Abstract
Cervical cancer is the second leading cause of cancer death for women in the Dominican Republic. Pap smear screening in the Dominican Republic has not achieved adequate reduction in cervical cancer mortality. The purpose of this study was to examine Dominican provider practices for cervical cancer screening and the use of national or international screening guidelines. We surveyed 101 gynecology specialists, 50 non-specialists, and 51 obstetrics-gynecology residents in the Santo Domingo and Monte Plata provinces of the Dominican Republic regarding their cervical cancer screening practices and use of guidelines. Bivariate (chi-square) analyses were conducted to compare screening practices by demographic and practice characteristics. The majority of providers followed WHO guidelines (62.9%) and/or Dominican national norms (59.4%). The majority (87%) of providers use time since first sexual activity as the basis for screening initiation; 96% advise screening every 6–12 months. The most commonly used screening test is the conventional Pap smear. Colposcopy was recommended most often for all abnormal Pap results. Dominican providers report they follow national and/or international cervical cancer screening guidelines. They do not follow age-based screening guidelines, nor have they adopted an extended interval for screening and continue to recommend screening at least annually. A culture of early and frequent screening has consequences in terms of cost, high demand for follow-up services, and reduced capacity to reach the populations at highest risk. Early screening also may challenge the acceptability of adopting alternative screening technologies such as HPV testing.
Keywords: Global women’s health, Cervical cancer screening, Dominican Republic, Latin America and the Caribbean
Introduction
Cervical cancer is a major cause of premature death for women in many parts of the world. The most recent global statistics estimate there were 570,000 new cases and 311,000 deaths from cervical cancer in 2018 [1]. More than 85% of cervical cancer cases and deaths occur in low-and middle-income countries that have not succeeded in establishing or maintaining effective cervical cancer screening programs [1]. In the Dominican Republic, like many countries in Latin America and the Caribbean, Pap smear screening is available but has not achieved adequate reduction in cervical cancer mortality. There is no national cancer registry in the Dominican Republic and precise demographic data for cervical cancer are therefore not available. Recent estimates from the GLOBOCAN global cancer database indicate a decrease in cervical cancer rates in the Dominican Republic since previous reports [1, 2], but cervical cancer incidence (ASR 17.1 per 100,000) and mortality (ASR 9.9 per 100,000) remain high [1].
To effectively reduce cervical cancer incidence and mortality, the World Health Organization (WHO) advocates the scale up of primary prevention with human papillomavirus (HPV) vaccination and secondary prevention with population-level cervical cancer screening for women at highest risk. The WHO recommends screening all women ages 30–49 every 3 to 5 years depending on the screening test used [3]. In low-resource settings, visual inspection with acetic acid (VIA) is recommended every 3 to 5 years, and in other settings, cytology (Pap smear) every 3 to 5 years or HPV testing every 5 years is recommended. The Dominican Republic’s national norms for cervical cancer screening define the priority population for screening as women ages 35–64, and those that have additional risk factors: women who began sexual activity at an early age, have had multiple sexual partners, have never been screened, and/or those who have a history of abnormal Pap smears [4]. Pap smear screening is recommended every year for 2 years, then every 3 years if previous annual testing was normal [4]. The US-based guidelines, endorsed by the American Society for Colposcopy and Clinical Pathology (ASCCP), recommend beginning Pap smear alone for women ages 21–29 every 3 years, followed by either Pap smear alone every 3 years, Pap smear and HPV co-testing every 5 years, or HPV testing alone every 5 years for women ages 30–65 [5].
Published studies regarding cervical cancer prevention in the Dominican Republic are few. The last national survey in 2013 indicated only 52% of women ages 30–49 had been screened in the last year [6], suggesting screening coverage—ideally, 80% of the target population–[3, 7] remains a challenge. In a qualitative study in the Dominican Republic that explored cervical cancer screening norms, we found that women in Santo Domingo and the surrounding areas participated regularly in Pap smear screening. Focus group findings suggested women were being screened every 6–12 months and that women were being screened at a much younger age than the WHO (age 30) or Dominican National Guidelines (age 35) recommend for screening initiation [8]. There has not been any information published to date regarding current Dominican health care provider cervical cancer screening practices or the extent to which providers follow national or international guidelines for cervical cancer screening. This study is part of a larger mixed methods study on barriers to implementation of evidence-based practice for cervical cancer prevention in the Dominican Republic. The focus of this analysis is on Dominican provider practices for cervical cancer screening and management of abnormal screening tests and on provider use of cervical cancer screening guidelines.
