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

Cervical cancer diagnoses and deaths in the United States (US) plummeted following the initiation of Papanicolaou (Pap) testing in the 1970s. This was due to a simple approach of annual cytology screening followed, when indicated, by a diagnostic evaluation to detect precancers or early cancers with subsequent treatment if needed (Braly et al., 1996). This approach was very successful because screening was frequent, and abnormalities were usually detected prior to cancer development. However, this approach also led to overdiagnosis and treatment of transient and clinically insignificant lesions with potential personal and health care costs that were not offset by improvements in cancer prevention (Kulasingam et al., 2006).

With an increased understanding of disease etiology and natural history, evidence-based guidelines for cervical cancer screening and management of abnormal tests have been developed to better address the potential harms of screening, diagnosis, and treatment. Starting with the 2012 guidelines, recommendations became more nuanced by varying testing by patient age, time intervals between tests, and a cascade of subsequent surveillance steps based on more individualized estimations of risk for developing precancer (cervical intraepithelial neoplasia level 3 [CIN3]) or worse (Massad et al., 2013; Moyer and Force, 2012; Saslow et al., 2012). Test options now include Pap (cytology) testing, human papillomavirus (HPV) testing, both in combination (co-testing), or HPV testing in response to pre-specified Pap results (reflex testing), with test intervals one to five years based on a combination of risk factors, including patient age and current and previous test results.

Although the 2012 and 2019 cervical cancer management guidelines are evidence-based (Fontham et al., 2020; Perkins et al., 2020), they were formulated primarily using data from a single integrated healthcare system with insured patients covered mostly by employer-based plans. Due to the limited generalizability of these data, it is not clear if these guidelines are applicable to different populations, including those with less access to care or with more fragmented care. This may not affect the absolute risk for a patient who is optimally managed, but it might affect cancer risk due to sub-optimal management, as demonstrated elsewhere (Saraiya et al., 2021). Additionally, there are no empirical data establishing optimal time intervals between abnormal results and diagnostic evaluations. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) is the only US group issuing quality metrics on cervical cancer diagnostic evaluation. NBCCEDP requires that ≥90% of women with abnormal screening tests have complete diagnostic follow-up, with at least 75% completed within 90 days (Yancy et al., 2014). It is generally accepted that patients with higher grade screening abnormalities, including HPV 16- or 18-positivity, should be prioritized for earlier colposcopy than lower grade abnormalities if scheduling constraints are a concern.

To-date, most research has evaluated how patient characteristics, including age, screening abnormality, insurance status, and race, are associated with subsequent colposcopy (Perkins et al., 2021; Tosteson et al., 2016). Patient-level barriers to diagnostic evaluation have also been well-characterized (Alimena et al., 2021a; Carrillo et al., 2021; Liang et al., 2022). However, healthcare system characteristics (e.g., structure, having centralized population health teams, screening and follow-up policies, incentives for cancer screening) and provider characteristics (e.g., type, specialty) may further explain some of the differences observed in timeliness and completion of colposcopy (Zapka et al., 2014), but these relationships are not well elucidated. An improved understanding of the variation in these measures within and across healthcare settings and among providers within these settings (i.e., at levels beyond the patient) may provide opportunities to more closely examine system- and provider-level characteristics that may mitigate patient-level barriers to subsequent colposcopy.

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