Curbside Consultation

Physicians Who Do Not Follow Screening Guidelines

Am Fam Physician. 2006 Jan 1;73(1):161-162.

Case Scenario

A patient recently moved to my city from New York and told me that her previous physician gave her a Papanicolaou (Pap) smear twice per year. She had never had an abnormal result. She was astonished when I told her that Pap smears traditionally are performed yearly, and every three years if the results are consistently normal. Since then, I have discovered that it is more common than I realized for physicians to perform Pap smears twice a year. A colleague of mine said that one of her medical students was working with a preceptor who required patients taking hormonal contraceptives to receive Pap smears biannually. Should my colleague allow her medical student to learn from a doctor whose practice is so discrepant with accepted guidelines? Should my colleague confront this community preceptor? Why are some physicians deviating so drastically from accepted guidelines?

Commentary

This scenario asks two basic questions: (1) Why would a physician perform screening tests more often than recommended? and (2) What should a physician do if he or she has a colleague who does not follow current practice recommendations? The U.S. Preventive Services Task Force (USPSTF) screening guidelines are conservative and are considered to be the standard for prevention.1 It is well known that many patients are not tested or counseled as often as guidelines recommend. For example, in 2003 only 24 percent of older adults had a fecal occult blood test within the previous year, and only 39 percent had a lower gastrointestinal endoscopy within the previous five years.2 What is less widely appreciated, however, is that patients may also be tested or counseled more frequently than recommended. Possible reasons include:

  • Other guidelines differ from the USPSTF recommendations.

  • Some physicians are unfamiliar with current USPSTF guidelines.

  • Patients demand more frequent screening (e.g., mammography).

  • Many of the physician’s patients are symptomatic or at high risk.

  • The physician is concerned about the effectiveness and sensitivity of tests or about false negatives.

  • The USPSTF sometimes cites insufficient evidence to offer recommendations for screening, and some physicians perform tests more often than generally accepted in practice.

  • The physician, a medical organization, or patient benefits economically from more frequent screening.

The main reason for screening patients is to reduce morbidity and mortality associated with certain conditions. However, the morbidity and mortality related to cervical cancer is not as high as it used to be. In 2004, 10,500 American women were diagnosed with cervical cancer, and 3,900 women died from the disease.3 Most women who were diagnosed had never had a Pap smear or had not had a Pap smear within the previous five years. An average family physician with 1,200 female patients will have one patient die of cervical cancer approximately every 30 years.4,5

Pap smears are only moderately expensive; therefore, the remuneration for the practice is not a strong motivator for more frequent use. However, the estimated cost per year of life saved by screening women older than 30 years with Pap and reflex human papillomavirus (HPV) DNA tests is more than $95,000.6

Recommendations have changed based on improved understanding of the natural history of cervical cancer and the use of the newer liquid-based cytology and HPV DNA testing. The USPSTF, the American Academy of Family Physicians (AAFP), the American Cancer Society, and the American College of Obstetricians and Gynecologists recommend Pap smears every three years for most women older than 30 years, and the USPSTF and AAFP recommend this interval for all low-risk sexually active women younger than 65 years (Table 1).710

TABLE 1

Papanicolaou (Pap) Smear Screening Recommendations*

Organization Frequency and preferred testing method Age to stop screening (years)

USPSTF, AAFP

Every three years; no recommendation on method

65

ACS

Annually using traditional cytology or every two years using liquid-based cytology until 30 years of age

70

After 30 years of age: every two to three years using traditional or liquid-based cytology alone or every three years if additional HPV DNA testing is used

ACOG

Annually until 30 years of age using traditional or liquid-based cytology

No recommendation

After 30 years of age: every two to three years using traditional or liquid-based cytology alone or every three years if additional HPV DNA testing is used


USPSTF = U.S. Preventive Services Task Force; AAFP = American Academy of Family Physicians; ACS = American Cancer Society; HPV = human papillomavirus, ACOG = American College of Obstetricians and Gynecologists.

*—Recommendations will differ for high-risk patients. All organizations listed recommend that women begin receiving Pap smears three years after becoming sexually active or by 21 years of age.

Information from references 7 through 10.

