Cervical Cancer Screening in Primary Care: Family Physician Ada Stewart, MD, on Guidelines, Patient Hesitancy, and HPV Self-Collection

Cervical cancer screening remains a cornerstone of preventive health, but variations in guidelines, patient hesitancy, and emerging technologies like HPV self-collection present challenges for primary care physicians. According to the US Preventive Services Task Force (USPSTF), screening should begin at age 21 with cytology every 3 years through age 29, with multiple options available for women aged 30 to 65, including cytology every 3 years, high-risk HPV testing every 5 years, or cotesting every 5 years.

In this interview with Patient Care^®, Ada Stewart, MD, a board-certified family physician, discusses how primary care clinicians can navigate these complexities. She emphasizes patient-centered communication, practical strategies for reducing screening hesitancy, and the role of HPV self-collection in expanding access.

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: Cervical cancer screening can be uncomfortable and even intimidating for some women. What strategies do you suggest clinicians use to ease those concerns?

Ada Stewart, MD: 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 health care settings. For which patients do you feel self-collection is appropriate? And how should family physicians and PCPs implement it in their practice?

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: 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.