Review
Clinicians' attitude towards changes in Australian National Cervical Screening Program

https://doi.org/10.1016/j.jcv.2015.11.018Get rights and content

Highlights

  • 60% of clinicians surveyed are willing to change practice if guidelines recommend it.

  • 56% of respondents were concerned about delaying screening from 18 to 25 years.

  • Effective change management strategies can be informed by these results.

  • Further education of clinicians as to the safety of the new cervical screening program will be required.

Abstract

Background

Australian guidelines for cervical cancer screening are being revised under the “renewal program”. Physicians’ willingness to accept these changes will play a pivotal role in its success.

Objective

To understand the willingness and acceptance of, as well as barriers and facilitators for Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) affiliates to screening using human papillomavirus (HPV) testing, starting at 25 years of age, every 5 years.

Study design

An electronic survey of RANZCOG affiliates was undertaken April–June 2014, while renew was announced April 28th 2014. Responses used a 7 point Likert scale, which was dichotomized as ≤4, indicating ‘unwilling’ and >4, indicating ‘willing’ to adopt revised practices.

Results

Response rate was 22% (n = 956): 60% were obstetricians and gynaecologists (OG); 27% general practitioner diplomates; 13% OG trainees. Overall, 60% (n = 526/874) were willing to revise their screening practice. This correlated with awareness of new guidelines (p = <0.001). Fifty percent (n = 438/869) of respondents were concerned about delaying to 25 years, and 48% (n = 421/869) concerned cervical cancers would be missed. Reasons respondents gave for wishing to continue screening from 18 years contrary to guidelines included: women not being vaccinated (65.6%), immunosuppressed women (92.2%) and women who had been victims of childhood sexual assault (73.9%).

Conclusions

The majority of RANZCOG affiliates were willing to change screening practice however, a number of barriers to delaying onset of screening age to age 25 years were reported. Effective change management strategies will need to be implemented to address the concerns raised to ensure best practice for cervical screening.

Section snippets

Background

The Australian National Cervical Screening Program (NCSP) has enabled organized screening for cervical cancers and pre-cancers since 1991 with great success [1]. Compared to other countries with cancer registration systems, Australia now has the second lowest incidence rate of cervical cancer in the world at 9.6 per 100,000 women and one of the lowest mortalities at 2.0 per 100,000 women [2].

The advent of high-risk human papillomavirus (hr-HPV) DNA testing is anticipated to profoundly change

Objectives

This paper aims to assess the attitudes and acceptance, barriers and facilitators of affiliates of the Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) who are largely OGs and GP diplomats, (GPs undertaking a diploma in obstetrics and gynecology), regarding the potential new recommendations for cervical screening. Specifically, ‘willingness’ to perform HPV DNA testing every 5 years from 25 years of age was assessed. The results can help inform effective

Study design

This was a cross-sectional observational study of RANZCOG affiliates. An electronic survey (SurveyMonkey®, Palo Alto, CA, USA) with a brief cover letter was distributed to 4725 RANZCOG affiliates on 4th April 2014, with two reminders sent out 17th April and 26th May 2014. Revised cervical screening guidelines had been announced April 28th 2014 to commence in 2016 (while the survey was active). The survey closed on 13th June 2014.

Potential participants included all RANZCOG fellows, members,

Data analysis

Analysis was performed using Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics Desktop V22.0, New York). The answer to the statement ‘For my patients, I would be willing to perform an HPV test to screen for cervical cancer at/after the age of 25 and every five years instead of a Pap smear every two years after onset of sexual activity, if the NHMRC or NCSP guidelines recommended’ was used to determine physicians’ willingness to adhere to potential new guidelines revisions.

Results

Of 4725 RANZCOG affiliates, 3292 (69.7%) did not respond, 467 (9.9%) had missing or undeliverable emails, 10 (0.2%) were excluded as they did not answer beyond demographic information and 956 (22.5%) clinicians responded to the survey. Demographic data is summarized in Table 1.

Of those responded, HPV DNA testing every 5 years, and HPV testing starting at 25 years were equally acceptable: 39.4% [344/874] and 37.8% [330/874] respectively, (χ2(1) = 0.47, p = 0.491). However, 526 (60.2%) reported that

Discussion

Australia introduced a publicly funded HPV vaccination program in 2007. Since then the country has seen a reduction in high grade dysplasia, genital warts and hr-HPV prevalence in young women [19], [20], [21], [22], [23]. A recent Australian cross-sectional survey showed a substantial (77%) fall in HPV16 prevalence in women aged 18–24 years in 2010–2011, compared to pre-vaccination levels [24]. Optimizing screening in the long term is likely to depend on an eventual transition to primary HPV

Conclusions

This study of RANZCOG clinicians sheds light on a practitioner’s willingness to accept new national guidelines, and explores barriers and facilitators. This study informs areas the guidelines will need to address as well as areas for further research and areas for targeted education. Introduction of the new cervical screening guidelines is now set for May 1st 2017. Good change management strategies will be critical to clinicians adopting the new guidelines, which will ensure the successful

Conflict of interest

None.

Funding

YJ has received scholarship funding from the Cancer Council Victoria, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and Royal Australasian Chapter of Sexual Health Medicine (Novartis Scholarship) and grant funding from the Victorian Cancer Agency and Victorian Comprehensive Cancer Network for unrelated projects. SG has received grant support from CSL Bio, Merck and GlaxoSmithKline to conduct HPV vaccine studies (VIVIANNE) trial. SG is a member of the Merck Global

Ethical approval

Approval was provided by the RANZCOG Continuing Professional Development committee, and registered with the Royal Women’s Hospital and University of Melbourne Human Research Ethics Committees.

Contributors

  • (1)

    Conception and design of the study: YJ, GO, SG, XL, SH, AG, JT, DW.

  • (2)

    Acquisition of data: XL, SH, YJ, SG, AG.

  • (3)

    Analysis and interpretation of data: all authors.

  • (4)

    Drafting the article or revising it critically for important intellectual content: all authors.

  • (5)

    Final approval of the version to be submitted: all authors.

Competing interest

None declared.

Acknowledgements

We would like to thank and acknowledge all those whose contributions were invaluable for completion of this paper, in particular the participants, the RANZCOG CPD Committee and the administrative staff at RANZCOG.

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