Public cervical cancer screening recommendations from US cancer centers: Assessing adherence to national guidelines

Introduction

Widespread adoption of cervical cancer screening (CCS) in the US has been associated with a 54% reduction in invasive cervical cancer incidence from 1973 to 2007 ¹ and lower cervical squamous carcinoma mortality. ² CCS also has the inherent risks of any screening modality, including false-positives and false-negatives, anxiety, and unnecessary follow-up tests and treatments.^2–4 Because longer screening intervals identify clinically important disease with equal efficacy, newer guidelines have decreased screening frequency, to optimize the benefit/risk balance. In 2018, the US Preventive Service Task Force (USPSTF) recommended women undergo cervical cytology (Papanicolaou testing) every three years from age 21 to 30, with the option to switch to primary human papillomavirus (HPV) testing or cytology/HPV co-testing every five years from age 30 to 65, after which screening is not recommended with normal prior testing and average risk. ² The American Cancer Society (ACS) updated CCS guidelines in 2020, recommending primary HPV testing every five years from age 25 to 65; if unavailable, then cytology/HPV co-testing every five years or cytology every three years. ³ Many cancer center websites make public recommendations on cancer screening. We previously reported that these recommendations often deviate from national guidelines.^5,6 Here, we examined US cancer center website alignment with national CCS guidelines.

Methods

We reviewed CCS recommendations provided on public websites by 1024 cancer centers accredited by the US Commission on Cancer during January–August 2022. We recorded the recommended frequency and type of CCS and any screening risks mentioned, comparing against national USPSTF and ACS guidelines. We compared recommendations between National Cancer Institute (NCI) and non-NCI-designated centers using a two-tailed Fisher's test with α<0.05. This study was deemed exempt from review by the Weill Cornell Medical Institutional Review Board.

Results

Of 1024 US cancer centers, 60% (610) provided CCS recommendations. Approximately one quarter of centers (23%, 141) specifically referenced USPSTF and/or ACS guidelines; one-third of centers (35%, 212) referenced any national guidelines, further including the American College of Obstetricians and Gynecologists (ACOG), NCI, National Institute of Health (NIH), and Centers for Disease Control and Prevention (CDC). Of 565 centers that specified a starting age for screening, 88% (496) recommended age 21, and 8% (48) recommended age 25 (Figure 1). Of 470 centers specifying an age to stop, 94% (440) recommended age 65.

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Figure 1.

US cancer center recommendations regarding ages to begin (n = 565) and stop (n = 470) cervical cancer screening.

Of the 565 US cancer centers that specified a starting age, 82% (466) recommend standalone cervical cytology for ages 21–25. For ages 25–35, most of these centers (75%, 423) recommend cytology and only 6% (32) recommend standalone HPV testing over other screening options. For ages 35–65, 20% (114) recommend screening with cytology, 6% (36) recommend HPV testing, 23% (128) recommend co-testing, 47% (267) recommend multiple options, and 4% (20) recommend screening in general but do not specify a specific screening modality.

Of 508 centers specifying the frequency of standalone cervical cytology, most (83%, 419) recommended a screening interval of three years: 14% (73) recommended shorter and 3% (16) recommended longer intervals (Figure 2). NCI centers trended towards recommending a three-year interval more frequently than non-NCI centers (96% and 82% respectively, p = 0.10). Screening risks were mentioned by 20% (124/610) of centers, most commonly noting false-positives (69%, 86/124).

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Figure 2.

US cervical cancer center screening recommendations (n = 508) regarding standalone cervical cytology frequency.

Discussion

Most US cancer centers’ public recommendations for CCS align with national guidelines for starting and stopping ages. Few centers mention potential risks of CCS (20%). A sizeable fraction of cancer centers (14%; 73/508) recommend cervical cytology more frequently than the three-year interval recommended by the ACS/USPSTF. US cancer center websites providing recommendations that conflict with national guidelines do not justify their rationale. The updated 2020 ACS guidelines reflect a shift in the US towards primary (standalone) HPV testing every five years as the preferred screening modality and towards the later starting age of 25, given studies demonstrating its efficiency and accuracy.^2,7,8 However, only around 6% of centers recommend primary HPV testing over other screening options from age 25 to 65, suggesting a slower adoption of the evolving CCS paradigm. The delayed shift toward primary HPV testing may reflect the longstanding reputation and pre-existing infrastructural support of cervical cytology as the prototypical CCS modality, as well as the significant financial and logistical investment needed to establish a newer screening method on a large scale. ⁹ Further, with several national guidelines currently listing multiple screening options, the superiority of HPV testing perhaps requires clearer emphasis for both physicians and patients.

A limitation to this analysis is that cancer center website recommendations may not reflect physicians’ practices at these centers. Nevertheless, these public recommendations are a source of guidance for physicians and the public. Recommendations for more intensive screening than national guidelines recommend may lead to unnecessary procedures with concomitant anxiety, and increased costs to individuals and the healthcare system. ⁴ However, as screening access and cervical cancer outcomes demonstrate racial disparities, adherence to any screening guidelines may be beneficial in underserved groups.

Previous research has shown that cancer centers’ public recommendations have varying levels of alignment in screening age ranges and frequency with national guidelines across different types of cancers. Similar to CCS, most cancer centers align with national society guidelines for prostate cancer screening (74%), although 26% recommend universal prostate-specific antigen screening in men instead of the shared decision making recommended by national guidelines. ⁵ In contrast, few centers align with national society guidelines for breast cancer screening (19%), with most centers recommending that women begin screening mammography at an earlier age than 2016 USPSTF recommendations. ⁶

Fewer than half of US cancer centers mention potential risks of cancer screening (38% prostate, 48% lung, 20% cervical).^5,10 Drivers of recommendation differences among cancers are unclear, but our findings highlight the importance of education on screening benefits and risks for physicians and patients to enable shared decision making based on available evidence-based guidelines.