Public Release: 

Nov/Dec 2003 Annals of Family Medicine tip sheet

Annals of Family Medicine focuses on cervical cancer screening

American Academy of Family Physicians

The November/December 2003 issue of Annals of Family Medicine focuses on cervical cancer screening, a preventive practice that has contributed to the significant decline in the number deaths from cervical cancer over the past several decades. According to the American Cancer Society, between 1955 and 1992, the number of cervical cancer deaths in the United States dropped by 74 percent, in large part due to the increased use of the screening test.

A cluster of articles on the topic attempt to answer new questions about the screening test, which is among the most common performed by family physicians. How could understanding women's experiences change the way clinicians communicate with patients whose Pap smear results are mildly abnormal? Are annual Pap smears so firmly entrenched that patients or clinicians might resist recommendations to reduce their frequency? Is it reasonable to screen for common cancers, like breast cancer and cervical cancer, among the elderly? Do most family physicians routinely use a chaperone when collecting a Pap smear? Is a speculum examination necessary for accurate collection of a sample to detect human papillomavirus, one of the strongest known precursors of cervical cancer?

The November/December issue also includes two additional articles on other important clinical topics. A study by Dickinson and colleagues questions whether a simple care recommendation letter could improve the functional status of patients with somatization disorder - a condition in which frequent unexplained physical symptoms cause patient distress and frequent physician visits. In another article, Yawn and colleagues analyze exercise stress test results to determine whether heart rate recovery would be a useful addition to the diagnostic criteria for predicting cardiac and all-cause mortality.

In This Issue:

Women Reluctant to Consider Risk-Based Cervical Cancer Screening
* A full-length press release detailing this study can be found at the bottom of this tip sheet.*
Despite recommendations from the U.S. Preventive Services Task Force that low-risk women need Pap smears only every three years after three consecutive normal Pap smear results, researchers found that women might be reluctant to engage in risk-based cervical cancer screening. Using a series of focus group interviews, the authors found that most participants were "firmly set" against reducing the frequency of Pap tests. The women gave a variety of reasons for believing that yearly Pap tests are desirable, including the belief that a Pap tests are successful in reducing cervical cancer mortality, that some Pap tests are inaccurate and therefore need to be repeated, a suspicion that recommendations for reducing the frequency of testing were driven by organized medicine and the insurance industry, a mistrust of clinicians, and vivid personal experiences with cancer. The study results indicate that the habit of having an annual visit to a clinician for a Pap smear is firmly entrenched and an integral part of women's health care -- a habit that has been socialized and will be difficult to change. The authors encourage policy makers to consider the perceptions and concerns of women when considering guideline changes, and they suggest a proactive approach that includes education, communication and reassurance will be necessary to overcome the barriers identified during the interviews.
Periodic Abstinence from Pap (PAP) Smear Study: Women's Perceptions of Pap Smear Screening
Mindy Smith, M.D., M.S., et al

Click here to view a pdf of the complete article.

Breast and Cervical Cancer Screening Among Elderly Increasing Despite Limited Evidence of Advantage
Despite limited scientific evidence for the benefit of screening mammograms and Pap smears for elderly women, the use of the tests is increasing at a substantial societal cost. Analyzing data from two large national studies, the Health and Retirement Study (HRS) and Asset and Health Dynamics Among the Oldest Old (AHEAD) survey, the authors found that while the use of mammography and Pap tests for screening declines into old age, use of the tests increased between 1996 and 2000 for all age-groups. Specifically, the authors found that receipt of mammography was relatively stable at 70 to 80 percent (in the previous two years) among women 50 to 64 years of age but then declined to around 40 percent among women who were 85 to 90 years of age. For Pap tests, there was a decline from 75 percent among women 50 to 54 years of age to 25 percent in those 85 to 90 years of age. Higher education, being married, higher income, not smoking and vigorous exercise were consistently associated with higher screening rates. The authors suggest the increase in screening rates from 1996 to 2000 might be attributable to better access to health services in general, increases in the perception of the utility of these interventions and increasing concern regarding the diseases in question. They point out the significant socioeconomic impact of over-screening, estimating that in 2000, 4.6 million women over the age of 70 had mammograms, costing approximately $460 million, and 3.7 million had Pap smears, costing $47 million. They assert that these figures will only grow as the U.S. population ages. Given increase in utilization despite a lack of evidence of effect in older age-groups, the authors conclude that national clinical guidelines should more specifically address screening among the elderly, taking into consideration qualitative estimates of life expectancy, risk of cancer death and screening outcomes.
Screening Mammography and Pap Tests Among Older American Women 1996-2000: Results from the Health and Retirement Study (HRS) and Asset and Health Dynamics Among the Oldest Old (AHEAD)
Dr. Truls Ostbye, M.D., M.P.H., M.B.A., Ph.D., et al

Click here to view a pdf of the complete article.