Methods
Sample and Setting
The study was reviewed by both the Institutional Review Board at the Dominican National Cancer Institute [Instituto Nacional del Cáncer Rosa Emilia Sánchez Pérez de Tavares (INCART)] and New York University’s Washington Square Campus Institutional Review Board and was approved via expedited review. Survey participants read the informed consent document, gave verbal consent to participation, and received a copy of the consent form.
In February 2019, we recruited a group of 200 physicians (obstetricians-gynecologists (OB/GYNS), general practice physicians, family practice physicians, and OB/GYN residents) in the provinces of Santo Domingo and Monte Plata who perform cervical cancer screening. The Dominican public health system is divided into nine regions (Region 0–VIII). Region 0 is comprised of the provinces of Santo Domingo and Monte Plata and was selected as it serves a large portion (40%) of the population in the public health system [6]. The provinces in Region 0 include the Distrito Nacional of the capital city, Santo Domingo, as well as suburban and rural areas outside of the metropolitan area. An external advisory board, comprised of Ministry of Health leadership and GYN specialists from the public and private health sectors, was formed to advise regarding recruitment and data collection, and to facilitate health system entry. According to the external advisory board, though most cervical cancer screening is done by OB/GYNS, family practice and general practice physicians also do screening in some settings. Nurses are not included in this study as they reportedly do not perform cervical cancer screening.
Those eligible for the survey were health care providers in Region 0, with female patients of screening age (over 30 years of age), who actively do cervical cancer screening (i.e., have performed at least one Pap smear or HPV test in the last year). This included providers in public and private (i.e., private practice or non-governmental organizations (NGO)) health sectors. Factors such as patient volume, years in practice, and other demographic and training characteristics were examined in the analyses, but providers were not excluded from recruitment based on these factors.
Quota sampling was used to seek balanced representation of 100 specialists (OB/GYNS), 50 non-specialists (i.e., family practice and general practice physicians), and 50 OB/GYN residents in Region 0, with providers representing both urban and rural practice settings. Based on the geographic concentration of physicians [9], 85% of the sample was recruited from the municipalities of the Santo Domingo province and 15% from the municipalities in the more rural Monte Plata province.
Procedures
The director of INCART sent formal letters of invitation to secondary and tertiary hospitals in Santo Domingo and to the four hospitals in Monte Plata. The Dominican co-investigator (NF) followed up to confirm site approval to recruit participants and identify a site contact person. We trained a team of Dominican surveyors, experienced in health-related surveys, on the research topic, content of the survey questionnaire, and use of digital data collection using KoboToolbox. This team conducted interviewer-administered surveys for individual participants in their hospital, primary health care center, or private clinic settings. As many providers practice in both the public and private health sectors, participants were asked to focus their responses on the particular institution in which they were interviewed. Surveys were conducted in settings ranging from rural clinics, to public and private primary level health centers, to secondary level municipal hospitals, to tertiary level large maternity hospitals and private practice gynecology clinics.
Survey Instrument
The survey was adapted from cervical cancer–related provider surveys used in USA and international settings [10, 11], obtained from a question bank compiled by the US Centers for Disease Control and Prevention (CDC). The survey was translated from English to Spanish, back-translated by a bilingual Dominican Spanish speaker, and checked for semantic equivalence [12, 13]. The survey was then piloted with a focus group of Dominican health care providers, and refined by the principal investigator (EL); NF, a GYN-oncologist and expert in cervical cancer prevention in the Dominican Republic; and a Dominican research consultant with extensive experience in survey research in the Dominican Republic. The 43-question survey measured demographic, training, and practice characteristics; knowledge, attitudes, and beliefs regarding cervical cancer screening, including HPV testing; cervical cancer screening practices; and attitudes regarding barriers to cervical cancer screening and treatment of cervical pre-cancers. This analysis focused on items related to provider practices for cervical cancer screening (including screening initiation and frequency of screening) and management of abnormal screening tests, as well as use of guidelines for cervical cancer screening. A comparison of Dominican national norms and international screening guidelines is presented in Table 1.
Table 1.
