Description

Please read through these step by step directions for a better understanding of the assignment. At the end you will see a video presentation going over the rubric and how to submit.  Step 1: Introduction Write an introduction to the topic and end the paragraph with a thesis statement. The introduction should include 2-3 attention grabbing statements and end with 1 concise thesis statement that describes the overall purpose of your paper. Step 2: Describing Quantitative Research Describe what quantitative research is in your own words.  Then discuss how and what type of Quantitative Data you would collect related to your POI. For example, if I was interested in changing a policy on pain scales in the pediatric setting, I might collect data on how many pain scales are used in the facility, what pain scores are and at what point a pain score (data) warrants medication administration to a patient and their expected level of relief. It is not necessary to include the design of a study in this section.  Step 3: Appraisal Tools, Studies and Matrix Locate your 2 quantitative studies so you can appraise each separately with the tool below. Students must include: one (1) meta-analysis or systematic review AND one (1) single study, e.g. randomized control trials, quasi-experimental studies, correlation or observational studies, case control or retrospective studies, cohort studies.  Mixed studies may be used for the single study, but you can NOT use it for the next assignment. Once you have found 2 different quantitative study designs as specified, complete the appraisal tool for each study using the following link. Appraisal Tool -PDF document use this tool to appraise both quantitative studies separately. Attach the completed sections to your paper or with your assignment.  Only complete the section of the tool related to the quantitative appraisal unless you have a mixed methods study in which case you will complete all sections of the tool.  Appraisal Tool Word Document Follow all the steps carefully as the tool will guide you which step to move to in each section of the tool.  Review this video   (Links to an external site.) to help you complete the tool. (click on “video” in blue) Creating an Evidence Matrix  Create an evidence matrix of the 2 appraisal studies for this assignment. There is an example provided to you below. Include both studies used in the appraisal from this paper on the matrix. Keep this matrix as it will be used on the following paper as well AND NU 611 if you are in the DNP track, so be sure to put it in a safe place that you will be able to easily find again. The matrix determine if students can  identify the study design, methodology, findings, results, limitations, level of evidence. The matrix should be included as an appendix OR you may upload as a separate attachment if needed. Use either link below to complete, one is a pdf, the other is a word document.  Matrix  PDF  you will need to complete the matrix for this assignment  Matrix Word Document SUBMISSION: You will need to submit your 2 studies, completed appraisal tools and completed matrix (with each quantitative study included on it) along with your assignment. The documents may be submitted separately or merged to the paper.  Step 4:  Article Discussion Use the information from your appraisal tool to discuss in detail the following information for each study:  Purpose , research design and methodology (steps, procedures and strategies for gathering and analyzing data) used in each study Data Collection describing the procedures devleoped to guide the collection of data in each study  Concepts of validity, reliability and other related terms that are applicable to each study. A full discussion of the terms and support directly from each study is expected.  Use the text book required readings to assist with this section.  Results and clinical implications  Level of evidence and quality of evidence ratings (according to tool). Discuss what the level and quality ratings mean in relation to strength of the evidence and decision to sue (or not use) this information to guide practice. You need to fully support this section from evidence in the study and other resources. Understanding the levels of evidence tells you about the type of study performed, design, methods, etc. and if those findings should be applied to your own practice area. Grade of Recommendation is  important because it helps you make a judgement about the quality of evidence; together they impact the decision about implementation into practice. The following tool can be used to help you determine strength and quality, but this information is also  listed directly on the tool. John Hopkins Evidence Rating Scale  (Links to an external site.) Other helpful links to understanding this information can be found in the required and recommended resources. Step 5: Applicability to Practice and Future Research Discuss how the two studies may influence your practice by supporting how the findings can influence at least three (3) fo the Institute of Medicine Aims: safety, efficiency, effectiveness, patient-centered, timely, and equity. You must first discuss what the aim means first. Then, show how the aim can be met through the recommendations from the article that apply to your practice setting.  Step 6: Conclusion: Provide a conclusion to the paper summarizing all main points. A conclusion should NOT state any new information that was not previously addressed in the paper. It should not re-state the purpose of your writing, but summarize the writing. Determining the main points of each section of the paper (body of text) will help you formulate your conclusion. Step 7: Turnitin  Be sure to submit your paper to turnitin. You do not have to submit your matrix or the appraisal tools to turnitin as they will skew your similarity report findings. If this happens, please just let your instructor know and re-submit the paper without those items. See Rubric for specific directions on Scholarship deductions. Page limit: 6 pages, excluding the title page, reference page and any attachments or appendices References: 2 studies that you used in the appraisal and at least 2 additional peer reviewed references; text books should be used to support findings. All sources should be current no older than 5 yrs. Order of Paper for FINAL SUBMISSION of Paper: Title page, paper, references, appendices OR attachments. Documents must be uploaded as a Microsoft Word OR Adobe PDF.  To see the rubric, go the next section of the Module and click on the rubric link.  Quantitative Paper Quantitative Paper Criteria Ratings Pts This criterion is linked to a Learning Outcome Introduction Introductory Paragraph & Thesis Statement: 1. Introduce the topic to the reader in 2-3 sentences to grab the reader’s attention. 2. Conclude this paragraph with a clear and concise statement informing the reader of the purpose or primary objective of the paper/discussion. 0.5 pts Met or Exceeds Criteria The information fully addresses the required elements and demonstrates understanding of the material. 0.38 pts Met Minimum Requirements Students met minimum requirements for introduction by including a few attention grabbing statement and a thesis statement. Organization or detail may be lacking. 0.25 pts Missing Significant Criteria Information fails to address the required elements and the introduction or thesis statement may not be included. 0 pts Missing Student did not address or poorly addressed introduction in 1 sentence or only included a thesis statement. 