Patient Perspectives on Primary HPV Testing for Routine Cervical Cancer Screening

INTRODUCTION

Driven by advances in screening technologies and an increased understanding of the natural history of cervical cancer, routine cervical cancer screening guidelines have changed from annual screening with cytology to less frequent screening using cytology alone triennially or in conjunction with high-risk human papillomavirus (HPV) testing every 5 years.¹ In August 2018, the United States Preventive Services Task Force (USPSTF) released updated screening recommendations, which added the option for women aged 30–65 to be screened every 5 years with primary HPV testing alone² and further solidified interim guidance on primary HPV testing released in 2015_.³ Previous studies have shown patient concerns regarding HPV testing prior to the new guidelines.^{4, 5} We assessed women’s perspectives on primary HPV testing following the release of 2018 USPSTF recommendations.

METHODS

From September 2018 to January 2019, we conducted a mixed-methods study to identify multilevel factors shaping cervical cancer screening practices across an academic healthcare system; the analysis presented here examines patients’ perspectives on primary HPV testing and screening guidelines. Study-eligible women (aged ≥ 21, not considered high risk, and received routine Pap testing between April and August 2018) were identified via electronic medical records and randomly invited in batches to participate. Although primary HPV testing is not currently recommended for women outside the ages of 30–65, we included women in younger and older age groups to assess future acceptance (in women aged 21–29) and perspectives among women who continue to screen beyond age 65. Of the 186 women invited, 46 enrolled and completed a structured questionnaire adapted from previous surveys^{4, 5} and semi-structured interview (in-person or via telephone). Quantitative data were analyzed descriptively and qualitative data were analyzed thematically using the constant comparative method.⁶ All procedures were approved by the Institutional Review Board.

RESULTS

The 46 women interviewed ranged in age from 21 to 76 with 67% identifying as White and 24% as Black. Most respondents (70%) thought women their age should have a Pap smear at minimum annually. However, if recommended by their provider, the majority stated they would be screened triennially with Pap smear alone (76%) or every 5 years with Pap and HPV test (57%). A third (35%) said they would be screened every 5 years using HPV testing alone in a future visit, whereas only 11% would prefer it among all recommended screening options (Table 1).

Table 1 Participant Characteristics

In interviews, women described influential factors shaping their screening practices and perspectives on screening guidelines including uncertainty or discomfort with HPV testing, limited awareness or distrust of extended screening intervals, and provider recommendation and communication (Table 2). Concerns over the evidence supporting guidelines and HPV testing and comfort with cytology further shaped women’s views and practices in complex ways. Several women indicated the need for additional information on the effectiveness of HPV testing and individualized recommendations from their provider as potential factors that would increase their comfort with adopting primary HPV testing.

Table 2 Representative Quotes Across Qualitative Themes

DISCUSSION

This study provides insights into women’s perspectives on primary HPV testing following 2018 USPSTF guidelines, highlighting the persistent limited awareness of HPV testing (with or without cytology) as an evidence-based option for routine cervical cancer screening.^{4, 5} Many women also expressed continued resistance to extended interval screening, driven in part from lack of knowledge of different screening options, the evidence behind screening recommendations, and the potential harms of overscreening. While our study is limited because it was conducted at a single healthcare system, it provides timely insight into perspectives on recent guidelines.

In summary, our findings suggest that to increase adoption of primary HPV testing for routine screening, development and implementation of patient-directed communication strategies that ensure awareness regarding effectiveness and evidence supporting HPV testing are needed. Furthermore, given the availability of multiple recommended screening strategies for women aged 30–65, incorporation of informed screening preferences into patient-provider discussions might further help to support patient-centered care and adoption of evidence-based practices.