Cervical cancer screening, abnormal cytology management, and counseling practices in the United States

OBJECTIVE: We assessed clinician knowledge and practices since the marketing of tests for sexually transmitted human papillomavirus (HPV) and the release of HPV testing guidelines for two indications: 1) as an adjunct to cytologic screening and 2) to guide colposcopic triage of patients with atypical squamous cells of undetermined significance (ASC-US) cytology results. METHODS: In mid-2004, we surveyed nationally representative, random samples of clinicians practicing specialties that provide cytologic screening. Mail surveys addressed HPV-related knowledge, screening, abnormal cytology management, HPV testing, and counseling practices. RESULTS: The overall adjusted response rate was 82%. Of the 2,980 (89%) clinicians providing cytologic screening, 99% knew that HPV infection increases cervical cancer risk, and 91% were aware of HPV tests. Of the 21% who reported ever using HPV tests as an adjunct to cytology, more reported usually testing patients aged less than 30 years (which guidelines do not recommend) than older patients (which guidelines do recommend). Of the 63% of clinicians who ever ordered HPV tests for abnormal cytology results, 84% usually ordered tests for ASC-US results and preferentially advised colposcopy if HPV tests were positive, as guidelines recommend. However, more than 60% usually ordered HPV tests for higher-grade abnormalities, which is not recommended for colposcopy triage. Although few sought HPV test consent, most discussed sexually transmitted HPV with patients with abnormal cytology or positive HPV tests despite potentially negative psychosocial consequences. CONCLUSION: New HPV tests and testing guidelines have transformed screening, abnormal cytology management, and counseling practices. Although many U.S. clinicians reported using HPV tests according to guidelines, many also reported inappropriate use.