Challenges in Cervical Cancer Prevention: A Survey of U.S. Obstetrician-Gynecologists

doi:10.1016/j.amepre.2013.03.019

American Journal of Preventive Medicine

Volume 45, Issue 2, August 2013, Pages 175-181

https://doi.org/10.1016/j.amepre.2013.03.019 Get rights and content

Background

Current cervical cancer prevention recommendations include human papillomavirus (HPV) vaccination, Pap and HPV co-testing, and Pap testing at 3- to 5-year intervals.

Purpose

To examine attitudes, practice patterns, and barriers related to HPV vaccination and cervical cancer screening guidelines among U.S. obstetrician-gynecologists.

Methods

In 2011–2012, a national sample of members of the American Congress of Obstetricians and Gynecologists responded to a 15-item (some with multiple parts) questionnaire assessing sociodemographic characteristics, clinical practices, and perceived barriers to HPV vaccination and cervical cancer screening. Multivariate logistic regression was used to identify factors associated with guideline adherence. Analyses were conducted in 2012.

Results

A total of 366 obstetrician-gynecologists participated. Ninety-two percent of respondents offered HPV vaccination to patients, but only 27% estimated that most eligible patients received vaccination. Parent and patient refusals were commonly cited barriers to HPV vaccination. Approximately half of respondents followed guidelines to begin cervical cancer screening at age 21 years, discontinue screening at age 70 years or after hysterectomy, and appropriately utilize Pap and HPV co-testing. Most physicians continued to recommend annual Paps (74% aged 21–29 years, 53% aged ≥30 years). Physicians felt that patients were uncomfortable with extended screening intervals and were concerned that patients would not come for annual exams without concurrent Paps. Solo practitioners were less likely to follow both vaccination and screening guidelines than those in group practices.

Conclusions

This survey of obstetrician-gynecologists indicates persistent barriers to the adoption of HPV vaccination and cervical cancer screening guidelines. Interventions to promote guideline adherence may help improve the quality of cervical cancer prevention.

Introduction

Recent breakthroughs in the field of cervical cancer prevention include HPV vaccination and testing. Since 2006, HPV vaccination has been recommended for women aged 11–26 years.1, 2 In 2009, the American Congress of Obstetricians and Gynecologists (ACOG) issued guidelines³ recommending the initiation of Paps at age 21 years, biennial screening between ages 21 and 29 years, triennial screening for women aged ≥30 years 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. In March of 2012, guidelines were issued by the U.S. Preventive Services Task Force, American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology, and subsequently 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 5-year intervals for women aged 30–65 years, regardless of whether they have received HPV vaccination.⁴

Recommendations do not always translate into practice, however. Although 90% of obstetrician-gynecologists administer HPV vaccines in their offices,⁵ HPV vaccination rates are lowest among women aged 19–26 years⁶ who are seen frequently by obstetrician-gynecologists.⁵ By 2007, fewer than half of obstetrician-gynecologists were using Pap and HPV co-testing,⁷ and roughly one quarter had adopted triennial screening intervals.⁸ To our knowledge, there are no empirical studies of the implementation of the ACOG 2009 guidelines³ among obstetrician-gynecologists. Because guideline implementation takes time, understanding the uptake of the 2009 guidelines may predict obstetrician-gynecologists’ behavior related to the 2012 guidelines. Between September 2011 and January 2012, prior to publication of the new guidelines, a systematic examination was conducted for the current paper on practice patterns, attitudes, and barriers associated with adherence to ACOG’s existing HPV vaccination and cervical cancer screening guidelines among practicing clinicians.

Section snippets

Participants and Data Collection

More than 90% of obstetrician-gynecologists in the U.S. are members of ACOG. From a list of all ACOG members stratified by age, gender, and geography, 1000 representative obstetrician-gynecologists were selected at random for participation in the survey. The sample was further stratified into two groups: (1) members in ACOG’s Collaborative Ambulatory Research Network (CARN), a group of ACOG members who agree to participate in four to six surveys every 12 months (n=300); or (2) ACOG members who

Results

A total of 1000 surveys were distributed, 20 physicians were excluded because of retirement or being unreachable, and 397 physicians returned surveys for a total response rate of 40.5%, consistent with other national ACOG studies.5, 18 Thirty-one participants were excluded because of incomplete responses, leaving 366 participants in the final sample. Participants’ average age and years in practice were 53 and 21, respectively (Appendix B, available online at www.ajpmonline.org). Half of

Discussion

This survey of a national sample of obstetrician-gynecologists reveals limited implementation of HPV vaccination and cervical cancer screening guidelines 6 and 3 years, respectively, after guideline publication. This survey occurred prior to release of the new 2012 guidelines and may portend very slow uptake of these guidelines unless efforts are made to hasten implementation. Although nearly all physicians offered HPV vaccination to their patients, only one third estimated that most eligible

Acknowledgements

Funding for the research was provided by grant UA6MC19010, through DHHS, Health Resources and Services Administration, Maternal and Child Health Research Program and by an American Cancer Society Mentored Research Scholar Grant (MRSG-09-151-01). No commercial support was obtained.

The authors acknowledge Sadiqa Mahmood and Olivera Vragovic for their statistical contributions.

No financial disclosures were reported by the authors of this paper.

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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.
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Of 5,368,713 patients identified, co-testing was performed in 2,873,070 (53.5%), cytology in 2,422,480 (45.1%), and primary HPV testing in 73,163 (1.4%). The cumulative incidence of repeat screening among all women by seven years was 81.9%. Of those who underwent repeat screening, 85.7% with index cytology and 96.6% with index co-testing were rescreened early. Only, 12.2% with index cytology had appropriate rescreening and 2.1% had delayed rescreening. Among the index co-testing group, 3.2% had appropriate rescreening and 0.3% had delayed rescreening.
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Citation Excerpt :
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Research ArticleChallenges in Cervical Cancer Prevention: A Survey of U.S. Obstetrician-Gynecologists

Background

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Participants and Data Collection

Results

Discussion

Acknowledgements

J Pediatr Adolesc Gynecol

Prev Med

Womens Health Issues

Am J Prev Med

Lancet

Lancet Oncol

Vaccine

Gynecol Oncol

Curr Probl Cancer

Am J Prev Med

Am J Prev Med

Human papillomavirus vaccination

Committee Opinion

Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Comitte on Immunization Practices

MMWR Morbidity and Mortality Weekly Report

Cervical cytology screening

Practice Bulletin

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer

Am J Clin Pathol

Completion of the human papillomavirus vaccine series among insured females between 2006 and 2009

Cancer

Low-risk human papillomavirus testing and other nonrecommended human papillomavirus testing practices among U.S. health care providers

Obstet Gynecol

Cervical cancer screening with both human papillomavirus and Papanicolaou testing vs Papanicolaou testing alone: what screening intervals are physicians recommending?

Arch Intern Med

Gynecologists' attitudes regarding human papilloma virus vaccination: a survey of Fellows of the American College of Obstetricians and Gynecologists

Infect Dis Obstet Gynecol

Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians

Cancer Epidemiol Biomarkers Prev

Research Article
Challenges in Cervical Cancer Prevention: A Survey of U.S. Obstetrician-Gynecologists