Comparison of cervical cancer screening guidelines
| WHO guidelines (2014) | Dominican national norms (2007) | ASCCP (2012) | |
|---|---|---|---|
| Target age group (prioritized as women at highest risk for cervical cancer) | 30–49 | 35–64 | 21–65 |
| Screening initiation for average-risk (i.e., HIV negative) women | Age 30 • May be extended to younger ages if evidence of a high risk for CIN2+ |
Age 35 • Women with history of multiple partners • Women who began sexual activity at an early age • If a woman requests it (but priority should be given to above criteria) |
Age 21, regardless of age of sexual debut |
| Screening interval following normal screening tests (in HIV negative women) | Every 3–5 years for VIA or cytology 5 years (minimum) for HPV negative |
Every 1 year ×2, then if normal every 1–3 years | • Every 3 years from 21 to 29 • Every 3–5 years from 30 to 65 (depending on test) |
| Screening test(s) | HPV test where possible VIA Cytology (Pap smear) |
• Cytology, liquid-based cytology where available • HPV test (for all “at-risk” women in the health centers that have availability) and where available for triage of ASCUS/abnormal Pap • VIA |
• Pap (cytology) age 21–29 • Pap/HPV co-test age 30–65 OR Pap alone age 30–65 (3 year) HPV alone age 30–65 |
| Discontinuing screening | Not specified | Not specified | Age 65 if up to date on screening in previous 10 years and no history of CIN 2+ |
VIA visual inspection with acetic acid, CIN cervical intraepithelial neoplasia, ASCCP American Society for Colposcopy and Cervical Pathology
Data Management and Analysis
Survey responses were entered by the interviewer on a digital device and uploaded directly to the secure KoboToolbox server. Following data cleaning, descriptive statistics were calculated for all survey items. Age in years was dichotomized into < 40 and ≥ 40. Years in practice was dichotomized into < 10 and ≥ 10. Medical specialty was grouped into GYN specialists, non-specialists (including family physicians and general practice physicians), and OB/GYN residents. Smaller municipalities within Santo Domingo and Monte Plata provinces were grouped together into Santo Domingo and Monte Plata practice location. Pearson’s chi-square statistics were used to compare whether or not providers follow WHO cervical cancer screening guidelines, Dominican national norms, and/or American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines, by demographic and practice characteristics. We also examined differences in provider practices regarding screening initiation, frequency of screening, screening tests used, discontinuation of screening, and management of abnormal screening tests, by demographic and practice characteristics and report of guidelines followed. Fisher’s exact test was used in cases of small cell sizes (i.e., five or fewer observations per cell). Values of p ≤ .05 were considered statistically significant. All analyses were done using SPSS 25.0 (IBM Corp., Armonk, NY). Additional analysis to examine overlap in guideline use was performed in Stata 15.1 (StataCorp LLC, College Station, TX).
Results
Participant Demographic and Practice Characteristics
Survey participants included 101 (50.0%) OB/GYNS, 23 (11.4%) family practice physicians, 27 (13.4%) general practice physicians, and 51 (25.2%) OB/GYN residents, from four of the five municipalities of Santo Domingo province, and all of the four municipalities of Monte Plata province. Providers had a mean age of 42 (standard deviation = 10.97, range 19 to 72 years), were majority female (67%), and had almost all trained in the Dominican Republic (99.5% for medical training, 91.6% for residency). Distribution by practice setting, medical specialty, and practice location was determined by design. Most participants reported their patients came from either strictly urban areas (48.5%) or a combination of urban and rural areas (43.6%, Table 2).
Table 2.
Demographic/practice characteristics of providers doing cervical cancer screening in Santo Domingo and Monte Plata, Dominican Republic (2019) (N = 202)
| n (%)1 | |
|---|---|
| Mean age (SD, range) | 41.73 (10.97, 19–72) |
| Median age (IQR) | 40 (19, 32–51) |
| Sex | |
| Male | 66 (33) |
| Female | 136 (67) |
| Country of medical training | |
| Dominican Republic | 201 (99.5) |
| Other | 1 (0.5) |
| Country of residency/specialty training | |
| Dominican Republic | 185 (91.6) |
| Other | 4 (2) |
| Mean years practicing medicine (SD, range) | 14.46 (9.80, 0–46) |
| Median years practicing medicine (IQR) | 12 (16, 6–22) |
| Practice setting | |
| Public | 154 (76.2) |
| Private | 48 (23.8) |
| Medical specialty | |
| Obstetrician-gynecologist | 101 (50.0) |
| Family practice physician | 23 (11.4) |
| General practice physician | 27 (13.4) |
| OB/GYN resident | 51 (25.2) |
| Practice location | |
| Santo Domingo | 172 (85.1) |
| Monte Plata | 30 (14.9) |
| Patients generally come from… | |
| Rural areas | 16 (7.9) |
| Urban areas | 98 (48.5) |
| Both | 88 (43.6) |
SD standard deviation, OB/GYN obstetrician-gynecologist, IQR interquartile range
Unless otherwise indicated
Use of Cervical Cancer Screening Guidelines
All providers reported they followed cervical cancer screening guidelines of some kind, and many indicated they followed more than one set of guidelines (Fig. 1). The majority followed WHO guidelines (62.9%) and/or Dominican national norms (59.4%), with a smaller percentage following the US-based ASCCP guidelines or other international guidelines (Table 3). OB/GYN residents were more likely than GYN specialists or non-specialists to follow ASCCP guidelines (23% vs. 12.9% and 6.0%, respectively, p = .04).
