cervical cancer screening varies
Ob/gyns report that a large majority of their patients are familiar with cervical cancer screening methods and the collection process. In fact, ob/gyns recognize how much women value the Pap test as part of their overall health and well-being. When asked whether they believe their patients are familiar with the Pap test, more than 3 in 4 (76%) report their patients are familiar. Further, all HCPs combined report similarly high rates of familiarity. As well, more than 6 in 10 ob/gyns (63%) and all HCPs combined (64%) report their patients as being aware that the Pap test and HPV test are collected in the same way, adding no extra time or frequency to visits with their HCPs. Ob/gyns with longer tenures are more confident their patients are aware of this. Of ob/gyns with 20 years or more experience, 73% report the majority of their patients are aware, compared to 64% of ob/gyns with 11 to 19 years of experience and just 45% of ob/gyns who have 10 years or less of experience.
Despite strong patient awareness of the different screening methods, most ob/gyns report that their patients are unaware of the link between HPV and cervical cancer. Although 98% of ob/gyns report being comfortable discussing an HPV diagnosis with their patients (96% typically discuss HPV with patients as part of their wellness exams, and 76% believe it is important to discuss HPV with their patients), only 39% of ob/gyns report that their patients are aware HPV can cause cervical cancer. Again, there is divergence in attitudes by ob/gyn experience. Nearly 47% of ob/gyns (1 in 2) with 20 or more years of experience report their patients are aware, compared to 41% of ob/gyns with 11 to 19 years of experience and just 22% of ob/gyns with 10 or less years of experience.
The varied confidence that ob/gyns have in their patients’ awareness of screening methods and cervical cancer risks may be due in part to a conversation gap between providers and patients. Although 76% of all HCPs combined claim to discuss cervical cancer and HPV frequently as part of their routine exams, patients say that they do not discuss these conditions as frequently as HCPs believe. Only 27% say they talk about cervical cancer with their HCP most or all of the time, while 25% say they never discuss it and 20% say they rarely do. These conflicting perceptions highlight the importance of ensuring cervical cancer screening is prioritized as a point for discussion during regular exam visits.
Implications for ob/gyns and patient health
Ob/gyns play a critical role in helping protect their patients’ health against the threat of cervical cancer by providing screening and education. There is strong agreement among ob/gyns that both the Pap test and cotesting are valuable cervical cancer screening methods. More than 8 in 10 report that they will continue to use Pap testing and cotesting with their patients. This unified support is reinforced by nearly universal agreement that HPV alone screening presents a number of risks, as evidenced by less than 1% of HCPs reporting that they screen using HPV alone.
There are differences, however, in ob/gyn endorsement of screening guidelines, screening practices, and perception of patient awareness about cervical cancer. Although most are familiar with screening guidelines, less than half believe they have had a positive effect on women’s health. This may be due to the lengthening of screening intervals given the overwhelming support for screening strategies involving the Pap test. In fact, ob/gyns with 20 or more years of experience are least likely to recommend testing 5 years after an initial screening as per the guidelines. In contrast, ob/gyns with less than 10 years of experience are most likely to comply with the guidelines.
Finally, there are differences in ob/gyn perceptions of their patients’ awareness about cervical cancer. For example, ob/gyns with 20 or more years of experience are more confident their patients know that the Pap test and HPV test are collected the same way compared to ob/gyns with less tenure. More experienced ob/gyns are also more confident that their patients are aware of the link between HPV and cervical cancer.
More research is needed to identify differences in social and health outcomes based on the tenure of ob/gyns. It is important to determine if generational differences in attitudes and practices of ob/gyns are leading to different provision of care and variation in health outcomes. Finally, more research is needed to identify the determinants of diverging attitudes and practices among ob/gyns. Are differences in medical training and experience leading to systematic differences in cervical cancer screening? Does patient population and insurance type affect the feedback loop between patient and provider? And what type of educational outreach may be needed to ensure that any future changes to guidelines are communicated appropriately to ob/gyns?
Our findings clearly show that ob/gyns and all HCPs combined continue to support cotesting and the Pap test. These insights along with real-world research favor continued use of these methods as the most effective way to screen for cervical cancer. Any future evolution to screening guidelines and practices should account for the preferences of HCPs to ensure proper compliance, screening effectiveness, and, ultimately, the best protection for women’s health.
Dr. DaCarla M. Albright is a practicing ob/gyn and professor with nearly 20 years of clinical experience ranging from prenatal care to gynecologic surgery. She is a member of the Women’s Health Advisory Council of HealthyWomen, a fellow of the American College of Obstetricians and Gynecologists, and a member of the Association of Professors of Gynecology and Obstetrics. Her academic interests are strongly focused in medical education. Dr. Albright received her medical degree from the University of Michigan Medical School in Ann Arbor, Michigan, followed by a residency in obstetrics and gynecology at Sinai Hospital of Baltimore in Baltimore, Maryland.