Increasing cervical cancer screening among underserved women in a large urban county health system: can it be done? What does it take?

Gaps in the screening process for women diagnosed with cervical cancer in four diverse US health care settings

BACKGROUND

Potential care gaps in the cervical cancer screening process among women diagnosed with cervical cancer in an era with increased human papillomavirus (HPV) testing have not been extensively evaluated.

METHODS

Women diagnosed with cervical cancer between ages 21 and 65 at four study sites between 2010 and 2014 were included. Screening histories were ascertained from 0.5 to 4 years prior to cervical cancer diagnosis. We identified potential care gaps in the screening history for each woman and classified them into one of three mutually exclusive types: lack of a screening test, screening test failure, and diagnostic/treatment care gap. Distributions of care gaps were tabulated by stage, histology, and study site. Multivariable nominal logistic regression was used to examine the associations between demographic and cancer characteristics and type of care gap.

RESULTS

Of 499 women evaluated, 46% lacked a screening test in the time window examined, 31% experienced a screening test failure, and 22% experienced a diagnostic/treatment care gap. More than half of the women with advanced cancer and squamous cell carcinoma lacked a screening test compared to 31% and 24% of women with localized cancer and adenocarcinoma, respectively. Women aged 21-29 at diagnosis were more likely to experience screening test failure and diagnostic/treatment care gap, while those aged 50-65 were more likely to lack a screening test, compared to women aged 30-39.

CONCLUSIONS

Our findings demonstrate a continuing need to develop interventions targeting unscreened and under-screened women and improve detection and diagnosis of adenocarcinoma in women undergoing cervical cancer screening and diagnostic follow-up.

Segmenting women eligible for cervical cancer screening using demographic, behavioural and attitudinal characteristics

The best ways to communicate effectively to under-screened women about cervical cancer screening are unknown. Segmentation techniques create homogeneous segments of women in the population that are different from one another, and help to determine on whom communication efforts should be focused and how messaging should be tailored. We used segmentation techniques to better understand the demographics, attitudes and behaviours of women eligible for cervical screening. We developed a brief online questionnaire that consisted of demographic characteristics, attitudes toward health, and cervical screening behaviour. Simple descriptive statistics were used to describe the study population and principal components analysis was used to define the segments. The study sample consisted of 615 women living in Ontario, 508 from the general population and 107 from South Asia; 63.1% reported regular screening. We defined four segments that represented the sample: i) Proactive, ii) Family First, iii) Social and Stylish, and iv) Faith-Driven. South Asians were represented in all segments. Women who were in the Family First and Faith-Driven segments were least likely to have regular Pap tests and were least likely to know about human papilloma virus (HPV)'s role in cervical cancer. The Internet was very popular among women in all segments as a source of health information, particularly among Faith-Driven women. Only 69.2% of Family First women listed their family physician as a source of health information vs. 91.1% of Proactive women. Future research should focus on how to most effectively reach women who meet the Family First and Faith-Driven profiles, and through which communication media.

Increasing Cervical Cancer Screening Among US Hispanics/Latinas: A Qualitative Systematic Review

Hispanic/Latina women experience the highest cervical cancer incidence rates of any racial/ethnic group in the USA and tend to present with more severe cases and experience higher mortality compared to most other populations. The goals of this qualitative systematic review were to explore existing interventions to increase cervical cancer screening among US Hispanics/Latinas and to identify characteristics of effective interventions and research gaps. Six online databases were searched from their inception through June 30, 2013, using designated search terms and keywords. Peer-reviewed articles that documented an intervention designed to improve screening for cervical cancer among Hispanics/Latinas ages 18 years and older living in the USA were reviewed. Data were abstracted using a standardized form to document intervention characteristics and results. Forty-five articles, describing 32 unique interventions, met inclusion criteria. Identified interventions consisted primarily of educational programs and/or provision of screening. Interventions used lay health advisors (LHAs), clinic-based outreach/delivery strategies, partnerships with churches, and mass media campaigns. Twelve interventions resulted in significant increases in cervical cancer screening rates. Interventions developed utilizing theory, applying community-based participatory research approaches, and using LHAs were identified as having the greatest potential for improving cervical cancer screening among Hispanics/Latinas. There continues to be a need for the development of interventions in geographic areas with new and emerging Hispanic/Latino populations and that are comprehensive, follow participants for longer periods of time, and broaden the roles and build the capacities of LHAs.