Fig. 1.
Cervical cancer screening guidelines followed by Dominican providers
Table 3.
Cervical cancer screening practices of providers in Santo Domingo and Monte Plata Provinces (2019) (N = 202)
| n (%)2 | |
|---|---|
| Mean for approximate number of women screened for cervical cancer in 1 month (SD, range) | 73.25 (159.27,0–201) |
| Median number of women screened (IQR) | 35.50 (19.75–69.25) |
| Mean for average age estimated at which patients become sexually active (SD, range) | 14.20 (1.78, 10–19) |
| Median for estimated average age starting sexual activity (IQR) | 14.00 (13–15) |
| Professional guidelines followed for cervical cancer screening and management of abnormal screening tests | |
| World Health Organization | 127 (62.9) |
| National norms for the Dominican Republic | 120 (59.4) |
| ASCCP | 25 (12.4) |
| NCCN | 10 (5.0) |
| Other | 2 (1.0) |
| Principal criterion used for deciding when to initiate cervical cancer screening for average-risk women | |
| Age | 16 (7.9) |
| *What age: mean reported (SD, range) | 20.29 (3.41, 14–25) |
| Median age reported (IQR) | 21 (17.5–22.0) |
| Time since initiation of sexual activity | 175 (86.6) |
| *How long after sexual activity begins (N =175) | |
| < 1 year | 93 (46.0) |
| 1 year | 73 (36.1) |
| > 1 year | 9 (4.5) |
| Patient requests to be screened | 11(5.4) |
| Screening tests used in practice | |
| Conventional cytology (Pap) | 175 (86.6) |
| Liquid-based cytology (Pap) | 75 (37.1) |
| High-risk HPV test | 50 (24.8) |
| Other | 3 (1.5) |
| How often do you recommend routine screening with these tests? | |
| Every 6 months | 70 (34.7) |
| Annually | 124 (61.4) |
| > 1 year | 8 (4.0) |
| Based on what criteria do you decide when to stop cervical cancer screening in your patients? | |
| Age | 50 (24.8) |
| *What age: mean age reported (SD, range) | 68.06 (6.91, 45–90) |
| Median age reported (IQR) | 65 (65–70) |
| After 3 normal tests | 46 (22.8) |
| After menopause | 31 (15.3) |
| When they stop coming in | 65 (32.2) |
| If the woman is not sexually active | 35 (17.3) |
| Other | 38 (18.8) |
| Most common = never stop recommending | 23 (60.5)3 |
| Hysterectomy | 4 (10.5)3 |
| What evaluation or treatment do you recommend for your patients with a cytology result of ASCUS? | |
| Repeat the test in 6 months | 65 (32.2) |
| Repeat the test in 1 year | 5 (2.5) |
| High-risk HPV test | 52 (25.7) |
| Colposcopy | 143 (70.8) |
| What evaluation or treatment do you recommend for your patients with a cytology result of LSIL? | |
| High-risk HPV test | 88 (43.6) |
| Colposcopy | 128 (63.4) |
| Treatment with cryotherapy or LEEP | 29 (14.4) |
| What evaluation or treatment do you recommend for your patients with a cytology result of HSIL? | |
| High-risk HPV test | 54 (26.7) |
| Colposcopy | 126 (62.4) |
| Treatment with cryotherapy or LEEP | 116 (57.4) |
SD standard deviation, LSIL low-grade intraepithelial lesion, IQR interquartile range, HSIL high-grade intraepithelial lesion, ASCUS atypical squamous cells of undetermined significance, LEEP loop electrosurgical excision
Unless otherwise indicated
N = 38 (for “other” category)
Cervical Cancer Screening Practices
Screening Initiation
Providers were asked to specify the principal criterion used for deciding when to initiate cervical cancer screening for average-risk women and given the response choices of age, time since onset of sexual activity, or “patient requests to be screened.” Eighty-seven percent of providers said their decision to start cervical cancer screening for women was based on time since onset of sexual activity, with only 7.9% starting screening based on the patient’s age and 5.4% because patients requested to be screened (Table 3). Among those who selected age as the criterion for initiating screening, the median age recommended was 21. Among those who selected time since onset of sexual activity, 82.1% recommended screening within 1 year of onset of sexual activity. Though only a small percentage, providers with fewer than 10 years in practice were more likely to choose age as the criterion for screening initiation than those with ten or more years in practice (14.1% vs. 4.0%, respectively, p = 0.4) (Table 4). OB/GYN residents were also more likely to choose age, when compared to GYN specialists and non-specialists (19.6% vs. 5.0% and 2.0%, respectively, p = .01). Similarly, those who reported they followed ASCCP guidelines were more likely to choose age as the parameter for screening initiation than those who did not follow ASCCP guidelines (21.4% vs. 5.7%, respectively, p = .01).
