Primary Care Providers' Views and Understanding of Current Recommended Guidelines for Cervical Cancer Screening

Cervical cancer remains a common cause of death and disability among women both within the
United States and world-wide. Potential exists for significant prevention and early
detection if cervical cancer screening is performed at the correct frequencies, with correct
methods, on the appropriate women. Since the development of the Papanicolaou smear (Pap
smear), cervical cancer screening has been recommended as a component of preventative
healthcare for women. The tradition of an annual pap smear remains a common component of
American medicine. For over four decades, controversy has existed as to the optimal method
and timing of cervical cancer screening. The result has been great confusion amongst
providers.

Significant developments have led to a dramatic change in recommendations for cervical
cancer screening. The understanding that the Human Papilloma Virus (HPV) is the cause of
nearly 100% of cervical cancer cases and the development of new technologies for detection
of HPV DNA at time of cervical cancer screening, has produced changes in preventive
healthcare policy for this condition. In an unprecedented event, the American College of
Obstetrics and Gynecology, the American Cancer Society and the U.S. Preventive Services Task
Force recommended dramatic and unified changes in screening utilizing this new technology:
In healthy women, A: do not start screening prior to age 21, B: screen every 3 years between
ages 21-29, C: screen only every 5 years between ages 30-65, and D: stop any further
screening for cervical cancer after 65. This significant reduction in the number of cervical
cancer screenings is the result of these new technologies for the detection of the HPV
virus, as well as evidence-based findings on the lack of risk for cancer in women who test
negative for HPV. From a public health policy standpoint, the new recommendations are
revolutionary. Whereas a women previously might have received 62 "Pap Smears" between the
ages of 18-79, with new recommendations, only 6 cervical cancer screenings would be required
over her lifetime.

Understanding these new recommendations and complying with these new unified recommendations
would have a dramatic effect on health policy. The current multi-billion dollar cost of
annual cervical cancer screening would be dramatically reduced. The time and physical
inconvenience of this examination would be lessened. At a time when there is a great
shortage of primary care providers (MD's, PA's and NP's) in many parts of the U.S., these
dramatically reduced needs for cervical cancer screening might allow primary care providers
greater time for more important health policy. No studies of significance have evaluated
(since guideline change in 2013), whether primary care providers find the new
recommendations authoritative and believe in them, or whether providers understand
implementation of these new guidelines given the many decades of contradictory and differing
recommendations.

The implications for health policy are significant:

1. To the extent that primary care providers don't believe in the new guidelines, then
providers should be educated on the evidence-based rationale from which they were
constructed. In other words: to overcome whatever misgivings providers might harbor as
to the new recommendations.

2. To the extent that primary care providers believe in the new guidelines, but can't
correctly apply them, then health policy would suggest an educational campaign to
indicate correct application.

3. To the extent that primary care providers harbor biases, further research to understand
and develop strategies to overcome these biases would be indicated.

For this study, the opinions of primary care providers who care for patients in the 194
federally designated regions of Primary Care provider shortage within California will be
studied. Using the California Medical Board database of licensed providers, a questionnaire
will be mailed to a random subset. The sample will be randomized to include providers in
both urban and rural areas of provider shortages, with a spectrum of patients of differing
ethnic and economic status. It is anticipated that approximately 5,000 questionnaires will
be mailed out with the goal of 1,000 responses.

The study will investigate the following issues: 1) Do primary care providers in these
regions believe in these new and dramatically different guidelines? 2) Are the providers
able to correctly apply these guidelines in four different clinical vignettes? 3) Do the
providers hold a bias which may influence their willingness to follow these new guidelines?
It is anticipated that the analysis will show varying contempt, confusion and compliance
with new guidelines exists. Understanding these factors will have beneficial health policy
implications in terms of overcoming barriers to these cost-effective, less intrusive, and
more accurate health policy guidelines in the prevention and early detection of cervical
cancer.

Inclusion Criteria:

- Primary care providers who care for patients within the 194 federally designated
regions of Primary Care provider shortage within California

Exclusion Criteria:

- Outside of federally designated region of Primary Care provider shortage within
California