Study Identifies Ways to Improve Communication and Care for Women with Abnormal Pap Smear Results
Women suffer significant emotional distress and are dissatisfied with the care they receive after learning of abnormal Pap smear results, according to this study by Karasz and colleagues. In-depth interviews with 17 low-income Hispanic and African-American women with low-grade Pap smear abnormalities indicated a widespread misunderstanding of cervical cancer and the purpose of the Pap test. Through qualitative interviews, the researchers found that women have unique and complex models for explaining their illness, which often include both biomedical and folk elements. Stemming from these unique illness beliefs are emotions of shame, guilt and fear, which are often not adequately addressed during a brief or one-sided consultation with their physician. The authors suggest that to relieve distress and increase satisfaction with care, physicians delivering news of abnormal Pap test results need to take the time to understand women's unique concerns and illness representations, and to provide care that addresses the considerable threat they perceive. Based on their findings, the authors also recommend that physicians take the time to explain the inherent ambiguity of Pap smear results.
Women's Experiences of Abnormal Cervical Cytology: Illness Representations, Care Processes and Outcomes
Alison Karasz, Ph.D., et al

Click here to view a pdf of the complete article.

Male Physicians More Likely to Use a Chaperone when Collecting a Pap Smear
Men are significantly more likely than women to use chaperones when collecting a Papa smear. According to this survey of 2,748 family physicians, 84 percent of men reported using chaperones compared to 31 percent of women respondents. Additionally, the researchers found that family physicians who did fewer Pap smears per month were more likely to report routine use of a chaperone. Only 70 percent of physicians who performed more than 20 Pap smears per month reported using a chaperone compared with 81 percent of those who performed fewer than 20. The researchers also found that geographic location of a practice was associated with the use of a chaperone, with physicians in the South using chaperones more often than physicians in other parts of the country. While the use of chaperones during gynecologic exams is a controversial issue with no formal guidelines or legal mandates, chaperone use has been strongly advocated for legal protection. The authors point out, however, that it is still unclear whether chaperone use actually decreases malpractice claims.
Chaperone Use by Family Physicians During the Collection of a Pap Smear
Mack T. Ruffin, IV, M.D., M.P.H.., et al

Click here to view a pdf of the complete article.

Speculum Examination Not Necessary for HPV Detection
Self-testing may provide a feasible alternative to cervical testing by a clinician for the detection of the human papillomavirus (HPV), one of the strongest known precursors of cervical cancer. According to a randomized trial of 103 women, a self-sampling technique using two consecutive vaginal swabs, which are mailed to a laboratory, is as accurate in detecting HPV as clinician sampling. The researchers also found that collection of a sample for accurate HPV detection is not affected by recent intercourse, the number of days between tests or the week of the menstrual cycle - good news for the convenience of HPV testing either by clinicians or by women themselves. The researchers suggest that this self-administered technique may provide an inexpensive, feasible alternative to examination by a clinician that is viewed by most women as convenient and acceptable.
Factors Affecting the Detection Rate of Human Papillomavirus
Diane M. Harper, M.D., M.P.H., M.S., et al

Click here to view a pdf of the complete article.

Heart Rate Recovery Not a Useful Addition to Exercise Stress Test Results
Using a community-practice-based sample of 90 patients, Yawn and colleagues found that heart rate recovery following an exercise stress test is not a stable measurement and therefore its role as a prognostic tool is limited. Heart rate recovery -- the ability to slow the heart after an exercise stress test -- has been suggested as a useful addition to current criteria for predicting cardiac and all-cause mortality from stress. However, comparing the data from patients who underwent two exercise stress tests within an 18-week period, the researchers found that heart rate recovery rates were not sufficiently consistent for the measurement to be used as a diagnostic tool. The standard deviation of the difference in heart rate recovery for the two tests was significant (9.5 for men and 9.8 for women). The authors conclude that the lack of short-term test-retest reproducibility in this study calls into question the value of using the measure in clinical practice for diagnostic purposes.
Test-Retest Reproducibility of Heart Rate Recovery after Treadmill Exercise
Barbara P. Yawn, M.D. M.Sc., et al.

Click here to view a pdf of the complete article.

