An Exploratory Study of Primary Care Clinicians' Perspectives on 2021 New and Updated Cancer Screening Guidelines.

BACKGROUND AND OBJECTIVE: Cancer screening rates remain low in rural, racial and ethnic minority, low-income, and uninsured populations. Prior studies showed that cancer screening recommendations vary based on clinicians' factors. We conducted an exploratory study on primary care clinicians' beliefs about new or updated cancer screening guidelines according to clinician demographics. METHODS: This cross-sectional study involved administering a web-based survey in July and August of 2021 to primary care clinicians practicing in diverse ambulatory settings in the Pacific Northwest belonging to the same health system. The survey assessed clinician demographics, attitudes about the impact of cancer screening on mortality, and how clinicians stay up-to-date with guidelines. RESULTS: Of the 191 clinicians, 81 responded (42.4%), after removing 13 incomplete surveys, we analyzed 68 (35.6%). The majority agreed/strongly agreed that breast (76.1%), colorectal (95.5%), and cervical (90.9%) cancer screening, and HPV vaccination (85.1%) prevent early cancer mortality: there were no differences according to clinician gender or years in practice. Female compared to male clinicians were more likely to agree/strongly agree that tobacco smoking cessation (female: 100% vs male: 86.4%, P = .01) prevents early cancer mortality, whereas male compared to female clinicians were more likely to agree/strongly agree that lung cancer screening (male: 86.4% vs female: 57.8%, P = .04) prevents early cancer mortality. One-third (33.3%) of clinicians were unaware of the 2021 update on lung cancer screening and females were more likely than males to say they did not know about this change (females: 43.2% vs males: 13.6%, P = .02). CONCLUSIONS: This study suggests that clinicians' attitudes are not likely the primary factor affecting low cancer screening rates in some populations and that few differences exist in beliefs based on gender, and none based on years in practice.

ASCCP Committee Opinion: Adjuvant Human Papillomavirus Vaccine for Patients Undergoing Treatment for Cervical Intraepithelial Neoplasia.

OBJECTIVES: Individuals treated for cervical intraepithelial neoplasia grade 2 or worse (CIN2+) are at long-term risk of persistent or recurrent disease despite treatment. This committee opinion aims to summarize and provide evidence-based recommendations for adjuvant human papillomavirus (HPV) vaccination based on available, published literature. METHODS: A task force from the ASCCP Practice Committee reviewed current Centers for Disease Control and Prevention (CDC) guidelines and previously published literature about the role of adjuvant HPV vaccination in previously unvaccinated individuals undergoing treatment for CIN2+ and other HPV-related diseases. RESULTS: Current CDC guidelines recommend routine or catch-up HPV vaccination for individuals aged 9 to 26 years, and shared decision making regarding vaccination for individuals aged 27 to 45 years. Multiple published studies suggest a possible benefit for adjuvant HPV vaccination in previously unvaccinated individuals undergoing treatment for CIN2+. CONCLUSIONS: The American Society for Colposcopy and Cervical Pathology recommends adherence to current CDC recommendations for vaccination of individuals aged 9 to 26 years and consideration of the possible benefit of adjuvant HPV vaccination during shared decision making for previously unvaccinated individuals aged 27 to 45 years who are undergoing treatment for CIN2+.

Risk-based guidelines: Redefining management of abnormal cervical cancer screening results.

In making the 2019 guidelines for risk-based management of patients with abnormal cervical cancer screening tests and cancer precursors, the guidelines committee shifted from results-based to risk-based management recommendations, based on the patient's immediate and 5-year risks of grade 3 or higher cervical intraepithelial neoplasia (CIN 3+). The risk is determined by current and prior screening results (human papillomavirus infection, cytology testing) and the clinical history including age. An immediate 4% or higher risk of CIN 3+ was established as the dividing line between higher and lower risks, and the corresponding management recommendations. This article reviews the changes and their evidence base and discusses clinical implications of the revised guidelines.

Human Papillomavirus Immunization in Rural Primary Care.

INTRODUCTION: Despite the safety and efficacy of the human papillomavirus vaccine, thousands are impacted by human papillomavirus and its related cancers. Rural regions have disproportionately low rates of human papillomavirus vaccination. Primary care clinics play an important role in delivering the human papillomavirus vaccine. A positive deviance approach is used to identify workflows, organizational factors, and communication strategies in rural clinics with higher human papillomavirus vaccine up-to-date rates. Positive deviance is a process by which exceptional behaviors and strategies are identified to understand factors that enable success. METHODS: Rural primary care clinics were rank ordered by human papillomavirus vaccine up-to-date rates using 2018 Oregon Immunization Program data, then recruited via purposive sampling of clinics in the top and bottom quartiles. Two study team members conducted previsit interviews, intake surveys, and 2-day observation visits with 12 clinics and prepared detailed field notes. Data were collected October-December 2018 and analyzed using a thematic approach January-April 2019. RESULTS: Four themes distinguished rural clinics with higher human papillomavirus vaccine up-to-date rates from those with lower rates. First, they implemented standardized workflows to identify patients due for the vaccine and had vaccine administration protocols. Second, they designated and supported a vaccine champion. Third, clinical staff in higher performing sites were comfortable providing immunizations regardless of visit type. Finally, they used clear, persuasive language to recommend or educate parents and patients about the vaccine's importance. CONCLUSIONS: Positive deviance identified characteristics associated with higher human papillomavirus vaccine up-to-date rates in rural primary care clinics. These findings provide guidance for rural clinics to inform human papillomavirus vaccination quality improvement interventions.

