Is the PAP test for cervical cancer screening being overused?

by Kristina Fiore

Physicians do not appear likely to reduce the frequency of cervical cancer screening — not even with the availability of the sensitive human papillomavirus (HPV) DNA test, researchers say.

When given a clinical vignette of a 35-year-old woman with a normal Pap test and a negative HPV test, only 19% of the more than 1,200 physicians surveyed said they would wait three years before conducting another Pap test, Mona Saraiya, MD, MPH, of the CDC, and colleagues reported in the June 14 issue of Archives of Internal Medicine.

Most said they would perform the test earlier than that.

“Until measures are in place to reinforce extended screening intervals among women with negative HPV and normal Pap test results, there is no advantage gained” with HPV co-testing, and, the researchers added “it is more expensive.”

U.S. Preventive Services Task Force guidelines recommend screening for cervical cancer among women 30 and up every three years. But the American Cancer Society (ACS) and the American College of Obstetrics and Gynecology (ACOG) have recommended three consecutive normal Pap tests before switching to screening less often than annually.

However, the addition of the HPV DNA test has resulted in stronger recommendations by ACS and ACOG to extend screening intervals to three years without prior normal Pap test results, the researchers said.

HPV testing has greater sensitivity to detect high-grade cervical precancers and cancers compared with the Pap test, according to background provided in the article. With a negative test result, clinicians can determine which women may be at low risk of developing high-grade precancer and cancer of the cervix for the next 10 years, the authors noted.

The USPSTF has not yet endorsed HPV co-testing, Saraiya and colleagues said, and many physicians still recommend an annual Pap test.

So to investigate whether the addition of HPV testing to routine screening for cervical cancer would prompt physicians to extend screening intervals among low-risk women, the researchers conducted a survey of 1,212 physicians between Sept. 1, 2006 and May 31, 2007.

They found that, overall, 82% of physicians recommended HPV testing. Most recommended an HPV test following an abnormal Pap test, with noticeable differences by specialty:

* General internists: 44.7%
* Family practitioners: 64.2%
* Ob/Gyns: 78.2%

Just a little over a quarter — 28.3% — recommended co-testing with HPV.

With regard to the clinical vignettes, only 31.8% said they would order the next Pap test in three years for a 35-year-old woman with three normal Pap test results.

More Ob/Gyns said they would conduct another Pap test in one year, compared with family practitioners and general internists, the researchers said.

In another vignette — a 35-year-old woman with a normal Pap test and a negative HPV test — only 19% reported that they would conduct the Pap test in three years.

Most — 78% — said they would conduct it more frequently. But this time, more Ob/Gyns recommended a three-year interval than did general internists and family practitioners (P<0.001).

Among the internists and family practitioners, “the addition of a negative HPV test result seemed to offer less security in recommending extension to triennial screening than a history of three previous normal pap test results and no new sexual partners,” they wrote.

“The most likely explanation for the changes by specialty may be lower familiarity with HPV and HPV testing guidelines among [internists] and [family practitioners], as found in other studies,” they added.

Generally, the researchers said they were surprised by the results, “given the endorsement of extension of screening intervals with HPV co-testing by two major guideline-setting organizations five years before our survey was fielded.”

They noted that the “financial incentive of annual testing” may also play a key role in yearly Pap tests, and added that the influence of opinion leaders within the local practice community is “essential” for behavior change.

Finally, they cautioned that cost-effectiveness models suggest the practices observed in the study “are likely to increases costs with little improvement in reducing cervical cancer incidence and increasing survival.”

The authors noted that the study was limited by self-report and by the fact that it used patient vignettes, not real cases.

Kristina Fiore is a MedPage Today staff writer.

Originally published in MedPage Today. Visit MedPageToday.com for more OB/GYN news.

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