Underscreening, overscreening, and guideline-adherent cervical cancer screening in a national cohort

Published:September 20, 2022DOI:


      • In a national cohort, approximately 18% of women met high-risk criteria requiring more frequent cervical cancer screening.
      • Among average-risk women, fewer than one in five are screened as recommended by national guidelines.
      • Guideline-adherent screening was highest for primary HPV testing, then HPV/Pap co-testing, then Pap testing alone.



      To explore rates of under- and overscreening for cervical cancer among a national cohort.


      The MarketScan database, a national administrative database of employee-sponsored insurance, was queried for elements relevant to cervical cancer screening among women aged 21–65 with 6 years of continuous enrollment (2015–2019). Average-risk women were defined as those without high-risk medical conditions or abnormal screening histories, and without evidence of hysterectomy with removal of the cervix for benign indications. Average-risk women were considered adequately screened if they had Pap tests alone at 2.5–3.5 year intervals, or HPV tests or co-tests at 4.5–5.5 year intervals. Logistic regressions were used to predict the odds of receiving guideline-adherent screening, underscreening, and overscreening.


      Among 1,872,809 eligible patients, 1,471,063 (78.5%) qualified for routine screening. Of these, only 18.1% received guideline-adherent screening, and 25.4% were unscreened during the 6-year period. Younger women (aged 21–39) were more likely to be overscreened [OR 1.46]. Older women (aged 50–64) were more likely to be underscreened or unscreened during the study period [OR 2.54]. Guideline-adherent screening was highest with HPV testing alone (80%) followed by co-testing (44%), and lowest with cytology alone (15%). A total of 329,062 women in this general population sample (18%) met high-risk criteria that required increased frequency of screening.


      High rates of both underscreening and overscreening indicate a need for additional strategies to improve guideline-adherent care.
      Clinical trial registration: N/A.



      CKC (Cold knife cone), CPT (Current procedural terminology), HIV (Human Immunodeficiency Virus), HPV (Human Papillomavirus), ICD-9 (International Classification of Diseases, 9th Revision), ICD-10 (International Classification of Diseases, 10th Revision), LEEP (Loop electrosurgical excision procedure)
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