2019 ASCCP Risk-Based Management Consensus Guidelines: Methods for Risk Estimation, Recommended Management, and Validation.

OBJECTIVE: To manage cervical screening abnormalities, the 2019 ASCCP management consensus guidelines will recommend clinical action on the basis of risk of cervical precancer and cancer. This article details the methods used to estimate risk, to determine the risk-based management, and to validate that the risk-based recommendations are of general use in different settings. METHODS: Based on 1.5 million patients undergoing triennial cervical screening by cotesting at the Kaiser Permanente Northern California from 2003 to 2017, we estimated risk profiles for different clinical scenarios and combinations of past and current human papillomavirus and cytology test results. We validated the recommended management by comparing with the estimated risks in several external data sources. RESULTS: Risk and management tables are presented separately by Egemen et al. and Demarco et al. Risk-based management derived from the Kaiser Permanente Northern California largely agreed with the management implied from the estimated risks of the other data sources. CONCLUSIONS: The new risk-based guidelines present management of abnormal cervical screening results. By describing the steps used to develop these guidelines, the methods presented in this article can provide a basis for future extensions of the risk-based guidelines.

Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines.

The 2019 American Society for Colposcopy and Cervical Pathology Risk-Based Management Consensus Guidelines for the management of cervical cancer screening abnormalities recommend 1 of 6 clinical actions (treatment, optional treatment or colposcopy/biopsy, colposcopy/biopsy, 1-year surveillance, 3-year surveillance, 5-year return to regular screening) based on the risk of cervical intraepithelial neoplasia grade 3, adenocarcinoma in situ, or cancer (CIN 3+) for the many different combinations of current and recent past screening results. This article supports the main guidelines presentation by presenting and explaining the risk estimates that supported the guidelines. METHODS: From 2003 to 2017 at Kaiser Permanente Northern California (KPNC), 1.5 million individuals aged 25 to 65 years were screened with human papillomavirus (HPV) and cytology cotesting scheduled every 3 years. We estimated immediate and 5-year risks of CIN 3+ for combinations of current test results paired with history of screening test and colposcopy/biopsy results. RESULTS: Risk tables are presented for different clinical scenarios. Examples of important results are highlighted; for example, the risk posed by most current abnormalities is greatly reduced if the prior screening round was HPV-negative. The immediate and 5-year risks of CIN 3+ used to decide clinical management are shown. CONCLUSIONS: The new risk-based guidelines present recommendations for the management of abnormal screening test and histology results; the key risk estimates supporting guidelines are presented in this article. Comprehensive risk estimates are freely available online at https://CervixCa.nlm.nih.gov/RiskTables.

Key Collaborative Factors When Medicaid Accountable Care Organizations Work With Primary Care Clinics to Improve Colorectal Cancer Screening: Relationships, Data, and Quality Improvement Infrastructure.

PURPOSE: Accountable Care Organizations (ACOs) are implementing interventions to achieve triple-aim objectives of improved quality and experience of care while maintaining costs. Partnering across organizational boundaries is perceived as critical to ACO success. METHODS: We conducted a comparative case study of 14 Medicaid ACOs in Oregon and their contracted primary care clinics using public performance data, key informant interviews, and consultation field notes. We focused on how ACOs work with clinics to improve colorectal cancer (CRC) screening - one incentivized performance metric. RESULTS: ACOs implemented a broad spectrum of multi-component interventions designed to increase CRC screening. The most common interventions focused on reducing structural barriers (n = 12 ACOs), delivering provider assessment and feedback (n = 11), and providing patient reminders (n = 7). ACOs developed their processes and infrastructure for working with clinics over time. Facilitators of successful collaboration included a history of and commitment to collaboration (partnership); the ability to provide accurate data to prioritize action and monitor improvement (performance data), and supporting clinics' reflective learning through facilitation, learning collaboratives; and support of ACO as well as clinic-based staffing (quality improvement infrastructure). Two unintended consequences of ACO-clinic partnership emerged: potential exclusion of smaller clinics and metric focus and fatigue. CONCLUSION: Our findings identified partnership, performance data, and quality improvement infrastructure as critical dimensions when Medicaid ACOs work with primary care to improve CRC screening. Findings may extend to other metric targets.