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 decreased since the survey was
done in 2006.
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.
MICHAEL S. POLICAR, M.D., is a clinical professor of obstetrics
and gynecology and reproductive sciences at the University of
California, San Francisco. He is medical director at UCSF's Family PACT
Evaluation and Bixby Center for Global Reproductive Health. He said he
had no relevant financial disclosures.