0.5 pts This criterion is linked to a Learning Outcome Describing Quantitative Research Student summarizes: 1. Quantitative research by using support from text books or other peer reviewed resources to explain what quantitative is and how it is measured using data. 2. How and what type of quantitative data would be collected related to your specific POI 2.5 pts Met or Exceeds Criteria Student fully supported discussion of what quantitative research in using support from text books or peer reviewed resources. Clearly address how and what type of quantitative data would be used related to specific POI. 1.8 pts Met Minimum Requirements Student minimally supported discussion for quantitative research. May or may not have provided adequate support form text books or peer reviewed resources. May be missing the “how” or “what” type of quantitative data would be used related to specific POI. 1.25 pts Missing Significant Criteria Student may or may not have summarized quantitative research using appropriate support from text books or peer reviewed sources OR is lacking a full explanation on how AND what type of quantitative data could be collected related to POI. 0 pts Missing Student missing discussion on quantitative research and/or how and what quantitative data would be collected related to POI. Discussion not well supported with text books or peer reviewed resources. 2.5 pts This criterion is linked to a Learning Outcome Appraisal Tools, Studies, & Matrix Student completes and submits the following with the assignment. 1. Appraisal tools completed accurately for both studies 2. Tools are submitted with assignment. 3. Studies that were appraised are submitted to assignment area 4. Matrix is complete and attached OR merged to the assignment -Students who selected an incorrect study for this assignment will have additional points deducted in this area as they are not able to meet the requirements of this section. 4 pts Met or Exceeds Criteria Student successfully all requirements of this rubric criterion. Data is accurate and complete; tools, studies and matrix all submitted with assignment. 3 pts Met Minimum Criteria Student missing required criterions or is missing signfiicant details in at least one of the criteria in one of the four required areas. 2 pts Missing Significant Criteria Student missing significant details in more than 1 of the required criterions or failed to submit all required documents. 0 pts Missing Student failed to submit all of the required documents. Lacking significant details in most of the criterions. 4 pts This criterion is linked to a Learning Outcome Article Discussion Using the information from both appraisal tools, discuss in detail the following information: 1. Purpose, research design and methodology (steps, procedures and strategies for gathering and analyzing data) used in each study 2. Data Collection describing the procedures developed to guide the collection of data of each study, and sampling of participants. 3. Concepts of validity, reliability and other related terms that are applicable to each study. A full discussion of the terms and support directly from each study expected. 4. Results and clinical implications. 5. Level of evidence & quality of evidence (directly from tool) and include what that means in terms of strength of the evidence and decision to use this information in practice. Justification should be provided for each study. -Information should be well supported from findings in the study, peer reviewed resources or text books and should be specific to each study. -Students must apply the above points to each study. -Students must demonstrate understanding of each concept discussed above for full credit. -Students who selected an incorrect study for this assignment will have additional points deducted in this area as they are not able to meet the requirements of this section. Each item is worth approximately 2 points each 10 pts Met or Exceeds Criteria Student demonstrated full understanding of the concepts by including all information as described in the grading criterion. 7.5 pts Met Minimum Criteria Student met minimum criterion requirements. Details lacking to demonstrate full understanding of the material. Information may or may not be fully supported with text books or peer reviewed references or studies. 5 pts Missing Significant Criteria Student missing a thorough and in-depth discussion showing full understanding of elements in discussion. Failed to meet the required discussion crierions. AND/OR Not fully supported with detail or information directly from the study, text books or other peer reviewed resources. 0 pts Missing Student missing significant detail in the discussions of each study’s findings or in multiple aresa of the criterion listed. Information not well supported throughout discussion. 10 pts This criterion is linked to a Learning Outcome Applicability to Practice and Future Research Discuss how the two studies may influence your practice by supporting how the findings can influence at least three (3) of the Institute of Medicine Aims: safety, efficiency, effectiveness, patient-centered timely, and equity. You must discuss what the aim means first. Then show how that aim can be met through the recommendations from the article that apply to your practice setting. Student includes peer reviewed references and/or text books to support this discussion. 5 pts Met or Exceeds Criteria Student fully discussed implications to practice from both studies to support how the findings can influence a minimum of three (3) IOM aims. This section is fully supported with peer reviewed resources and/or texts. 3.75 pts Met Minimum Criteria Student missing details in one of the discussions related to implications in practice OR missing a discussion of 1 of the required 3 IOM aims. May or may not be fully supported with peer reviewed resources or texts. 2.5 pts Missing Significant Criteria Student did not fully discuss implications to practice from one or both studies. Missing appropriate detail in at least 2 of the required 3 IOM aims. This section may or may not be fully supported with peer reviewed resources and/or texts. 0 pts Missing Student did not discuss in detail the implications to practice for one or both of the studies and/or did not include a detailed discussion of at least three (3) IOM aims demonstrating full understanding of each aim. Peer reviewed references and/or texts missing from discussion to fully support discussion. 5 pts This criterion is linked to a Learning Outcome Conclusion 1. Summarize the major points of the paper in one (1) paragraph. 2. No new information or references should be included in this section. 0.5 pts Met Or Exceeds Criteria The information fully summarizes the main points of the paper/discussion, without including any new information or references. 0.38 pts Met Minimum Criteria Information summarized with minimal detail. 0.25 pts Missing Significant Criteria The information did not adequately summarize the main points of the paper/discussion. New information or references may have been introduced. 0 pts Missing Student did not address or poorly addressed in one (1) sentence. 0.5 pts This criterion is linked to a Learning Outcome Scholarship Demonstrate Graduate Level Scholarship. Follows guidelines in the 7th Edition APA manual. 1. Formal, scholarly writing style, no first-person language. 2. Writing should be clear and concise. 3. Organize work by headings. 4. Full paper (except reference page, appendices and/or attachments) submitted to Turnitin with minimal similarity. 5. Correctly formatted title page included with page numbers formatted according to APA 7th edition standards. 6. Writing should be free of APA errors. 7. Paper to include a minimum of 2 peer-reviewed or scholarly references in addition to required EBP guideline. 8. Citations and references follow APA 7th edition format. 9. Writing should be free of grammatical and spelling errors. 10. Paper not to exceed 6 pages excluding title page, reference page and any appendices. 11. Follow all assignments instructions/directions. 12. Additional deductions may apply for late submissions, plagiarism or lack of scholarship and professionalism in the assignment. 2.5 pts Met or Exceeds Criteria The student’s application of graduate level critical thinking, writing skills, and application of 7th edition APA format are exemplary. Faculty discretion may apply 1.8 pts Met Minimum Criteria The student’s application of graduate level critical thinking, writing skills, and application of 7th edition APA format are good with room for minor improvements. Additional assistance outside of class optional. Faculty discretion may apply. 1.25 pts Missing Significant Criteria The student’s application of graduate level critical thinking, writing skills, and application of APA format illustrates some competency with room for moderate improvements. Additional assistance outside of class recommended. See Student and CON Resources and Support for information on how to create an eTutoring account with the Center for Academic Excellence and/or help with Scholarly Writing. Faculty discretion may apply. 0 pts Lacking/Missing Scholarship The student’s application of graduate level critical thinking, writing skills, and application of APA format are absent with major improvements necessary. Additional assistance outside of class likely required for success in the course. See Student Resources and Support for information on how to create an eTutoring account with the Center for Academic Excellence and/or help with Scholarly Writing. Faculty discretion may apply. 2.5 pts Total Points: 25 Previous Next

