Variation in the receipt of human papilloma virus co-testing for cervical screening: Individual, provider, facility and healthcare system characteristics

Utilization and outcomes of serial cervical cancer screening in a National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in a non-Medicaid expansion state

PURPOSE

Since 1990, the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has offered free cervical cancer screening to low-income, uninsured patients, increasing single time point screening and early detection rates. Little is known about NBCCEDP's longitudinal effectiveness. The objective of this study was to assess utilization of Kansas's NBCCEDP, early detection works (EDW) for one-time versus serial screening and compare rates of cervical dysplasia between groups.

METHODS

A retrospective cohort study was conducted among patients who received cervical cancer screening through EDW from 2001 to 2021. Demographic factors, Papanicolaou (Pap) test, and human papillomavirus (HPV) results were compared between patients with one screening versus multiple. Descriptive statistics were performed.

RESULTS

From 2014 to 2021, 3.71-7.06% of eligible patients completed screening through EDW annually. 17.4% of 58,582 eligible patients were up-to-date with screening in 2020. Rural patients and those under age forty were less likely to have EDW screening. Of 43,916 ever-screened patients, 14,638 (33.3%) received multiple screenings. 77% of patients did not have HPV testing; rates were lower in serially screened patients. Cervical dysplasia rates differed minimally between groups.

CONCLUSION

Despite screening 24,017 patients over 7 years, EDW maintains up-to-date screening for under one-fourth of eligible Kansans. Young and rural patients less frequently access EDW. HPV testing is underutilized, which limits the negative predictive value of screening. Serial screening is largely used by low-risk patients currently. Identification and prioritization of serial screening in high risk could increase program impact.

Cervical cancer screening rates in females living with HIV at three healthcare settings in the United States, 2010-2019

PURPOSE

Females living with human immunodeficiency virus (FLWHIV) are at increased risk of cervical cancer and U.S. guidelines, first published in 2009 and updated since then, recommend more frequent screening in this population. We examined screening rates among FLWHIV in the U.S. during 2010-2019.

METHODS

This cohort study included 18-89-year-old FLWHIV during 2010-2019 at three U.S. healthcare settings. Sociodemographics, comorbidities, and cervical cancer screening tests were ascertained from administrative and clinical databases. We reported cervical cancer screening rates overall and by modality. Generalized estimating equations with Poisson distribution were used to estimate screening rate ratios (SRRs) and 95% confidence intervals (CIs) for the associations between screening rates and calendar year, age, race and ethnicity, and comorbidity.

RESULTS

Among 3,556 FLWHIV, a total of 7,704 cervical cancer screening tests were received over 18,605 person-years during 2010-2019 (screening rate = 41.4 per 100 person-years). Relatively lower screening rates were associated with later calendar years (SRR = 0.71 [95% CI 0.68-0.75] for 2017-2019 versus 2010-2013), older age (SRR = 0.82 [95% CI 0.74-0.89] for 50-65-year-olds versus 18-29-year-olds), non-Hispanic white race versus non-Hispanic Black race (SRR = 0.89 [95% CI 0.81-0.98]) and greater comorbidity burden (SRR = 0.89 [95% CI 0.82-0.98] for ≥ 9 versus 0-6 comorbidity score).

CONCLUSION

The decrease in cervical cancer screening rates during 2010-2019 in this large cohort of FLWHIV may be explained at least partly by guideline changes during the study period recommending longer screening intervals. Our findings of relatively lower screening rates in FLWHIV who were non-Hispanic white, older, and with greater comorbidity burden should be confirmed in other U.S.

SETTINGS

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.

Association between racial residential segregation and screening uptake for colorectal and cervical cancer among Black and White patients in five US health care systems

BACKGROUND

Despite increased recognition that structural racism contributes to poorer health outcomes for racial and ethnic minorities, there are knowledge gaps about how current patterns of racial residential segregation are associated with cancer screening uptake. The authors examined associations between Black residential segregation and screening for colorectal cancer (CRC) and cervical cancer among non-Hispanic Black and non-Hispanic White adults.

