A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial

Patient Perceptions on the Follow-Up of Abnormal Cancer Screening Test Results

BACKGROUND

Timely follow-up after an abnormal cancer screening test result is needed to maximize the benefits of screening, but is frequently not achieved. Little is known about patient experiences with the process of following up abnormal screening results.

OBJECTIVE

Assess patient experiences and perceptions regarding the process of a diagnostic workup following abnormal breast, cervical, or colorectal cancer screening results.

DESIGN

Survey of participating patients between April 2021 and June 2022 after reaching the primary outcome time point in a randomized controlled trial to improve follow-up of overdue abnormal screening results.

PARTICIPANTS

Patients from 44 participating practices in three primary care practice networks.

MAIN MEASURES

Self-reported ease of scheduling follow-up, perceived barriers or concerns, provider trust, and satisfaction with communication and care received for the follow-up of abnormal screening results.

RESULTS

Overall, 241 (25.0%) patients completed the survey including 66 (32.8%) with breast, 79 (25.3%) with cervical, and 96 (21.3%) with colorectal screening test; median age 55 years, 79.7% women, 80.5% non-Hispanic white, and 51.0% did not complete recommended follow-up. Most patients were worried that the test would find cancer (63.1%), but fewer worried about discomfort or side effects (34.4%), and neither were associated with completing follow-up. However, 17% of patients did not think they needed follow-up tests or appointments and were less likely to complete follow-up (10.5% vs. 24.0%, respectively, p-value 0.009). Most patients were very satisfied with their overall care (71.0%), but only 50.2% strongly agreed that they trusted their provider to put their medical needs above all else when making recommendations.

CONCLUSIONS

Patients with overdue abnormal breast, cervical, and colorectal cancer screening test results reported important deficiencies in the management of recommended follow-up. Addressing patient concerns about fear of cancer and effectively communicating the need for follow-up procedures may improve timely follow-up after an abnormal cancer screening result.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03979495.

Multilevel intervention for follow-up of abnormal FIT in the safety-net: IMProving Adherence to Colonoscopy through Teams and Technology (IMPACTT)

BACKGROUND

Fecal immunochemical testing (FIT) is a widely used first step for colorectal cancer (CRC) screening. Abnormal FIT results require a colonoscopy for screening completion and CRC diagnosis, but the rate of timely colonoscopy is low, especially among patients in safety-net settings. Multi-level factors at the clinic- and patient-levels influence colonoscopy completion after an abnormal FIT. Our study aims to implement a multi-level approach consisting of a clinic- and patient-level intervention to improve the completion of diagnostic colonoscopy after an abnormal FIT.

METHODS

We will test a multilevel intervention with one safety-net system across 12 primary care clinics - a clinic-level intervention using a stepped wedge design and a patient-level intervention with patient-level randomization. At the clinic level, we will implement a "best practices bundle" to improve workflow for primary care providers and staff using a stepped-wedge design. At the patient level, we will randomize 2000 patients to receive text messages and call reminders or usual care.

RESULTS

For the main analysis, we will use a mixed effects logistic model to assess the impact of the clinic intervention on the primary outcome (completion of colonoscopy within 180 days after abnormal FIT). Secondary outcomes include median days to colonoscopy completion, rate of referral to colonoscopy at 42 days, rate of scheduled colonoscopy at 56 days, and bowel preparation quality at colonoscopy.

DISCUSSION

This study will assess the extent to which a multi-level intervention can improve timely colonoscopy completion in a diverse patient population cared for in a safety-net setting.

TRIAL REGISTRATION

NCT, NCT06191185. Registered 20 December 2023, https://clinicaltrials.gov/study/NCT06191185.

Delivering Guideline-Concordant Care for Patients With High-Risk HPV and Normal Cytologic Findings

Importance

As US health care systems shift to human papillomavirus (HPV)-based cervical cancer screening, more patients are receiving positive high-risk non-16/18 genotype HPV results and negative for intraepithelial lesion or malignancy (NILM) cytological findings. Risk-based management guidelines recommend 2 consecutive negative annual results to return to routine screening.

Objective

To quantify patterns of surveillance testing and associated outcomes for patients after an HPV-positive results and NILM cytologic findings.