Contents lists available at ScienceDirect
Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed
Review Article
Reducing overuse of cervical cancer screening: A systematic review
Julia M. Albera,1, Noel T. Brewerb, Cathy Melvinc, Alyssa Yacklea,2, Jennifer S. Smithb,
Linda K. Kod, Anatasha Crawforde,3, Karen Glanza,⁎
a University of Pennsylvania, Philadelphia, PA 19104, United States
b University of North Carolina, Chapel Hill, NC 27599, United States
c Medical University of South Carolina, Charleston, SC 29425, United States
d Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N. M3-B232, Seattle, WA, 98109-1024, United States
e Oak Ridge Institute for Science Education, 100 ORAU Way, Oak Ridge, TN 37830, United States
A R T I C L E I N F O
Keywords:
Quality of care
Cancer screening
Appropriate use
Overuse
Pap tests
A B S T R A C T
Overuse of clinical preventive services increases healthcare costs and may deprive underserved patients of necessary
care. Up to 45% of cervical cancer screening is overuse. We conducted a systematic review of correlates
of overuse of cervical cancer screening and interventions to reduce overuse. The search identified 25 studies (20
observational; 5 intervention). Correlates varied by the type of overuse measured (i.e., too frequent, before/after
recommended age to start or stop screening, after hysterectomy), the most common correlates of overuse related
to patient age (n=7), OBGYN practice or provider (n=5), location (n=4), and marital status (n=4). Six
observational studies reported a decrease in overuse over time. Screening overuse decreased in all intervention
studies, which used before-after designs with no control or comparison groups. Observational studies suggest
potential targets for de-escalating overuse. Randomized clinical trials are needed to establish best practices for
reducing overuse.
1. Background
As new evidence emerges, changes in recommendations for routine
medical care are common (Prasad et al., 2013). The successful dissemination
and implementation of new recommendations can improve
patient care and reduce healthcare costs (Prasad and Ioannidis, 2014).
Yet, use of low-value preventive services is prevalent (Elshaug et al.,
2012; Schwartz et al., 2014). Low-value services are health care services
or procedures that are overused (e.g., screening more often than
recommended), misused (e.g., screening with the wrong test), wasted
(e.g., screening that is not recommended); or benefit neutral, marginal
or harmful to patients (e.g., screening that causes small harms and does
not significantly increase chances of survival). According to one study
in the United States, 24% of Medicare beneficiaries received at least one
low-value service in 2009 (Schwartz et al., 2014). Foregoing use of lowvalue
services, particularly overuse of services, has the potential to
improve quality of care while reducing healthcare spending (Colla,
2014).
Overuse of cervical cancer screening results in higher healthcare
costs while providing marginal benefits and potential harm to patients
(Sawaya et al., 2015). Cervical cancer screening, mainly with Pap
(Papanicolaou) testing, is critical for identifying women with cervical
precancerous lesions (Wentzensen, 2016) and has contributed to the
dramatic decrease in invasive cervical cancer in the United States
(Gustafsson et al., 1997). In previous recommendations made in 1996
and 2003, the U.S. Preventive Services Task Force (USPSTF) recommended
cervical cancer screening at least every three years (Saslow
et al., 2012; U.S. Preventive Services Task Force, 1996; U.S. Preventive
Services Task Force, 2003). In 2012, the USPSTF released updated recommendations
for cervical cancer screening. Of the five recommendations,
four were graded as D (e.g., The USPSTF recommends
against the service. There is moderate or high certainty that the service
has no net benefit or that the harms outweigh the benefits) and only one
received a grade of A (The USPSTF recommends the service. There is
high certainty that the net benefit is substantial). The USPSTF recommends
screening for cervical cancer in women age 21 to 65 years
with cytology (Pap smear) every 3 years or, for women age 30 to
65 years who want to lengthen the screening interval, screening with a
https://doi.org/10.1016/j.ypmed.2018.08.027
Received 5 March 2018; Received in revised form 8 August 2018; Accepted 21 August 2018
⁎ Corresponding author.
1 Present address: California Polytechnic State University, Department of Kinesiology and Public Health, San Luis Obispo, CA 93407 United States.
2 Present address: Society of Clinical Research Associates, 530 W. Butler Dr. #109, Chalfont, PA 18914 United States.
3 Present address: TRM Oncology, 5901 Peachtree Dunwoody Rd NE, Atlanta, GA 30328 United States.
E-mail address: kglanz@pennmedicine.upenn.edu (K. Glanz).
Preventive Medicine 116 (2018) 51–59
Available online 24 August 2018
0091-7435/ © 2018 Elsevier Inc. All rights reserved.
T
combination of cytology and human papillomavirus (HPV) testing
every 5 years (U.S. Preventive Services Task Force, n.d.). Organizations,
including the American College of Obstetricians and Gynecologists and
American Cancer Society, harmonized their cervical cancer screening
recommendations with the USPSTF recommendations (The American
College of Obstertricians and Bynecologists, n.d.; American Cancer
Society, n.d.). While periodic screening is useful to detect precancerous
cervical lesions, false-positive results from excessive screening can result
in unnecessary colposcopies and biopsies among patients who are
unlikely to develop invasive cancer, resulting in higher costs, as well as
pain and disease-specific distress (Sawaya et al., 2015; Korfage et al.,
2012; Welch and Black, 2010).
Adherence to the new cervical cancer screening recommendations is
relatively low (Salz et al., 2010; Teoh et al., 2015; Frederiksen et al.,
2015). For example, in one cross-sectional study of 135 health care
providers in Minnesota, U.S., 88% of health care providers were aware
of a change in cervical cancer screening guidelines, but only 61% reported
following these guidelines (Teoh et al., 2015). In another study
of 216 obstetricians, gynecologists, midwives, nurse practitioners, and
physicians practicing in Indiana, U.S., only 38% self-reported following
the most current cervical cancer screening guidelines (King et al.,
2014). Low adherence to the current guidelines among patients was
similarly found in a study of 8000 U.S. women ages 30 years and older
in one academic medical center-affiliated group: only 34% of women
self-reported receiving guideline-based cervical cancer screening, while
45% were screened more frequently than recommended (Almeida et al.,
2013). More research is needed to understand what motivates providers
and patients to overuse cervical cancer screening in order to inform
interventions that can increase adherence to cervical cancer screening
recommendations.