Challenges and Opportunities to Improve Cervical Cancer Screening Rates in US Health Centers through Patient-Centered Medical Home Transformation

Over the last 50 years, the incidence of cervical cancer has dramatically decreased. However, health disparities in cervical cancer screening (CCS) persist for women from racial and ethnic minorities and those residing in rural and poor communities. For more than 45 years, federally funded health centers (HCs) have been providing comprehensive, culturally competent, and quality primary health care services to medically underserved communities and vulnerable populations. To enhance the quality of care and to ensure more women served at HCs are screened for cervical cancer, over eight HCs received funding to support patient-centered medical home (PCMH) transformation with goals to increase CCS rates. The study conducted a qualitative analysis using Atlas.ti software to describe the barriers and challenges to CCS and PCMH transformation, to identify potential solutions and opportunities, and to examine patterns in barriers and solutions proposed by HCs. Interrater reliability was assessed using Cohen's Kappa. The findings indicated that HCs more frequently described patient-level barriers to CCS, including demographic, cultural, and health belief/behavior factors. System-level barriers were the next commonly cited, particularly failure to use the full capability of electronic medical records (EMRs) and problems coordinating with external labs or providers. Provider-level barriers were least frequently cited.

Innovative approaches to cervical cancer screening for sex trade workers: an international scoping review

OBJECTIVE

Female sex trade workers are among those at highest risk for developing and dying of cervical cancer, and yet many-particularly the most marginalized-are less likely than other women to be screened. This review summarizes global findings on innovative approaches to cervical cancer screening for female sex trade workers, highlights current gaps in the delivery of cervical cancer screening for female sex trade workers globally, and suggests areas for future research and policy development.

DATA SOURCES

A scoping review of peer-reviewed publications and grey literature was conducted. Medline (OVID), PubMed, EMBASE, and SCOPUS were searched for relevant studies written in English. There were no limitations placed on dates. Grey literature was identified by hand searching and through discussion with health care providers and community outreach workers currently working with sex trade workers.

STUDY SELECTION

Twenty-five articles were deemed suitable for review. Articles detailing innovative ways for female sex trade workers to access cervical cancer screening were included. Articles about screening for sexually transmitted infections were also included if the findings could be generalized to screening for cervical cancer. Articles limited to exploring risk factors, knowledge, awareness, education, prevalence, and incidence of cervical cancer among sex trade workers were excluded from the review.

DATA EXTRACTION AND SYNTHESIS

Successful screening initiatives identified in the studies reviewed had unconventional hours of operation, understood the difference between street-based and venue-based sex trade workers, and/or used peers for outreach.

CONCLUSION

Two significant gaps in health care service delivery were highlighted in this review: the limited use of unorthodox hours and the nearly exclusive practice of providing sexually transmitted infection screening for female sex trade workers without cervical cancer screening. In addition, although street-based (as opposed to venue-based) sex trade workers are likely at higher risk for developing cervical cancer, they are much less likely than other eligible women to participate in screening programs, meaning traditional outreach methods are unlikely to be successful.

Improving cervical cancer screening rates in an urban HIV clinic

Human immunodeficiency virus (HIV)-infected women are at increased risk of invasive cervical cancer; however, screening rates remain low. The objectives of this study were to analyze a quality improvement intervention to increase cervical cancer screening rates in an urban academic HIV clinic and to identify factors associated with inadequate screening. Barriers to screening were identified by a multidisciplinary quality improvement committee at the Washington University Infectious Diseases clinic. Several strategies were developed to address these barriers. The years pre- and post-implementation were analyzed to examine the clinical impact of the intervention. A total of 422 women were seen in both the pre-implementation and post-implementation periods. In the pre-implementation period, 222 women (53%) underwent cervical cancer screening in the form of Papanicolaou (Pap) testing. In the post-implementation period, 318 women (75.3%) underwent cervical cancer screening (p < 0.01). Factors associated with lack of screening included fewer visits attended (pre: 4.2 ± 1.5; post: 3.4 ± 1.4; p < 0.01). A multidisciplinary quality improvement intervention was successful in overcoming barriers and increasing cervical cancer screening rates in an urban academic HIV clinic.

