The report is a product of the VA/HSR Evidence Synthesis Program.

Evidence Brief: Accuracy of Self-Report for Cervical and Breast Cancer Screening

Guideline-based breast and cervical cancer screening are considered essential health benefits and are fundamental components of high-quality primary care services in the United States. The aim of cancer screening is to identify cancers in an early stage when treatment is more likely to be effective. Accurate measurement of cancer screening rates is vital to understanding if women are adequately screened and to determining if disparities exist in receipt of screening. There are trade-offs to consider when utilizing self-report versus medical record documentation. Although self-report data may reduce administrative burden compared to medical record documentation, its accuracy is often questioned.

Concerns about the accuracy of self-report data for cervical and breast cancer screening and the potential for adverse outcomes, including missed screenings, missed diagnoses, or duplicative screening, have led to policy variations in requirements for reporting documentation of these screenings. Prior to considering changing documentation requirements, it is important to understand the benefits and harms of accepting self-report. Thus, the purpose of this evidence review is to provide an updated synthesis of the evidence on the accuracy of self-reported measures of cervical and breast cancer screening compared to medical records – and the benefits and potential harms of relying on patient self-report instead of medical record documentation.

Investigators with VA's Evidence Synthesis Coordinating Center in Portland, OR reviewed the literature including: MEDLINE®, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and other sources up to November 2018. Investigators identified 1,213 unique, potentially relevant articles and included 39 diagnostic accuracy studies (22 in cervical cancer screening, 29 in breast cancer screening, and 1 systematic review) in their analysis. A total of 61,383 patients were included in studies of cervical cancer screening, and 444,055 patients were included in studies of breast cancer screening. No studies assessed clinical or system-level outcomes and no studies included Veterans.

Summary of Findings
Overall, results indicate that unscreened women tend to over-report screening, while screened women more accurately reported their screening:

• 48% to 61% of unscreened women, according to their medical records, accurately reported not having been screened, while 39% to 52% over-reported being screened.
• 96% of screened women, according to their medical records, accurately reported their screening. Investigators have moderate confidence in these findings, as there were a large number of mostly fair-quality studies directly assessing the accuracy of self-report compared to medical records, and the findings are consistent with the most recent meta-analysis.

Limitations
Investigators found no studies that reported on clinical outcomes or adverse events or unintended consequences of accepting self-report. In addition, there was significant heterogeneity among studies, which may be due to differences between the populations studied. Most studies had unclear risk of bias due to unclear reporting of blinding and incomplete medical record review.

Implications for VHA Policy/Practice
Although VA has good systems for tracking screening services delivered by VA, many women Veterans obtain some Pap smears or mammograms from providers in the community. Since records from such visits are not always available in the VA electronic record, clinicians may query women about whether they have had recent screening tests that are not in the record. VHA performance indicators on cervical and breast cancer screening align with HEDIS (Healthcare Effectiveness Data and Information Set) and require documentation of evidence of screening results. The date of the study must be documented by the provider as part of the medical history, but this information may come from patient self-report. With over-reporting of screening by self-report there is the potential to overestimate the success of screening interventions, mask disparities in screening prevalence, under-screen individuals, and miss cancer diagnoses.

Future Research
Future research should investigate potential clinical adverse outcomes including the potential for missed cancer diagnoses and the masking of disparities in cancer screening, and also may evaluate system-level outcomes (i.e., patient and provider burden) to weigh the potential harms of accepting self-report against the time and resource burden of tracking medical records.

Reference
Anderson J, Bourne D, Peterson, K, Mackey K. Evidence Brief: Accuracy of Self-report for Cervical and Breast Cancer Screening. VA ESP Project #09-199; 2019.

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This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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