Effective strategies are needed to reduce overuse of preventive
services, including the overuse of cervical cancer screening (Prasad and
Ioannidis, 2014; Berwick and Hackbarth, 2012). We conducted a systematic
review to understand the drivers of cervical cancer screening
overuse, and to identify strategies to increase adherence to cervical
cancer screening recommendations that have been evaluated. More
specifically, our systematic review aimed to answer two research
questions: 1) What are correlates of overuse of cervical cancer screening
according to observational studies; and 2) What interventions have
effectively reduced overuse of cervical cancer screening?
2. Study data and methods
2.1. Search strategy
This analysis reports findings from a larger review on the overuse of
cancer screening that included cervical cancer as well as mammography,
colon cancer screening, and prostate-specific antigen (PSA)
testing for prostate cancer. A biomedical librarian assisted our team
with the identification and application of various combinations of
search terms related to overuse, cancer screening, and cervical cancer
testing to achieve a comprehensive search within each of four databases
(i.e., PubMed, CINAHL, Embase, and Cochrane Central Register of
Controlled Trials) (see Appendix A1). Because of the unique issues related
to cervical cancer screening, this analysis is limited to studies of
cervical cancer screening. Fig. 1 contains an outline for the search,
screening, and extraction process. After the initial search, the research
team reviewed reference lists from eligible articles to identify additional
relevant articles for review. The search was conducted between
May 27, 2016 and January 13, 2017.
2.2. Inclusion/exclusion criteria
Inclusion criteria for observational and intervention studies were: 1)
published between January 1990 and May 2016, 2) original, quantitative
research, 3) full-text available in English, 4) included participants
age ≥18 years, and 5) conducted in a high-income or upper-middleincome
country, as defined by the World Bank (World Bank Country
and Lending Groups, n.d.). For observational studies, additional inclusion
criteria were that the study: 1) examined correlates of overuse of
cervical cancer screening, and 2) measured outcomes that included
current or past overuse of cervical screening. Additional inclusion criteria
for intervention studies were that each study: 1) evaluated an
intervention intended to reduce overuse of cervical cancer screening
tests, 2) included a measure of change in current or past overuse of
cervical cancer screening, and 3) used a pre-post, quasi-experimental or
experimental design to assess the impact of the intervention (i.e., collected
measurements before and after the intervention, or included a
comparison group). We excluded observational and intervention studies
that examined: 1) screening generally but not cervical cancer screening
specifically, 2) diagnostic testing but not preventive screening, or 3)
only post-treatment surveillance.
We defined overuse of cervical cancer screening as screening practices
graded as D by the USPSTF. More specifically, the practice was
considered overuse if screening for cervical cancer occurred in women
younger than age 21 years; in women older than age 65 years who have
had adequate prior screening and are not otherwise at high risk for
cervical cancer; and in women who have had a hysterectomy with removal
of the cervix and who do not have a history of a high-grade
precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or
3) or cervical cancer. Studies published before the release of updated
screening recommendations were evaluated based on the USPSTF recommendation
at the time of the study (2003–2012 or post-2012).
Studies published outside of the United States were also evaluated using
the USPSTF criteria given the similarity in the included countries’
guidelines and the USPSTF guidelines.
2.3. Screening of articles
Article screening and abstraction was completed in three steps: 1)
initial screening of titles and abstracts to determine eligibility based on
first five inclusion criteria, 2) full screening of titles and abstracts for all
inclusion and exclusion criteria, and 3) abstraction of eligible articles.
For each step, two reviewers independently screened a random sample
of articles and compared results to ensure inter-coder reliability
(McHugh, 2012). The study’s principal investigator adjudicated disagreements.
2.4. Data extraction
We developed standardized data extraction forms for each research
1,365 Records identified through
database search
542 Duplicate records removed
823 Unique records screened 741 Records excluded
82 Full-text articles assessed for
eligibility
58 Articles excluded
17 Not original quantitative research
29 No measure of low-value service
11 Did not examine correlates of lowvalue
cancer screening
1 Focused on increasing screening
1 Article added after
review of reference lists
25 Articles included in data
extraction (reporting 25 studies)
Fig. 1. PRISMA flow diagram.
J.M. Alber et al. Preventive Medicine 116 (2018) 51–59
52
question, based on previous literature review extraction forms and
guidelines, (Zaza et al., 2000; STROBE, 2007), and pilot tested the
forms. Reviewers went through training before completing abstractions.
Data extraction forms had fields for 1) general article information (i.e.,
authors, title, journal, funding, purpose, hypotheses), 2) study information
(i.e., study design, primary outcomes, location, length,
measurement of predictor and outcome variables, eligibility criteria,
sample size, response rate, study demographics, statistical analysis, and
main findings), and 3) study limitations (descriptions, sampling, measurement,
analysis, interpretation of results, and other issues) (Zaza
et al., 2000; STROBE, 2007). We identified limitations using guidelines
developed by the Task Force on Community Preventive Services for
systematic reviews (Zaza et al., 2000). For research question 1 (observational
studies), 16 different limitations were possible, while for
research question 2 (intervention studies), 21 limitations were possible.
Two reviewers independently extracted data from each article, compared
their extractions and reconciled differences with a third judge
when necessary.
3. Results
3.1. Correlates of overuse
The search identified 20 observational studies (Table 1). Of these,
nine were cross-sectional in design, seven were successive independent
sample studies, and four were retrospective in design. Sixteen of the 20
studies were conducted in the U.S. Measures of overuse as a primary
outcome varied across studies with some studies measuring multiple
outcomes: 11 studies investigated cervical cancer screening outside the
recommended ages, 10 studies examined too frequent cervical cancer
screening, and six studies examined screening in women who had received
hysterectomies. Observational studies had a median of 1 limitations
(range 0 to 8), with the most common limitations being a low
response rate (n=12) and the sample not being clearly described
(n=7).
Studies examined four overuse outcomes: too frequent (Teoh et al.,
2015; Almeida et al., 2013; Arbyn et al., 1997; Barbadoro et al., 2015;
Verrilli et al., 2014; Perkins et al., 2013; Arrossi et al., 2010), after a
hysterectomy (Almeida et al., 2013; Watson et al., 2000–2010;
Marchand et al., 2003; Sirovich and Welch, 2004), before the recommended
age to start screening (Henderson et al., 2013; Tsui et al.,
2014; Summers et al., 2015), and after the recommended age to stop
screening (Teoh et al., 2015; Guo et al., 2015; Royce et al., 2014; Kale
et al., 2013; Meissner et al., 2008; Salloum et al., 2014) (Table 2).
