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Research Letter |

Overuse of Papanicolaou Testing Among Older Women and Among Women Without a Cervix FREE

Deanna Kepka, PhD, MPH1,2,3; Nancy Breen, PhD3; Jessica B. King, MPH4; Vicki B. Benard, PhD5; Mona Saraiya, MD, MPH5
[+] Author Affiliations
1Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City
2College of Nursing, University of Utah, Salt Lake City
3Health Services and Economics Branch, National Cancer Institute, National Institutes of Health, Rockville, Maryland
4Cancer Surveillance Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
5Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
JAMA Intern Med. 2014;174(2):293-296. doi:10.1001/jamainternmed.2013.12607.
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Leading national organizations are increasingly using evidence-based recommendations for Papanicolaou testing. As of 2003, organizations recommended against Papanicolaou testing for women without a cervix following a hysterectomy who do not have a history of high-grade precancerous lesion or cervical cancer and for women older than 65 years with adequate prior screening and who are not at high risk.13 Few studies have investigated overuse of Papanicolaou testing among US women. We aimed to investigate overuse of Papanicolaou testing in relation to cervical cancer screening recommendations.

A cross-sectional study was conducted using data from the 2010 National Health Interview Survey (NHIS). The NHIS is a nationally representative survey of the civilian noninstitutionalized population of the United States that uses a random, stratified, multistage cluster sampling design. Analyses of public use data are considered exempt by the institutional review board (IRB) of the National Cancer Institute; IRB approval and informed consent were obtained in the original study. In 2010, the NHIS included a Cancer Control Supplement, which is the most recently available national data set that includes detailed items on cervical cancer screening and hysterectomy status, including, for the first time, questions to assess date of self-reported hysterectomy. The Cancer Control Supplement, fielded to adults 18 years and older, had a response rate of 60.8%.4 Because women younger than 30 years are less likely to have undergone a hysterectomy, our study sample includes women 30 years and older from NHIS 2010 who responded to questions about Papanicolaou test use and hysterectomy status and reported that their Papanicolaou test was for screening purposes (“part of a routine exam”) (N = 9494).

We examined sociodemographic characteristics for our study sample by hysterectomy status and age. We then investigated timing of most recent Papanicolaou test (within the past year, 1-3 years ago, >3 years ago) by sociodemographic characteristics and by hysterectomy status. National estimates of Papanicolaou testing overuse were calculated using the population weights from the 2010 NHIS. Women who reported a history of cervical cancer, an abnormal Papanicolaou test result within the past 3 years, or whose last Papanicolaou test was not part of a routine test were excluded from the results used to generate the national estimates. SAS-callable SUDAAN, version 9.2, was used in all analyses to account for the stratification and clustering of data within the complex survey design of the NHIS.

Among women reporting a hysterectomy, 34.1% (95% CI, 31.7%-36.6%) reported a Papanicolau test in the past year (Table 1). A total of 64.8% (95% CI, 62.2%-67.3%) of women reporting a hysterectomy also reported a recent Papanicolaou test since their hysterectomy, and among women 65 years and older without a hysterectomy, 58.4% (95% CI, 55.3%-61.4%) reported receipt of a Papanicolaou test in the past 3 years (Table 2), together representing approximately 14 million women.

Table Graphic Jump LocationTable 1.  Characteristics of Women by Hysterectomy Status and by Age, National Health Interview Survey (NHIS) (2010)a
Table Graphic Jump LocationTable 2.  Receipt of a Papanicolaou Test Among Women 30 Years and Older by Hysterectomy Status and Sociodemographic Characteristics, National Health Interview Survey (NHIS) (2010)a

For more than a decade, the US Preventive Services Task Force (USPSTF) has recommended that women discontinue Papanicolaou testing if they have received a total hysterectomy and have no history of cervical cancer or if they are older than 65 years and have ongoing and recent normal Papanicolaou test results.5 Nevertheless, in 2010, nearly two-thirds of women reported a Papanicolaou test since their hysterectomy and approximately one-half of women older than 65 years reported a Papanicolaou test in the past 3 years. With the implementation of the Affordable Care Act, the use of electronic medical records, health care provider reminder systems, decision support, and new strategies to improve quality of care may improve guideline-consistent practices among clinicians.6

Limitations of this study are the use of self-reported data to obtain information on Papanicolaou testing and the lack of detail on type of hysterectomy received and on whether older women were adequately screened prior to stopping use of the test.