TABLE 1   Papanicolaou (Pap) Smear Screening Recommendations*

View Table

TABLE 1

Papanicolaou (Pap) Smear Screening Recommendations*

Organization Frequency and preferred testing method Age to stop screening (years)

USPSTF, AAFP

Every three years; no recommendation on method

65

ACS

Annually using traditional cytology or every two years using liquid-based cytology until 30 years of age

70

After 30 years of age: every two to three years using traditional or liquid-based cytology alone or every three years if additional HPV DNA testing is used

ACOG

Annually until 30 years of age using traditional or liquid-based cytology

No recommendation

After 30 years of age: every two to three years using traditional or liquid-based cytology alone or every three years if additional HPV DNA testing is used


USPSTF = U.S. Preventive Services Task Force; AAFP = American Academy of Family Physicians; ACS = American Cancer Society; HPV = human papillomavirus, ACOG = American College of Obstetricians and Gynecologists.

*—Recommendations will differ for high-risk patients. All organizations listed recommend that women begin receiving Pap smears three years after becoming sexually active or by 21 years of age.

Information from references 7 through 10.

What should physicians do if they encounter a physician who screens low-risk, asymptomatic women with Pap smears more often than recommended? The practice will probably be flagged by a fiscal intermediary if biannual Pap examinations are outside the standard of care. However, many physicians may be recommending annual Pap smears because they are not knowledgeable about current recommendations.

Should the colleague in the scenario confront the preceptor? It depends on the relationship between the two physicians. Ultimately, it will take widespread patient and physician education regarding the use of guidelines to stop this practice. This would be a great topic for a national women’s education program. It is also an appropriate area of inquiry for a practice-based research network: namely, what are the current practice patterns of Pap smear utilization (and other preventive services), and what interventions will change them?

REFERENCES

1. U.S. Preventative Services Task Force. List of screening guidelines. Accessed online September 28, 2005, at: http://www.ahrq.gov/clinic/uspstf/uspstopics.htm#Ctopics.

2. Centers for Disease Control and Prevention (CDC). Colorectal cancer test use among persons aged > 50 years—United States, 2001. MMWR Morb Mortal Wkly Rep. 2003;52:193–6.

3. Cancer facts and figures 2004. Atlanta: American Cancer Society, 2004. Accessed online September 28, 2005, at: http://www.cancer.org/downloads/STT/CAFF_finalPWSecured.pdf.

4. American Cancer Society. Surveillance Research. Estimated new cancer cases and deaths by sex for all sites, U.S., 2005. Accessed online October 12, 2005, at: http://www.cancer.org/downloads/stt/Estimated_New_Cancer_Cases_and_Deaths_by_Sex_for_All_Sites,_US,_2005.pdf.

5. The Central Intelligence Agency. United States. In: the world factbook 2005. Accessed online October 12, 2005, at: http://www.odci.gov/cia/publications/factbook/geos/us.html.

6. Goldie SJ, Kim JJ, Wright TC. Cost-effectiveness of human papillomavirus DNA testing for cervical cancer screening in women aged 30 years or more. Obstet Gynecol. 2004;103:619–31.

7. U.S. Preventive Services Task Force. Screening for cervical cancer. Summary of recommendations. Accessed online September 28, 2005, at: http://www.ahrq.gov/clinic/uspstf/uspscerv.htm.

8. American Academy of Family Physicians. Recommendations for clinical preventive services. Accessed online September 28, 2005, at: http://www.aafp.org/patient-care/clinical-recommendations/cps.html.

9. The American Cancer Society. Detailed guide: cervical cancer. Can cervical cancer be prevented? Accessed online September 28, 2005, at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_Can_cervical_cancer_be_prevented_8.asp.

10. The American College of Obstetricians and Gynecologists. Cervical cancer screening: testing can start later and occur less often under new ACOG recommendations [press release]. July 31, 2003. Accessed online September 28, 2005, at: http://www.acog.org/from_home/publications/press_releases/nr07-31-03-1.cfm.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. The commentary in this issue was written by Jonathan Rodnick, M.D., San Francisco, California.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.


Copyright © 2006 by the American Academy of Family Physicians.
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