U.S. Physicians Cling to Annual Pap Testing

I am not surprised by these results, but I am disappointed to see how prevalent overtesting for cervical cancer has been. There is no reason to think that U.S. screening rates have reduced since the survey was done in 2006.

Dr. Michael S. Policar

Some medical groups and health delivery systems such as Kaiser Permanente have initiatives to reduce overscreening for cervical cancer. Family PACT, the family planning program run by California (and where I work) has seen a progressive reduction in the number of cervical cytology tests done following provider education programs, including widely-distributed clinical practice guidelines and webinars.

Given the aggressive and direct-to-consumer marketing of HPV cotesting, it is reasonable to think that even more physicians now use HPV testing than the 51% in 2006. But results from this study and others indicate that physicians are using HPV cotesting incorrectly. Study findings also show that most clinicians start cervical cytology screening too early, continue too late, and screen too often.

Women either do not know the recommendations on testing intervals or they believe they are primarily financially motivated. Women have been educated since the 1940s regarding the need for an annual Pap test. There has not been a public health campaign to inform women about the new guidelines.

Providers are too quick to comply with patients’ requests for testing, regardless of the real need. Providers also are fearful of being sued if a woman was to develop an interval cancer. They fear that women will skip their annual well visits without the need for a Pap test to bring them into the office. Even time constraints work against deferred testing because it is quicker to perform a cervical cytology test than to explain why it isn’t being done. And there is concern that if testing is not given to a woman who asks for it she may leave for a different physician.

The public must be educated and persuaded that the public health message of the 20th century regarding the need for annual Pap testing in all women has been significantly changed for the purpose of improving the quality of care. In addition, providers must be convinced that the guidelines are based on the best evidence, and they must be held accountable for following the guidelines. They should receive periodic reports that compare their adherence to the guidelines with that of their peers. And Medicaid, health plans, and other payers must stop paying for cervical testing that falls outside of consensus recommendations.

Dr. Michael S. Policar is a clinical professor of obstetrics and gynecology and reproductive sciences at the University of California, San Francisco. He is medical director at the UCSF Family PACT Evaluation and The Bixby Center for Global Reproductive Health, UCSF. He said he had no relevant financial disclosures.