行动中的实施:在美国合作向宫颈癌的初级HPV筛查过渡

IF 503.1 1区 医学 Q1 ONCOLOGY
Levi S. Downs Jr MD, Ritu Nayar MD, Jane Gerndt MPH, Debbie Saslow PhD, for the American Cancer Society Primary HPV Screening Initiative Steering Committee
{"title":"行动中的实施:在美国合作向宫颈癌的初级HPV筛查过渡","authors":"Levi S. Downs Jr MD,&nbsp;Ritu Nayar MD,&nbsp;Jane Gerndt MPH,&nbsp;Debbie Saslow PhD,&nbsp;for the American Cancer Society Primary HPV Screening Initiative Steering Committee","doi":"10.3322/caac.21786","DOIUrl":null,"url":null,"abstract":"<p>In July 2020, the American Cancer Society (ACS) released an updated cervical cancer screening guideline calling for primary human papillomavirus (HPV) screening as the preferred strategy.<span><sup>1</sup></span> <i>Primary HPV screening</i> refers to cervical cancer screening with an HPV test alone as the initial screening modality. Under this strategy, cervical cytology is reserved for use as one option for a triage test should the HPV test result be positive. The scientific data supporting this recommendation have been reviewed both in the United States and in other countries that have transitioned to primary HPV screening.<span><sup>2, 3</sup></span></p><p>The Primary HPV Screening Initiative (PHSI), nested under the ACS National Roundtable on Cervical Cancer, is a national consortium supported by the ACS that convenes key partners and experts on six workgroups and a Steering Committee charged with identifying critical barriers and opportunities for transitioning to primary HPV screening. The workgroups engage approximately 100 volunteers who began their activities in the fall of 2021. Workgroup members are multiprofessional and include leaders in health care policy, health care delivery, and patient care as well as patient advocates. The project is overseen by a Steering Committee (Figure 1) made up of the co-chairs of each of the six workgroups and other experts identified for their leadership in the areas of cervical cancer screening and health care policy. The final deliverable is an implementation report (<i>roadmap</i>), complete with tools and recommendations to support health systems, laboratories, providers, patients, and payors as they make this transition.</p><p>The <i>Provider Needs Workgroup</i> is developing resources in a variety of formats both to educate providers and to help them educate their patients about the benefits and safety of primary HPV screening. The deliverables include tools to aid in the management of patients with abnormal screening results. Success will be defined by change in provider behavior and will depend in large part on the degree to which major professional organizations (e.g., American College of Obstetricians and Gynecologists, American Academy of Family Physicians, Nurse Practitioners in Women's Health, and American Society for Colposcopy and Cervical Pathology) promote primary HPV screening as the standard for excellent care. The US Preventive Services Task Force recommends primary HPV screening as one of three strategies to screen for cervical cancer starting at age 30 years but does not give preference to modality.<span><sup>4</sup></span> As of this writing, updated recommendations from the US Preventive Services Task Force are pending. It is desirable that all organizations agree on preferred screening guidelines to facilitate prevention efforts that are supported by evidence and widely accessible. Providers are most likely to follow guidelines promoted by their professional societies, so they are the audience of many of this workgroup's deliverables.</p><p>Currently, there appears to be limited and variable understanding among many stakeholders regarding why primary HPV screening is better than cotesting. Primary HPV screening has been shown to be more effective than screening with cytology alone and performs similarly to and with lower costs than screening with cotesting.<span><sup>5</sup></span> Transitioning laboratories to support the changes needed to implement primary HPV screening in the United States is a major yet necessary undertaking. For many laboratories that do not have a US Food and Drug Administration-approved primary HPV screening platform, the logistics of changes in instrumentation, specimen workflow, implementation of newly approved tests for triage of HPV-positive cases, modification of existing quality-assurance/accreditation requirements for cytology-based testing, and impact on the cytologist workforce all need careful consideration based on size and other laboratory-specific attributes. Furthermore, quality assurance for primary HPV screening, the performance of cytology as a triage test, and that of colposcopic biopsy in vaccinated cohorts are additional challenges that affect laboratory reporting in the primary HPV screening paradigm. The <i>Laboratory Infrastructure Workgroup</i> has been working on developing educational and practical resources to address many of these concerns.</p><p>As many as 20% of patients in the United States are currently screened for cervical cancer using cytology alone.<span><sup>6</sup></span> These patients tend to be served by safety-net providers in underserved areas and are more likely to be low-income and from communities of color.<span><sup>7</sup></span> Screening with cytology alone requires more frequent testing, frequent follow-up for minor, low-risk abnormalities, and does not screen for high-risk HPV, the causative agent of virtually all cases of cervical cancer. Although it is more specific in detecting precancer, cytology is less sensitive than HPV screening, has a high number of equivocal results, and has interlaboratory variability. HPV self-sampling, once US Food and Drug Administration-approved, may be especially helpful to improve screening rates in currently underscreened populations. Therefore, changing screening practices from cytology alone to primary HPV screening is essential and may have a different set of challenges than the transition faced by programs performing cotesting, such as access and cost considerations. The <i>Moving from Cytology Alone Workgroup</i> is addressing the specific needs and barriers anticipated for these lower resource programs.