The role of family history of cancer on cervical cancer screening behavior in a population-based survey of women in the Southeastern United States

BACKGROUND

Our objective was to determine the association of self-reported family history of cancer (FHC) on cervical cancer screening to inform a potential link with cancer preventive behaviors in a region with persistent cancer disparities.

METHODS

Self-reported FHC, Pap test behavior, and access to care were measured in a statewide population-based survey of human papillomavirus and cervical cancer (n = 918). Random-digit dial, computer-assisted telephone interviews were used to contact eligible respondents (adult [ages 18-70] women in South Carolina with landline telephones]. Logistic regression models were estimated using STATA 12.

FINDINGS

Although FHC+ was not predictive (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.55-2.51), private health insurance (OR, 2.35; 95% confidence interval [CI], 1.15-4.81) and younger age (18-30 years: OR, 7.76; 95% CI, 1.91, 3.16) were associated with recent Pap test behavior. FHC and cervical cancer screening associations were not detected in the sample.

CONCLUSIONS

Findings suggest targeting older women with screening recommendations and providing available screening resources for underserved women.

Cervical cancer screening, diagnosis and treatment interventions for racial and ethnic minorities: a systematic review

OBJECTIVES

To systematically review the literature to determine which interventions improve the screening, diagnosis or treatment of cervical cancer for racial and/or ethnic minorities.

DATA SOURCES

Medline on OVID, Cochrane Register of Controlled Trials, CINAHL, PsycINFO and Cochrane Systematic Reviews.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

We searched the above databases for original articles published in English with at least one intervention designed to improve cervical cancer prevention, screening, diagnosis or treatment that linked participants to the healthcare system; that focused on US racial and/or ethnic minority populations; and that measured health outcomes. Articles were reviewed to determine the population, intervention(s), and outcomes. Articles published through August 2010 were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

One author rated the methodological quality of each of the included articles. The strength of evidence was assessed using the criteria developed by the GRADE Working Group.

RESULTS

Thirty-one studies were included. The strength of evidence is moderate that telephone support with navigation increases the rate of screening for cervical cancer in Spanish- and English-speaking populations; low that education delivered by lay health educators with navigation increases the rate of screening for cervical cancer for Latinas, Chinese Americans and Vietnamese Americans; low that a single visit for screening for cervical cancer and follow up of an abnormal result improves the diagnosis and treatment of premalignant disease of the cervix for Latinas; and low that telephone counseling increases the diagnosis and treatment of premalignant lesions of the cervix for African Americans.

LIMITATIONS

Studies that did not focus on racial and/or ethnic minority populations may have been excluded. In addition, this review excluded interventions that did not link racial and ethnic minorities to the health care system. While inclusion of these studies may have altered our findings, they were outside the scope of our review.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Patient navigation with telephone support or education may be effective at improving screening, diagnosis, and treatment among racial and ethnic minorities. Research is needed to determine the applicability of the findings beyond the populations studied.

The impact of interventions to improve attendance in female cancer screening among lower socioeconomic groups: a review

OBJECTIVE

To review the scientific evidence on the effectiveness of interventions to promote attendance to breast and cervical cancer screening among lower socioeconomic groups.

METHODS

We performed a computerized literature search looking for relevant papers published between 1997 and 2006. Papers were classified into three groups based on the type of intervention evaluated: (1) implementation of organized population screening programs; (2) different strategies of enhancing attendance within an organized program; (3) local interventions in disadvantaged populations.

RESULTS

The available evidence supports the hypothesis that while organized population screening programs are successful in increasing overall participation rates, they may not per se substantially reduce social inequalities. Some strategies were consistently found to enhance access to screening among lower socioeconomic groups, including cost-reducing interventions (e.g. offering free tests and eliminating geographical barriers), a greater involvement of primary-care physicians and individually tailored pro-active communication that addresses barriers to screening.