Studies found five categories of screening overuse correlates: patient
demographics (Table 2); patient health characteristics (Almeida et al.,
2013; Arbyn et al., 1997; Barbadoro et al., 2015; Perkins et al., 2013;
Henderson et al., 2013; Tsui et al., 2014; Guo et al., 2015; Meissner
et al., 2008; Salloum et al., 2014); patient healthcare access (Henderson
et al., 2013; Tsui et al., 2014; Guo et al., 2015; Royce et al., 2014;
Salloum et al., 2014); clinic or provider characteristics (Teoh et al.,
2015; Almeida et al., 2013; Perkins et al., 2013; Marchand et al., 2003;
Summers et al., 2015; Guo et al., 2015); and other. The most common
correlates related to patient age (n=7), time (overuse decreased over
time in longitudinal studies) (n=6), OBGYN practice or provider
(n=5), geographic location (n=4), and marital status (n=4).
Correlates of overuse defined as too frequent were patient age,
younger age of first sexual contact, younger age of end of educational
attainment, having at least one contraceptive management visit, no
reports of having depression or diabetes, lower income, location (varied
by study), marital status (widowed or divorced), residing in smaller
population density (less than metropolitan city), the practice where the
screening took place being private, having two or more pregnancies,
male gender of provider, lower provider knowledge, provider specialty
(OBGYN), former smoker, no sexually transmitted disease history, high
social class, and greater number of clinic visits over study period. The
Table 1
Observational studies, characteristics.
Author (year) Country Study design Limitationsa Sample size Data collection Type of overuse
Almeida et al. (2013) U.S. Retrospective 0 8018 women 2007–2009 Too frequent, after hysterectomy
Arbyn et al. (1997) Belgium Cross-sectional 0 1502 women 1995 Too frequent
Arrossi et al. (2010) Argentina Cross-sectional 8 19 provinces 2007–008 Too frequent, outside age range
Barbadoro et al. (2015) Italy Cross-sectional 1 36,162 women 2004–2005 Too frequent
Guo et al. (2015) U.S. Cross-sectional 1 1753 women 2013 Outside age range
Henderson et al. (2013) U.S. Successive independent samples study 1 7856 women 2002, 2006–2008 Too frequent
Kale et al. (2013) U.S. Successive independent samples study 3 182,063 adults 1999, 2009 Outside age range
Kepka et al. (2014) U.S. Cross-sectional 1 9494 women 2010 Outside age range, after hysterectomy
Marchland et al. (2003) U.S. Cross-sectional 6 341 providers 1999 Outside age range, after hysterectomy
Meissner et al. (2008) U.S. Successive independent samples study 2 43,200 women 1993, 1998, 2000, 2005 Outside age range
Perkins et al. (2013) U.S. Cross-sectional 0 397 obstetrician-gynecologists 2011–2012 Too frequent, outside age range, after hysterectomy
Royce et al. (2014) U.S. Successive independent samples study 1 27,911 adults 2000–2010 Outside age range
Salloum et al. (2014) U.S. Successive independent samples study 1 9760 female Medicare beneficiaries 2001–2007 Outside age range
Sirovich & Welch (2004) U.S. Successive independent samples study 2 188,391 women 1992–2000,2002 Outside age range, after hysterectomy
Spence et al. (1996) U.K. Retrospective 4 85,594 women 1988–1992 Too frequent
Summers et al. (2015) U.S. Retrospective cohort 2 799 women 2009–2010 Outside age range
Teoh (2015) U.S. Cross-sectional 1 135 providers 2013–2013 Too frequent, after hysterectomy
Tsui et al. (2014) U.S. Retrospective cohort 0 17,337 women 2007–2012 Outside age range
Verrilli et al. (2014) U.S. Cross-sectional 4 123 gynecologists 7/2012–8/2012 Too frequent, outside age range
Watson et al. (2014) U.S. Successive independent samples study 1 244,721 women 2000, 2010 After hysterectomy
a 16 possible limitations; adapted from the Task Force on Community Preventive Services data collection instrument for systematic reviews.
J.M. Alber et al. Preventive Medicine 116 (2018) 51–59
53
Table 2
Observational studies, correlates.
Author (year) Variables measured Outcomes
Significanta Not significant
Almeida et al. (2013) Patient age (higher among 30–50 years vs. older age groups) Cerebrovascular disease Too frequent; after cervix is removed
Contraceptive management visit (at least one) CME attendance
Depression comorbidity (not having depression) Coronary artery disease
Diabetes comorbidity (not having diabetes) Female provider gender
Provider type (higher for gynecology than family medicine) Great than 7 years in practice
Hypertension
Internal medicine specialty
Language
Number of pap test
Race/ethnicity
Arbyn et al. (1997) Age of first sexual contact (odds of overuse increase with
age)
Age Too frequent
Age at end of educational studies (overuse increased as age
at end of education decreased)
Employment
Income (higher for <40,000 compared to higher income) Family status (e.g. living alone or with
others)
Marital status (higher for widowed compared to other) Number of sexual partners
Sexually transmitted disease (no higher than yes) Province
Smoking status
Use of oral contraceptives
Arrossi et al. (2010) ⁎No significance testing ⁎No significance testing Too frequent; before recommended age; after
recommended age
Barbadoro et al. (2015) Patient age (lower for older 35–64 compared to 24–34) Education Too frequent
Location (island compared to North-western) Perceived health status
Marital status (divorced compared to single)
Population density (cities less than metropolitan city)
Pregnancy (two or more compared to none)
Smoking status (former vs current smoker)
Social class (high social class compared to low social class)
Guo et al. (2015) Patient age (higher 70–74 vs. over 80 years) Race/ethnicity After recommended age
Clinical visits (have visited OBGYN and have not)
Doctor’s recommendation for test (yes)
Smoking status (former)
Visited OBGYN (yes vs no)
Henderson et al. (2013) Patient age (higher among 18–20 vs. 15–17 years) HPVb vaccination Before recommended age
Born in US (vs outside)
Continuous health insurance (yes)
Hormonal contraception (yes)
Mother’s education (some college or more vs less than
college)
Number of sexual partners in past year (higher for multiple
vs one or none)
Pregnancy (in last 12 months)
Race (black vs white)
Residence (higher in non-urban vs urban)
Sexual activity (active in last 36 months)
Time (decreased over time)
Type of health insurance (higher for public health insurance
vs private)
Kale et al. (2013) Time (decreased from 1999 to 2009) After recommended age
Kepka et al. (2014) ⁎No significance testing ⁎No significance testing After recommended age; after cervix is
removed
(continued on next page)
J.M. Alber et al. Preventive Medicine 116 (2018) 51–59
54
Table 2 (continued)
Author (year) Variables measured Outcomes
