Recent changes in cervical cancer screening and management guidelines reflect our evolving knowledge about cervical carcinogenesis. In the pursuit of precision, however, decision-making has become complicated. We provide an overview of cervical cancer screening with a focus on what clinicians can do to maximize screening benefits while minimizing screening harms. The approach relies on categorizing women at each step in the screening process by their estimated risk of high-grade precancerous lesions and cervical cancer. Current screening guidelines are designed to find a reasonable balance between benefits and harms by recommending less screening in most women. Current management guidelines are designed to assure consistent decisions regarding referral to colposcopy. After initial colposcopy, we outline three major management options based on risk assessment. For treatment, we recommend ablational procedures when appropriate because they are similarly effective, less costly, and potentially safer than excisional procedures. We advise caution in adopting new screening strategies until they demonstrate cost-effective patient-centered improvements compared with current strategies. Clinicians can maximize their effect on cervical cancer prevention by being attentive to guidelines, assuring that women have access to appropriate human papillomavirus vaccination and providing low-cost, high-quality screening and treatment.

Cervical cancer screening in the United States has accompanied profound decreases in cancer incidence and mortality over the last half century. Two screening strategies are currently endorsed by US-based guideline groups: (1) triennial cytology for women aged 21 to 65 years, and (2) triennial cytology for women aged 21 to 29 years followed by cytology plus testing for high-risk human papillomavirus types every 5 years for women aged 30 years and older. Providing women with affordable, easily accessible screening, follow-up of abnormal tests, and timely treatment will result in the greatest impact of screening on cervical cancer incidence and mortality.

Introduction

Current U.S. cervical cancer screening guidelines recommend a 3- or 5-year screening interval depending on age and screening modality. However, many women continue to be screened annually. The purpose of this study is to investigate U.S. women's self-reported frequency of cervical cancer screening, acceptance of an extended screening interval (once every 3-5 years), and preferred screening options.

Methods

Data from a 2012 web-based survey of U.S. women aged ≥18 years who had not undergone a hysterectomy or been diagnosed with cervical cancer (N=1,380) were analyzed in 2014. Logistic regression models of extended screening interval use, acceptance, and preference were developed.

Results

Annual Pap testing was the most widely used (48.5%), accepted (61.0%), and preferred (51.1%) screening option. More than one third of respondents (34.4%) indicated that an extended screening interval would be acceptable, but only 6.3% reported that they were currently screened on an extended interval. Women who preferred an extended screening interval (32.9% of those willing to accept regular screening) were more likely to report no primary care visits during the last 12 months (AOR=2.05, p<0.003), no history of abnormal Pap test results (AOR=1.71, p=0.013), and that their last Pap test was performed by an internist/family practitioner rather than an obstetrician-gynecologist (AOR=2.03, p<0.001).

Conclusions

U.S. women's acceptance of and preference for an extended cervical cancer screening interval appears to be more widespread than utilization. Strategies to educate women about the reasoning behind recommendations for less-than-annual testing and to foster informed preferences should be devised and evaluated.

