Many Physicians Do Not Follow Guidelines on Pap Testing, Study Finds

November 4, 2009 — A survey of more than 1,200 primary care doctors in the U.S. found that less than 25% made Pap test recommendations that were fully in line with major guidelines, according to a study published Monday in the Annals of Internal Medicine, Reuters reports. The majority of doctors reported overusing the test, rather than failing to recommend it.

The study, led by Robin Yabroff of the U.S. National Cancer Institute, examined surveys from 1,212 physicians who were given four patient scenarios and asked for their Pap testing recommendations in each case. For example, one scenario involved an 18-year-old patient with no sexual experience, while another involved a 66-year-old woman with lung cancer. The physicians' answers were compared with recommendations from the American Cancer Society, the American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force.

Reuters reports that three groups generally recommend women begin annual Pap tests at age 21 or within three years of first sex, depending on which is first. The groups recommend annual screening until age 30, after which they recommend testing every two to three years if a woman has had normal results on three consecutive tests. According to some groups, women do not need to be screened beyond ages 65 through 70 if they have had normal results on recent tests. ACS also says women can discontinue the screening if they have had a total hysterectomy for a noncancerous condition or have a serious disease that limits their life expectancy.

Details of Findings

The study found that 22% of doctors followed the guidelines consistently for all four presented scenarios. For example, 50% of doctors said they would recommend Pap testing for the 18-year-old woman, which is not consistent with guidelines. For the scenario with the 66-year-old woman -- from whom most groups would not require testing -- more than 40% of doctors said they would recommend Pap testing, with some recommending annual testing.

The researchers found that 27% of internists consistently followed the guidelines, which was the highest figure among various types of doctors. About 21% of family and general practitioners were consistent in guideline adherence, as were 16% of ob-gyns. The researchers noted that some groups were more likely to follow the guidelines: doctors younger than age 40, those who were board-certified and those who were part of large, multi-specialty practices.

It was not clear why doctors overused Pap testing, although the researchers said some physicians may see a financial incentive for frequent testing, be concerned about medical malpractice claims if they miss a diagnosis or disagree with the recommendations from the medical groups. Others might be confused by changes to the recommendations over the years, the researchers said. According to Reuters, ACS and ACOG in the early 2000s revised their guidelines to recommend less frequent testing from some women. The revisions were made in response to research indicating that many women ages 30 and older do not need annual Pap screening if they have had three negative cytology tests and that more frequent testing could create unnecessary patient anxiety or follow-up testing, Reuters reports (Reuters, 11/2).