Significanta Not significant
Marchand et al. (2003) Provider type (advanced practice nurse vs family physician
and OBGYN)
After cervix is removed
Meissner et al. (2008) Chronic disability (no) Charlson comorbidity index After recommended age
Health status (higher for good excellent/good vs fair/poor)
Hysterectomy (negatively associated)
Perkins et al. (2013) Location (south) Provider age Too frequent
Provider gender (male) Provider race
Provider specialty (other than OBGYN) Provider years in practice
Provider type (solo) Racial composition of practice
Royce et al. (2014) Patient age (decreased with age) Race After recommended age
Educational attainment (higher)
Health insurance (yes)
Location (U.S. south region)
Marital status (married) Sex
Mortality risk (lower)
Time (decreased from 2003 to 2010)
Usual source of care (yes)
Salloum et al. (2014) Patient age (decreased with increasing age) History of non-skin cancer
Insurance type
After recommended age
Education (less than high school negatively associated)
Health status (fair to poor health negatively associated) Residence
Hispanic
Household income (< $25,000 negative association) History of non-skin cancer
Hysterectomy (negatively associated) Insurance type
Location (metropolitan area); Residence
Marital status (married)
Race (black)
Usual source of care (yes)
Sirovich & Welch
(2004)
Time After cervix is removed
Spence et al. (1996) ⁎No significance testing ⁎No significance testing Too frequent
Summers et al. (2015) Cervical cytology performed (yes) BMI Before recommended age
History of cervical intraepithelial neoplasia (yes) Diagnosis with cytology order
Reason for office visit (routine care) History of sexual active
Specialty (OBGYN) Hormonal contraceptive
Time (decreased from 2009 to 2010) Prior screening
Race
Type of insurance
Teoh (2015) Provider knowledge (lower knowledge) Too frequent; after recommended age
Tsui et al. (2014) Patient age (higher among 16–20 vs. 13–15 years) Race Before recommended age
Clinic type (gynecologic)
Clinical visits (more)
Health insurance (none)
HPVb vaccination (yes)
Language (Spanish)
STIc test (positive)
Time (declined over two periods)
Verrilli et al. (2014) Practice type (private) Too frequent
Watson et al. (2014) Time (decreased from 2000 to 2010) After cervix is removed
a All correlates were associated with greater overuse with exception of time, where decreases were found in overuse of specific time periods.
b Human papillomavirus.
c Sexually transmitted infection.
J.M. Alber et al. Preventive Medicine 116 (2018) 51–59
55
two studies that found patient age was a significant predictor had
conflicting results: one reported higher overuse among 30–50 year olds
compared to older groups, while another study reported lower overuse
among 35–64 year olds compared 24–34 year olds.
Correlates of overuse defined as cervical cancer screening after a
hysterectomy were younger patient age, at least one contraceptive
management visit, no depression or diabetes, and advanced practice
nursing or gynecology provider.
Correlates of overuse defined as starting screening before the recommended
age included older patient age, being born in the U.S., a
prior cervical cytology being performed, the clinic being gynecologic
where screening took place, more clinical visits, health insurance
(varied by study), history of cervical intraepithelial neoplasia, use of
hormonal contraception, previous HPV vaccination, primary language
being Spanish, higher mother education, multiple sexual partners and
previous sexual activity, pregnancy in the last 12 months, race (white),
coming for a routine care visit, residing in an non-urban residence, and
time (overuse decreased over time).
Correlates of overuse defined as continuing screening after the recommended
age to stop screening were older patient age, no chronic
disability, previous visit to the OBGYN, higher education, having health
insurance, good/excellent health status, Hispanic ethnicity, race
(black), lower education, having a hysterectomy (negatively), location
(metropolitan area and south region of U.S.), lower mortality risk, low
provider knowledge, former smoker, time (overuse decreased over
time), and having a usual source of care.
3.2. Effectiveness of interventions
The search identified 5 intervention studies. All intervention studies
used before-after designs with no comparison or control groups, had
durations of 12 months or less, and were limited to one location or
clinic (Table 3). All intervention studies reported decreases in overuse
of cervical cancer care over time. However, intervention studies had
substantial limitations (median=7.6 limitations, range 5–9).
The most often-reported interventions were updates to electronic
health records (EHR), reported in three intervention studies (White and
Kenton, 2013; White, 2014; Broach et al., 2014). EHR updates included
revising the language of the EHR forms (e.g., stating that HPV testing
was not appropriate for women under 30 years old), setting automatic
alerts when a test was requested for an individual outside the recommended
parameters (e.g., Pap test is ordered for women under
21 years old), and providing a link to a website with more information
about guidelines. Two intervention studies evaluated the effects of
provider education on current screening guidelines and making changes
to the EHR system (Hills et al., 2015; Schwaiger et al., 2013). Other
intervention studies included manual or pocket guides to help guide
providers determine the appropriate screening for a patient (Hills et al.,
2015; Schwaiger et al., 2013). One intervention study provided clinical
decision support, which included having a person in the clinic review
patient charts to determine when patients were due for screening (Hills
et al., 2015). None of the intervention studies included patient education
or patient decision-making components for decreasing overuse.
4. Discussion
Our systematic review sought to identify correlates of overuse of
cervical cancer screening and interventions that could decrease overuse
of cervical cancer screening. The use of varied designs, variables measured,
and analysis strategies do not lead to clear or definitive conclusions.
However, a few findings emerged in multiple studies. With
respect to correlates, overuse of cervical cancer screening has been
decreasing over time across several measures; however, overuse is still
prevalent. Screening at a gynecology practice was often associated with
greater overuse (Tsui et al., 2014; Summers et al., 2015; Guo et al.,
2015; Almeida et al., 2013) as was greater number of clinical visits
Table 3
Intervention studies, characteristics and key results.