METHODS

This was a retrospective study of CRC and cervical cancer screening-eligible adults from five health care systems within the Population-Based Research to Optimize the Screening Process (PROSPR II) Consortium (cohort entry, 2010-2012). Residential segregation was measured using site-specific quartiles of the Black local isolation score (LIS). The outcome was receipt of CRC or cervical cancer screening within 3 years of cohort entry (2010-2015). Logistic regression was used to calculate associations between the LIS and screening completion, adjusting for patient-level covariates.

RESULTS

Among CRC (n = 642,661) and cervical cancer (n = 163,340) screening-eligible patients, 456,526 (71.0%) and 106,124 (65.0%), respectively, received screening. Across PROSPR sites, living in neighborhoods with higher LIS tended to be associated with lower odds of CRC screening (Kaiser Permanente Northern California: adjusted odds ratio [aOR] LIS trend in Black patients, 0.95 [p < .001]; aOR LIS trend in White patients, 0.98 [p < .001]; Kaiser Permanente Southern California: aOR LIS trend in Black patients, 0.98 [p = .026]; aOR LIS trend in White patients, 1.01 [p = .023]; Kaiser Permanente Washington: aOR LIS trend in White patients, 0.97 [p = .002]. However, for cervical cancer screening, associations with the LIS varied by site and race (Kaiser Permanente Washington: aOR LIS trend in White patients, 0.95 [p < .001]; Mass General Brigham: aOR LIS trend in Black patients, 1.12 [p < .001]; aOR LIS trend in White patients, 1.03 [p < .001]).

CONCLUSIONS

Across five diverse health care systems, the direction of the association between Black residential segregation and screening varied by PROSPR site, race, and screening type. Additional research, including studies that examine multiple dimensions of segregation and structural racism using intersectional approaches, are needed to further disentangle these relationships.

Association Between Clinician Confidence and Making Guideline-Recommended Decisions in the Management of Abnormal Cervical Cancer Screening Results

BACKGROUND

Guidelines for managing abnormal cervical cancer screening results are complex and adherence is challenging for clinicians. Previous studies have identified gaps in knowledge as a possible cause; few have explored the confidence clinicians have in their management decisions. Confidence in decision-making may influence management practices, particularly when guidelines are complex and evolving.

OBJECTIVE

Assess whether confidence in decision-making is associated with making guideline-concordant recommendations for abnormal cervical cancer screening results.

DESIGN

A clinician survey used vignettes to ask clinicians to make a management recommendation for different abnormal results and rate their level of confidence in their response.

PARTICIPANTS

Physicians and advanced practice providers (APPs) at three diverse health systems in Washington, Texas, and Massachusetts.

MAIN MEASURES

Correct response to each vignette based on either the 2012 or 2019 American Colposcopy and Cervical Pathology (ASCCP) management guidelines.

KEY RESULTS

In total, 501 clinicians completed the survey between October and December 2020 (response rate 53.7%). Overall, most clinicians made guideline-recommended management decisions for two vignettes (73.2 and 73.7%), but fewer were confident in their selection (48.3% and 46.6%, respectively). Clinicians who reported high levels of confidence were more often correct than those who reported lower levels of confidence (85.8% vs. 62.2% and 87.5% vs. 60.7%, both p<0.001). After adjusting for clinician and practice characteristics, confidence remained significantly associated with selecting the correct answer.

CONCLUSIONS

Clinician confidence in management decisions for abnormal cervical cancer screening results was significantly associated with knowing guideline-concordant recommendations. Given the complexity of cervical cancer management guidelines, solutions to improve clinician confidence in decision-making are needed.

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.

Variation in cervical cancer screening test utilization and results in a United States-based program

BACKGROUND

Little is known about cervical cancer screening strategy utilization (cytology alone, cytology plus high-risk human papillomavirus [HPV] testing [cotesting], primary HPV testing) and test results in the United States.