</p><p>Information technology plays an important role in how health care providers order and manage primary HPV screening tests and how laboratories handle patient specimens and report results. The <i>Information Technology/Electronic Health Records Needs Workgroup</i> is identifying anticipated barriers that health systems may face and outlining recommendations to address them, recognizing that recommendations must be broad enough to apply to different electronic health record (EHR) platforms but specific enough to be useful. The importance of standardized structured data to facilitate implementation of cervical cancer screening and management clinical decision support systems into the EHR will be emphasized and explained. National Current Procedural Terminology codes and Logical Observation Identifiers Names and Codes terminology currently do not differentiate between HPV tests collected for primary HPV screening versus cotesting, which affects accurate test ordering, results tracking, and preventive care tracking tools. This issue is also being addressed by this workgroup.</p><p>In the United States, payors significantly affect which screening modalities are used in clinical practice. For a successful transition to the widespread use of primary HPV screening, the <i>Insurance Coverage/Payors Workgroup</i> is providing support for billing and coding for primary HPV screening. It is essential that these billing codes be available to use for patients starting at age 25 years. In addition, insurance plans across the country will need to work with their network providers to support the use of primary HPV screening. One challenge faced by this workgroup is the need to balance efforts to promote the use of primary HPV screening while ascertaining that low-resource health centers providing care to the most at-risk patients are not penalized for anticipated delays in uptake of new screening guidelines based on the costs and logistics of capital investments and implementation.</p><p>Implementation processes of previous cervical cancer screening guidelines have demonstrated that patient perception and education are important considerations when implementing new approaches. This will likely be the case for primary HPV screening and screening done using self-collected specimens in the future. The <i>Patient Perceptions Workgroup</i> is creating educational tools for patients that will destigmatize the role of HPV in cervical cancer screening and encourage use of the right test(s) for the right patient at the right time. Although primary HPV screening has been adopted in many countries, this workgroup will focus on issues facing women and people with a cervix in the United States that are often different than those in other countries because of cultural differences and/or different health care delivery models.</p><p>The combined efforts of these six workgroups are resulting in the creation of a catalog of resources for providers, professional societies, health systems, patients, payors, and various other stakeholders. There is intentional overlap among the workgroups and the issues that they aim to address. With the support of the Steering Committee, workgroups collaborate on issues and deliverables that are cross-cutting. We will inform partners about our work and outcomes through commentaries like this one as well as through presentations, workshops at professional society meetings, social media and email communications, website announcements, and other stakeholder forums.<span><sup>2, 8</sup></span> Upon dissemination of the implementation report and tools, the members of this initiative hope to see guideline alignment and primary HPV screening being used more across the United States. This initiative will help to advance future cervical cancer areas of work, including preparing for self-sampling, and other guideline implementation opportunities.</p><p>The PHSI innovatively accelerates progress beyond guideline development and into the guideline implementation space. This initiative is a crucial step in the successful adoption of primary HPV screening and guideline alignment across organizations. In addition, the initiative is positively contributing to growing synergistic relationships and is a foundation for the newly formed ACS National Roundtable on Cervical Cancer (NRTCC).<span><sup>9</sup></span> The ACS NRTCC aims accelerate progress toward cervical cancer elimination by reducing barriers to care, eliminating disparities, reducing harms, and promoting new technologies that reduce the morbidity and mortality of cervical cancer for everyone. Achieving the Initiative's objectives and harnessing the power of these collaborative relationships over the next year will provide a critical and model infrastructure to support advancements in cervical cancer prevention and elimination in the coming years through the ACS NRTCC and other channels.</p><p>To learn more and give comment or input to our efforts, you can visit our website (cervicalroundtable.org).</p><p>The authors disclosed no conflicts of interest.</p>","PeriodicalId":137,"journal":{"name":"CA: A Cancer Journal for Clinicians","volume":"73 5","pages":"458-460"},"PeriodicalIF":503.1000,"publicationDate":"2023-06-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.3322/caac.21786","citationCount":"2","resultStr":"{\"title\":\"Implementation in action: Collaborating on the transition to primary HPV screening for cervical cancer in the United States\",\"authors\":\"Levi S. Downs Jr MD,&nbsp;Ritu Nayar MD,&nbsp;Jane Gerndt MPH,&nbsp;Debbie Saslow PhD,&nbsp;for the American Cancer Society Primary HPV Screening Initiative Steering Committee\",\"doi\":\"10.3322/caac.21786\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p>In July 2020, the American Cancer Society (ACS) released an updated cervical cancer screening guideline calling for primary human papillomavirus (HPV) screening as the preferred strategy.