Introduction
Cervical cancer screening and colposcopy have played an integral role in
reducing the prevalence of cervical cancer over the past 40 years (1).
The guidelines for cervical cancer screening and colposcopy were
established more than 15 years ago by the American Society for
Colposcopy and Cervical Pathology (ASCCP) and modified over the years as
a broader understanding of cervical cancer screening has increased (2).
While all women are at risk for cervical cancer, women over the age of
30 are at a greater risk of developing cervical cancer (1). Furthermore,
the majority of human papillomavirus (HPV) in women under the age of 24
resolve spontaneously within one to three years (3). The 2012 ASCCP
guidelines were developed to identify cervical pathology as well as
minimize overtreatment of lesions that may resolve spontaneously.
Colposcopy and loop electrosurgical excision procedures (LEEP) allow for
the identification and treatment of pre-invasive lesions, and aid in
early detection of invasive cervical lesions when treatment is more
effective (4). Unnecessary colposcopy procedures may result in increased
cost, unnecessary treatment, and serious psychological consequences for
women (5). Additionally, the 2019 ASCCP guidelines have transitioned
from result-based algorithms to risk based (6).
There have been several studies that evaluated the adherence of health
care providers to the 2012 guidelines in terms of correct screening
intervals and knowledge of HPV co-testing (7,8). According to Teoh et
all, 15% of providers were unaware of 2012 guideline changes however,
this study did not report on adherence to guidelines regarding referring
abnormal cytology results for colposcopy (7).
Virginia Commonwealth University (VCU) Department of Obstetrics and
Gynecology
conducts diagnostic procedures such as colposcopies for referred
patients. The gynecology trained faculty physicians at
VCU review all referrals and based
on the referred cytology and HPV results make recommendations for
subsequent care. The objectives of this study include evaluation of
adherence to the 2012 ASCCP guidelines by outside physicians referring
patients to a large academic center for a colposcopy and by the large
academic center physician’s recommendations following a colposcopy
procedure, as well as, the identification of factors associated with
referrals that are considered non-adherent to the 2012 ASCCP guidelines.
An understanding of the factors associated with incorrect referrals for
the 2012 ASCCP guidelines allows for identification of potential areas
for concern in the implementation of the 2019 ASCCP guideline updates.
Methods
A retrospective study was performed evaluating the women referred to VCU
for colposcopy or LEEP from January 2015 to December 2016. Electronic
health records of 430 patients referred to the VCU clinic were utilized
to identify patient demographics,
cervical cytology, HPV status, prior cervical dysplasia, type of
referring provider, patient show rate, the length of time from when the
ASCCP guidelines were published and when the referral was received, and
the recommended intervention. Except in specific clinical scenarios, pap
tests are not recommended until 21 years of age and many women after the
age of 65 stop receiving screening for cervical cancer therefore
patients under the age of 21 and over the age of 65 were excluded from
the study. The final study population consisted of 430 patients. The
institutional review board approved this study (IRB HM2004659) as exempt
on March 3, 2018, as it was a review of already existing information and
posed minimal/no risk to subjects. Figure 1 is a pictorial reference of
the methods process. All p-values less than 0.05 are considered
statistically significant.