METHODS

Data from the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program were analyzed for 199,578 persons aged 21-65 years screened from 2019 to 2020. Screening test utilization and results were stratified by demographic characteristics and geographic region. Age-standardized pooled HPV test positivity and genotyping test positivity were estimated within cytology result categories.

RESULTS

Primary HPV testing was performed in 592 persons (0.3%). Among the remaining 176,290 persons aged 30-65 years, cotesting was utilized in 72.1% (95% confidence interval [CI] 71.9-72.3%), and cytology alone was utilized in 27.9% (95% CI 27.7-28.1%). Utilization of cytology alone varied by geographic region, ranging from 18.3% (95% CI 17.4-19.1%) to 49.0% (95% CI 48.4-49.6%). HPV genotyping test utilization among those with positive pooled HPV test results was 33.9%. In persons aged ≥30 years, variations in age-adjusted test results by region were observed for pooled HPV-positive test results and for HPV genotyping-positive test results.

CONCLUSIONS

Cervical cancer screening strategy utilization and test results vary substantially by geographic region within a national screening program. Variation in utilization may be due to regional differences in screening test availability or the preferences of healthcare systems, screened persons and/or clinicians. Test result variations may reflect differing risk factors for HPV infections by geographic region.

Breast and cervical cancer screening rates in student-run free clinics: A systematic review

OBJECTIVE

To assess rates of breast and cervical cancer screening at student-run free clinics to understand challenges and strategies for advancing quality and accessibility of women's health screening.

METHODS

The authors performed a systematic search of publications in Ovid MEDLINE, PubMed, Web of Science, and Google Scholar databases from database inception to 2020. English-language publications assessing rates of breast and cervical cancer screening in student-run free clinics were included. Structured data extraction was completed for each publication by two reviewers independently. Risk of bias was assessed using a modified Agency for Healthcare Research and Quality checklist. Results were synthesized qualitatively because of study heterogeneity.

RESULTS

Of 3634 references identified, 12 references met study inclusion criteria. The proportion of patients up-to-date on breast cancer screening per guidelines ranged from 45% to 94%. The proportion of patients up-to-date on cervical cancer screening per guidelines ranged from 40% to 88%.

CONCLUSION

Student-run free clinics can match breast and cervical cancer screening rates among uninsured populations nationally, although more work is required to bridge the gap in care that exists for the underinsured and uninsured.

A model-based analysis of the health impacts of COVID-19 disruptions to primary cervical screening by time since last screen for current and future disruptions

We evaluated how temporary disruptions to primary cervical cancer (CC) screening services may differentially impact women due to heterogeneity in their screening history and test modality. We used three CC models to project the short- and long-term health impacts assuming an underlying primary screening frequency (i.e., 1, 3, 5, or 10 yearly) under three alternative COVID-19-related screening disruption scenarios (i.e., 1-, 2-, or 5-year delay) versus no delay in the context of both cytology-based and human papillomavirus (HPV)-based screening. Models projected a relative increase in symptomatically detected cancer cases during a 1-year delay period that was 38% higher (Policy1-Cervix), 80% higher (Harvard), and 170% higher (MISCAN-Cervix) for underscreened women whose last cytology screen was 5 years prior to the disruption period compared with guidelines-compliant women (i.e., last screen 3 years prior to disruption). Over a woman's lifetime, temporary COVID-19-related delays had less impact on lifetime risk of developing CC than screening frequency and test modality; however, CC risks increased disproportionately the longer time had elapsed since a woman's last screen at the time of the disruption. Excess risks for a given delay period were generally lower for HPV-based screeners than for cytology-based screeners. Our independent models predicted that the main drivers of CC risk were screening frequency and screening modality, and the overall impact of disruptions from the pandemic on CC outcomes may be small. However, screening disruptions disproportionately affect underscreened women, underpinning the importance of reaching such women as a critical area of focus, regardless of temporary disruptions.