<span><sup>1</sup></span> <i>Primary HPV screening</i> refers to cervical cancer screening with an HPV test alone as the initial screening modality. Under this strategy, cervical cytology is reserved for use as one option for a triage test should the HPV test result be positive. The scientific data supporting this recommendation have been reviewed both in the United States and in other countries that have transitioned to primary HPV screening.<span><sup>2, 3</sup></span></p><p>The Primary HPV Screening Initiative (PHSI), nested under the ACS National Roundtable on Cervical Cancer, is a national consortium supported by the ACS that convenes key partners and experts on six workgroups and a Steering Committee charged with identifying critical barriers and opportunities for transitioning to primary HPV screening. The workgroups engage approximately 100 volunteers who began their activities in the fall of 2021. Workgroup members are multiprofessional and include leaders in health care policy, health care delivery, and patient care as well as patient advocates. The project is overseen by a Steering Committee (Figure 1) made up of the co-chairs of each of the six workgroups and other experts identified for their leadership in the areas of cervical cancer screening and health care policy. The final deliverable is an implementation report (<i>roadmap</i>), complete with tools and recommendations to support health systems, laboratories, providers, patients, and payors as they make this transition.</p><p>The <i>Provider Needs Workgroup</i> is developing resources in a variety of formats both to educate providers and to help them educate their patients about the benefits and safety of primary HPV screening. The deliverables include tools to aid in the management of patients with abnormal screening results. Success will be defined by change in provider behavior and will depend in large part on the degree to which major professional organizations (e.g., American College of Obstetricians and Gynecologists, American Academy of Family Physicians, Nurse Practitioners in Women's Health, and American Society for Colposcopy and Cervical Pathology) promote primary HPV screening as the standard for excellent care. The US Preventive Services Task Force recommends primary HPV screening as one of three strategies to screen for cervical cancer starting at age 30 years but does not give preference to modality.<span><sup>4</sup></span> As of this writing, updated recommendations from the US Preventive Services Task Force are pending. It is desirable that all organizations agree on preferred screening guidelines to facilitate prevention efforts that are supported by evidence and widely accessible. Providers are most likely to follow guidelines promoted by their professional societies, so they are the audience of many of this workgroup's deliverables.</p><p>Currently, there appears to be limited and variable understanding among many stakeholders regarding why primary HPV screening is better than cotesting. Primary HPV screening has been shown to be more effective than screening with cytology alone and performs similarly to and with lower costs than screening with cotesting.<span><sup>5</sup></span> Transitioning laboratories to support the changes needed to implement primary HPV screening in the United States is a major yet necessary undertaking. For many laboratories that do not have a US Food and Drug Administration-approved primary HPV screening platform, the logistics of changes in instrumentation, specimen workflow, implementation of newly approved tests for triage of HPV-positive cases, modification of existing quality-assurance/accreditation requirements for cytology-based testing, and impact on the cytologist workforce all need careful consideration based on size and other laboratory-specific attributes. Furthermore, quality assurance for primary HPV screening, the performance of cytology as a triage test, and that of colposcopic biopsy in vaccinated cohorts are additional challenges that affect laboratory reporting in the primary HPV screening paradigm. The <i>Laboratory Infrastructure Workgroup</i> has been working on developing educational and practical resources to address many of these concerns.</p><p>As many as 20% of patients in the United States are currently screened for cervical cancer using cytology alone.<span><sup>6</sup></span> These patients tend to be served by safety-net providers in underserved areas and are more likely to be low-income and from communities of color.<span><sup>7</sup></span> Screening with cytology alone requires more frequent testing, frequent follow-up for minor, low-risk abnormalities, and does not screen for high-risk HPV, the causative agent of virtually all cases of cervical cancer. Although it is more specific in detecting precancer, cytology is less sensitive than HPV screening, has a high number of equivocal results, and has interlaboratory variability. HPV self-sampling, once US Food and Drug Administration-approved, may be especially helpful to improve screening rates in currently underscreened populations. Therefore, changing screening practices from cytology alone to primary HPV screening is essential and may have a different set of challenges than the transition faced by programs performing cotesting, such as access and cost considerations. The <i>Moving from Cytology Alone Workgroup</i> is addressing the specific needs and barriers anticipated for these lower resource programs.