Factors Associated With Guideline-Concordant Cervical Cancer Screening Exit: A Mixed Methods Study

More than 20% of cervical cancers are diagnosed in women older than 65 years. Guidelines recommend screening exit at age 65 for average-risk patients only if certain criteria are met, yet most women aged 64-66 years in the United States are inadequately screened. In this mixed methods study, we explored clinician knowledge of exit criteria.

We explored factors associated with clinician-reported guideline-concordant screening exit, as well as facilitators and barriers to appropriate cervical cancer screening exit. Guideline concordance required that clinicians be aware that patients can exit screening if they have received a hysterectomy for benign reasons or had either three consecutive negative Pap tests or two consecutive negative human papilloma virus tests-and that they should not exit screening if they have a history of precancer treatment in the prior 25 years.

In 2021, a national sample of 1,251 clinicians completed surveys; a subset (n = 55) completed qualitative interviews. Although most (>70%) correctly identified criteria related to hysterectomy and prior negative screening requirements, only 35% of participants (n = 434) responded correctly to all screening exit items. In logistic regression models, male clinicians, OB/GYNs, and those in academic or hospital-based practices were more likely to respond correctly. Interview responses indicated variable understanding of the nuances of exit criteria. Those who continued screening patients past age 65 cited concerns related to new sexual partners and missing cancers. Several providers noted difficulty accessing adequate records.

Clinicians who routinely perform cervical cancer screening have knowledge gaps around exit criteria and also describe difficulty applying the criteria in practice. As fewer women undergo hysterectomy and life expectancy increases, the number of individuals older than 65 at risk for cervical cancer will continue to rise. Adjusting guidelines to decrease the complexity of exit criteria should be considered.