Adherence to recommendations for follow-up to abnormal Pap tests

Chatbot-interfaced and cognitive-affective barrier-driven messages to improve colposcopy adherence after abnormal Pap test results in underserved urban women: A feasibility pilot study

Challenges in ensuring adherence to colposcopy and follow-up recommendations, particularly within underserved communities, hinder the delivery of appropriate care. Informed by our established evidence-based program, we sought to assess the feasibility and acceptability of a novel cognitive-affective intervention delivered through a Chatbot interface, aimed to enhance colposcopy adherence within an urban inner-city population. We developed the evidence-based intervention, CervixChat, to address comprehension of colposcopy's purpose, human papillomavirus (HPV) understanding, cancer-related fatalistic beliefs, procedural concerns, and disease progression, offered in both English and Spanish. Females aged 21-65, with colposcopy appointments at an urban OBGYN clinic, were invited to participate. Enrolled patients experienced real-time counseling messages tailored via a Chatbot-driven barriers assessment, dispatched via text one week before their scheduled colposcopy. Cognitive-affective measures were assessed at baseline and through a 1-month follow-up. Participants also engaged in a brief post-intervention satisfaction survey and interview to capture their acceptance and feedback on the intervention. The primary endpoints encompassed study adherence (CervixChat response rate and follow-up survey rate) and self-evaluated intervention acceptability, with predefined feasibility benchmarks of at least 70% adherence and 80% satisfaction. Among 48 eligible women scheduled for colposcopies, 27 (56.3%) agreed, consented, and completed baseline assessments. Participants had an average age of 34 years, with 14 (52%) identifying as non-Hispanic White. Of these, 21 (77.8%) engaged with the CervixChat intervention via mobile phones. Impressively, 26 participants (96.3%) attended their diagnostic colposcopy within the specified timeframe. Moreover, 22 (81.5%) completed the follow-up survey and a brief interview. Barriers assessment revealed notable encodings in the Affect and Values/Goals domains, highlighting concerns and understanding around HPV, as well as its impact on body image and sexual matters. Persistent and relatively high intrusive thoughts and lowered risk perceptions regarding cervical cancer were reported over time, unaffected by the intervention. Post-intervention evaluations documented high satisfaction and perceived usefulness, with recommendations for incorporating additional practical and educational content. Our findings underscore the robust satisfaction and practicality of the CervixChat intervention among a diverse underserved population. Moving forward, our next step involves evaluating the intervention's efficacy through a Sequential Multiple Assignment Randomized Trial (SMART) design. Enhanced by personalized health coaching, we aim to further bolster women's risk perception, address intrusive thoughts, and streamline resources to effectively improve colposcopy screening attendance.

Sexual orientation and gender identity inequities in cervical cancer screening by race and ethnicity

BACKGROUND

In the United States, inequities in preventive health behaviors such as cervical cancer screening have been documented. Sexual orientation, gender identity, and race/ethnicity all individually contribute to such disparities. However, little work has investigated their joint impact on screening behavior.

METHODS

Using sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date cervical cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications.

RESULTS

Within all races, individuals who identify as members of sexual and gender minority (SGM) communities reported higher rates of never being screened (except for Black transgender men) than straight or cisgender individuals (p < 0.0001). [*START* Across all races, the Asian/Pacific Islander transgender population (32.4%; weighted n (w.n.) = 1,313) had the lowest proportion of lifetime screening, followed by the Asian/Pacific Islander gay/lesbian (53.0%, w.n. = 21,771), Hispanic transgender (58.7%; w.n. = 24,780), Asian/Pacific Islander bisexual (61.8%, w.n. = 54,524), and Hispanic gay/lesbian (69.6%, w.n. = 125,781) populations. *END*] Straight or cisgender Non-Hispanic White (w.n. = 40,664,476) individuals had the highest proportion of lifetime screening (97.7% and 97.5%, respectively). However, among individuals who had been screened at least once in their lifetime, identifying as SGM was not associated with a decreased proportion of up-to-date screening within or between races.

CONCLUSIONS

Due to small sample sizes, especially among Asian/Pacific Islander and Hispanic populations, confidence intervals were wide. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed.

IMPACT

These screening disparities reveal the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.

Impact of COVID-19 on cervical cancer screening: Challenges and opportunities to improving resilience and reduce disparities

The COVID-19 pandemic has a major impact on a wide range of health outcomes. Disruptions of elective health services related to cervical screening, management of abnormal screening test results, and treatment of precancers, may lead to increases in cervical cancer incidence and exacerbate existing health disparities. Modeling studies suggest that a short delay of cervical screening in subjects with previously negative HPV results has minor effects on cancer outcomes, while delay of management and treatment can lead to larger increases in cervical cancer. Several approaches can mitigate the effects of disruption of cervical screening and management. HPV-based screening has higher accuracy compared to cytology, and a negative HPV result provides longer reassurance against cervical cancer; further, HPV testing can be conducted from self-collected specimens. Self-collection expands the reach of screening to underserved populations who currently do not participate in screening. Self-collection and can also provide alternative screening approaches during the pandemic because testing can be supported by telehealth and specimens collected in the home, substantially reducing patient-provider contact and risk of COVID-19 exposure, and also expanding the reach of catch-up services to address backlogs of screening tests that accumulated during the pandemic. Risk-based management allows prioritizing management of patients at highest risk of cervical cancer while extending screening intervals for those at lowest risk. The pandemic provides important lessons for how to make cervical screening more resilient to disruptions and how to reduce cervical cancer disparities that may be exacerbated due to disruptions of health services.