Table 4.
Cervical cancer screening initiation and frequency by demographic and practice characteristics
| Total | Main parameter for initiating cervical cancer screening | If responded time since first sexual activity. How long after first sexual activity do you start screening? | How often do you recommend routine cervical cancer screening? | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
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| N (%) | Age n (%) | Time since first sexual activity n (%) | Patient request n (%) | p value3 | N (%) | < 1 year n (%) | 1 year n (%) | > 1 year n (%) | p value | Every 6 months | Annually | 1 year | p value | |
| Age | 0.17 | 0.75 | 0.26 | |||||||||||
| <40 | 96 (47.5) | 11 (11.5) | 81 (84.4) | 4 (4.2) | 81 (46.3) | 41 (50.6) | 35 (43.2) | 5 (6.2) | 31 (32.3) | 59 (61.5) | 6 (6.3) | |||
| >40 | 106 (52.5) | 5 (4.7) | 7 (6.6) | 94 (88.7) | 94 (53.7) | 52 (55.3) | 38 (40.4) | 4 (4.3) | 39 (36.8) | 65 (61.3) | 2 (1.9) | |||
| Sex | p = 0.20 | 0.09 | 0.24 | |||||||||||
| Male | 66 (32.7) | 8 (12.1) | 56 (84.8) | 2 (3.0) | 56 (32.0) | 23 (41.1) | 29 (51.8) | 4 (7.1) | 18 (27.3) | 46 (69.7) | 2(3) | |||
| Female | 136 (67.3) | 8 (5.9) | 119 (87.5) | 9 (6.6) | 119 (68.0) | 70 (58.8) | 44 (37.0) | 5 (4.2) | 52 (38.2) | 78 (57.4) | 6 (4.4) | |||
| Years in practice | 0.04 | 0.86 | 0.06 | |||||||||||
| <10 years | 78 (38.6) | 11 (14.1) | 63 (80.8) | 4 (5.1) | 63 (36.0) | 32 (50.8) | 28 (44.4) | 3 (4.8) | 23 (29.5) | 49 (62.8) | 6 (7.7) | |||
| >10 years | 124 (61.4) | 5 (4.0) | 112 (90.3) | 7 (5.6) | 112 (64.0) | 61 (54.5) | 45 (40.2) | 6 (5.4) | 47 (37.9) | 75 (60.5) | 2 (1.6%) | |||
| Practice setting | 0.35 | 0.46 | 0.75 | |||||||||||
| Public | 154 (76.2) | 14 (9.1) | 133 (86.4) | 7 (4.5) | 133 (76.0) | 74 (55.6) | 52 (39.1) | 7 (5.3) | 53 (34.4) | 94 (61.0) | 7 (4.5) | |||
| Private | 48 (23.8) | 2 (4.2) | 42 (87.5) | 4 (8.3) | 42 (24.0) | 19 (45.2) | 21 (50.0) | 2 (4.8) | 17 (35.4) | 30 (62.5) | 1 (2.1) | |||
| Medical specialty | 0.01 | 0.03 | 0.48 | |||||||||||
| GYN specialist | 101 (50.0) | 5 (5.0) | 90 (89.1) | 6 (5.9) | 90 (51.4) | 44 (48.9) | 41 (45.6) | 5 (5.6) | 36 (35.6) | 60 (59.4) | 5 (5.0) | |||
| Non-specialist | 50 (24.8) | 1 (2.0) | 47 (94.0) | 2 (4.0) | 47 (26.9) | 34 (72.3) | 12 (25.5) | 1 (2.1) | 19 (38.0) | 31 (62.0) | 0 (0.0) | |||
| Ob/gyn resident | 51 (25.2) | 10 (19.6) | 38 (74.5) | 3 (5.9) | 38 (21.7) | 15 (39.5) | 20 (52.6) | 3 (7.9) | 15 (29.4) | 33 (64.7) | 3 (5.9) | |||
| Practice location | 0.22 | 0.03 | 0.36 | |||||||||||
