Assessing Management of Abnormal Cervical Cancer Screening Results and Concordance with Guideline Recommendations in Three US Healthcare Settings.

BACKGROUND: Follow-up of abnormal results is essential to cervical cancer screening, but data on adherence to follow-up are limited. We describe patterns of follow-up after screening abnormalities and identify predictors of guideline-concordant follow-up. METHODS: We identified the index screening abnormality (positive human papillomavirus [HPV] test or atypical squamous cells of undetermined significance [ASC-US] or more severe cytology) among women 25-65 years old at three U.S. healthcare systems during 2010-2019. We estimated the cumulative incidence of surveillance testing, colposcopy, or treatment after the index abnormality and initial colposcopy. Logistic regressions were fit to identify predictors of guideline-concordant follow-up according to contemporaneous guidelines. RESULTS: Among 43,007 patients with an index abnormality, the cumulative incidence of any follow-up was 49.6% by 4 years for those with ASC-US/HPV-negative and higher for abnormalities warranting immediate colposcopy. The 1-year cumulative incidence of any follow-up after colposcopy was 70% for patients with normal results or cervical intraepithelial neoplasia (CIN) I and 90% for patients with CIN II+. Rates of concordant follow-up after screening and colposcopy were 52% and 47%. Discordant follow-up was associated with factors including age, race/ethnicity, overweight/obese BMI, and specific types of public payor coverage or being uninsured. CONCLUSIONS: Adherence to recommended follow-up of cytologic and histopathologic abnormalities is inconsistent in clinical practice. Concordance was poor for mild abnormalities and improved, though suboptimal, for more severe abnormalities. IMPACT: There remain gaps in the cervical cancer screening process in clinical practice. Further work is needed to understand barriers to appropriate management of cervical abnormalities.

Factors associated with timely colposcopy following an abnormal cervical cancer test result.

Successful cervical cancer prevention requires screening and appropriate management of abnormal test results. Management includes diagnostic evaluation and treatment, if indicated, based on cervical cancer risk after most abnormal test results. There is little guidance on the optimal timing of diagnostic evaluation, and few data exist on factors associated with timely management. We quantified time-to-colposcopy within 12 months of an abnormal cervical cancer screening or surveillance test result from 2010 to 2018 across three diverse healthcare systems and described factors associated with timely colposcopy. Among 21-65 year-old patients with an abnormal test result for which colposcopy was indicated (n = 28,706), we calculated the proportion who received a colposcopy within 12 months of the abnormal test and used Kaplan-Meier methods to estimate the probability of colposcopy within 12 months. Across all systems, 75.3% of patients received a colposcopy within 12 months, with site-specific estimates ranging from 70.0 to 83.0%. We fit mixed-effects multivariable logistic regression models to identify factors associated with receipt of colposcopy within 12 months. The healthcare system and cytology result severity were the most important factors associated with of timely colposcopy. We observed that sites with more centralized processes had higher proportions of colposcopy completion, and patients with high-grade results were more consistently evaluated earlier than patients with low-grade results. Patient age also affected receipt of timely colposcopy, though this association differed by healthcare system and result severity. These data suggest opportunities for system-level interventions to improve management of abnormal cervical cancer test results.

Cervical Cancer Burden and Opportunities for Prevention in a Safety-Net Healthcare System.