Lead time on confirmatory test after abnormal Pap test in the COVID-19 era

During the COVID-19 pandemic, there are concerns about medical delay, including confirmatory tests after screening for various cancers. We evaluated the lead time to a confirmatory test after an abnormal screening Papanicolaou (Pap) test in women before the COVID-19 period and during the COVID-19 period.The medical records of 1144 women who underwent colposcopy at a single institution located in Seoul after abnormal Pap results from January 2019 to December 2020 were reviewed. The lead time to colposcopy from the Pap test between 2019 and 2020 was compared; the adverse factors for a long lead time to colposcopy were also evaluated.Age, residence, institution, and the Pap results did not differ between women who underwent colposcopy in 2019 (n = 621) and 2020 (n = 523). The time to colposcopy from the Pap test was also not different. A higher number of women were diagnosed with high-grade dysplasia in 2020 and underwent excision procedures; however, the difference was not statistically significant. Instead, patients' residence, institution of the Pap test, and results of the Pap test were associated with a long lead time to colposcopy of >6 weeks.The lead time to colposcopy from the abnormal Pap test was not delayed in the COVID-19 era compared to before. However, regional factors could affect a long lead time.

Understanding the role of oncogenic human papillomavirus (HPV) status on adherence behaviors among women with abnormal cervical cytology

BACKGROUND

With the introduction of oncogenic Human Papillomavirus (HPV) testing into cervical screening there is a renewed focus on primary prevention among high-risk groups. To date, little is known about the effectiveness of this program, and the extent to which individual-level factors, such as psychosocial health and agency, may play a role. In particular, it is unclear if knowledge of one's oncogenic HPV status impacts on adherence behaviors amongst women with screening abnormalities. The purpose of this study was to identify if clinical, demographic or psychosocial factors predict non-adherence with recommended colposcopy follow-up.

METHODS

This prospective pilot study included 145 women referred to a large Toronto colposcopy clinic between December, 2013 and September, 2014. Demographic, clinical and psychosocial characteristics were collected at three points in time: (1) at initial colposcopy consultation; (2) 4-6 weeks following initial consultation, and; (3) at time of follow-up appointment (within 12 months of initial consultation).

RESULTS

Overall, 13% (n = 145) of the women were classified as non-adherent. Older women (OR = 0.73, p < 0.01) and those with higher-grade lesions (OR = 0.10, p < 0.01) were less likely to be non-adherent, whereas current smokers (OR = 22.46, p < 0.01) were more likely to be non-adherent. While not statistically significant, variation in rates of non-adherence amongst the various HPV status groups (untested; 15.3%, HPV positive; 5.3%, HPV negative; 6.7%) warrants further study.

CONCLUSION

Findings of this study indicate that younger women, those with higher-grade lesions and current smokers were more likely to be non-adherent to recommended colposcopy follow-up. While HPV status did not reach statistical significance, the direction of this finding suggests that testing for HPV may have a positive reinforcing role on adherence to follow-up. The direction of this finding warrants further study, and potentially a practical clinical goal as HPV testing for women becomes standard of care.

Label-free, High-Resolution Optical Metabolic Imaging of Human Cervical Precancers Reveals Potential for Intraepithelial Neoplasia Diagnosis

While metabolic changes are considered a cancer hallmark, their assessment has not been incorporated in the detection of early or precancers, when treatment is most effective. Here, we demonstrate that metabolic changes are detected in freshly excised human cervical precancerous tissues using label-free, non-destructive imaging of the entire epithelium. The images rely on two-photon excited fluorescence from two metabolic co-enzymes, NAD(P)H and FAD, and have micron-level resolution, enabling sensitive assessments of the redox ratio and mitochondrial fragmentation, which yield metrics of metabolic function and heterogeneity. Simultaneous characterization of morphological features, such as the depth-dependent variation of the nuclear:cytoplasmic ratio, is demonstrated. Multi-parametric analysis combining several metabolic metrics with morphological ones enhances significantly the diagnostic accuracy of identifying high-grade squamous intraepithelial lesions. Our results motivate the translation of such functional metabolic imaging to in vivo studies, which may enable improved identification of cervical lesions, and other precancers, at the bedside.