| Santo Domingo | 172 (85.1) | 16 (9.3) | 147 (85.5) | 9 (5.2) | 147 (84.0) | 72 (49.0) | 66 (44.9) | 9 (6.1) | 56 (32.6) | 109 (63.4) | 7 (4.1) | |||
| Monte Plata | 30 (14.9) | 0 (0.0) | 28 (93.3) | 2 (6.7) | 28 (16.0) | 21 (75.0) | 7 (25.0) | 0 (0.0) | 14 (46.7) | 15 (50.0) | 1 (3.3) | |||
| Patients come from... | 0.60 | 0.54 | 0.53 | |||||||||||
| Rural areas | 16 (7.9) | 0 (0.0) | 15 (93.8) | 1 (6.3) | 15 (8.6) | 11 (73.3) | 4 (26.7) | 0 (0.0) | 8 (50.0) | 8 (50.0) | 0 (0.0) | |||
| Urban areas | 98 (48.5) | 8 (8.2) | 83 (84.7) | 7 (7.1) | 83 (47.4) | 43 (51.8) | 35 (42.2) | 5 (6.0) | 32 (32.7) | 63 (64.3) | 3 (3.1) | |||
| Both | 88 (43.6) | 8 (9.1) | 77 (87.5) | 3 (3.4) | 77 (44.0) | 39 (50.6) | 34 (44.2) | 4 (5.2) | 30 (34.1) | 53 (60.2) | 5 (5.7) | |||
| GUIDELINES | ||||||||||||||
| Follow WHO | 0.67 | 0.80 | 0.18 | |||||||||||
| WHO no | 75 (37.1) | 5 (6.7) | 67 (89.3) | 3 (4.0) | 67 (38.3) | 34 (50.7) | 30 (44.8) | 3 (4.5) | 20 (26.7) | 52 (69.3) | 3 (4.0) | |||
| WHO yes | 127(62.9) | 11 (8.7) | 108 (85.0) | 8(6.3) | 108 (61.7) | 59 (54.6) | 43 (39.8) | 6 (5.6) | 50 (39.4) | 72 (56.7) | 5(3.9) | |||
| Follow DR norms | 0.64 | 0.49 | 0.67 | |||||||||||
| DR norms no | 81 (40.1) | 8 (9.9) | 68 (84.0) | 5 (6.2) | 68 (38.9) | 37 (54.4) | 26 (38.2) | 5 (7.4) | 30 (37.0) | 47 (58.0) | 4 (4.9) | |||
| DR norms yes | 121 (59.9) | 8 (6.6) | 107 (88.4) | 6 (5.0) | 107 (61.1) | 56 (52.3) | 47 (43.9) | 4 (3.7) | 40 (33.1) | 77 (63.6) | 4 (3.3) | |||
| Follow ASCCP | 0.01 | 0.50 | 0.54 | |||||||||||
| ASCCP no | 174 (86.1) | 10 (5.7) | 155 (89.1) | 10 (5.7) | 155 (88.0) | 84 (54.2) | 64 (41.3) | 7 (4.5) | 62 (35.6) | 106 (60.9) | 6 (3.4) | |||
| ASCCP yes | 28 (13.9) | 6 (21.4) | 20 (71.4) | 2 (7.1) | 20 (11.4) | 9 (45.0) | 9 (45.0) | 2 (10.0) | 8 (28.6) | 18 (64.3) | 2 (7.1) | |||
Pearson’s χ2 unless otherwise indicated
Screening Tests Used
The majority (86.6%) of providers use conventional cytology (Pap smear) for cervical cancer screening. Fewer providers use liquid-based cytology (37.1%) and HPV tests (24.8%) (Table 3). This was a multiple-response item, so there were providers who were using more than one type of screening test. Providers in the public sector were more likely than private sector providers to report using conventional cytology (92.9% vs. 66.7%, respectively, p = .001), as were non-specialists compared to GYN specialists (100% vs 80.2%, respectively, p = .003). Liquid-based cytology and HPV tests were much more commonly used in the private sector, by GYN specialists and in Santo Domingo, and these differences were statistically significant (Table 5).
Table 5.