BACKGROUND: The high prevalence of cervical cancer at safety-net health systems requires careful analysis to best inform prevention and quality improvement efforts. We characterized cervical cancer burden and identified opportunities for prevention in a U.S. safety-net system. METHODS: We reviewed tumor registry and electronic health record (EHR) data of women with invasive cervical cancer with ages 18+, diagnosed between 2010 and 2015, in a large, integrated urban safety-net. We developed an algorithm to: (i) classify whether women had been engaged in care (≥1 clinical encounter between 6 months and 5 years before cancer diagnosis); and (ii) identify missed opportunities (no screening, no follow-up, failure of a test to detect cancer, and treatment failure) and associated factors among engaged patients. RESULTS: Of 419 women with cervical cancer, more than half (58%) were stage 2B or higher at diagnosis and 40% were uninsured. Most (69%) had no prior healthcare system contact; 47% were diagnosed elsewhere. Among 122 engaged in care prior to diagnosis, failure to screen was most common (63%), followed by lack of follow-up (21%), and failure of test to detect cancer (16%). Tumor stage, patient characteristics, and healthcare utilization differed across groups. CONCLUSIONS: Safety-net healthcare systems face a high cervical cancer burden, mainly from women with no prior contact with the system. To prevent or detect cancer early, community-based efforts should encourage uninsured women to use safety-nets for primary care and preventive services. IMPACT: Among engaged patients, strategies to increase screening and follow-up of abnormal screening tests could prevent over 80% of cervical cancer cases.

Evidence-Based Consensus Recommendations for Colposcopy Practice for Cervical Cancer Prevention in the United States.

The American Society for Colposcopy and Cervical Pathology (ASCCP) Colposcopy Standards recommendations address the role of colposcopy and directed biopsy for cervical cancer prevention in the United States (US). The recommendations were developed by an expert working group appointed by ASCCP's Board of Directors. An extensive literature review was conducted and supplemented by a systematic review and meta-analysis of unpublished data. In addition, a survey of practicing colposcopists was conducted to assess current colposcopy practice in the US. Recommendations were approved by the working group members, and the final revisions were made based on comments received from the public. The recommendations cover terminology, risk-based colposcopy, colposcopy procedures, and colposcopy adjuncts. The ASCCP Colposcopy Standards recommendations are an important step toward raising the standard of colposcopy services delivered to women in the US. Because cervical cancer screening programs are currently undergoing important changes that may affect colposcopy performance, updates to some of the current recommendations may be necessary in the future.

ASCCP Colposcopy Standards: Role of Colposcopy, Benefits, Potential Harms, and Terminology for Colposcopic Practice.

OBJECTIVES: The American Society for Colposcopy and Cervical Pathology Colposcopy Standards address the role of and approach to colposcopy and biopsy for cervical cancer prevention in the United States. Working Group 1 was tasked with defining the role of colposcopy, describing benefits and potential harms, and developing an official terminology. METHODS: A systematic literature review was performed. A national survey of American Society for Colposcopy and Cervical Pathology members provided input on current terminology use. The 2011 International Federation for Cervical Pathology and Colposcopy terminology was used as a template and modified to fit colposcopic practice in the United States. For areas without data, expert consensus guided the recommendation. Draft recommendations were posted online for public comment and presented at an open session of the 2017 International Federation for Cervical Pathology and Colposcopy World Congress for further comment. All comments were considered for the final version. RESULTS: Colposcopy is used in the evaluation of abnormal or inconclusive cervical cancer screening tests. Colposcopy aids the identification of cervical precancers that can be treated, and it allows for conservative management of abnormalities unlikely to progress. The potential harms of colposcopy include pain, psychological distress, and adverse effects of the procedure. A comprehensive colposcopy examination should include documentation of cervix visibility, squamocolumnar junction visibility, presence of acetowhitening, presence of a lesion(s), lesion(s) visibility, size and location of lesions, vascular changes, other features of lesion(s), and colposcopic impression. Minimum criteria for reporting include squamocolumnar junction visibility, presence of acetowhitening, presence of a lesion(s), and colposcopic impression. CONCLUSIONS: A recommended terminology for use in US colposcopic practice was developed, with comprehensive and minimal criteria for reporting.

Off-label high-risk HPV DNA testing of vaginal ASC-US and LSIL cytologic abnormalities at Parkland hospital.