</p><p>Information technology plays an important role in how health care providers order and manage primary HPV screening tests and how laboratories handle patient specimens and report results. The <i>Information Technology/Electronic Health Records Needs Workgroup</i> is identifying anticipated barriers that health systems may face and outlining recommendations to address them, recognizing that recommendations must be broad enough to apply to different electronic health record (EHR) platforms but specific enough to be useful. The importance of standardized structured data to facilitate implementation of cervical cancer screening and management clinical decision support systems into the EHR will be emphasized and explained. National Current Procedural Terminology codes and Logical Observation Identifiers Names and Codes terminology currently do not differentiate between HPV tests collected for primary HPV screening versus cotesting, which affects accurate test ordering, results tracking, and preventive care tracking tools. This issue is also being addressed by this workgroup.</p><p>In the United States, payors significantly affect which screening modalities are used in clinical practice. For a successful transition to the widespread use of primary HPV screening, the <i>Insurance Coverage/Payors Workgroup</i> is providing support for billing and coding for primary HPV screening. It is essential that these billing codes be available to use for patients starting at age 25 years. In addition, insurance plans across the country will need to work with their network providers to support the use of primary HPV screening. One challenge faced by this workgroup is the need to balance efforts to promote the use of primary HPV screening while ascertaining that low-resource health centers providing care to the most at-risk patients are not penalized for anticipated delays in uptake of new screening guidelines based on the costs and logistics of capital investments and implementation.</p><p>Implementation processes of previous cervical cancer screening guidelines have demonstrated that patient perception and education are important considerations when implementing new approaches. This will likely be the case for primary HPV screening and screening done using self-collected specimens in the future. The <i>Patient Perceptions Workgroup</i> is creating educational tools for patients that will destigmatize the role of HPV in cervical cancer screening and encourage use of the right test(s) for the right patient at the right time. Although primary HPV screening has been adopted in many countries, this workgroup will focus on issues facing women and people with a cervix in the United States that are often different than those in other countries because of cultural differences and/or different health care delivery models.</p><p>The combined efforts of these six workgroups are resulting in the creation of a catalog of resources for providers, professional societies, health systems, patients, payors, and various other stakeholders. There is intentional overlap among the workgroups and the issues that they aim to address. With the support of the Steering Committee, workgroups collaborate on issues and deliverables that are cross-cutting. We will inform partners about our work and outcomes through commentaries like this one as well as through presentations, workshops at professional society meetings, social media and email communications, website announcements, and other stakeholder forums.<span><sup>2, 8</sup></span> Upon dissemination of the implementation report and tools, the members of this initiative hope to see guideline alignment and primary HPV screening being used more across the United States. This initiative will help to advance future cervical cancer areas of work, including preparing for self-sampling, and other guideline implementation opportunities.</p><p>The PHSI innovatively accelerates progress beyond guideline development and into the guideline implementation space. This initiative is a crucial step in the successful adoption of primary HPV screening and guideline alignment across organizations. In addition, the initiative is positively contributing to growing synergistic relationships and is a foundation for the newly formed ACS National Roundtable on Cervical Cancer (NRTCC).<span><sup>9</sup></span> The ACS NRTCC aims accelerate progress toward cervical cancer elimination by reducing barriers to care, eliminating disparities, reducing harms, and promoting new technologies that reduce the morbidity and mortality of cervical cancer for everyone. Achieving the Initiative's objectives and harnessing the power of these collaborative relationships over the next year will provide a critical and model infrastructure to support advancements in cervical cancer prevention and elimination in the coming years through the ACS NRTCC and other channels.</p><p>To learn more and give comment or input to our efforts, you can visit our website (cervicalroundtable.org).</p><p>The authors disclosed no conflicts of interest.</p>\",\"PeriodicalId\":137,\"journal\":{\"name\":\"CA: A Cancer Journal for Clinicians\",\"volume\":\"73 5\",\"pages\":\"458-460\"},\"PeriodicalIF\":503.1000,\"publicationDate\":\"2023-06-22\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://onlinelibrary.wiley.com/doi/epdf/10.3322/caac.21786\",\"citationCount\":\"2\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"CA: A Cancer Journal for Clinicians\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://onlinelibrary.wiley.com/doi/10.3322/caac.21786\",\"RegionNum\":1,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"ONCOLOGY\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"CA: A Cancer Journal for Clinicians","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.3322/caac.21786","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"ONCOLOGY","Score":null,"Total":0}
引用次数: 2