Current cervical cancer screening tests used
| Total | Conventional cytology (Pap) | Liquid-based Pap | hrHPV test | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
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| N (%) | No n (%) | Yes n (%) | p value4 | No n (%) | Yes n (%) | p value | No n (%) | Yes n (%) | p value | |
| Age | 0.11 | 0.002 | 0.37 | |||||||
| < 40 | 96 (47.5) | 9 (9.4) | 87 (90.6) | 71 (74.0) | 25 (26.0) | 75 (78.1) | 21 (10.4) | |||
| > 40 | 106 (52.5) | 18 (17.0) | 88 (83.0) | 56 (52.8) | 50 (47.2) | 77 (72.6) | 29 (27.4) | |||
| Sex | 0.34 | 0.88 | 0.12 | |||||||
| Male | 66 (32.7) | 11 (16.7) | 55 (83.3) | 36 (54.5) | 30 (45.5) | 45 (68.2) | 21 (31.8) | |||
| Female | 136 (67.3) | 16 (11.8) | 120 (88.2) | 91 (66.9) | 45 (33.1) | 107 (78.7) | 29 (21.3) | |||
| Years in practice | 0.30 | 0.001 | 0.44 | |||||||
| < 10 years | 78 (38.6) | 8 (10.3) | 70 (89.7) | 60 (76.9) | 18 (23.1) | 61 (78.2) | 17 (21.8) | |||
| > 10 years | 124 (61.4) | 19 (15.3) | 105 (84.7) | 67 (54.0) | 57 (46.0) | 91 (73.4) | 33 (26.6) | |||
| Practice setting | 0.001 | 0.001 | 0.001 | |||||||
| Public | 154 (76.2) | 11 (7.1) | 143 (92.9) | 121 (78.6) | 33 (21.4) | 128 (83.1) | 26 (16.9) | |||
| Private | 48 (23.8) | 16 (33.3) | 32 (66.7) | 6 (12.5) | 42 (87.5) | 24 (50.0) | 24 (50.0) | |||
| Medical specialty | 0.003 | 0.001 | 0.004 | |||||||
| GYN specialist | 101 (50.0) | 20 (19.8) | 81 (80.2) | 45 (44.6) | 56 (55.4) | 68 (67.3) | 33 (32.7) | |||
| Non-specialist | 50 (24.8) | 0 (0.0) | 50 (100.0) | 42 (84.0) | 8 (16.0) | 46 (92.0) | 4 (8.0) | |||
| Ob/gyn resident | 51 (25.2) | 7 (13.7) | 44 (86.3) | 40 (78.4) | 11 (21.6) | 38 (74.5) | 13 (25.5) | |||
| Practice location | 0.38 | 0.003 | 0.04 | |||||||
| Santo Domingo | 172 (85.1) | 25 (14.5) | 147 (85.5) | 101 (58.7) | 71 (41.3) | 125 (72.7) | 47 (27.3) | |||
| Monte Plata | 30 (14.9) | 2 (6.7) | 28 (93.3) | 26 (86.7) | 4 (13.3) | 27 (90.0) | 3 (10.0) | |||
| Patients come from… | 0.73 | 0.22 | 0.20 | |||||||
| Rural areas | 16 (7.9) | 2 (12.5) | 14 (87.5) | 12 (75.0) | 4 (25.0) | 15 (93.8) | 1 (6.3) | |||
| Urban areas | 98 (48.5) | 15 (15.3) | 83 (84.7) | 56 (57.1) | 42 (42.9) | 72 (73.5) | 26 (26.5) | |||
| Both | 88 (43.6) | 10 (11.4) | 78 (88.6) | 59 (67.0) | 29 (33.0) | 65 (73.9) | 23 (26.1) | |||
hrHPV test high-risk HPV test
Pearson’s χ2 unless otherwise indicated
Frequency of Screening
Providers almost universally recommend screening every 6 months (34.7%) or every year (61.4%), with only 4% recommending a screening interval of more than 1 year (Table 3). There were no significant differences in these recommendations by demographic or practice characteristics (Table 4).
Discontinuation of Screening
Provider responses were more varied (as were the response options) regarding what criteria providers use for discontinuing cervical cancer screening (Table 3). Of the 24.8% who chose age, the median age at which they recommended stopping screening was 65. The most commonly chosen response (32.2%) was “when they stop coming in,” and likely overlapped with the “other” category, within which the most common open-ended response was that they never stop recommending screening. Given the variability in responses, as well as the fact that criteria for discontinuing screening are not clearly defined by guidelines (with the exception of ASCCP guidelines), bivariable analyses were not conducted for this item.
Management of Abnormal Screening Tests
Providers were asked a series of three questions regarding management of abnormal cytology (Pap smear) results (Bethesda criteria [14]). These items again were multiple-response options. The most commonly recommended management following abnormal Pap tests was colposcopy: 70.8% for ASCUS (Atypical Squamous Cells of Undetermined Significance); 63.4% for LSIL (low-grade intraepithelial lesion); and 62.4% for HSIL (high-grade intraepithelial lesion) (Table 3).