Design, Setting, and Participants

This cohort study analyzed patients in the METRICS (Multi-level Optimization of the Cervical Cancer Screening Process in Diverse Settings and Populations) cohort of the PROSPR II (Population-Based Research to Optimize the Screening Process) Cervical Consortium. Population-based data were obtained from 3 diverse health care systems (Mass General Brigham [MGB] in Massachusetts, Kaiser Permanente Washington [KPWA] in Washington, and Parkland Health [PH] in Texas) in the METRICS cohort. Participants were patients aged 21 to 65 years who received an HPV-positive (non-16/18 or pooled genotypes) result and NILM cytologic finding from January 2010 to August 2018 and were followed up through December 2019. Data analyses were performed between April 2021 and November 2024.

Main Outcomes and Measures

Test receipt and outcomes delivered within 16 months after the index result (round 1 surveillance).

Results

The final sample across the 3 health care systems comprised 13 158 female patients (3228 Hispanic or Latine [24.5%], 1990 non-Hispanic African American or Black [15.1%], 749 non-Hispanic Asian [5.7%], and 6559 non-Hispanic White [49.8%] individuals). Sociodemographic characteristics varied by site, with more non-Hispanic White (2277 [63.7%] and 4061 [61.2%]) and commercially insured patients (3137 [87.8%] and 4365 [65.7%]) at KPWA and MGB, and more Hispanic or Latine (1664 [56.5%]) and uninsured patients (2352 [79.9%]) at PH. During round 1 surveillance, 43.7% of patients were tested, of whom 18.2% (2394) had HPV-negative results and NILM cytologic findings and 25.5% (3351) had abnormal results. Many patients remained in the cohort and were untested through round 1 surveillance (overall: 49.4% [6505]; across sites: 39.0% [1395] to 69.4% [2043]), while fewer exited the cohort (overall: 6.9% [908]; across sites: 0.2% [12] to 24.6% [879]). Groups with lower odds of timely testing were younger adults (aged 25-29 vs 30-39 years: adjusted odds ratio [AOR], 0.65; 95% CL, 0.53-0.81), non-Hispanic African American or Black compared with non-Hispanic White patients (AOR, 0.78; 95% CL, 0.68-0.89), and those with Medicaid compared with commercial insurance (AOR, 0.81; 95% CL, 0.72-0.91), while those with a primary care clinician were more likely to have timely testing (AOR, 1.44; 95% CL, 1.21-1.70). Cancer was diagnosed in 10 patients (0.2%) untested in round 1 surveillance compared with 0 cancers in those with an HPV-negative results and NILM cytologic findings.

Conclusions and Relevance

This cohort study found that among patients with HPV-positive results and NILM cytologic findings, less than half received a surveillance cotest during the guideline-recommended time frame. Health care systems should monitor annual surveillance and gather evidence on interventions to optimize the delivery of surveillance testing.

Moving Beyond Medical Statistics: A Systematic Review on Missing Data Handling in Electronic Health Records

Background: Missing data in electronic health records (EHRs) presents significant challenges in medical studies. Many methods have been proposed, but uncertainty exists regarding the current state of missing data addressing methods applied for EHR and which strategy performs better within specific contexts. Methods: All studies referencing EHR and missing data methods published from their inception until 2024 March 30 were searched via the MEDLINE, EMBASE, and Digital Bibliography and Library Project databases. The characteristics of the included studies were extracted. We also compared the performance of various methods under different missingness scenarios. Results: After screening, 46 studies published between 2010 and 2024 were included. Three missingness mechanisms were simulated when evaluating the missing data methods: missing completely at random (29/46), missing at random (20/46), and missing not at random (21/46). Multiple imputation by chained equations (MICE) was the most popular statistical method, whereas generative adversarial network-based methods and the k nearest neighbor (KNN) classification were the common deep-learning-based or traditional machine-learning-based methods, respectively. Among the 26 articles comparing the performance among medical statistical and machine learning approaches, traditional machine learning or deep learning methods generally outperformed statistical methods. Med.KNN and context-aware time-series imputation performed better for longitudinal datasets, whereas probabilistic principal component analysis and MICE-based methods were optimal for cross-sectional datasets. Conclusions: Machine learning methods show significant promise for addressing missing data in EHRs. However, no single approach provides a universally generalizable solution. Standardized benchmarking analyses are essential to evaluate these methods across different missingness scenarios.