摘要

2020年7月,美国癌症协会(ACS)发布了一份更新的宫颈癌筛查指南,呼吁将原发性人乳头瘤病毒(HPV)筛查作为首选策略原发性人乳头瘤病毒筛查是指以人乳头瘤病毒检测作为最初筛查方式的宫颈癌筛查。根据这一策略,如果HPV检测结果呈阳性,则保留宫颈细胞学检查作为分诊检查的一种选择。支持这一建议的科学数据已经在美国和其他已经过渡到初级HPV筛查的国家进行了审查。原发性HPV筛查倡议(PHSI)隶属于ACS国家宫颈癌圆桌会议,是由ACS支持的一个国家联盟,它召集了六个工作组的主要合作伙伴和专家,以及一个指导委员会,负责确定过渡到原发性HPV筛查的关键障碍和机会。这些工作组有大约100名志愿者参与,他们于2021年秋季开始活动。工作组成员是多专业人士,包括卫生保健政策、卫生保健提供和患者护理方面的领导者以及患者倡导者。该项目由一个指导委员会(图1)监督,该委员会由六个工作组中的每个工作组的联合主席和在宫颈癌筛查和保健政策领域被确定为领导的其他专家组成。最终可交付成果是一份实施报告(路线图),其中包括支持卫生系统、实验室、提供者、患者和付款人进行这一过渡的工具和建议。提供者需求工作组正在开发各种形式的资源,以教育提供者并帮助他们教育患者关于初次HPV筛查的益处和安全性。可交付成果包括帮助管理筛查结果异常的患者的工具。成功与否将取决于提供者行为的改变,并在很大程度上取决于主要专业组织(如美国妇产科医师学会、美国家庭医生学会、妇女健康执业护士和美国阴道镜和宫颈病理学会)将初级HPV筛查作为优质护理标准的推广程度。美国预防服务工作组建议,从30岁开始筛查宫颈癌的三种策略中,HPV初筛是其中之一,但没有给出优先选择的方式在撰写本文时,美国预防服务工作组的最新建议正在等待中。希望所有组织都能就首选筛查指南达成一致,以促进有证据支持和可广泛获取的预防工作。提供者最有可能遵循由他们的专业协会提出的指导方针,因此他们是该工作组许多可交付成果的受众。目前,在许多利益相关者中,关于为什么初次HPV筛查比共同检测更好的理解似乎是有限的和可变的。原发性HPV筛查已被证明比单独进行细胞学筛查更有效,其效果与竞争筛查相似且成本更低过渡实验室以支持在美国实施初级HPV筛查所需的变化是一项重大但必要的工作。对于许多没有美国食品和药物管理局批准的主要HPV筛查平台的实验室来说,仪器变化的后勤、标本工作流程、新批准的HPV阳性病例分诊测试的实施、现有细胞学检测的质量保证/认证要求的修改以及对细胞学工作者队伍的影响都需要根据规模和其他实验室特定属性仔细考虑。此外,原发性HPV筛查的质量保证,细胞学作为分诊测试的表现,以及接种疫苗人群的阴道镜活检是影响原发性HPV筛查范式实验室报告的额外挑战。实验室基础设施工作组一直致力于开发教育和实用资源,以解决许多这些问题。在美国,多达20%的患者目前仅使用细胞学检查进行宫颈癌筛查这些患者往往在服务不足的地区由安全网提供者提供服务,并且更有可能是低收入和有色人种社区单独使用细胞学筛查需要更频繁的检测,对轻微的低风险异常进行频繁的随访,并且不能筛查几乎所有宫颈癌病例的病原体高危HPV。虽然细胞学在检测癌前病变方面更有特异性,但它的敏感性低于HPV筛查,有大量模棱两可的结果,并且具有实验室间的可变性。 一旦美国食品和药物管理局批准,HPV自采样可能特别有助于提高目前筛查不足人群的筛查率。因此,将筛查实践从单独的细胞学检查转变为原发性HPV筛查是必不可少的,并且可能与进行联合检测的项目所面临的一系列挑战不同,例如获取和成本考虑。从细胞学单独移动工作组正在解决这些低资源项目的特定需求和预期障碍。