Author (year) Country Study design Limitationsa Intervention components Sample sizeb Data collection periods Key results
Broach et al. (2014) U.S. Before-after study; no control or
comparison group
8 Updates to EHRs Pre 1709 HPV
tests
Pre 1/2010–6/2010 Decrease in overuse (proportion of HPV tests among women
under 21 significantly decreased)
Post 1678 HPV
tests
Post 7/2010–12/2010
Hills et al. (2015) U.S. Before-after study; no control or
comparison group
5 Clinical decision support Pre 1032 patients Pre 6/1/2012 Significant decrease in overuse (proportion of screening too
Provider education Post 1032 patients Post 6/1/2013 frequently)
Clinical procedure
manual
Schwaiger et al.
(2013)
U.S. Before-after study; no control or
comparison group
7 Provider education Pre 119 charts Pre 10/1/2010–10/31/
2010
Significant decrease in overuse (“early” pap tests)
Pocket guide Post 102 charts Post 10/1/2011–10/31/
2011
White (2014) U.S. Before-after study; no control or
comparison group
9 Updates to EHRs Pre 759 patients Pre 1/2010–12/2010 Significantly decrease in overuse (pap tests in women under 21)
Post 1274 patients Post 1/2011–9/2011
White & Kenton
(2013)
U.S. Before-after study; no control or
comparison group
9 Updates to EHRs Pre 229 pap tests Pre 1/2010–6/2010 Significant decrease in overuse (co-tests and pap tests in women
Post 151 pap tests Post 7/2010–12/2010 under 21)
a 21 possible limitations; adapted from the Task Force on Community Preventive Services data collection instrument for systematic reviews.
b Only one intervention study, Hills et al. 2015, used a matched sample for the pre-and post- intervention measurements.
J.M. Alber et al. Preventive Medicine 116 (2018) 51–59
56
(Tsui et al., 2014; Almeida et al., 2013). Several studies reported a
decrease in overuse among older patients, particularly for too-frequent
screening (Arbyn et al., 1997; Barbadoro et al., 2015; Almeida et al.,
2013) and after the recommended age to stop screening of 65 years
among women with a history of normal screening results (Guo et al.,
2015; Royce et al., 2014). However, for studies examining screening
before the recommended starting age of 21 years, older patient age was
associated with overuse (Henderson et al., 2013; Tsui et al., 2014).
More than half of U.S. women who reported having a hysterectomy
also reported having an unnecessary Pap test following their hysterectomy,
and approximately half of women ages 65 years and older reported
receiving a Pap test within the past three years, in an analysis of
National Health Interview Survey data (Kepka et al., 2014). In addition,
younger patient age, Hispanic and Black race/ethnicity, income exceeding
400% of poverty level, and private health insurance coverage
were associated with receipt of a recent Pap test after a hysterectomy
(Kepka et al., 2014), indicating that these may be thus targets for interventions
to reduce overuse.
One of the inherent issues of screening programs is the presence of
false-positive screening results. False-positive results from excessive
cervical cancer screening can result in costly, painful, and stressful
colposcopies and biopsies among women who are unlikely to develop
invasive cancer (Korfage et al., 2012; Welch and Black, 2010). Excisional
procedures (i.e., LEEP/LLETZ or cold knife conization) may lead
to short- and long-term health effects. Some evidence suggests that
excisional procedures may increase chances of preterm delivery leading
to higher neonatal morality (Sawaya et al., 2015). Because most lowgrade
cervical precancerous lesions clear spontaneously in younger age
women, increasing the age of the first Pap test from 18 to 21 years has
yielded substantial cost savings, with small differences in discounted
average quality adjusted life expectancy (Sawaya et al., 2015).
With respect to interventions, strategies to reduce overuse focused
mostly on providers and systems including provider education and EHR
updates noting the appropriateness of screening for different age
groups. As Pap testing is often initiated by the woman or health care
provider, it is important that strategies address both the provider and
the patient (Nayar et al., 2014; Arbyn et al., 2014; Makkonen et al.,
2017). No strategies specifically targeted patients which may lead to
confusion if the patients were not aware of revised clinical guidelines,
and even mistrust if they viewed their providers as not providing adequate
care (Allen et al., 2013). None of the intervention studies published
to date examined patient preferences regarding cervical cancer
screening, or included options for a patient-centered approach to
shared decision making regarding de-escalation of cervical cancer
screening. These approaches to engaging patients – which may help
them to reflect on their values, understand the potential harms, and
reduce screening overuse – have been recommended for other types of
cancer screening, e.g., colorectal cancer screening and PSA testing (Li
et al., 2013; Hoffman et al., 2010). It could be argued that they are less
relevant for cervical cancer screening, but the emergence of HPV cotesting
as an option might make shared decision making more applicable.
A comprehensive intervention strategy aimed at patients, providers,
and systems may hold the most promise for improving adherence to the
new guidelines. Providers’ nonadherence to the new cervical cancer
screening recommendations is high, ranging from 38% (King et al.,
2014) to 61% (Teoh et al., 2015) in some studies. Providers have reported
that the barriers to following USPSTF recommendations were
patient concerns, provider disagreement with revised recommendations,
concern about the risk of malpractice lawsuits, and limited time
to discuss risk and benefits of low value screening with patients.
Awareness alone does not seem to address nonadherence given that
healthcare providers’ awareness of the recommendations did not always
lead to higher adherence. Provision of education focusing on patients’
needs and wants, as well as harmonizing patients’ and providers’
knowledge of new screening recommendations may be conducive to
more effective patient-provider communication around the changing
recommendations (Pelzang, 2010).
Systems approaches, such as updating the EHR with accurate information
about revised screening guidelines, were used in three intervention
studies in our review. The EHR has emerged as an important
tool for understanding patients’ medical history, creating care-summary
documents, developing and providing education materials for patients,
performing care reconciliation, and submitting key data electronically
to public health entities (Jha, 2010). Future research may explore
leveraging this tool for patient education, provider’s feedback and reminders,
as well as clinic-level adherence tracking.
Findings from our review should be viewed in the context of the
substantial limitations of the available published literature. Too few
observational studies examined the same correlates and outcomes to
make firm conclusions, and quantitative synthesis of pooled data across
studies was not possible. No intervention studies used control or comparison
groups. Given the decrease in overuse over time in observational
studies, the putative intervention effects may well reflect secular
trends or attention effects. Studies were conducted primarily in the
U.S., and their findings’ generalizability to other countries is unknown.