Use of Short Messaging Service to Improve Follow-Up for Abnormal Pap Test Results in Minority and Medically Underserved Women in North Carolina: Questionnaire on Attitudes and Acceptability

Background

An estimated one in eight cervical cancer cases are due to a lack of follow-up care for abnormal Pap test results. Low rates of completion of follow-up care particularly affect low-income minority women. The burden of cervical cancer could be reduced through interventions that improve timely colposcopy follow-up and treatment of abnormal screening results. Mobile communications via text messaging present a low-cost opportunity to increase rates of clinic return among women referred to follow-up after obtaining abnormal screening results.

Objective

Our aims were to determine the acceptability and feasibility of using text messaging to increase completion of follow-up care following abnormal cervical cancer screening (Pap test) results and to examine factors that may affect the acceptability and use of text messaging to increase communications between health care providers (HCP) and low-income minority women.

Methods

The study participants were 15 low-income women who had undergone a Pap test within the preceding 12 months. Semistructured interviews, including open- and closed-ended questions from a validated questionnaire, were conducted by phone or in person. Responses to closed-ended survey items were tabulated, and descriptive statistics were generated using Microsoft Excel. Responses to the open-ended questions were coded and analyzed using NVivo 11 qualitative analysis software.

Results

Nearly all participants (14/15, 93%) were comfortable receiving a text message from an HCP stating that their Pap test results were available (<40 years: 100%; ≥40 years: 86%). Over half (8/15; 53%) of the participants were comfortable receiving a text message stating that their Pap test results were abnormal, although many preferred to receive such information via a phone call (6/15; 40%). Most participants (9/15; 60%) believed that receiving a text reminder would make them more likely to attend their appointment. The preferred method for receiving a reminder appeared to vary by age, with older women preferring telephone reminders over text messaging reminders. Analysis of open-ended questions suggested that text messaging appeals to some women due to its wide use and convenience for communicating with HCPs. However, women cited concerns about the confidentiality of messages and barriers to understanding the messages, including the physical capacity to read and accurately interpret the content of the messaging.

Conclusions

Most participants indicated a willingness to receive text messages from their HCPs about cervical cancer screening results and believed that text messages were the best way to remind them of appointments for follow-up care. Potential concerns could be addressed by excluding explicit references to the nature of the appointment in the text message in order to avoid disclosure of sensitive health information to unauthorized individuals. Although text messaging seems promising to improve adherence to timely follow-up, personal preferences should be considered by allowing patients to opt-out of text communications.

Barriers and facilitators of follow-up among women with precancerous lesions of the cervix in Cameroon: a qualitative pilot study

Purpose

This pilot study explores the barriers to adherence to follow-up among women with cervical precancer in urban Cameroon. While follow-up of women with a positive screening of cervical precancer is the most important aspect of cervical cancer secondary prevention, women with cervical precancer do not adhere frequently to recommended follow-up schedule in Cameroon. The aim of the study was to explore and describe the barriers and facilitators to follow-up for cervical precancer among women infected and uninfected with HIV in Cameroon.

Participants and methods

A qualitative research design was used to answer the research questions. Participants included eight HIV-infected and -uninfected women diagnosed with cervical precancer and 19 nurses. Data were collected by in-depth individual patient interviews and focus groups with nurses. An interview guide with open-ended questions, using the social ecological model as a framework, included questions that addressed the complexities of the lives of individuals and professionals within a relational context. The interviews were audio-taped and transcribed verbatim in English language. Thematic analysis of data was completed with no epistemological or theoretical perspective underpinning the analyses.

Results

Four major themes emerged from the study. They were clinic, personal, and social barriers, and strategies to improve follow-up.

Conclusion

The use of reminder phone calls and fee reduction, coupled with peer counseling and navigation of women who have been diagnosed with cervical precancer, could be effective ways of improving adherence to follow-up. Further research is needed to explore the same phenomenon among women in rural areas, especially those who were initially attended to in mobile clinics.

Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium

Timely follow-up for positive cancer screening results remains suboptimal, and the evidence base to inform decisions on optimizing the timeliness of diagnostic testing is unclear. This systematic review evaluated published studies regarding time to follow-up after a positive screening for breast, cervical, colorectal, and lung cancers. The quality of available evidence was very low or low across cancers, with potential attenuated or reversed associations from confounding by indication in most studies. Overall, evidence suggested that the risk for poorer cancer outcomes rises with longer wait times that vary within and across cancer types, which supports performing diagnostic testing as soon as feasible after the positive result, but evidence for specific time targets is limited. Within these limitations, we provide our opinion on cancer-specific recommendations for times to follow-up and how existing guidelines relate to the current evidence. Thresholds set should consider patient worry, potential for loss to follow-up with prolonged wait times, and available resources. Research is needed to better guide the timeliness of diagnostic follow-up, including considerations for patient preferences and existing barriers, while addressing methodological weaknesses. Research is also needed to identify effective interventions for reducing wait times for diagnostic testing, particularly in underserved or low-resource settings. CA Cancer J Clin 2018;68:199-216. © 2018 American Cancer Society.