信息技术在卫生保健提供者如何订购和管理初级HPV筛查测试以及实验室如何处理患者标本和报告结果方面发挥着重要作用。信息技术/电子健康记录需求工作组正在确定卫生系统可能面临的预期障碍,并概述解决这些障碍的建议,认识到建议必须足够广泛,以便适用于不同的电子健康记录(EHR)平台,但必须足够具体,以便有用。将强调和解释标准化结构化数据对促进在电子病历中实施宫颈癌筛查和管理临床决策支持系统的重要性。国家现行程序术语代码和逻辑观察标识符名称和代码术语目前没有区分为原发性HPV筛查收集的HPV检测与共同检测,这影响了准确的检测排序、结果跟踪和预防性护理跟踪工具。这个工作组也正在处理这个问题。在美国,付款人对临床实践中使用的筛查方式有很大影响。为了成功过渡到广泛使用HPV初级筛查,保险覆盖/付款人工作组正在为HPV初级筛查的计费和编码提供支持。从25岁开始,患者就可以使用这些计费代码,这一点至关重要。此外,全国各地的保险计划将需要与其网络提供者合作,以支持使用初级HPV筛查。该工作组面临的一项挑战是,需要平衡促进使用HPV初级筛查的努力,同时确定向最危险患者提供护理的资源匮乏的保健中心不会因为基于资本投资和实施的成本和后勤的新筛查指南的预期延迟而受到惩罚。以前的子宫颈癌筛查指南的实施过程表明,在实施新方法时,患者的认知和教育是重要的考虑因素。这很可能是在初次HPV筛查和使用自行收集的标本进行筛查的情况下。患者认知工作组正在为患者创建教育工具,以消除HPV在宫颈癌筛查中的作用,并鼓励在正确的时间为正确的患者使用正确的检测。虽然许多国家已经采用了初级HPV筛查,但该工作组将重点关注美国妇女和宫颈患者面临的问题,这些问题往往与其他国家不同,因为文化差异和/或不同的卫生保健提供模式。这六个工作组的共同努力正在为提供者、专业协会、卫生系统、患者、付款人和各种其他利益攸关方创建资源目录。在工作组和它们旨在解决的问题之间有意存在重叠。在指导委员会的支持下,各工作组就跨领域的问题和可交付成果进行协作。我们将通过以下方式向合作伙伴通报我们的工作和成果:本文的评论、演讲、专业协会会议研讨会、社交媒体和电子邮件交流、网站公告以及其他利益相关方论坛。2,8在传播实施报告和工具后,该倡议的成员希望看到指南的一致性和初级HPV筛查在美国得到更多的使用。这一举措将有助于推进今后宫颈癌领域的工作,包括为自我抽样做准备,并为其他指南的实施提供机会。PHSI创新地加速了指南制定和指南实施领域的进展。这一举措是跨组织成功采用HPV初级筛查和指南一致性的关键一步。此外,该倡议积极促进了增效关系的发展,并为新成立的ACS全国宫颈癌圆桌会议(NRTCC)奠定了基础。 ACS NRTCC旨在通过减少护理障碍、消除差异、减少危害和推广新技术来降低每个人宫颈癌的发病率和死亡率,从而加速消除宫颈癌的进程。在接下来的一年里,实现该倡议的目标并利用这些合作关系的力量,将为未来几年通过ACS NRTCC和其他渠道支持宫颈癌预防和消除方面的进展提供关键和示范基础设施。欲了解更多信息,并对我们的工作提出意见或建议,请访问我们的网站(cervicalroundtable.org)。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Implementation in action: Collaborating on the transition to primary HPV screening for cervical cancer in the United States

