Clinical follow-up practices after cervical cancer screening by co-testing: A population-based study of adherence to U.S. guideline recommendations

Abstract

Failure to follow-up women after abnormal cervical screening could lead to cervical cancers, yet little is known about adherence to recommended follow-up after abnormal co-testing [cytology and high-risk human papillomavirus (hrHPV) testing]. We documented clinical management following cervical screening by co-testing in a diverse population-based setting. A statewide surveillance program for cervical screening, diagnosis, and treatment was used to investigate all cytology, hrHPV and biopsy reports in the state of New Mexico from January 2015 through August 2019. Guideline-adherent follow-up after co-testing required 1) biopsy within 6 months for low-grade cytology if positive for hrHPV, for high-grade cytology irrespective of hrHPV, and for HPV 16/18 positive results irrespective of cytology and; 2) repeat co-testing within 18 months if cytology was negative and hrHPV test was positive (excluding types 16/18). Screening co-tests (2015-2017) for 164,522 women were analyzed using descriptive statistics, Kaplan Meier curves, and pairwise comparisons between groups. Guideline adherence was highest when both cytology and hrHPV tests were abnormal, ranging from 61.7% to 80.3%. Guideline-adherent follow-up was lower for discordant results. Women with high-grade cytology were less likely to receive a timely biopsy when hrHPV-testing was negative (48.1%) versus positive (83.3%) (p < 0.001). Only 47.9% of women received biopsies following detection of HPV16/18 with normal cytology, and 30.8% received no follow-up within 18-months. Among women with hrHPV-positive normal cytology without evidence of HPV 16/18 infection, 51% received no follow-up within 18 months. Provider education and creation of robust recall systems may help ensure appropriate follow-up of abnormal screening results.

Keywords: Cervical câncer screening; Clinical practice; Co-testing; Cotesting follow-up.

Fig. 1.. Time to biopsy for different screening co-test results.

Figure describes time to biopsy estimated by Kaplan Meier method for a) NILM cytology co-test b) low-grade (LG) cytology co-test c) high-grade (HG) cytology co-test, by HPV status (HPV16/18 positive, HPV16/18 negative other hrHPV positive or typing unknown, or HPV negative) following the first co-test per woman, for women attending routine screening in 2015–2017 aged 30–64 years. Total number of at-risk women included in Figure is 8478. NILM: Negative for Intraepithelial Lesion and Malignancy, HPV: Human Papillomavirus. Low-grade (LG) includes both atypical squamous cells of unknown significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL). High-grade (HG) includes atypical cells of unknown significance favor high-grade (ASC–H), atypical glandular cells (AGC) and high-grade squamous intraepithelial lesions (HSIL) and worse (HSIL+). Other high-risk (hr) HPV positive includes no genotyping and partial genotyping groups.