Predictors of adherence to follow-up recommendations after an abnormal Pap smear among underserved inner-city women

OBJECTIVES

This study aimed to identify cognitive-affective predictors of adherence to initial diagnostic colposcopy and 6-month follow-up recommendations among underserved women.

METHODS

A secondary data analysis was completed of a randomized clinical trial assessing tailored telephone counseling for colposcopy adherence after an abnormal screening Pap smear among 210 underserved inner-city women.

RESULTS

Adherence to initial diagnostic colposcopy was significantly associated with greater self-efficacy (OR=1.504, 95% CI 1.021-2.216). Women with lower monitoring attentional style had significantly greater adherence to 6-month follow-up recommendations compared to women with higher monitoring scores (OR=0.785, 95% CI 0.659-0.935).

CONCLUSION

Increasing cervical cancer-related self-efficacy and tailoring cervical cancer risk communication to monitoring attentional style may help improve adherence to follow-up recommendations after an abnormal Pap smear test result.

PRACTICE IMPLICATIONS

Future research is needed to develop and implement psychosocial approaches to improving adherence to diagnostic colposcopy and follow-up recommendations adherence among underserved women.

Recent trends in racial and regional disparities in cervical cancer incidence and mortality in United States

BACKGROUND

Although black women experienced greater cervical cancer incidence and mortality rate reduction in recent years, they continue to have higher incidence rates than whites. Great variations also exist among geographic regions of the US, with the South having both the highest incidence and mortality rates compared to other regions. The present study explores the question of whether living in the South is associated with greater racial disparity in cervical cancer incidence and mortality by examining race- and region-specific rates and the trend between 2000 and 2012.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) 18 Program data was used. Cervical cancer incidence and mortality rates, annual percent changes, and disparity ratios were calculated using SEER*Stat software and Joinpoint regression for four groups: US14-Non-Hispanic White (NHW), US14-Non-Hispanic Black (NHB), South-NHW, and South-NHB, where South included 4 registries from Georgia and Louisiana and US14 were 14 US registries except the four South registries.

RESULTS

The average age-adjusted cervical cancer incidence rate was the highest among South-NHBs (11.1) and mortality rate was the highest among US14-NHBs (5.4). In 2012, the degree of racial disparities between South-NHBs and South-NHWs was greater in terms of mortality rates (NHB:NHW = 1.80:1.35) than incidence rates (NHB:NHW = 1.45:1.15). While mortality disparity ratios decreased from 2000-2012 for US14-NHB (APC: -1.9(-2.3,-1.4), mortality disparity ratios for South-NHWs (although lower than NHBs) increased compared to US14-NHW. Incidence rates for NHBs continued to increase with increasing age, whereas rates for NHWs decreased after age 40. Mortality rates for NHBs dramatically increased at age 65 compared to a relatively stable trend for NHWs. The increasing racial disparity with increasing age in terms of cervical cancer incidence rates became more pronounced when corrected for hysterectomy prevalence.

CONCLUSIONS

Black race and South region were associated with higher cervical cancer incidence and mortality. Cervical cancer rates uncorrected for hysterectomy may underestimate regional and racial disparities. Increasing incidence rates for older NHBs compared to NHWs warrant further research to determine whether screening should continue for NHBs over age 65.

Disparities in Cervical Cancer Incidence and Mortality: Can Epigenetics Contribute to Eliminating Disparities?

Screening for uterine cervical intraepithelial neoplasia (CIN) followed by aggressive treatment has reduced invasive cervical cancer (ICC) incidence and mortality. However, ICC cases and carcinoma in situ (CIS) continue to be diagnosed annually in the United States, with minorities bearing the brunt of this burden. Because ICC peak incidence and mortality are 10-15 years earlier than other solid cancers, the number of potential years of life lost to this cancer is substantial. Screening for early signs of CIN is still the mainstay of many cervical cancer control programs. However, the accuracy of existing screening tests remains suboptimal. Changes in epigenetic patterns that occur as a result of human papillomavirus infection contribute to CIN progression to cancer, and can be harnessed to improve existing screening tests. However, this requires a concerted effort to identify the epigenomic landscape that is reliably altered by HPV infection specific to ICC, distinct from transient changes.

Women's Attitudes Toward Cervicovaginal Self-Sampling for High-Risk HPV Infection on the US-Mexico Border

OBJECTIVE

The purpose of this study was to assess the acceptability and intention to use cervicovaginal self-sampling for high-risk human papillomavirus infection after receiving an educational intervention among the predominantly Hispanic population residing along the US-Mexico border.

METHODS

Women received an educational intervention about cervical cancer prevention through screening with conventional cytology and with self-sampling for high-risk human papillomavirus. After the educational intervention, women performed the self-sampling test. Women's attitudes toward the self-sampling test and cervical cytology were assessed and compared.