OBJECTIVE: To investigate the frequency and outcome of high-risk human papillomavirus (HPV) DNA testing of atypical squamous cell of unknown significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL) vaginal ThinPrep Pap tests (TPPTs). METHODS: Atypical squamous cell of unknown significance and LSIL vaginal TPPTs (from women without a cervix) from 2005 to 2008 were identified retrospectively. The frequency of HPV testing in response to these cytologic abnormalities and results of testing were determined and compared with cervical TPPTs. The frequency and results of subsequent vaginal biopsies were reviewed. RESULTS: Of the ASC-US vaginal TPPTs, 76.5% (270/353) underwent HPV testing, with 31.9% (86/270) positive. Atypical squamous cell of unknown significance cervical TPPTs underwent HPV testing less often (69.5%, 7,155/10,297) but were more commonly HPV-positive (49.7%, 3,558/7,155). Similarly, the majority of LSIL vaginal TPPTs (59.2%, 202/341) underwent HPV testing, with 66% (133/202) testing positive. This compares with only 11.0% (1,092/9,947) of cervical LSIL TPPTs undergoing HPV testing, with 73.2% (799/1,092) positive. The increased rates of HPV test performance and lower rates of HPV positivity in vaginal ASC-US and LSIL TPPTs compared with similarly abnormal cervical TPPTs were statistically significant (p <.05) by χ analysis. Histologic evaluation was more common after HPV-positive ASC-US or LSIL vaginal TPPTs compared with HPV-negative results. Most high-grade vaginal neoplasias were diagnosed subsequent to a positive HPV result. CONCLUSIONS: Human papillomavirus testing of ASC-US and LSIL vaginal TPPTs is common; lower rates of HPV positivity were found in vaginal versus cervical ASC-US and LSIL TPPTs. The majority of high-grade vaginal neoplasias were diagnosed subsequent to positive HPV testing. Evidence-based guidelines for the use of HPV testing for the management of vaginal cytologic abnormalities are needed.

Loop electrosurgical excision procedure and risk of preterm birth.

OBJECTIVE: To examine whether preterm birth is related to the loop electrosurgical excision procedure (LEEP) itself or intrinsic to the women undergoing the procedure. METHODS: Rates of preterm birth, defined as births before 37 weeks of gestation, as well as causes were analyzed in women undergoing LEEP before or after an index pregnancy. These rates were compared with the general obstetric population. RESULTS: A total of 241,701 women were delivered of singletons at Parkland Hospital between January 1992 and May 2008; of these women, 511 previously had undergone LEEP and another 842 underwent LEEP after the index pregnancy. When compared with the general obstetric population, no increased risk of preterm birth was observed for either group. This was true regardless of the reason for preterm birth. Likewise, there was no increased risk of delivery before 34 weeks or between 34 and 36 weeks of gestation. CONCLUSION: No association was observed between LEEP and preterm birth in women undergoing the procedure before or after an index pregnancy.

Comparison of human papilloma virus testing and spectroscopy combined with cervical cytology for the detection of high-grade cervical neoplasia.

OBJECTIVE: This study compared the performance of cervical cytology plus human papilloma virus testing (Pap + HPV) or cervical spectroscopy (Pap + CS) for identifying high-grade cervical neoplasia in a high-risk population of women referred for colposcopy. MATERIALS AND METHODS: Each of 113 subjects underwent spectroscopy, thin-layer cytology, HPV testing, colposcopy, biopsy when indicated, and/or endocervical curettage. Evaluable data for analysis were collected for 102 of the subjects. Sensitivity and specificity were calculated for both strategies. RESULTS: Pap + HPV and Pap + CS achieved equivalent sensitivities (95%) for high-grade lesions, with both detecting 17 of 18 histology confirmed cervical intraepithelial neoplasia (CIN) 2+ lesions. Pap + HPV had a specificity of only 27.4% compared with 65.5% for Pap + CS (p < .0001). CONCLUSIONS: Spectroscopic interrogation of the cervix is equally sensitive and 2-fold more specific than HPV testing when combined with cervical cytology for identifying high-grade cervical neoplasia.