Importance:Ovarian cancer is relatively rare but the fifth-leading cause of cancer mortality among United States women. Objective:To systematically review evidence on benefits and harms of ovarian cancer screening among average-risk women to inform the United States Preventive Services Task Force. Data Sources:MEDLINE, PubMed, Cochrane Collaboration Registry of Controlled Trials; studies published in English from January 1, 2003, through January 31, 2017; ongoing surveillance in targeted publications through November 22, 2017. Study Selection:Randomized clinical trials of ovarian cancer screening in average-risk women that reported mortality or quality-of-life outcomes. Interventions included transvaginal ultrasound, cancer antigen 125 (CA-125) testing, or their combination. Comparators were usual care or no screening. Data Extraction and Synthesis:Independent critical appraisal and data abstraction by 2 reviewers. Meta-analytic pooling of results was not conducted because of the small number of studies and heterogeneity of interventions. Main Outcomes and Measures:Ovarian cancer mortality, false-positive screening results and surgery, surgical complications, and psychological effects of screening. Results:Four trials (N = 293 587) were included; of these, 3 (n = 293 038) assessed ovarian cancer mortality, and 1 (n = 549) reported only on psychological outcomes. Evaluated screening interventions included transvaginal ultrasound alone, transvaginal ultrasound plus CA-125 testing, and CA-125 testing alone. Test positivity for CA-125 was defined by a fixed serum level cutpoint or by a proprietary risk algorithm based on CA-125 level, change in CA-125 level over time, and age (risk of ovarian cancer algorithm [ROCA]). No trial found a significant difference in ovarian cancer mortality with screening. In the 2 large screening trials (PLCO and UKCTOCS, n = 271 103), there was not a statistically significant difference in complete intention-to-screen analyses of ovarian, fallopian, and peritoneal cancer cases associated with screening (PLCO: rate ratio, 1.18 [95% CI, 0.82-1.71]; UKCTOCS: hazard ratio [HR], 0.91 [95% CI, 0.76-1.09] for transvaginal ultrasound and HR, 0.89 [95% CI, 0.74-1.08] for CA-125 ROCA). Within these 2 trials, screening led to surgery for suspected ovarian cancer in 1% of women without cancer for CA-125 ROCA and in 3% for transvaginal ultrasound with or without CA-125 screening, with major complications occurring among 3% to 15% of surgery. Evidence on psychological harms was limited but nonsignificant except in the case of repeat follow-up scans and tests, which increased the risk of psychological morbidity in a subsample of UKCTOCS participants based on the General Health Questionnaire 12 (score ≥4) (odds ratio, 1.28 [95% CI, 1.18-1.39]). Conclusions and Relevance:In randomized trials conducted among average-risk, asymptomatic women, ovarian cancer mortality did not significantly differ between screened women and those with no screening or in usual care. Screening harms included surgery (with major surgical complications) in women found to not have cancer. Further research is needed to identify effective approaches for reducing ovarian cancer incidence and mortality.

Objective

A shift toward later initiation of cervical cancer screening for women began in 2002. We generated national estimates of screening prevalence rates and guideline-consistent screening among U.S. women ages 15-29 before and after the first evidence-based recommendations for reduced cervical cancer screening.

Method

We used National Survey of Family Growth data to compare self-reported cervical cancer screening in 2002 and 2006-2008, stratified by age (15-17, 18-20, 21-29) and sexual activity. We also assessed receipt of guideline-consistent screening by selected demographic variables.

Results

Among females ages 15-17, the proportion screened decreased from 23% to 12%, and screening was significantly more likely to be guideline-consistent. Among females ages 18-20, 24% were screened too early in 2006-2008, but among those not yet sexually active, screening declined to 8%, appropriately reflecting new guidelines. In multivariable analysis, private health insurance, pregnancy, and hormonal contraceptive use were associated with guideline-consistent screening among sexually-active women.

Conclusion

Fewer adolescents were being screened before sexual initiation, representing newer guidelines. However, sexually-active young adult women also should have later screening initiation. Factors related to health care access contribute to receipt of screening. Monitoring and provider education are needed to improve guideline-consistent screening, as newer guidelines call for less screening.

Objectives

To understand obstetrician-gynecologist perceptions of the value of external genitalia inspection and speculum examinations in older and younger healthy women across the life span.

Design

National survey from May 2010 to January 2011 asking obstetrician-gynecologists about the need for and importance of external inspection and speculum examination in four scenarios of asymptomatic healthy women aged 70, 55, 35, and 18 who present for routine health visits. Separate questions asked about the importance of various reasons for these examinations.

Setting

Mail-in survey of a national sample of obstetrician-gynecologists.

Participants

Probability sample of obstetrician-gynecologists from the American Medical Association Physician Masterfile (N = 521).

Measurements

Proportion of obstetrician-gynecologists who would perform external inspection and speculum examinations and consider these examinations to be very important.