In July 2020, the American Cancer Society (ACS) released an updated cervical cancer screening guideline calling for primary human papillomavirus (HPV) screening as the preferred strategy.1 Primary HPV screening refers to cervical cancer screening with an HPV test alone as the initial screening modality. Under this strategy, cervical cytology is reserved for use as one option for a triage test should the HPV test result be positive. The scientific data supporting this recommendation have been reviewed both in the United States and in other countries that have transitioned to primary HPV screening.2, 3

The Primary HPV Screening Initiative (PHSI), nested under the ACS National Roundtable on Cervical Cancer, is a national consortium supported by the ACS that convenes key partners and experts on six workgroups and a Steering Committee charged with identifying critical barriers and opportunities for transitioning to primary HPV screening. The workgroups engage approximately 100 volunteers who began their activities in the fall of 2021. Workgroup members are multiprofessional and include leaders in health care policy, health care delivery, and patient care as well as patient advocates. The project is overseen by a Steering Committee (Figure 1) made up of the co-chairs of each of the six workgroups and other experts identified for their leadership in the areas of cervical cancer screening and health care policy. The final deliverable is an implementation report (roadmap), complete with tools and recommendations to support health systems, laboratories, providers, patients, and payors as they make this transition.

The Provider Needs Workgroup is developing resources in a variety of formats both to educate providers and to help them educate their patients about the benefits and safety of primary HPV screening. The deliverables include tools to aid in the management of patients with abnormal screening results. Success will be defined by change in provider behavior and will depend in large part on the degree to which major professional organizations (e.g., American College of Obstetricians and Gynecologists, American Academy of Family Physicians, Nurse Practitioners in Women's Health, and American Society for Colposcopy and Cervical Pathology) promote primary HPV screening as the standard for excellent care. The US Preventive Services Task Force recommends primary HPV screening as one of three strategies to screen for cervical cancer starting at age 30 years but does not give preference to modality.4 As of this writing, updated recommendations from the US Preventive Services Task Force are pending. It is desirable that all organizations agree on preferred screening guidelines to facilitate prevention efforts that are supported by evidence and widely accessible. Providers are most likely to follow guidelines promoted by their professional societies, so they are the audience of many of this workgroup's deliverables.

Currently, there appears to be limited and variable understanding among many stakeholders regarding why primary HPV screening is better than cotesting. Primary HPV screening has been shown to be more effective than screening with cytology alone and performs similarly to and with lower costs than screening with cotesting.5 Transitioning laboratories to support the changes needed to implement primary HPV screening in the United States is a major yet necessary undertaking. For many laboratories that do not have a US Food and Drug Administration-approved primary HPV screening platform, the logistics of changes in instrumentation, specimen workflow, implementation of newly approved tests for triage of HPV-positive cases, modification of existing quality-assurance/accreditation requirements for cytology-based testing, and impact on the cytologist workforce all need careful consideration based on size and other laboratory-specific attributes. Furthermore, quality assurance for primary HPV screening, the performance of cytology as a triage test, and that of colposcopic biopsy in vaccinated cohorts are additional challenges that affect laboratory reporting in the primary HPV screening paradigm. The Laboratory Infrastructure Workgroup has been working on developing educational and practical resources to address many of these concerns.

As many as 20% of patients in the United States are currently screened for cervical cancer using cytology alone.6 These patients tend to be served by safety-net providers in underserved areas and are more likely to be low-income and from communities of color.7 Screening with cytology alone requires more frequent testing, frequent follow-up for minor, low-risk abnormalities, and does not screen for high-risk HPV, the causative agent of virtually all cases of cervical cancer. Although it is more specific in detecting precancer, cytology is less sensitive than HPV screening, has a high number of equivocal results, and has interlaboratory variability. HPV self-sampling, once US Food and Drug Administration-approved, may be especially helpful to improve screening rates in currently underscreened populations. Therefore, changing screening practices from cytology alone to primary HPV screening is essential and may have a different set of challenges than the transition faced by programs performing cotesting, such as access and cost considerations. The Moving from Cytology Alone Workgroup is addressing the specific needs and barriers anticipated for these lower resource programs.