RESULTS

A total of 110 women aged 30 to 65 years completed the study. The mean (SD) age of the population was 48 (9.3) years. Most (87%) self-identified as being Hispanic and half were born in Mexico; 16% had not had cervical cytology done in 3 years. Self-sampling was more acceptable than cervical cytology; mean (SD) acceptability scores were 25.0 (2.9) and 22.7 (3.0), respectively, with the maximum possible score being 28 (p < .001). A large proportion (42.7%) of women preferred both tests equally. We found high intention to use and recommend self-sampling. Contrary to previous studies, there were no differences between cervical cytology and self-sampling regarding women's concerns about performing the test well and the accuracy of the test, which we attribute to the educational intervention.

CONCLUSION

The high acceptability of self-sampling after participants received education about the test and the reported intention to use it if made available add to the evidence on the feasibility of integrating self-testing within cervical cancer screening guidelines.

Impact of Patient Navigation Interventions on Timely Diagnostic Follow Up for Abnormal Cervical Screening

OBJECTIVE

As part of the Patient Navigation Research Program, we examined the effect of patient navigation versus usual care on timely diagnostic follow-up, defined as clinical management for women with cervical abnormalities within accepted time frames.

METHODS

Participants from four Patient Navigation Research Program centers were divided into low- and high-risk abnormality groups and analyzed separately. Low-risk participants (n = 2088) were those who enrolled with an initial Pap test finding of atypical squamous cells of undetermined significance (ASCUS) with a positive high-risk human papillomavirus (HPV) serotype, atypical glandular cells, or low-grade squamous intraepithelial lesion (LGSIL). High-risk participants were those with an initial finding of high-grade squamous intraepithelial lesion (HGSIL) (n = 229). A dichotomous outcome of timely diagnostic follow-up within 180 days was used for the low-risk abnormality group and timely diagnostic follow-up within 60 days for the high-risk group, consistent with treatment guidelines. A logistic mixed-effects regression model was used to evaluate the intervention effect using a random effect for study arm within an institution. A backward selection process was used for multivariable model building, considering the impact of each predictor on the intervention effect.

RESULTS

Low-risk women in the patient navigation arm showed an improvement in the odds of timely diagnostic follow-up across all racial groups, but statistically significant effects were only observed in non-English-speaking Hispanics (OR 5.88, 95% CI 2.81-12.29). No effect was observed among high-risk women.

CONCLUSION

These results suggest that patient navigation can improve timely diagnostic follow-up among women with low-risk cervical abnormalities, particularly in non-English-speaking Hispanic women.

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.

Inconsistencies between medical records and patient-reported recommendations for follow-up after abnormal Pap tests

PURPOSE

Adherence with recommended follow-up after an abnormal Pap test is a critical step in the prevention of cervical cancer. Here, we focused on identifying inconsistencies between self-reported and health department record recommendations for follow-up.

METHODS

Self-reported recommendations for follow-up were collected by questionnaire from 519 women with abnormal Pap tests in rural Appalachia as part of a trial of the efficacy of patient navigation. Health department medical records were reviewed to collect healthcare provider recommendations. Measures of inconsistency (discordance) were calculated for overall recommendations and each of three particular follow-up recommendations: repeat Pap test, referral for further tests, and other gynecologist referral.

RESULTS

The inconsistencies between the recommendation from the health department records and self-reports ranged from 15.0% (repeat Pap test) to 35.3% (gynecologist referral). Inconsistencies were most common among women with a history of abnormal Pap tests and those with more severe initial results. Recommendations for repeat Pap tests were correctly reported most often when the women recalled receiving a letter stating the results. Of greatest concern were the inconsistencies regarding recommendations for referral to a gynecologist. The more severe the Pap test result, the greater the odds of inaccurate self-reports of receiving a referral to a gynecologist for follow-up, p<0.001.

CONCLUSIONS

Clinicians should be aware that patients with a history of abnormal results and severe Pap test abnormalities are at risk of misreporting recommendations for follow up.

Timeliness of cervical cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program

OBJECTIVES

To examine time intervals from cervical cancer screening to diagnosis and treatment initiation among low-income and uninsured women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) during two consecutive time periods.

METHODS

We analyzed NBCCEDP data for women with abnormal Pap tests (n=100,167), from which 1,417 invasive cervical cancers were diagnosed. We examined two time intervals for this study: diagnostic interval (time from abnormal Pap test to the date of definitive diagnosis) and treatment initiation interval (time from definitive diagnosis to treatment initiation) for two time periods: 1996-2002 and 2003-2009. We compared median time intervals for diagnostic and treatment initiation using the Kruskal-Wallis test. Adjusted proportions (predicted marginals) were calculated using logistic regression to examine diagnosis and treatment within program benchmarks (≤60 days).

RESULTS

Median diagnostic intervals decreased overall by 6 days (54 vs. 48 days, p<0.001). This decrease in the median diagnostic interval was noted for all variables examined. The median treatment initiation intervals remained stable over the two time periods.

CONCLUSIONS

Women screened by the NBCCEDP receive diagnostic follow-up and initiate treatment within preestablished program guidelines.