Study Shows a Basic Letter Could Lead to Better Treatment of Somatization in Primary Care
A simple care recommendation letter identifying patients as having the diagnosis of somatization and providing recommendations for appropriate care was shown to significantly improve family physicians' treatment of patients with multisomatoform disorder. In a study of 188 patients with somatization disorder, the intervention was shown to decrease costs associated with care and improve the physical functioning of those patients. Additionally, the researchers found that the intervention letter was significantly more effective for patients with multisomatoform disorder who had one or more comorbid chronic diseases than those without comorbidity. The implications of this study are especially important given the considerable patient impairment and increased health care costs associated with treating somatization, a common and debilitating condition in which patients report numerous unexplained physical complaints. The authors suggest that a care recommendation letter is an effective and inexpensive tool for first-stage primary care treatment for somatizing patients.
A Randomized Clinical Trial of a Care Recommendation Letter Intervention for Somatization in Primary Care
Perry Dickinson, M.D.

Click here to view a pdf of the complete article.


EMBARGOED FOR RELEASE
Tuesday, November 25, 2003, 12 p.m. EDT

Contact: Angela Lower
Annals of Family Medicine
(913) 906-6253 or (800) 274-2237 ext. 5224
alower@aafp.org

Women Reluctant to Consider Less Frequent Cervical Cancer Screening, Study Finds

Click here to view a pdf of the complete article.

LEAWOOD, Kan. -- Despite recent recommendations that low-risk women need Pap smears only every three years after three consecutive normal Pap smear results, a study in the current issue of Annals of Family Medicine reports that women might be reluctant to engage in risk-based cervical cancer screening.

"Most of the women we interviewed were firmly set against reducing the frequency of Pap tests," said the study's lead author, Mindy Smith, M.D., M.S., from the Department of Family Practice at Michigan State University. "The habit of having an annual visit to a clinician for a Pap smear appears to be firmly entrenched and viewed as an integral part of a woman's health care. It is a habit that has been socialized over many years and will likely be difficult to change."

In a series of eight focus group interviews, women offered a variety of reasons for believing that yearly Pap tests are desirable, including the belief that Pap tests are successful in reducing cervical cancer mortality, that some Pap tests are inaccurate and therefore need to be repeated, a suspicion that recommendations for reducing the frequency of testing were driven by organized medicine and the insurance industry, a mistrust of clinicians, and vivid personal experiences with cancer.

Approximately 16,000 new cases of cervical cancer are diagnosed each year, and approximately 4,800 women die from the disease annually. According to the American Cancer Society, between 1955 and 1992, the number of cervical cancer deaths in the United States dropped by 74 percent, in large part due to the increased use of the screening test and early detection.

Many groups, including the U.S. Preventive Services Task Force, American Cancer Society and American College of Obstetricians and Gynecologists, now recommend that low-risk women need Pap smears only every two to three years after three consecutive normal Pap smear results. They point to data showing little evidence that women who receive annual screening are at significantly lower risk for invasive cervical cancer than are women who are tested every three to five years. Combined data from a series of eight studies involving more than 1.8 million women showed that annual screening reduced the cumulative incidence of cervical cancer by only 2.7 percent compared with screening at a three-year interval. Proponents of triennial testing also point to important economic considerations. The U.S. Preventive Services Task Force points out that annual testing could double or triple the total number of smears taken on more than 92 million American women at risk, yet provide only limited added benefit in lowering mortality.

"We hope that the findings from our study will help enlighten the current debate over the frequency and timing of Pap tests based upon risk of cervical cancer," said Smith. "As this study makes clear, health-care providers face significant barriers to putting risk-based screening recommendations into practice."

The researchers suggest that those planning to limit a screening test that has been so well incorporated into popular culture need to take women's perceptions and concerns into account.

"Women need reasurrance," said Smith. "The women we interviewed were very distrustful of the rationale for the suggested changes, suspicious that reducing the frequency of testing is motivated by concern for cost rather than quality of care," commented Smith.

The researchers also note that women's reluctance to adopt a risk-based screening approach appears to stem in part from a lack of knowledge about the risk factors for cervical cancer, its natural history, and the effectiveness of annual compared with triennial screening. But, they point to a strong self-advocacy theme, which emerged in the interviews, as an opportunity for those trying to educate and influence women's beliefs.

"The women we interviewed expressed a strong will to take responsibility for their own health care and obtain the information they need to make informed health decisions," said Smith. "Policy makers and providers should take advantage of women's proactive approach to health care by providing educational materials that explain the facts about cervical cancer and screening for the disease."

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Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Practice, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the North American Primary Care Research Group. The journal is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. A board of directors with representatives from each of the sponsoring organizations oversees Annals. Complete editorial content and interactive discussion groups can be accessed free of charge on the journal's Web site, www.annfammed.org.

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