Results

The response rate was 62%. In a healthy 70-year-old woman, 98% of respondents would perform external inspection, and 86% would perform a speculum examination. Ninety percent would perform a speculum examination in a healthy 55-year-old woman after removal of her uterus, cervix, and ovaries. Respondents more often indicated that the external examination was very important in the 70-year-old (63%) than in younger women (46-53%). Reasons rated as very important included identifying cancers and benign lesions, reassuring women of their health, and adhering to standard of care.

Conclusion

Obstetrician-gynecologists would commonly perform external and speculum examinations in asymptomatic women and believe the external examination to be particularly important in older women for cancer detection. Clinicians should discuss limitations of screening pelvic examination guidelines and elicit health goals from older women to provide more person-centered gynecological care.

Several important lessons have been learnt from our experiences in screening for various cancers. Screening programmes for cervical and colorectal cancers have had the greatest success, probably because these cancers are relatively homogenous, slow-growing, and have identifiable precursors that can be detected and removed; however, identifying the true obligate precursors of invasive disease remains a challenge. With regard to screening for breast cancer and for prostate cancer, which focus on early detection of invasive cancer, preferential detection of slower-growing, localized cancers has occurred, which has led to concerns about overdiagnosis and overtreatment; programmes for early detection of invasive lung cancers are emerging, and have faced similar challenges. A crucial consideration in screening for breast, prostate, and lung cancers is their remarkable phenotypic heterogeneity, ranging from indolent to highly aggressive. Efforts have been made to address the limitations of cancer-screening programmes, providing an opportunity for cross-disciplinary learning and further advancement of the science. Current innovations are aimed at identifying the individuals who are most likely to benefit from screening, increasing the yield of consequential cancers on screening and biopsy, and using molecular tests to improve our understanding of disease biology and to tailor treatment. We discuss each of these concepts and outline a dynamic framework for continuous improvements in the field of cancer screening.

Background

The American Congress of Obstetricians and Gynecologists recommends that a pelvic examination be offered to asymptomatic women after an informed discussion with their provider. Although the adverse health outcomes that the examination averts were not delineated, the organization stated that it helps establish open communication between patients and physicians. Recent surveys have focused on obstetrician-gynecologists' attitudes and beliefs about the examination, but the perspectives of women have not been well-characterized.

Objective

The purpose of this study was to better understand women's beliefs about the purpose and value of routine pelvic examinations.

Study design

We completed structured interviews with 262 women who were 21-65 years old who agreed to participate in a 50-minute interview about cervical cancer screening. Recruitment took place in outpatient women's clinics at a public hospital and an academic medical center in San Francisco, CA. Women were shown an illustration of a bimanual pelvic examination and asked a series of closed-ended questions: if they knew why it was performed, if it reassured them of their health, and if they believed it helped establish open communication with their provider. Women were asked an open-ended question about their perception of the examination's purpose. Multivariable logistic regression analysis was used to identify demographic predictors of responses.

Results

Approximately one-half of the participants (56%) stated that they knew the examination's purpose. The most frequently cited reason was assurance of normalcy. Most of participants (82%) believed that the examination reassured them of their health. Approximately two-thirds of the participants (62%) believed that the examination helps establish open communication with their provider. In multivariate analyses, older age (≥45 years) independently predicted a higher likelihood of a belief that they knew the examination's purpose (odds ratio, 2.9; 95% confidence interval, 1.5-5.6) and a belief that it facilitates open communication (odds ratio, 2.1; 95% confidence interval, 1.1-3.9). Non-white race also was associated with a belief that the examination helps facilitate open communication between patients and providers (odds ratio, 1.9; 95% confidence interval, 1.1-3.1).

Conclusion

Approximately one-half of the women who participated in our study reported not knowing the purpose of the pelvic examination, yet most of them believed it to be of some value, especially reassurance of health. To achieve shared, informed decision-making, clinicians will need to communicate better to their patients the examination's purpose.