Information technology plays an important role in how health care providers order and manage primary HPV screening tests and how laboratories handle patient specimens and report results. The Information Technology/Electronic Health Records Needs Workgroup is identifying anticipated barriers that health systems may face and outlining recommendations to address them, recognizing that recommendations must be broad enough to apply to different electronic health record (EHR) platforms but specific enough to be useful. The importance of standardized structured data to facilitate implementation of cervical cancer screening and management clinical decision support systems into the EHR will be emphasized and explained. National Current Procedural Terminology codes and Logical Observation Identifiers Names and Codes terminology currently do not differentiate between HPV tests collected for primary HPV screening versus cotesting, which affects accurate test ordering, results tracking, and preventive care tracking tools. This issue is also being addressed by this workgroup.

In the United States, payors significantly affect which screening modalities are used in clinical practice. For a successful transition to the widespread use of primary HPV screening, the Insurance Coverage/Payors Workgroup is providing support for billing and coding for primary HPV screening. It is essential that these billing codes be available to use for patients starting at age 25 years. In addition, insurance plans across the country will need to work with their network providers to support the use of primary HPV screening. One challenge faced by this workgroup is the need to balance efforts to promote the use of primary HPV screening while ascertaining that low-resource health centers providing care to the most at-risk patients are not penalized for anticipated delays in uptake of new screening guidelines based on the costs and logistics of capital investments and implementation.

Implementation processes of previous cervical cancer screening guidelines have demonstrated that patient perception and education are important considerations when implementing new approaches. This will likely be the case for primary HPV screening and screening done using self-collected specimens in the future. The Patient Perceptions Workgroup is creating educational tools for patients that will destigmatize the role of HPV in cervical cancer screening and encourage use of the right test(s) for the right patient at the right time. Although primary HPV screening has been adopted in many countries, this workgroup will focus on issues facing women and people with a cervix in the United States that are often different than those in other countries because of cultural differences and/or different health care delivery models.

The combined efforts of these six workgroups are resulting in the creation of a catalog of resources for providers, professional societies, health systems, patients, payors, and various other stakeholders. There is intentional overlap among the workgroups and the issues that they aim to address. With the support of the Steering Committee, workgroups collaborate on issues and deliverables that are cross-cutting. We will inform partners about our work and outcomes through commentaries like this one as well as through presentations, workshops at professional society meetings, social media and email communications, website announcements, and other stakeholder forums.2, 8 Upon dissemination of the implementation report and tools, the members of this initiative hope to see guideline alignment and primary HPV screening being used more across the United States. This initiative will help to advance future cervical cancer areas of work, including preparing for self-sampling, and other guideline implementation opportunities.

The PHSI innovatively accelerates progress beyond guideline development and into the guideline implementation space. This initiative is a crucial step in the successful adoption of primary HPV screening and guideline alignment across organizations. In addition, the initiative is positively contributing to growing synergistic relationships and is a foundation for the newly formed ACS National Roundtable on Cervical Cancer (NRTCC).9 The ACS NRTCC aims accelerate progress toward cervical cancer elimination by reducing barriers to care, eliminating disparities, reducing harms, and promoting new technologies that reduce the morbidity and mortality of cervical cancer for everyone. Achieving the Initiative's objectives and harnessing the power of these collaborative relationships over the next year will provide a critical and model infrastructure to support advancements in cervical cancer prevention and elimination in the coming years through the ACS NRTCC and other channels.

To learn more and give comment or input to our efforts, you can visit our website (cervicalroundtable.org).

The authors disclosed no conflicts of interest.

求助全文
通过发布文献求助,成功后即可免费获取论文全文。 去求助
来源期刊
CiteScore
873.20
自引率
0.10%
发文量
51
审稿时长
1 months
期刊介绍: CA: A Cancer Journal for Clinicians" has been published by the American Cancer Society since 1950, making it one of the oldest peer-reviewed journals in oncology. It maintains the highest impact factor among all ISI-ranked journals. The journal effectively reaches a broad and diverse audience of health professionals, offering a unique platform to disseminate information on cancer prevention, early detection, various treatment modalities, palliative care, advocacy matters, quality-of-life topics, and more. As the premier journal of the American Cancer Society, it publishes mission-driven content that significantly influences patient care.
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术官方微信