Underscreening, Overscreening, and Guideline-Adherent Cervical Cancer Screening in a National Cohort
Authors: Lee Yeon Woo , Morgan Jake R. , Fiascone Stephen , Perkins Rebecca B. 
Published: March 2023

ABSTRACT
Cervical cancer screening is highly effective in reducing incidence and mortality of cervical cancer. Recommended cervical cancer screening involves cytology alone every 3 years between the ages of 21 and 29 years and with either human papillomavirus (HPV) testing alone or HPV plus cytology cotesting every 5 years or cytology alone ever 3 years for individuals of average risk between the ages of 30 and 65 years. Overscreening may result in subsequent overtreatment and increased costs, whereas underscreening may lead to lack of repeat testing after abnormal cytology or HPV test and increased incidence of preventable cervical cancer.
This retrospective study aimed to identify high-risk individuals who require more frequent screening and to examine rates of underscreening, overscreening, and guideline-adherent screening among women of average risk for cervical cancer. Data were obtained on women aged 21 to 64 years with continuous insurance coverage between 2014 and 2019 from the IBM MarketScan Commercial Claims and Encounters Database (MarketScan). Claims data were examined for low- and high-risk conditions, where low risk was defined as having undergone a hysterectomy, and high risk was defined as the presence of 1 or more conditions requiring more frequent screening including abnormal screening history, HIV-positive status, and solid organ transplant. Among average-risk women, underscreened was defined as Papanicolaou (Pap) tests recorded at <3.5- to 5-year intervals or HPV testing or cotesting at <5.5-year intervals, and overscreened as Pap tests recorded at <2.5-year intervals or HPV testing or cotesting at 2.5- to 4.5-year intervals. Logistic regression was used to determine the association between women's demographic and clinical characteristics and the odds of receiving appropriate screening, underscreening, and overscreening.
A total of 1,872,809 women were identified and included in the analysis, of whom 401,746 (22%) did not qualify for routine screening. Of these, 72,684 (4%) had evidence of hysterectomy without a cancer diagnosis, and 329,062 (18%) required more frequent screening due to high-risk medical conditions or prior screening abnormalities. A total of 1,471,063 women (79%) qualified for routine screening; however, 373,368 (25%) of them had no record of screening during the study time frame. Of the 278,938 women (19%) screened with Pap tests alone, 15% received guideline-adherent screening, 44% were underscreened (screened >3.5- to 5-year interval), 41% were overscreened (2.5- to 4.5-year interval), and 3% were severely underscreened (<5-year interval). Of the 493,028 women (33%) screened with HPV/Pap cotesting, 44% were guideline-adherent, 51% were overscreened, 33% were severely overscreened (<2.5-year interval), and 5% were underscreened. Logistic regression revealed women aged 30 to 39 years were more likely to receive guideline-adherent screening than other age groups (odds ratio [OR], 0.72, 0.87, and 0.71, with 95% confidence intervals [CIs] of 0.70–0.73, 0.86–0.88, and 0.70–0.72 for women aged 20–29, 40–49, and 50–64 years, respectively). Women with 1, 2, or 3 comorbidities had higher odds of appropriate screening compared with women with no comorbidities (OR, 1.18 [95% CI, 1.16–1.19], 1.15 [1.13–1.16], and 1.11 [1.09–1.13], respectively). Each additional gynecological visit was associated with lower odds of guideline-adherent screening (OR, 0.78; 95% CI, 0.78–0.78), whereas each preventive care visit was associated with higher odds of guideline adherence (OR, 1.06; 95% CI, 1.05–1.06).
The results of this study demonstrated that nearly 1 in 5 women had high-risk conditions necessitating more frequent screening and that only 1 in 5 average-risk women were screened according to guidelines, with high rates of underscreening particularly among women 50 years and older.