Predicting the Future by Studying the Past for Patients With Cancer Diagnosed in the Emergency Department

In the article that accompanies this editorial, Kapadia et al. developed a digital quality measure to identify emergency presentations of incident cancers, a measure they found to associated with both antecedent missed opportunities for diagnosis and subsequent 1-year all-cause mortality. Their work highlights the need for a cancer control continuum that includes, not only improved early detection, but also improved symptom recognition, expedited diagnostic work-up, and increased downstream support, including multilevel interventions focused on care continuity and symptom management for these patients with emergency presentations of cancer to improve cancer outcomes.

Assessing Management of Abnormal Cervical Cancer Screening Results and Concordance with Guideline Recommendations in Three US Healthcare Settings

BACKGROUND

Follow-up of abnormal results is essential to cervical cancer screening, but data on adherence to follow-up are limited. We describe patterns of follow-up after screening abnormalities and identify predictors of guideline-concordant follow-up.

METHODS

We identified the index screening abnormality (positive human papillomavirus test or atypical squamous cells of undetermined significance or more severe cytology) among women of ages 25 to 65 years at three US healthcare systems during 2010 to 2019. We estimated the cumulative incidence of surveillance testing, colposcopy, or treatment after the index abnormality and initial colposcopy. Logistic regressions were fit to identify predictors of guideline-concordant follow-up according to contemporaneous guidelines.

RESULTS

Among 43,007 patients with an index abnormality, the cumulative incidence of any follow-up was 49.6% by 4 years for those with atypical squamous cells of undetermined significance/human papillomavirus-negative and higher for abnormalities warranting immediate colposcopy. The 1-year cumulative incidence of any follow-up after colposcopy was 70% for patients with normal results or cervical intraepithelial neoplasia I and 90% for patients with cervical intraepithelial neoplasia II+. Rates of concordant follow-up after screening and colposcopy were 52% and 47%, respectively. Discordant follow-up was associated with factors including age, race/ethnicity, overweight/obese body mass index, and specific types of public payor coverage or being uninsured.

CONCLUSIONS

Adherence to the recommended follow-up of cytologic and histopathologic abnormalities is inconsistent in clinical practice. Concordance was poor for mild abnormalities and improved, although suboptimal, for more severe abnormalities.

IMPACT

There remain gaps in the cervical cancer screening process in clinical practice. Further study is needed to understand the barriers to the appropriate management of cervical abnormalities.

Humanistic Health Management and Cancer: Associations of Psychology, Nutrition, and Exercise with Cancer Progression and Pathogenesis

The incidence rate of cancer is increasing year by year due to the aging of the population, unhealthy living, and eating habits. At present, surgery and medication are still the main treatments for cancer, without paying attention to the impact of individual differences in health management on cancer. However, increasing evidence suggests that individual psychological status, dietary habits, and exercise frequency are closely related to the risk and prognosis of cancer. The reminder to humanity is that the medical concept of the unified treatment plan is insufficient in cancer treatment, and a personalized treatment plan may become a breakthrough point. On this basis, the concept of "Humanistic Health Management" (HHM) is proposed. This concept is a healthcare plan that focuses on self-health management, providing an accurate and comprehensive evaluation of individual lifestyle habits, psychology, and health status, and developing personalized and targeted comprehensive cancer prevention and treatment plans. This review will provide a detailed explanation of the relationship between psychological status, dietary, and exercise habits, and the regulatory mechanisms of cancer. Intended to emphasize the importance of HHM concept in cancer prevention and better prognostic efficacy, providing new ideas for the new generation of cancer treatment.

Improving follow-up of abnormal cancer screening results: Basic interventions and reminders in the electronic health record can help increase the benefits of timely follow-up for patients

This news section offers Cancer readers timely information on events, public policy analysis, topical issues, and personalities. In this issue, clinicians discuss how basic interventions and reminders in the electronic health record can help increase the benefits of timely follow‐up for patients who have abnormal cancer screening results. In addition, the results of two recent studies show that new first‐line therapies for advanced bladder cancer are showing improvements in survival.