Factors associated with time to colposcopy after abnormal Pap testing in HIV-infected women

BACKGROUND

HIV-infected women are at increased risk for cervical dysplasia and require timely follow-up after an abnormal Papanicolaou (Pap) test.

METHODS

This retrospective cohort study assessed the proportion of HIV-infected women with colposcopic evaluation after an abnormal Pap test. Time to colposcopy within 12 months after an abnormal Pap test was assessed with univariate and multivariate Cox proportional hazard modeling in a diverse cohort of HIV-infected women between October 1, 2003, and September 30, 2007.

RESULTS

One hundred seventy-seven subjects had an abnormal Pap test: 22 high-grade intraepithelial lesion (HSIL; 12%), 120 low-grade squamous intraepithelial lesion (LSIL; 68%), and 35 atypical squamous cells of undetermined significance, human papillomavirus positive (20%). One hundred twenty (68%) had follow-up colposcopy by 1 year. Decreased time to follow-up was associated with being married (HR 3.5, 95% CI 1.9-6.2), high school graduate or higher education level (HR 1.7, CI 1.2-2.6), HSIL Pap results (HR 2.8, CI 1.3-6.2), Pap testing performed by HIV nurse practitioner versus gynecology clinic (HR 1.7, 1.1-2.7), and CD4 count ≥500 cells/mm(3) (HR 1.8, CI 1.2-2.8), after adjusting for age, race/ethnicity, and LSIL Pap result. Private insurance was associated with decreased time to colposcopy in unadjusted, but not multivariate analysis. Drug use was not associated with time to follow-up colposcopy.

CONCLUSIONS

Almost one third of HIV-infected women did not have a follow-up colposcopy by 12 months after an abnormal Pap test. Since HIV-infected women are at particularly high risk for cervical cancer, these results are unacceptably poor. Identification of the barriers to appropriate follow-up and targeted interventions are necessary to improve timely follow-up for cytologic abnormalities in this high-risk population.

Comparative performance of human papillomavirus DNA testing using novel sample collection methods

To explore alternative cervical cancer screening approaches in an underserved population, we compared the performance of human papillomavirus (HPV) DNA assays in combination with different sample collection methods for primary cervical screening in the Mississippi Delta region. Three specimens were collected from women aged 26 to 65 years who were either routinely undergoing screening (n = 252) or not (n = 191): clinician-collected cervical specimens, clinician-collected cervicovaginal specimens, and self-collected cervicovaginal specimens taken at home. A novel collection device and medium were used for cervicovaginal sampling. Specimens were tested by three HPV DNA assays: hybrid capture 2 (HC2; Qiagen Corp., Gaithersburg, MD), Linear Array (LA; Roche Molecular Systems, Pleasanton, CA), and Amplicor (Roche Molecular Systems, Pleasanton, CA). Liquid-based cytology was performed on cervical specimens. We compared the overall positivity (a proxy for clinical specificity) for any carcinogenic HPV genotype and calculated the agreement across assay and specimen type using McNemar's test for differences in test positivity. Across all three assays there were no significant differences between clinician-collected and self-collected cervicovaginal specimens (P > 0.01 for all comparisons). For both cervicovaginal specimens (clinician collected and self-collected), fewer women tested positive by HC2 than by LA or Amplicor (P < 0.01 for all comparisons). HC2 had the best agreement between specimens for all assays. HC2 is likely more clinically specific, although possibly less sensitive, than either PCR test. Thus, use of HC2 on cervicovaginal specimens for screening could result in fewer referrals compared to LA and Amplicor.

Perspectives on Pap test follow-up care among rural Appalachian women

Approximately one- to three-quarters of women notified of abnormal Pap test results do not receive appropriate follow-up care, dramatically elevating their risk for invasive cervical cancer. We explored barriers to and facilitators of follow-up care for women in two counties in Appalachian Kentucky, where invasive cervical cancer incidence and mortality are significantly higher than the national average. In-depth interviews were conducted among 27 Appalachian women and seven local health department personnel. Those who had been told of an atypical Pap test result tended to have one of three reactions: (1) not alarmed and generally did not obtain follow-up care; (2) alarmed and obtained follow-up care; or (3) alarmed, but did not obtain care. Each of these typologies appeared to be shaped by a differing set of three categories of influences: personal factors; procedure/provider/system factors; and ecological/community factors. Recommendations to increase appropriate follow-up care included pursuing research on explanations for these typologies and developing tailored interventions specific to women in each of the response types.

Impact of the 2002 American society for Colposcopy and Cervical Pathology guidelines on cervical cancer diagnosis in a geographically diverse population of commercially insured women, 1999-2004

OBJECTIVE

To report the impact of the release of the 2002 American Society for Colposcopy and Cervical Pathology guidelines on the management of abnormal cytological findings on time to diagnosis of cervical cancer in an insured population.

METHODS

This retrospective study identified women with cervical cancer (invasive and carcinoma in situ) through commercially insured administrative claims data. The cervical cancer case definition required a claim for cervical cancer and a claim with a diagnostic procedure (colposcopy, conization, biopsy, or hysterectomy). Time to diagnosis was defined as days between the initial Pap screening and the diagnostic procedure.

