Disparities in Cervical Cancer Screening, HPV Awareness, Guidance Nonadherence Are Increasing

Adherence to current cervical cancer screening guidance is less than 10%, new data show.¹ These screening guidelines in the US have evolved rapidly, adding cotesting every 5 years in 2012 and primary human papillomavirus (HPV) testing in 2018 alongside triennial cytology. While intended to improve early detection, these frequent updates have contributed to confusion among both patients and clinicians, according to a new public health research letter published in JAMA Network Open.

Cervical cancer screening adherence and awareness of the HPV vaccine declined among US women after the COVID-19 pandemic, according to recent research from PLOS Global Public Health.² Data from the National Cancer Institute’s Health Information National Trends Survey showed that nonadherence to cervical cancer screening guidelines rose from 19.2% in 2019 to 25.8% in 2022, with the largest increase among Black women. Awareness of the HPV vaccine also dropped, with 21.7% of women unaware in 2022, a significant rise from 8.9% in 2019, particularly affecting Black women, pointing to ongoing racial and socioeconomic disparities in cervical cancer prevention.

International evidence, such as from Australia’s shift to HPV-based screening only, indicates that guideline confusion can lead to nonadherence, including overscreening (shorter-than-recommended intervals) and underscreening (longer-than-recommended intervals), the authors noted.¹ Overscreening can result in unnecessary procedures and higher health care costs, while underscreening may exacerbate disparities in cancer burden among racial and ethnic minority populations. Yet, the effect of evolving US guidelines on adherence across screening modalities and populations has remained unclear.

To address this gap, researchers analyzed the 2013–2021 Optum Clinformatics database of 13 million commercially insured individuals annually, examining cytology-only and cotesting modalities. The study assessed adherence by race, ethnicity, age, comorbidity, and socioeconomic status, using multivariable logistic regression to estimate overscreening and underscreening and test interactions by race, ethnicity, and modality.

Among 670,003 eligible individuals, 315,249 (47.1%) received cytology-only screening and 353,754 (52.9%) received cotesting. Guideline adherence was extremely low: only 49,941 (7.3%) of patients were adherent, while 412,777 (61.6%) were overscreened and 208,295 (31.1%) were underscreened. Overall adjusted predicted probabilities (PPs) were 89.4% (95% CI, 89.3%-89.5%) for overscreening and 81.0% (95% CI, 80.8%-81.1%) for underscreening.

Overscreening was significantly higher among those receiving cotesting vs cytology-only (96.2%; 95% CI, 96.1%-96.2% vs 82.4%; 95% CI, 82.2%-82.5%). It was most pronounced among non-Hispanic (NH) Black patients (PP, 91.0%; 95% CI, 90.8%-91.3%), younger individuals, those with high comorbidity scores, and high socioeconomic status (PP, 90.1%; 95% CI, 89.9%-90.3%; household net worth [HHN] ≥ $500,000: PP, 89.8%; 95% CI, 89.7%-90.0%).

Underscreening PPs were also higher with cotesting (93.1%; 95% CI, 93.0%-93.2%) vs cytology-only (68.7%; 95% CI, 68.4%-68.9%) and were most common among NH Asian patients (PP, 82.7%; 95% CI, 82.1%-83.3%), older individuals, those with high Charlson Comorbidity Index scores, and low socioeconomic status (PP, 81.3%; 95% CI, 81.1%-81.5%; HHN < $250,000: PP, 82.8%; 95% CI, 82.6%-83.0%).

Interaction analyses revealed that cotesting increased both overscreening and underscreening across all racial and ethnic groups. Overscreening was highest among NH Black participants receiving cotesting (96.8%; 95% CI, 96.6%-97.1%) and lowest among NH Asian participants (95.3%; 95% CI, 95.0%-95.7%). Underscreening was most prevalent in NH Asian patients receiving cotesting (PP, 93.6%; 95% CI, 93.1%-94.1%) and among Hispanic patients receiving cytology-only (PP, 71.9%; 95% CI, 71.1%-72.6%).

The findings indicate that guideline adherence is remarkably low, even among a commercially insured population with stable coverage, a finding the authors said reflects confusion among patients, clinicians, and health systems. Screening modality strongly influenced nonadherence, emphasizing the need for targeted strategies to reduce overscreening, increase guideline adherence, and address disparities in adoption of evolving guidelines.

Evidence-based interventions are needed to expand capacity for guideline-concordant screening, including new modalities such as HPV self-sampling. Tailored approaches for different communities will be critical to prevent widening disparities in cervical cancer outcomes. Limitations include exclusion of uninsured populations, potential coding errors, and imperfect classification of race and ethnicity, which may limit generalizability.

“Guideline adherence was less than 10%, and screening modality was strongly associated with nonadherence,” the authors wrote. “Targeted strategies are needed to improve adherence, de-implement unnecessary care, and address disparities in adoption of evolving screening guidelines.”

References

1. Shin MB, Axeen S, Cole AM, et al. Nonadherence to cervical cancer screening guidelines in commercially insured US Adults, 2013-2021. JAMA Netw Open. 2025;8(12):e2548512. doi:10.1001/jamanetworkopen.2025.48512
2. McCrear S. Cervical screening adherence and HPV knowledge worsened after COVID-19. AJMC^®. September 11, 2025. Accessed December 10, 2025. https://www.ajmc.com/view/cervical-screening-adherence-and-hpv-knowledge-worsened-after-covid-19