Cervical Cancer Screening in Primary Care: A Q&A with Family Physician Ada Stewart, MD

September marks Gynecologic Cancer Awareness Month, a timely opportunity for primary care physicians to revisit cervical cancer screening guidelines and strategies. In this interview, Dr. Ada Stewart, a board-certified family physician, shares insights on how clinicians can help women make informed decisions about screening, address patient hesitancy, and implement new tools like HPV self-collection.

The following transcript has been lightly edited for style and flow.

Ada Stewart, MD

Patient Care: Can you review the latest clinical guidelines on cervical cancer screening in the US?

Ada Stewart, MD: Currently, the guidelines vary somewhat by organization, but as a family physician, we follow the USPSTF recommendations. These state that cervical cancer screening should begin at age 21 with cytology every 3 years, continuing through age 29.

For individuals aged 30 to 65 years, there are three options: cytology with HPV testing every 5 years, HPV testing alone every 5 years, or cytology alone every 3 years.

It can be confusing, and that’s part of the challenge we face on the front lines. We need to be sure we are following the guidelines correctly, and often, we have to double-check to ensure we are up to date because recommendations can change.

Patient Care: Is there any patient hesitancy around screening? How do you recommend clinicians address that?

Ada Stewart, MD: Yes. It’s really important that, as a primary care clinician and family physician, I inform my patients and make sure that all decisions are shared between myself and them. I talk about the guidelines, the recommendations, and the limitations of the tests we perform. I also make sure to assess their comfort level with the Pap smear and address any concerns.

If it’s about pain with the speculum exam, I try to use the smallest available speculum. Sometimes I’ll have music playing in the background. I may even have one of my staff hold the patient’s hand. It’s all about shared decision-making—making sure the patient is well informed about what the guidelines say, what’s best for them, and what limitations may occur—while ensuring they are comfortable with the exam itself.

Patient Care: The FDA has approved HPV self-collection tests for use in healthcare settings. For which patients do you feel self-collection is appropriate, and how should primary care physicians implement it?

Ada Stewart, MD: As a family physician, we want to have all the options available to ensure we don’t miss opportunities to screen. Of course, we encourage the gold standard, which is the clinician-collected cytology Pap smear, ideally with HPV testing.

I care for individuals who have been traumatized, as well as patients who are gender diverse or trans male. For those patients, it’s about having a conversation. We know there are some limitations to self-collection, but for patients who feel it is their only option, we need to make sure they understand that if there is an abnormality, they will still need to return for a speculum exam performed by the clinician.

Self-collection gives us another option—another tool in our toolkit—to help ensure everyone gets screened and that we don’t miss opportunities to prevent cervical cancer. For me, the individuals for whom this may be an option are those who refuse to have any type of exam. The FDA approved this for average-risk patients, but assessing risk is difficult. Patients often don’t know their risk, and even we as clinicians may not be able to fully assess it. That’s why it’s incumbent upon us to make sure the best test is the one that is offered, the one most likely to identify precancers and cancers in our patients.

Patient Care: Do you have any tips for physicians implementing self-collection for the first time?

Ada Stewart, MD: Yes. First, it’s important to talk to patients about the benefits, risks, and limitations. Even though it’s a self-collection test, at this point it should be done in a clinical setting. Patients need clear instructions, and that may include having a nurse explain the process and what to expect while they collect their sample.

Patients also need to understand that if results are abnormal, they must return for follow-up and a speculum exam. That can be challenging, especially in communities with health disparities and social determinants of health barriers. For example, I may try to call a patient, but their phone number no longer works, or they may not have transportation to return to the clinic. These are issues we have to address upfront—making sure we have reliable contact information and confirming that they can come back if needed.

It’s critical that patients are well informed and that clinicians stay up to date on the limitations of self-collection. Shared decision-making between clinician and patient is the best way to ensure we provide optimal care and do not miss opportunities to prevent cervical cancer.

Patient Care: With Gynecologic Cancer Awareness Month underway, what are the most important steps physicians can take to improve cervical cancer screening and follow-through?

Stewart: The biggest thing is making sure that everyone gets screened—every female who is eligible for screening. Last Friday was what I call my Pap smear day, and that’s all I did. The whole day was dedicated to ensuring that everyone who was eligible and due for their Pap smear got it done. And of course, I did co-testing on everyone, and it was a success.

This is a time for us to ensure that every eligible patient who is due for a Pap smear gets it done, and it takes every visit to check on their screening. We are all about prevention as primary care clinicians, as family docs. For many of our patients, we are their only source of health care, so it is imperative for us as family medicine physicians and primary care doctors to ensure that prevention is number one.