CONCLUSIONS

Evidence from studies suggests that the attendance of deprived women to cancer screening can be improved with organized screening programs tailored to their needs. The same may apply to the prevention of adverse outcomes of other health conditions, such as hypertension, hypercholesterolemia, and diabetes.

Family history of cancer predicts Papanicolaou screening behavior for African American and white women

BACKGROUND

Understanding women's motivations for getting Papanicolaou (Pap) screening has the potential to impact cancer disparities. This study examined whether having a family history of cancer was a predictor for Pap screening.

METHODS

By using the National Health Interview Survey 2000 Cancer Control and Family modules, we identified a subsample (n=15,509) of African American (n=2774) and white women (n=12,735) unaffected by cancer, with and without a family history of cancer. Data were analyzed using logistic regression models.

RESULTS

African American and white women with a positive family history of cancer were 42% (P<.0001) more likely to have had a recent Papanicolaou (Pap) test than their counterparts without a family history of cancer. Among African American women, those with a positive family history of cancer were 53% more likely to have had a recent Pap test, whereas among white women those with a positive family history of cancer were 41% more likely to have received a Pap test. African American women with a family history of cancer were more likely to have had a recent Pap test than white women with or without a family history of cancer.

CONCLUSIONS

This study presents a unique perspective on Pap screening behavior. Having an immediate family member with any cancer statistically predicted having a recent Pap test for both African American and white women. Because these results demonstrated that regardless of the cancer type, having an immediate affected family member is a motivator for cervical cancer screening behavior, healthcare providers managing cancer treatment patients have a teachable opportunity that extends beyond the patient.

Physician Recommendation for Papanicolaou Testing Among U.S. Women, 2000

OBJECTIVE

Many women in the U.S. undergo routine cervical cancer screening, but some women have rarely or never had a Papanicolaou (Pap) test. Studies of other cancer screening tests (for example, mammograms) have shown that physician recommendation to get a screening test is one of the strongest predictors of cancer screening.

METHODS

In this study, we examined whether women in the U.S. had received a physician recommendation to get a Pap test using data from the 2000 National Health Interview Survey. Reported reasons for not receiving a Pap test were also explored.

RESULTS

Among women aged > or =18 years who had no history of hysterectomy, 83.3% [95% confidence interval (CI), 82.4-84.1%] of the 13,636 women in this sample had had a Pap test in the last 3 years. Among 2,310 women who had not had a recent Pap test, reported reasons for not receiving a Pap test included: "No reason/never thought about it" (48.0%; 95% CI, 45.5-50.7), "Doctor didn't order it" (10.3%; 95% CI, 8.7-12.0), "Didn't need it/didn't know I needed this type of test" (8.1%; 95% CI, 6.7-9.6), "Haven't had any problems" (9.0%; 95% CI, 7.6-10.5), "Put it off" (7.4%; 95% CI, 6.2-8.7), "Too expensive/no insurance" (8.7%; 95% CI, 7.3-10.2), "Too painful, unpleasant, embarrassing" (3.5%; 95% CI, 2.5-4.6), and "Don't have doctor" (1.7%; 95% CI, 1.2-2.4). Among women who had had a doctor visit in the last year but who had not had a recent Pap test, about 86.7% (95% CI, 84.5-88.6) reported that their doctor had not recommended a Pap test in the last year. African-American women were as likely as White women to have received a doctor recommendation to get a Pap test. Hispanic women were as likely as non-Hispanic women to have received a doctor recommendation to get a Pap test. In multivariate analysis, factors positively associated with doctor recommendation to get a Pap test included being aged 30 to 64 years, having been born in the U.S., and having seen a specialist or general doctor in the past year.

CONCLUSION

These findings suggest that lack of a physician recommendation contributes to underuse of Pap screening by many eligible women. Given research that shows the effectiveness of physician recommendations in improving use, increased physician recommendations could contribute significantly to increased Pap screening use in the U.S.

Taking a stand against cervical cancer

Help detect cervical cancer before it becomes difficult to treat. Here's how to encourage patients to get regular screening and to care for those with cancer.