RESULTS

Between 1999 and 2004, there were 3,325 women aged 18 to 64 years who met the case definition for cervical cancer. Median time to diagnosis decreased from 42 days (interquartile range = 23-93 d) to 36.5 days (interquartile range = 20.5-80 d) for women with invasive cancer after the guideline change. The number of follow-up Pap screenings before biopsy also decreased (p = .0067). Among women with carcinoma in situ whose initial Pap screening was completed by a family practice clinician, time to diagnosis was projected to be more than 9 days longer compared with those whose screening was performed by a gynecologist.

CONCLUSIONS

The 2002 American Society for Colposcopy and Cervical Pathology guidelines for the management of abnormal cytological findings seem to have had a positive impact on the time to diagnosis and Pap screening use before biopsy for women diagnosed with cervical cancer.

Barriers to follow-up of an abnormal Pap smear in Latina women referred for colposcopy

BACKGROUND

Lower rates of follow-up after an abnormal Pap smear in racial and ethnic minorities may contribute to the higher incidence and mortality rates of cervical cancer seen in these groups.

OBJECTIVE

To identify patient-perceived barriers to follow-up after an abnormal Pap smear result among Latina women. DESIGN, PARTICIPANTS AND APPROACH: Qualitative, semi-structured, one-on-one interviews were conducted with patients from an academic hospital-affiliated urban community health center. Three groups of women were interviewed: new colposcopy clinic patients, patients who had previous colposcopies and patients enrolled in the health center's patient navigator program. Open-ended questions explored their knowledge, beliefs and experiences with colposcopy. Content analysis of transcripts was performed using established qualitative techinques.

RESULTS

Of 40 Latina women recruited, 75% spoke only Spanish. The average age was 31.5 (range 18-55). Personal and system barriers identified were categorized into four themes: (1) anxiety/fear of procedure and diagnosis; (2) scheduling/availability of appointments interfering with work and/or child care; (3) inadequate communication about appointments, including lack of explanation regarding diagnosis, procedure and results; and (4) pain. New patients more commonly reported problems with scheduling and communication. Follow-up patients were more concerned about pain, and navigated women most often reported fear of results but had fewer concerns about inadequate communication.

CONCLUSION

Anxiety/fear was the most common personal barrier, while difficulty scheduling appointments and inadequate communication were the major systems barriers identified in these Latina women. Interventions to lower these barriers to colposcopy among Latina women may increase adherence to follow-up of abnormal Pap smears.

Colonoscopy utilization in the Black Women's Health Study

Cancer screening is important for health promotion and is a key element in reducing the disparities in cancer morbidity and mortality. Mortality rates for colorectal cancer are more than 40% higher among African Americans than among other ethnic populations in the United States. The primary objective of the present study is to determine correlates of colonoscopy utilization in the Black Women's Health Study. Our study sample comprised 10992 black women from the Black Women's Health Study whose ages ranged from 50 to 72 years at baseline in 1997; colonoscopy use in the subsequent 8 years was ascertained. The strongest correlate of colonoscopy use was mammography use: women who utilized mammography had 2.5 times the odds of having a colonoscopy, compared with those who never screened for breast cancer. Women who reported having health insurance had 2 times the odds of having a colonoscopy compared with women who did not have health insurance. Higher level of education was also associated with colonoscopy screening. Concurrent promotion of cancer screenings, ie, mammography and colonoscopy, may be a good approach to increasing colonoscopy utilization among women.

Timing of colposcopy after cervical cytologic abnormalities

OBJECTIVE

To examine the length of time from Pap test (index Pap) screening to follow-up colposcopy for women with abnormal Pap test results of low-grade squamous intraepithelial lesions (LSIL); atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions (ASC-H); or high-grade squamous intraepithelial lesions (HSIL).

METHODS

We identified 4,824 women aged 18 to 64 years with the index Pap test results of LSIL, HSIL, or ASC-H from health insurance claims in a large U.S. health care organization and who had a routine Pap test in 2004. We used a survival regression model to estimate factors related to the length of time (days) from the index Pap test to a follow-up colposcopy.

RESULTS

The expected length of time from an abnormal Pap test to a colposcopy differed by age and Pap test result. For women with an ASC-H result, those who were older were more likely to delay colposcopy compared with the younger women. For women with LSIL and HSIL results, the timing of colposcopy did not differ by age; however, the time was shorter compared with ASC-H. We found that physician specialties, health care settings, and area-level racial and ethnic density were related to timing of receiving follow-up procedures after an abnormal index Pap test result.

CONCLUSION

Women with LSIL and HSIL received a colposcopy in 3-4 months, but women with ASC-H were more likely to receive the procedure at a later time.

