Adherence to screening guidelines for breast and cervical cancer in postmenopausal women with coronary heart disease: an ancillary study of volunteers for hers

Health-related Factors Associated with Adherence to Breast Cancer Screening

Introduction:

In Belgium, an effective preventive program for breast cancer exists but as in many countries to few women participates in the screening. This study aims to describe the factors that affect the participation in the national breast cancer screening program.

Methods:

The participants were aged between 50 and 69 years and were recruited during an exhibition at the Brussels Exhibition Centre. Medical history and health-related parameters of the participants were recorded.

Results:

In total, 350 women aged between 50 and 69 years participated. After adjustment for age and region, 81.5% of the participants had a mammography during the past 2 years. The multivariate analysis confirms the association between not having had a mammography and (a) having an older age (odds ratio [OR]: 0.25–0.87), (b) having diabetes (OR: 0.08–0.80), (c) having a family history of coronary heart disease (OR: 0.16–0.80), (d) not following a cholesterol diet or treatment (OR: 0.10–0.91) and (e) having a higher body mass index (OR: 0.39–0.97). Having had a mammogram was associated with adherence to cervical smear screening (OR: 2.74–11.21).

Conclusions:

Most of these associations are most likely related to socioeconomic status. However, the relationship with diabetes offers opportunities to increase the participation in breast cancer screening programs because these patients have regular contacts with their family physicians.

Cancer Screening Among U.S. Medicaid Enrollees with Chronic Comorbidities or Residing in Long-Term Care Facilities

Background

Ensuring appropriate cancer screenings among low-income persons with chronic conditions and persons residing in long-term care (LTC) facilities presents special challenges. This study examines the impact of having chronic diseases and of LTC residency status on cancer screening among adults enrolled in Medicaid, a joint state-federal government program providing health insurance for certain low-income individuals in the U.S.

Methods

We used 2000-2003 Medicaid data for Medicaid-only beneficiaries and merged 2003 Medicare-Medicaid data for dually-eligible beneficiaries from four states to estimate the likelihood of cancer screening tests during a 12-month period. Multivariate regression models assessed the association of chronic conditions and LTC residency status with each type of cancer screening.

Results

LTC residency was associated with significant reductions in screening tests for both Medicaid-only and Medicare-Medicaid enrollees; particularly large reductions were observed for receipt of mammograms. Enrollees with multiple chronic comorbidities were more likely to receive colorectal and prostate cancer screenings and less likely to receive Papanicolaou (Pap) tests than were those without chronic conditions.

Conclusions

LTC residents have substantial risks of not receiving cancer screening tests. Not performing appropriate screenings may increase the risk of delayed/missed diagnoses and could increase disparities; however, it is also important to consider recommendations to appropriately discontinue screening and decrease the risk of overdiagnosis. Although anecdotal reports suggest that patients with serious comorbidities may not receive regular cancer screening, we found that having chronic conditions increases the likelihood of certain screening tests. More work is needed to better understand these issues and to facilitate referrals for appropriate cancer screenings.

Randomized controlled trial of a repeat mammography intervention: effect of adherence definitions on results

BACKGROUND

As overall mammography rates approach national goals, mammography promotion efforts must increasingly focus on repeat adherence. This randomized controlled trial examined the effect of two interventions on repeat mammography utilization using various adherence definitions.

METHODS

1,558 women aged 40-63 receiving a mammogram through a federally funded screening program were randomized to three groups: mailed reminder (minimum group); mailed thank you card, newsletters, and reminder (maximum group); no mailings (control). The primary outcome (repeat mammogram) was assessed 13, 15, 18, and 24 months after the qualifying mammogram using administrative data.

RESULTS

The proportions receiving a repeat mammogram within 13 months were 0.28, 0.30, and 0.32 for control, minimum, and maximum groups, respectively. The corresponding proportions were 0.38, 0.43, and 0.45 at 15 months; 0.43, 0.49, and 0.51 at 18 months; and 0.47, 0.52, and 0.54 at 24 months. There were no significant differences across study groups at 13 months. The differences between control and maximum subjects at 15, 18, and 24 months were statistically significant. The differences between control and minimum subjects were significant only at 18 months.

CONCLUSIONS

The two low-cost mailed interventions evaluated modestly increased repeat mammography utilization. However, effects were not visible until at least 15 months after the qualifying mammogram.

Geographic disparities in cervical cancer mortality: what are the roles of risk factor prevalence, screening, and use of recommended treatment?

CONTEXT

Despite advances in early detection and prevention of cervical cancer, women living in rural areas, and particularly in Appalachia, the rural South, the Texas/Mexico border, and the central valley of California, have had consistently higher rates of cervical cancer mortality than their counterparts in other areas during the past several decades.

