In this study of ethnically diverse older women with access to screening, over three quarters of women said they were interested in being tested for HPV, and over 90% of women wanting to be tested said they would want more frequent Pap tests if they had a positive HPV test with a normal Pap test. In addition, two thirds of women under age 65 indicated that they would be willing to switch to triennial Pap testing if they had a negative HPV test with a normal Pap test (Table ), and slightly more than half of those aged 65 and older indicated that they would be willing to discontinue Pap testing if they had a negative HPV test with a normal Pap test. These results suggest that a substantial proportion of older women are interested in using HPV testing to make decisions about frequency and duration of cervical cancer screening.
At the same time, our findings suggest that some older women may be reluctant to use HPV test results in a way that is clinically appropriate or consistent with current guidelines. For example, approximately a third of women under age 65 said they would not be willing to get less frequent than annual Pap tests, even if they had negative HPV and normal Pap tests, and even if their physician recommended it. Furthermore, over two thirds of women said they would want 2, 3, or 4 Pap tests per year if they had a positive HPV test with a normal Pap test, despite recommendations for annual Pap tests in this setting.
Our results are consistent with previous studies suggesting that some women are uncomfortable with stopping annual Pap testing even when advised by their physicians or confronted with evidence that annual, lifelong Pap testing offers little clinical benefit. For example, a recent telephone survey of 360 women aged 40 years and older found that 69% of women would try to continue being screened annually even if their physicians recommended less frequent screening and advised them of comparable benefits.16
Only 35% thought that there might come a time when they would stop getting Pap tests, despite national recommendations that elderly well-screened women may cease routine screening (at age 65 for the US Preventive Services Task Force, and age 70 for the American Cancer Society).5,17
Although women’s personal preferences for testing may not be the sole or even primary drivers of cancer screening practices, decisions about cancer screening in the United States are increasingly being made using a shared decision-making model.18–20
Current media coverage of HPV and its relationship to cervical cancer is on the rise,13,14
and women’s interest in and attitudes toward HPV testing are likely to have an increasing impact on decision-making about cervical cancer screening.
Our findings have implications for the impact of routine HPV testing on the total volume of Pap tests performed in the United States. Over the past 2 decades, the total number of Pap tests performed on U.S. women has increased from 50 million per year to more than 65 million per year.21–23
It has been estimated that the net effect of routine testing for HPV would be to reduce the total volume of Pap tests performed by 30%, or nearly 20 million per year.21
In practice, however, if up to one third of women are unwilling to forgo annual Pap testing in the setting of negative HPV and normal Pap test results, and if many women are interested in getting more frequent than annual Pap testing in the setting of positive HPV and normal Pap test results, HPV testing may not reduce overutilization of Pap testing to the extent projected unless there are other restrictions linked to payment for the test.
Our findings also provide insight into racial/ethnic and demographic differences in awareness of HPV and preferences for HPV testing in older women. In our study, women were significantly less likely to have previously heard of HPV if they were Asian or African American rather than White, if they had not graduated from college, or if they had been born outside of the United States. These findings suggest that despite increased media coverage of HPV, HPV awareness has not reached minority, immigrant, and less educated populations to the same extent as White, U.S.-born, educated women.
Furthermore, we found that older women’s decision-making about cervical cancer screening in the setting of HPV testing varied significantly by ethnicity. African American women were more likely to want more frequent than annual Pap testing after a positive HPV test, for example, and Latina women were more likely to insist on at least annual Pap testing even in the setting of a negative HPV and a normal Pap test. These trends were not explained by differences in women’s personal or family history of cancer, or other clinical characteristics such as general health status. Although a number of studies have documented racial or ethnic disparities in utilization of Pap tests,24–29
there has been little research on differences in women’s personal preferences for testing by ethnicity.30,31
Further research is needed to explore possible mediators for differences in testing preferences among ethnic groups, such as differences in women’s perception of the accuracy of HPV and Pap tests, willingness to undergo more frequent procedures, and belief that more frequent testing will decrease their long-term risk of developing cancer.
Our research has several important limitations. First, this study was conducted among women in the San Francisco Bay Area, a metropolitan area that was targeted in direct-to-consumer advertising campaigns for the HPV test, and thus our results may not apply to women from other geographic regions. Second, this study was conducted between October 2002 and January 2006, before the availability of a prophylactic vaccine against HPV types 6, 11, 16, and 18. Public debate about use of the HPV vaccine may have increased public awareness of HPV and its relationship of cervical cancer, even among older women who are not currently candidates for HPV vaccination.
In addition, the CRISP study enrolled women between 50 and 80 years of age only, to focus on older women who tend to face the most complex decisions about cancer screening in the face of competing medical priorities. However, younger women are also candidates for routine HPV testing under current guidelines, and our results may not apply to this age group. Finally, this study was primarily directed at understanding women’s attitudes toward HPV testing, rather than documenting their actual testing behavior or estimating their risk of cancer. As a result, we did not try to verify women’s self-reported data about their previous Pap testing or HPV testing history by consulting their physicians or medical records, nor did we collect detailed data about clinical or behavioral factors that might influence their clinical risk of developing cancer.
Nevertheless, this study raises important questions about the impact of routine HPV testing on older women’s decision making about cervical cancer screening. If clinical guidelines are not followed, HPV testing may lead to unnecessary pap smears, increased health care expenditures, more false positive tests and additional physician visits or tests to clarify these results without any clear benefits. If HPV testing is increasingly adopted as a primary screening strategy in the United States, efforts must be made to ensure that it is used to reinforce appropriate rather than inappropriate cervical cancer screening practices.