Misuse of Papanicolaou testing continues despite USPSTF recommendations, and health care resources could be spent better elsewhere. Targeted efforts are needed to reduce unnecessary testing among older women and women without a cervix in compliance with clinical recommendations for cervical cancer prevention.

Corresponding Author: Deanna Kepka, PhD, MPH, Huntsman Cancer Institute, College of Nursing, University of Utah, 2000 Circle of Hope, Room 4144, Salt Lake City, Utah 84112 (deanna.kepka@hci.utah.edu).

Published Online: November 25, 2013. doi:10.1001/jamainternmed.2013.12607.

Author Contributions: Dr Kepka had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kepka, Breen, Benard, Saraiya.

Acquisition of data: Breen.

Analysis and interpretation of data: All authors.

Drafting of the manuscript: Kepka, Breen, Benard, Saraiya.

Critical revision of the manuscript for important intellectual content: Kepka, Breen, King, Saraiya.

Statistical analysis: Kepka, Breen, King

Administrative, technical, or material support: Saraiya.

Study supervision: Kepka.

Conflict of Interest Disclosures: None reported.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Institutes of Health or the Centers for Disease Control and Prevention.

Additional Contributions: Helen I. Meissner, PhD, at the Office of Disease Prevention, Tobacco Regulatory Science Program, National Institutes of Health; and Katherine B. Roland, MPH, at the Cancer Surveillance Branch, Centers for Disease Control and Prevention, contributed to the design, data interpretation, and manuscript preparation of this investigation. Drs Meissner and Roland were not compensated for their contributions to this study.

US Preventive Services Task Force. Screening for Cervical Cancer: Recommendations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality; 2003.
Saslow  D, Runowicz  CD, Solomon  D,  et al; American Cancer Society.  American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002;52(6):342-362.
PubMed   |  Link to Article
ACOG Committee on Practice Bulletins.  ACOG Practice Bulletin: clinical management guidelines for obstetrician-gynecologists. number 45, August 2003. cervical cytology screening (replaces committee opinion 152, March 1995). Obstet Gynecol. 2003;102(2):417-427.
PubMed   |  Link to Article
Roland  KB, Benard  VB, Soman  A, Breen  N, Kepka  D, Saraiya  M.  Cervical cancer screening among young adult women in the United States. Cancer Epidemiol Biomarkers Prev. 2013;22(4):580-588.
PubMed   |  Link to Article
US Preventive Services Task Force. Guide to Clinical Preventive Services.2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 1996.
US Department of Health and Human Services. Key Features of the Affordable Care Act by Year. http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html. Accessed October 18, 2013.

Figures

Tables

Table Graphic Jump LocationTable 1.  Characteristics of Women by Hysterectomy Status and by Age, National Health Interview Survey (NHIS) (2010)a
Table Graphic Jump LocationTable 2.  Receipt of a Papanicolaou Test Among Women 30 Years and Older by Hysterectomy Status and Sociodemographic Characteristics, National Health Interview Survey (NHIS) (2010)a

References

US Preventive Services Task Force. Screening for Cervical Cancer: Recommendations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality; 2003.
Saslow  D, Runowicz  CD, Solomon  D,  et al; American Cancer Society.  American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002;52(6):342-362.
PubMed   |  Link to Article
ACOG Committee on Practice Bulletins.  ACOG Practice Bulletin: clinical management guidelines for obstetrician-gynecologists. number 45, August 2003. cervical cytology screening (replaces committee opinion 152, March 1995). Obstet Gynecol. 2003;102(2):417-427.
PubMed   |  Link to Article
Roland  KB, Benard  VB, Soman  A, Breen  N, Kepka  D, Saraiya  M.  Cervical cancer screening among young adult women in the United States. Cancer Epidemiol Biomarkers Prev. 2013;22(4):580-588.
PubMed   |  Link to Article
US Preventive Services Task Force. Guide to Clinical Preventive Services.2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 1996.
US Department of Health and Human Services. Key Features of the Affordable Care Act by Year. http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html. Accessed October 18, 2013.

Correspondence

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