METHODS

This paper reviews the published literature from 1966 to July 2002 to assess three potential pathways underlying this excess mortality--high human papilloma virus (HPV) prevalence, lack of or infrequent screening and advanced disease at diagnosis, and under-use of recommended treatment and shorter survival.

FINDINGS

Living in rural areas may impose barriers to cervical cancer control, including lack of transportation and medical care infrastructures. Population characteristics that place women at greater risk for developing and dying from cervical cancer, such as low income, lack of health insurance, and physician availability, are concentrated in rural areas. Published data, however, are insufficient to identify the key reasons for the observed mortality patterns.

CONCLUSIONS

At this time, given the lack of definitive evidence in the published literature, decisions about priorities in areas with high rates of cervical cancer mortality will depend on knowledge of current levels of screening, incidence, and stage distribution; and service delivery infrastructures, resources, and acceptability of interventions to the target population.

Cervical cancer in women with comprehensive health care access: attributable factors in the screening process

BACKGROUND

Invasive cervical cancer is highly preventable, yet it continues to occur, even among women who have access to cancer screening and treatment services. To reduce cervical cancer among such women, reasons for its occurrence must be better understood. We examined factors associated with the diagnosis of cervical cancer among women enrolled in health plans.

METHODS

We identified all cases of invasive cervical cancer (n = 833) diagnosed from January 1, 1995, through December 31, 2000, among women who were long-term members of seven prepaid comprehensive health plans and reviewed each woman's medical records for the 3 years prior to her cancer diagnosis. Women were classified into one of three categories based on Pap test histories 4-36 months before diagnosis: failure to screen with a Pap test, failure in detection by a Pap test, or failure in follow-up of an abnormal test result.

RESULTS

The majority of cases (n = 464; 56%) were in women who had no Pap tests during the period 4-36 months prior to diagnosis. Of the remaining cases, 263 (32%) were attributed to Pap test detection failure and 106 (13%) to follow-up failure. Being older (odds ratio [OR] = 6.48, 95% confidence interval [CI] = 3.89 to 10.79) or living in an area of higher poverty (OR = 1.72, 95% CI = 1.11 to 2.67) or having a lower education level (OR= 1.52; 95% CI = 1.07 to 2.16) was associated with the likelihood of being assigned to the failure to screen category versus either of the other two categories. A total of 375 (81%) of the 464 patients who had not had Pap screening had had at least one outpatient visit 4-36 months prior to cancer diagnosis. The cancer diagnostic process was triggered by a routine screening examination in 44% of patients, whereas 53% of the patients presented with symptoms consistent with cervical cancer; the remaining 3% were identified fortuitously during the course of receiving noncervical care.

CONCLUSIONS

To reduce the incidence of invasive cervical cancer among women with access to screening and treatment, Pap screening adherence should be increased. In addition, strategies to improve the accuracy of Pap screening could afford earlier detection of cervical cancer.

An analysis of the potential impact of computed tomographic colonography (virtual colonoscopy) on colonoscopy demand

BACKGROUND AND AIMS

There has been much speculation about the potential impact on the use of conventional colonoscopy if "virtual" computed tomographic colonography (CTC) became a widely accepted modality for colorectal cancer (CRC) screening. However, no formal analysis of the impact of CTC on colonoscopy demand has been reported.

METHODS

A mathematical model to predict colonoscopy demand based on several relevant input parameters was constructed. Current national colonoscopy practice, estimated using various published reports, was used as the foundation to project colonoscopy demand if CTC were implemented as the primary CRC screening modality.

RESULTS

In the base-case analysis, if CTC were used as the primary modality for CRC screening, 1.78 million colonoscopies could be eliminated from the total 6.47 million in 2003. Depending on the polyp size threshold used to define a CTC study as positive (6 or 10 mm), this loss would be partially offset by 1.21 million (6 mm) or .34 million (10 mm) follow-up colonoscopies for CTC examinations with positive findings, resulting in a net loss of .57 million (8.8% decrease) (6 mm) or 1.44 million (22.3% decrease) (10 mm). Extensive sensitivity analyses showed that the findings of this model were robust and insensitive to most parameters tested but were sensitive to a few parameters, including the percentage of CTC examinations with positive findings.

CONCLUSIONS

Wide-scale implementation of CTC for CRC screening would likely lead to a decrease in use of conventional colonoscopy. The percentage of CTC studies with positive findings seemed to be a pivotal variable, which would be determined in large part by the polyp size ultimately established to define a positive finding.