January 09, 2019
When it comes to tracking cervical cancer screening rates, studies have shown that patient self-reporting can often paint an overly optimistic picture of compliance.
However, a review of medical records in a cohort of 47,000 women in the Rochester Epidemiology Project (REP) database (women residing in Olmsted County, Minnesota) indicates that Pap test screening rates could be even worse than previously thought and are "unacceptably low," particularly in the youngest women.
The study also confirms racial disparities in screening rates and a significant increase in the use of Pap-HPV cotesting in women 30 to 65 years of age, say Kathy L. MacLaughlin, MD, of the Mayo Clinic in Rochester, Minnesota, and colleagues.
The study was published online January 7 in the Journal of Women's Health.
After assessing REP data for Pap and Pap-HPV cotesting among women age 16 years and older living in Olmsted County, the authors found significant declines in Pap test completion rates in eligible women of all ages between 2005 and 2016. The most concerning drop was observed in women 21 to 29 years of age, with Pap test rates falling from 62.8% in 2005 to 47.3% in 2016.
By comparison, the 2015 National Health Interview Survey (NHIS) demonstrated a much less severe decline in self-reported historical screening in this age group, from 86.8% in 2000 to 77.6% in 2015, the authors note.
In the current study, less than two thirds (64.6%) of women 30 to 65 years of age were up to date with cervical cancer screening in 2016.
"These cervical cancer screening rates are unacceptably low," said MacLaughlin in a statement issued by the Mayo Clinic.
"We, as clinicians, must start thinking outside the box on how best to reach these women...Routine screening every 3 years with a Pap test or every 5 years with a Pap-HPV cotest ensures precancerous changes are caught early and may be followed more closely or treated," she added.
The American Cancer Society estimates that over the last year (2018), 13,240 new cases of invasive cervical cancer were diagnosed in the US, and that 4170 unique deaths were attributable to cervical cancer.
The 2012 US Preventive Services Task Force (USPSTF) guidelines recommend cervical cancer screening begin no earlier than age 21, regardless of sexual history. Screening should be discontinued in average-risk women with adequate past screening after age 65.
Women 21 to 29 years of age should receive cervical cytology alone every 3 years. Women ages 30 to 65 can also receive cervical cytology every three years or alternatively, Pap-HPV cotesting every 5 years.
"I strongly support the current guidelines...but suspect that remembering to come in for a screening test every 3 or 5 years may be challenging, so we must ensure we are reminding our patients about this," MacLaughlin told Medscape Medical News.
The researchers were surprised by how much lower the cervical cancer screening rates were in their own study than in the NHIS report, she said. "Past studies have shown that these self-reports are often over-estimated. So we expected our rates would be somewhat lower since our data were based on confirmed Pap and HPV CPT [current procedural terminology] lab codes."
Self-collection of HPV for cervical cancer screening is being studied and "would likely help us reach women who are being missed," MacLaughlin pointed out. However, the use of at-home testing kits is not currently recommended by any national screening guideline group, she noted.
"There must be other barriers we aren't addressing. We need to figure out why we aren't reaching these women and how we can do a better job of explaining the importance of screening and providing screening opportunities that work for them. We may need to consider extended or weekend hours," she added.
Results showed that women of African American and Asian American descent were 50% and 30% less likely, respectively, to be current on cervical cancer screening than white women. Non-Hispanic women were more likely to have had Pap-HPV cotesting than Hispanic women.
These findings are consistent with previous studies highlighting racial disparities in cervical cancer screening, particularly among black and Hispanic women, the authors write.
They noted that in the 2015 NHIS, the lowest rates of cervical cancer screening were in Asian American women (75.8%). At the same time, non-Hispanic women (83.5%) reported higher overall Pap or Pap-HPV cotest completion than Hispanic women (78.6%).
The current study also confirms a significant increase in the use of Pap-HPV cotesting in women 30 to 65 years of age, from 10% in 2007 to 60.8% in 2016. This exceeds the cotest uptake reported in the 2015 NHIS data, the researchers noted.
In addition, an overall decline in screening for women 16 to 21 years of age and for those older than 65 years was observed. This suggests that many of the clinicians in Olmsted County are following the USPSTF recommendations, said MacLaughlin.
The researchers acknowledged that the study findings may be less applicable to regions other than the Olmsted County population. It is also recognized that individuals 20 to 29 years of age are over-represented in the REP data, they said.
This study was funded by the Rochester Epidemiology Project, which is supported by the National Institute on Aging of the National Institutes of Health, and by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. Dr MacLaughlin has disclosed no relevant financial relationships. Coauthor Robert M. Jacobson, MD, disclosed a relationship with Merck and Co. No other relevant financial relationships have been disclosed.
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SOURCE: Medscape, January 09, 2019. J Women's Health. Published online January 7, 2019.