In bivariable analyses, there were some differences in management of an ASCUS Pap result. Providers under age 40 (40.6% vs. 24.5% for providers 40 or older, p = .02) and non-specialists (46.0% vs. 22.8% for GYN specialists, p = .01) were more likely to choose “repeat test in 6 months” as a management option. Providers age 40 and older (81.1% vs. 59.4% for providers under age 40, p = .001), with 10 or more years in practice (78.2% vs. 59.0% for providers with less than 10 years in practice, p = .004), and GYN specialists (84.2% vs. 52.0% for non-specialists, p = .001) were more likely to choose colposcopy as a management option. Those providers that followed WHO guidelines were more likely than those who did not to choose colposcopy as a management option for ASCUS (77.2% vs. 60.0%, respectively, p = .01). Those providers that follow ASCCP guidelines were more likely than those who do not to choose “repeat test in 1 year” as a management option (10.7% vs. 1.1%, p = .02).
Discussion
This study found that Dominican providers in the Santo Domingo and Monte Plata provinces reported following national and/or international guidelines for cervical cancer screening. Findings also indicated that the vast majority of providers start screening women within a year of onset of sexual activity and screen women at least yearly. In addition, colposcopy is the most commonly used follow-up for abnormal cytology findings.
With regard to screening initiation, Dominican providers in this study do not follow age-based screening guidelines recommended by most international organizations [3, 7]. Providers follow Dominican national norms, because the norms prioritize screening women ages 35–64 but also define additional risk factors that would warrant screening, such as beginning sexual activity at an early age, and having a history of multiple sexual partners [4]. Such caveats leave much to the provider’s discretion in terms of screening initiation.
Providers do not appear to have adopted the practice of extended screening intervals, even those suggested by Dominican national norms, allowing a 3-year interval following two normal annual Pap tests. This confirms focus group findings in which women in the Santo Domingo area reported providers recommended screening every 6–12 months [8].
World Health Organization guidelines for cervical cancer screening recommend focusing on screening average-risk women ages 30–49 for maximum impact in terms of early detection of cervical pre-cancers and ultimately reduction of cervical cancer mortality [3]. The WHO guidelines also assume that guidelines will be adapted to the resources, setting and available epidemiologic data for the individual country. Dominican national norms reflect this type of adaptation, though lack the country-specific data on prevalence of cervical pre-cancers and cancer to inform decisions regarding screening women younger than age 30. In an area of high cervical cancer incidence and mortality, provider experience may drive a tendency towards earlier and more frequent screening. Previous studies in the USA and Latin America have found similar reticence among providers to extend the interval for screening beyond 1 year even as guidelines changed [11, 15].
The rationale for not screening immediately at very young ages is because the rates of cervical cancer are very low in women under age 25, while the rates of transient HPV infection and associated cervical neoplasias that will not develop into cancer are very high [5, 7]. A culture of early screening in a country such as the Dominican Republic may create a high demand for follow-up of abnormal Pap smears, in particular colposcopy, further burdening the health system and possibly creating delays in follow-up. In addition, as the science of global cervical cancer prevention evolves and countries move increasingly towards molecular testing with HPV tests [7, 16], defining the at-risk population appropriate for screening becomes increasingly important: for optimizing the reach of limited resources, maximizing public health impact in decreasing mortality from cervical cancer, and also in balancing benefits and harms to individual patients. Survey findings from this study of provider practices, along with contextual information regarding provider risk perception and decision-making regarding screening from qualitative findings (manuscript under review), suggest that there may be challenges to the acceptability of such screening modalities and practices in the Dominican Republic.
This study was limited to a small sample of providers in a single region and may not represent the practices of Dominican providers more broadly. In addition, survey responses were based on self-report from providers and there may be some reporting bias for questions such as estimated volume of women screened monthly and estimated average age at which women begin sexual activity. Given the interviewer-administered survey format, there is also the possibility of social desirability bias in responses to questions of guidelines used for cervical cancer screening. Finally, this study was limited to provider practices and does not address larger health system factors related to reaching the population at risk for cervical cancer.
Despite these limitations, this study provides important insight into current cervical cancer screening practices among Dominican providers. Findings may be used to refine the survey questionnaire for future research with a nationally representative sample of Dominican providers across regions, and to develop additional items regarding cervical cancer screening service delivery factors. Additionally, findings may inform future updating of national norms for cervical cancer prevention in the Dominican Republic as well as provider educational activities to share global and regional strategies for optimizing cervical cancer prevention efforts.
Funding Information
This research was supported in part by the NYU CTSA grant TL1 TR001447 from the National Center for Advancing Translational Sciences, National Institutes of Health. Additional support was received through New York University Rory Meyers College of Nursing Fred Schmidt and Paula Greenidge Scholarships and the Sigma Theta Tau Upsilon Chapter Research Grant.
Footnotes
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of interest.
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