5. Conclusions
Overuse of cervical cancer screening is declining but remains prevalent
(Watson et al., 2000–2010; Henderson et al., 2013; Tsui et al.,
2014; Royce et al., 2014; Kale et al., 2013). Additional research is
needed to understand the specific factors that account for the observed
discrepancy between current cervical cancer screening recommendations
and reported screening practices. Further, additional well-designed
research is needed to rigorously evaluate interventions directed
at patients, providers, and clinical systems to reduce overuse of cervical
cancer screening.
Conflict of interest statement
The authors declare that there are no conflicts of interest.
Grant support
This publication was supported by funding from the Centers for
Disease Control and Prevention, through cooperative agreements: 3
U48 DP005053-01S1; 3 U48 DP005000-01S2; 3 U48 DP005013-
01S1A3; and 3 U48 DP005017-01S8. The findings and conclusions reported
in this article are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and
Prevention.
Acknowledgments
Amber Cohen, Jade Avelis, Meagan Robichaud, Matt Kearney, Ryan
Quinn, Jenny Spencer, Dana Burshell.
Appendix A. Search terms
1. The systematic search used the following MeSH terms and keyword
combinations for all databased except CINAHL which required slight
adjustments. The search included cervical cancer screening tests as
well as other cancer screening tests as the original scope of the study
was broader and later revised to only include cervical cancer
screening test (“Health Services Misuse” OR overuse OR over-use OR
overscreen* or over-screen* OR overutiliz* OR over-utiliz* OR
“Patient Acceptance of Health Care” OR “Health Knowledge,
Attitudes, Practice” OR “Physician Practice Patterns” OR “Guideline
Adherence” OR nonadhere* OR “non-adhere*” OR noncompliance
OR non-compliance OR compliance OR “low-value care” or “low
value care” OR “Unnecessary Procedure*”)
J.M. Alber et al. Preventive Medicine 116 (2018) 51–59
57
2. AND (“Early Detection of Cancer” OR “cancer screening*”)
3. AND each of the following combination of terms:
a. (“uterine cervical neoplasms” OR “cervical neoplasms” OR “cervical
cancer” OR “cervix cancer”) AND (“papanicolaou test*” OR
“Human Papillomavirus DNA Test*” OR “human papillomavirus
test*” OR “HPV test*” OR “HPV DNA test*” OR “pap smear*” OR
“pap test*” OR “cervical smear*” OR “smear test*”);
b. (urinalysis OR cystoscopy OR “urine cytology” OR “hematuria
test*” OR “Urine tests for tumor markers” OR UroVysion OR
“BTA test*” OR “Immunocyt” OR “nuclear matrix protein 22” OR
“NMP22 BladderChek”) OR (“urinary bladder neoplasms” OR
“bladder neoplasms” OR “bladder tumor” OR “bladder cancer”);
c. (“Genes, BRCA1” OR “BRCA1 Gene” OR “FANCD1 protein” OR
“fanconi anemia complementation group D1 protein” OR “fanconi
anemia group D1 protein” OR “BRCA2 Gene Product” OR
“Breast Cancer 2 Gene Product” OR “fanconi anemia group D1
complementing protein” OR “breast cancer 2 protein” OR
“Genetic Testing” OR genetic test* OR “genetic counseling” OR
“risk assessment”) AND (“Breast Neoplasms” OR “breast neoplasms”
OR “breast cancer”);
d. (Mammography OR mammographies OR mammogram OR
mammograms OR “Breast Self-Examination” or “breast selfexam*”
or “breast self exam*” OR “digital mammography” OR
“digital mammographies” OR “digital mammogram” OR “digital
mammograms” OR “magnetic resonance imaging” OR MRI OR
“clinical breast exam*” OR “breast exam*”) AND (“breast neoplasms”
OR “breast cancer”);
e. (“colorectal neoplasms” OR “colon cancer” OR “colorectal
cancer” OR “colorectal polyps” OR “colorectal tumor*”) AND
(colonoscopy OR colonoscopies OR “colonoscopic surgery endoscope”
OR endoscopy OR endoscopies OR endoscopic OR
Sigmoidoscopes OR sigmoidoscope OR sigmoidoscopy OR proctosigmoidoscope
OR proctosigmoidoscopes OR “double-contrast
barium enema” OR “high-sensitivity fecal occult blood test*” OR
FOBT OR “fecal immunochemical test*” OR FIT OR “fecal immunochemical
test*” OR “stool DNA test*” OR “fecal DNA test*”
OR “computed tomographic colonography” OR “CT colonography”
OR “virtual colonoscopy”);
f. (“mouth neoplasm*” OR “oral neoplasm*”OR “mouth cancer” OR
“oral cancer”) AND (“oral cancer screening*” OR “Toluidine blue
stain” OR “Fluorescence staining” OR “Exfoliative cytology” OR
“Brush biopsy”);
g. (“ovarian neoplasm*” OR “ovary neoplasm*” OR “ovary cancer”
OR “ovarian cancer”) AND (“ovarian cancer screening*” OR
“Gynecological Exam*” OR “vaginal exam*” OR “pelvic exam*”
OR “Transvaginal ultrasound” OR TVU OR “CA-125 assay”);
h. (“pancreatic neoplasm*” OR “pancreas neoplasm*” OR “pancreatic
cancer” OR “pancreas cancer”) AND (“abdominal palpation*”
OR “abdominal exam*” OR ultrasonography OR
Ultrasound* OR ultrasonic OR sonography OR “serologic
marker*” OR “pancreatic cancer screening” OR “pancreas cancer
screening”);
i. (“prostatic neoplasm*” OR “prostatic cancer” OR “prostate
cancer”) AND (“prostate cancer screening*” OR “prostate-specific
antigen-based screening*” OR “PSA-based test*” OR “PSA blood
test*” OR “prostate specific antigen test*” OR PSA OR “PSA
Test*”);
j. (“skin neoplasm*” OR “skin cancer” OR melanoma* OR “cutaneous
melanoma*” OR “basal cell neoplasm*” OR “basal cell
cancer” OR “squamous cell skin cancer” OR “squamous cell carcinoma”)
AND (“self-exam*” OR “self exam*” or “whole-body
skin exam*” OR “skin exam*”);
k. (“testicular neoplasm*” OR “testicular tumor*” OR “testis neoplasm*”
OR “tumor of testis” OR “testis tumor*” OR “cancer of
testis” OR “testis cancer” OR “testicular cancer”) AND (“selfexam*”
OR “self exam*” OR “physical exam*” OR “testicular
cancer screening” OR “testis cancer screening”)
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