Recent guidelines to prevent cervical cancer via human papilloma virus (HPV) screening and Papanicolaou (Pap) smears have not led to widespread HPV vaccination, according to a study published in the July 9 issue of the American Journal of Preventive Medicine.
In 2006, the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention recommended HPV vaccination, as did the American Congress of Obstetricians and Gynecologists (ACOG) in 2010. In 2009, ACOG recommended Pap tests every 2 years from ages 21 through 29 years and then every 3 years after age 30 years for women who had previous normal Paps or negative concurrent HPV results. Screening should stop at age 70 years and after hysterectomy for a benign condition.
Rebecca B. Perkins, MD, from the School of Medicine, Boston University, Massachusetts, and colleagues sent a 15-item questionnaire to 1000 ACOG members to assess clinical practices, patient characteristics, and barriers to HPV vaccination and Pap smears.
Of the 366 obstetrician/gynecologists who completed and returned the questionnaires, 92% reported offering vaccination to patients, but only 27% of their eligible patients were vaccinated. The most highly cited barrier to vaccination was refusal by parent or patient. These results counter those of other studies that indicate high patient interest in HPV vaccination.
Most of the respondents continue to offer Paps annually, even though guidelines call for less-frequent tests, because they feel that their patients are uncomfortable with the extended periods and might not return. Approximately half of the respondents follow the guidelines to begin Paps at age 21 years and/or discontinue at age 70 years and use Pap and HPV cotesting.
Physicians in group practice were more likely to adhere to vaccination and Pap smear guidelines than those in private practice. More physicians (96%) were comfortable offering the vaccine to 13-year-olds than offering it to 11-year-olds (73%), and female physicians were more likely to offer it to the youngest patients than male physicians.
Respondents varied in cotesting for cervical cancer and HPV. Although 45% offered cotesting to women older than 30 years, 21% offered it only on patient request, 11% screened all patients with both tests, and 23% did not offer HPV testing at all.
The data were analyzed in 2012 before new guidelines from several medical societies recommending triennial Pap smears for women aged 21 to 29 years and cotesting with Pap smear and HPV tests every 5 years for those aged 30 to 65 years, whether or not they were vaccinated against HPV.
The researchers suggest their findings may indicate gaps in physician–patient communication while also pointing out that discussing the data in support of HPV vaccination and spacing Pap intervals uses otherwise reimbursable time.
Limitations of the study include self-reporting, selection bias, and underrepresentation of black and Hispanic women, who have higher risks for cervical cancer.
The researchers conclude that education of physicians and patients on the evidence in support of HPV vaccination and the value of cervical cancer and HPV cotesting every 5 years could help prevent this cancer.
Funding for the research was provided the Health Resources and Services Administration, Maternal and Child Health Research Program, and by an American Cancer Society Mentored Research Scholar Grant. The authors have disclosed no relevant financial relationships.
Am J Prev Med. 2013;45:175-181.
— Ricki Lewis, PhD0