Physicians slow to implement HPV vaccination and cervical cancer screening guidelines

Recent breakthroughs in cervical cancer prevention have resulted in new vaccination and cervical cancer screening guidelines. Recommendations do not always translate into practice, however. Less than one third of obstetrician-gynecologists vaccinate their eligible patients against the human papilloma virus (HPV), and only half adhere to cervical cancer prevention guidelines published three years previously, according to a survey published this month in the American Journal of Preventive Medicine.

Vaccination against HPV has been recommended for women aged 11–26 years since 2006. In 2009, the American Congress of Obstetricians and Gynecologists (ACOG) issued guidelines recommending the initiation of Pap tests for 21 year-old women, decreasing the frequency of screening to biennial screening between ages 21 and 29 years, triennial screening for women aged 30 years or more with either prior normal Paps or negative concurrent HPV co-testing, and discontinuation of screening at age ≥70 years or after hysterectomy for benign indications.

The investigators found that patient and physician interactions may pose important barriers to guideline implementation. "In the current survey and others, providers stated that the largest barrier to HPV vaccination was patients and parents declining to receive the vaccine. However, studies indicate that most patients support HPV vaccination, and that a strong physician recommendation is the most important determinant of vaccine uptake in young women," says lead investigator Rebecca B. Perkins, MD, MSc, of the Boston University School of Medicine.

Investigators queried 1,000 obstetrician-gynecologists, all members of ACOG, about their screening and vaccination practices, as well as barriers that prevented physicians from following the 2009 ACOG guidelines. A total of 366 responses were analyzed.

The investigators found low rates of HPV vaccination. Although 92% of respondents offered HPV vaccination to patients, only 27% estimated that most eligible patients received vaccination. The most commonly cited barriers to HPV vaccination were parent and patient refusals. Most practitioners (96%) would recommend HPV vaccination to a hypothetical 13 year-old patient, but only 73% said they would recommend vaccination to an 11 year-old patient.

Approximately half of the respondents followed guidelines to begin cervical cancer screening at age 21, discontinue screening at age 70 or after hysterectomy, and to utilize Pap and HPV co-testing appropriately.

Most physicians continued to recommend annual Pap test screening (74% ages 21-29, 53% ages 30 and above). Although the respondents were personally comfortable with extended screening intervals, they felt that patients were uncomfortable with extended screening intervals and were concerned that patients would not come for annual exams if a Pap were not offered. Solo practitioners were less likely to follow both vaccination and screening guidelines than those in group practices.