Discussion and Conclusions
Our study demonstrates that 17.4% of referrals for colposcopy to a tertiary academic center were discordant with the 2012 ASCCP guidelines. Patients referred outside of the guidelines were more likely to be women age 21 to 24 or 30 to 64 with low grade lesions (e.g. ASCUS, LSIL, NILM). Based on our results patients age 25-29 are rarely incorrectly referred. This likely reflects the simpler guidelines in the age 25-29 group as HPV only comes into account when it is reflexed for ASCUS and LSIL lesions are referred regardless of HPV status. A patient receiving a screening test at a family medicine or internal medicine clinic is also more likely to be incorrectly referred. Furthermore, this study indicates that in our region the health departments trend towards following ASCCP recommendations most closely. African American patients comprised the majority of our patient population, but while not statistically significant trended towards likelihood of incorrect referrals when compared White or Hispanic patients. This finding may indicate underlying bias.
Multiple patients were also referred for cervical cytology collected on vaginal cuffs despite hysterectomies performed for benign reasons. In some cases, referrals outside of evidence-based guidelines led to non-indicated biopsies and unnecessary procedures. Our study also indicates that over a two year period there does not seem to be a change in referral accuracy.
Cervical cancer screening and appropriate referral for biopsy and or excision has greatly decreased the mortality from cervical cancer in the United States, (9) but the effectiveness of the ASCCP guidelines depends on provider knowledge and adherence. The 2012 guidelines extended adolescent guidelines to age 24 with the understanding that HPV infection is common in this age group and dysplastic lesions are most likely to resolve without intervention (4). Furthermore, infection with HPV is known to be necessary for the development of cervical cancer, and the 2012 guidelines specifically address how to approach discordant cytology screening results (e.g. HPV-/LSIL) (10,11). Additionally, primary vaginal cancer is very rare, and cytology collection is not recommended on vaginal cuffs for women who never had CIN 2 or higher when hysterectomy is performed for benign indications (12). Similar to prior studies that indicate lack of knowledge and adherence to screening intervals recommended by the ASCCP (7,8). Our study suggests that there is also confusion regarding interpretation of cytology results specifically in women 21 to 24 and for discordant cytology and HPV results (e.g. HPV-/ LSIL). A survey administered in 2015 revealed that approximately 14% of advanced nurse practitioners were routinely collecting cytology on vaginal cuffs and 8% were unsure if patients who had a hysterectomy for benign reasons should have screening cytology (8). As shown in our study, patients with prior hysterectomies are not only incorrectly screened, but also being referred for un-indicated procedures
Future research in this field could include review of all cytology tests to identity patients that should have been referred for colposcopy, but were instead returned to screening. Future research could also include a survey to identify whether providers were aware of colposcopy guideline changes, the availability of a mobile application for interpretation and guidelines as well as a knowledge questionnaire of current guidelines. We could also expand data collection to include referrals from 2013 -current and again evaluate if there has been any change over time in referral concordance. Furthermore, guideline changes in cervical cancer screening have been published in 2020, education and vigilance to evidence-based algorithms must continue to be an important focus.
To our knowledge no other study has evaluated the adherence to referral guidelines for biopsy or excision. The strengths of this study include the large number of referrals reviewed and as shown in Table 1, the varied clinical subspecialties that referred to a large academic center for colposcopy and LEEP. This study is limited in that it does not identify patients with pathology that should have warranted a referral but were returned to routine screening.
Our study indicates that overall the majority of referrals to a tertiary center were concordant with published guidelines, however there is room for improvement, specifically for cytology results in the patients age < 25. Our results also indicate that some providers, especially in fields outside of gynecology may not take into account the necessity of HPV for the development of cervical cancer when referring patients for colposcopy, or the lack of need for screening in the context of hysterectomy performed for benign reasons. Referrals outside of evidence-based guidelines may lead to unnecessary procedures especially of the reproductive age patient, increased patient stress and added healthcare expense.
The 2019 ASCCP guidelines have transitioned from results- based algorithms to risk based algorithms. However in the age group 25 and under the algorithms have been carried forward (6). Our results indicated that in this age group where HPV has a high probability for regression, patients were incorrectly referred. Future studies could evaluate referral concordance overtime, especially in the less than 25 age group. Future research could also include surveys to providers that incorrectly refer and whether they use the updated ASCCP application, especially as the application is not free of charge.