Iffy Follow-Up Care for Many Patients With High-Risk HPV, Study Finds

Less than half of patients who were positive for high-risk human papillomavirus (HPV) with negative cytologic findings were retested during the guideline-recommended time frame, a cohort study showed.

During the first 16 months after an index positive HPV result, only 43.7% of patients received an initial surveillance test, of whom 18.2% had HPV-negative results and negative intraepithelial lesion or malignancy (NILM) cytologic findings and 25.5% had abnormal results, reported Jasmin Tiro, PhD, of the University of Chicago, and colleagues in JAMA Network Open.

Of note, many patients remained in the cohort and were untested through this first round of surveillance (overall: 49.4%; across sites: 39% to 69.4%), and few patients exited the cohort (overall: 6.9%; across sites: 0.2% to 24.6%).

Several groups had lower odds of timely testing, including:

• Younger adults (ages 25-29 vs 30-39): adjusted OR 0.65 (95% confidence limit [CL] 0.53-0.81)
• African American vs white patients: aOR 0.78 (95% CL 0.68-0.89)
• Those with Medicaid vs commercial insurance: aOR 0.81 (95% CL 0.72-0.91)

On the other hand, those with a primary care physician were more likely to have timely testing (aOR 1.44, 95% CL 1.21-1.70).

Cervical cancer was later diagnosed in 0.2% of patients who weren’t tested within the 16 months indicated by the guidelines compared with no cancer cases in those who had HPV-negative results and NILM cytologic findings.

In 2019, the American Society for Colposcopy and Cervical Pathology (ASCCP) released guidelines for managing abnormal cervical cancer screening results using a risk-based approach. In order to apply risk-based guidelines, data on screening history and risk factors, as well as ongoing engagement with healthcare systems, are necessary. However, screening history data are often missing and clinicians may not have access to complete data to make management recommendations at the time of an abnormal result.

“Collectively, the data showed low-level adherence to the annual surveillance regimen recommended by ASCCP guidelines and suggest that abnormal HPV-positive results and NILM cytologic findings may be challenging for healthcare systems to track and follow to resolution,” Tiro and colleagues wrote.

“Healthcare systems should monitor the delivery of annual surveillance and gather evidence on interventions to optimize delivery to patient groups at risk for low-level adherence, such as those experiencing adverse social determinants of health,” they concluded.

For this study, the researchers used data on patients across three diverse healthcare systems in the Multi-level Optimization of the Cervical Cancer Screening Process in Diverse Settings and Populations (METRICS) cohort of the Population-Based Research to Optimize the Screening Process (PROSPR II) Cervical Consortium: Mass General Brigham in Massachusetts, Parkland Health in Texas, and Kaiser Permanente Washington.

Patients received an index HPV-positive result and NILM cytologic findings between January 2010 and August 2018. They were followed up through December 2019.

The researchers chose patients with positive high-risk (non-16/18 or pooled genotypes) HPV test results and NILM findings due to the shift towards primary HPV screening and cotesting that makes this screening abnormality more common. In these cases, guideline-concordant practice is to “include annual surveillance cotesting to monitor for HPV persistence and potential progression of cervical dysplasia.” After two negative subsequent evaluations, a patient would return to average-risk screening, comprising cytology testing every 3 years and primary HPV or cotesting every 5 years.

The final sample included 13,158 female patients. The largest proportion (37.5%) were ages 30-39, 28.8% were 50-65, and 25% were 40-49. Nearly half were white, 24.5% were Hispanic or Latine, and 15.1% were Black. Sociodemographics varied across sites, with Parkland Health having more Hispanic or Latine and uninsured patients, and Kaiser Permanente Washington and Mass General Brigham having more white and commercially insured patients.

In terms of limitations, the authors noted that while the three health systems were geographically diverse, they do not represent the entire U.S., and these analyses may not be relevant to healthcare systems that modify ASCCP guidelines.

Additionally, patients who disenrolled or left healthcare systems without notifying their physician could have received follow-up elsewhere, which wouldn’t have been captured in this study.

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