A theory-based approach to understanding follow-up of abnormal Pap tests

We applied a general theoretical framework to understand intentions to attend recommended follow-up for abnormal Pap results. Participants were 338 women attending university-affiliated clinics. Intention was associated with favorable attitudes toward follow-up (OR = 5.3); perceiving attending follow-up as consistent with one's self-concept (OR = 3.0); self-efficacy (OR = 1.8); and believing one would be told exactly what is wrong (OR = 1.3). Intention was negatively associated with believing the problem could be avoided by not returning for follow-up (OR = 0.75). Beliefs, affect and attitudes differed by race and ethnicity (all p < .05). Attendance at follow-up was related to attitude and self-concept (both p < .05). Results have implications for theory development and patient education.

Preditores de não aderência ao seguimento preconizado para mulheres com lesão intraepitelial escamosa de alto grau (HSIL)

O câncer de colo uterino é um tumor de natureza multifatorial que persiste como um importante problema de saúde pública. Aderência à linha de cuidado é fator associado ao controle desse câncer. O objetivo deste estudo foi avaliar fatores associados à "Não aderência" ao seguimento preconizado para mulheres com lesão intraepitelial de alto grau (HSIL), atendidas em um serviço de saúde da Baixada Fluminense, no Rio de Janeiro. Este estudo do tipo coorte retrospectivo incluiu mulheres rastreadas por citologia, matriculadas entre 01/01/2002 e 31/12/2005 e submetidas à colposcopia. A coleta de dados terminou em 31/12/07. Foram revisados 1496 prontuários e identificadas 641 mulheres elegíveis com diagnóstico de HSIL obtido por excisão da zona de transformação do colo uterino. Após a aplicação dos critérios de exclusão, a população de estudo foi constituída por 537 (84%) mulheres, classificadas em dois grupos: "não aderentes" (29,4%), que abandonaram o seguimento, e "aderentes" (70,6%), que permaneceram no seguimento até a alta. A análise estatística foi realizada pelo teste do qui-quadrado, teste t e regressão logística. O modelo final incluiu as variáveis: ser fumante (OR 1,72), dona de casa (OR 1,56), ter realizado o exame com o uso do vídeo-colposcópio (OR 1,80), idade (OR 0,97) e antecedente de três ou mais gestações (OR 0,49). O estudo revelou um perfil de vulnerabilidade apontando para determinantes de ordem individual e organizacional. Estratégias para melhorar a aderência ao seguimento devem contemplar medidas dirigidas a fatores modificáveis do estilo de vida, como o tabagismo, e estruturais característicos dos serviços de saúde da região.

Assessment of follow-up for low-grade cytological abnormalities in the National Breast and Cervical Cancer Early Detection Program, 2000-2005

OBJECTIVE

To assess the management of women in the National Breast and Cervical Cancer Early Detection Program with low-grade squamous intraepithelial lesions (LSIL) before and after the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines for management of abnormal cytology were published in 2002.

MATERIALS AND METHODS

We examined the follow-up for 22,342 women with LSIL during 2 periods: 2000-2002 and 2003-2005.

RESULTS

The percentage of providers who followed the recommended guidelines with colposcopy for an LSIL Pap test result increased by 9% from the pre-ASCCP to the post-ASCCP period. An increase was seen in every age and racial/ethnic group. Younger women (<30 years) and white women were more likely than comparison groups to be followed by colposcopy rather than a repeat Pap test.

CONCLUSIONS

The increase in percentage of women having colposcopy in 2003, 1 year after the new guidelines were published, suggests a change in provider practices consistent with those guidelines.

Burden of cervical cancer in the United States, 1998-2003

BACKGROUND

Recent interest in human papillomavirus (HPV)-associated cancers and the availability of several years of data covering 83% of the US population prompted this descriptive assessment of cervical cancer incidence and mortality in the US during the years 1998 through 2003. This article provides a baseline for monitoring the impact of the HPV vaccine on the burden of cervical cancer over time.

METHODS

Data from 2 federal cancer surveillance programs, the Centers for Disease Control and Prevention (CDC)'s National Program of Cancer Registries and the National Cancer Institiute's Surveillance, Epidemiology, and End Results Program, were used to examine cervical cancer incidence by race, Hispanic ethnicity, histology, stage, and US census region. Data from the CDC's National Center for Health Statistics were used to examine cervical cancer mortality by race, Hispanic ethnicity, and US census region.

RESULTS

The incidence rate of invasive cervical cancer was 8.9 per 100,000 women during 1998 through 2003. Greater than 70% of all cervical carcinomas were squamous cell type, and nearly 20% were adenocarcinomas. Cervical carcinoma incidence rates were increased for black women compared with white women and for Hispanic women compared with non-Hispanic women. Hispanic women had increased rates of adenocarcinomas compared with non-Hispanic women. The South had increased incidence and mortality rates compared with the Northeast.

CONCLUSIONS

Disparities by race/ethnicity and region persist in the burden of cervical cancer in the US. Comprehensive screening and vaccination programs, as well as improved surveillance, will be essential if this burden is to be reduced in the future.