1
|
Stauder SK, Borkar SR, Glasgow AE, Runkle TL, Sherman ME, Spaulding AC, Mohseni MM, DeStephano CC. Emergency Department Visits Before Cancer Diagnosis Among Women at Mayo Clinic. Mayo Clin Proc Innov Qual Outcomes 2024; 8:213-224. [PMID: 38596167 PMCID: PMC11002794 DOI: 10.1016/j.mayocpiqo.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024] Open
Abstract
Objective To determine associations of incident cancer diagnoses in women with recent emergency department (ED) care. Patients and Methods A retrospective cohort study analyzing biological females aged 18 years and older, who were diagnosed with an incident primary cancer (12 cancer types studied) from January 1, 2015, to December 31, 2021, from electronic health records. The primary outcome was a cancer diagnosis within 6 months of a preceding ED visit. Secondary outcomes included patient factors associated with a preceding ED visit. Results Of 25,736 patients (median age of 62 years, range 18-101) diagnosed with an incident primary cancer, 1938 (7.5%) had an ED visit ≤6 months before a diagnosis. The ED-associated cancer cases were highest in lung cancer (n=514, 14.7%) followed by acute lymphoblastic leukemia (n=22, 13.3%). Patient factors increasing the likelihood of ED evaluation before diagnosis included 18-50 years of age (OR=1.32; 95% CI, 1.09-1.61), Elixhauser score (measure of comorbidities) >4 (OR=17.90; 95% CI, 14.21-22.76), use of Medicaid or other government insurance (OR=2.10; 95% CI, 1.63-2.69), residence within the institutional catchment areas (OR=3.18; 95% CI, 2.78-3.66), non-Hispanic Black race/ethnicity (OR=1.41; 95% CI, 1.04-1.88), and established primary care provider at Mayo Clinic (OR=1.45; 95% CI, 1.28-1.65). The ED visits were more likely in those who died within 6 months of diagnosis (n=327, 37.8%) than those who did not die (n=1611, 6.5%). Conclusion Patient characteristics identified in this study offer opportunities to provide cancer risk assessment and health navigation, particularly among individuals with comorbidities and limited health care access.
Collapse
Affiliation(s)
| | - Shalmali R. Borkar
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
| | - Amy E. Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Tage L. Runkle
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mark E. Sherman
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL
| | - Aaron C. Spaulding
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
| | | | | |
Collapse
|
2
|
Degife EA, Oliveira CR, Znamierowski E, Meyer JP, Sheth SS. Uptake of Cervical Cancer Screening Among Female Patients Using a Mobile Medical Clinic. Am J Prev Med 2023; 65:835-843. [PMID: 37220860 PMCID: PMC10592483 DOI: 10.1016/j.amepre.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/25/2023]
Abstract
INTRODUCTION Although cervical cancer causes morbidity, it can be prevented if diagnosed early; previous research has shown lower rates of screening in patients with health-related social needs by self-report data. This study assessed cervical cancer screening uptake among female patients with health-related social needs who access care through a community-based mobile medical clinic. METHODS A retrospective cohort was developed of all cis-female patients aged 21-65 years who sought care at the mobile medical clinic between January 1, 2016 and December 31, 2019, and their medical data were captured from the electronic health record. Bivariate and multivariate logistic regression (performed in 2022/2023) were used to investigate correlates of ever having received cervical cancer screening and of being up to date with cervical cancer screening. RESULTS Less than half of the 1,455 patient cohort had ever undergone Pap testing. In the multivariate model, ever having received cervical cancer screening was directly associated with being Hispanic or Black, living with HIV, and having received human papillomavirus vaccination. People who currently smoke showed significantly lower odds of ever having had cervical cancer screening than people who have never smoked. Patients who were single or had other marital status had lower adjusted odds of being up to date as well as those with a substance use history and those with unstable housing. CONCLUSIONS Cervical cancer screening rates in this community-based mobile medical clinic model were low, highlighting a need for increased attention to screening in this high-risk population. Mobile medical clinics have increased screening uptake internationally, and this model could be adopted domestically to promote screening to patients who access health care in various settings.
Collapse
Affiliation(s)
| | - Carlos R Oliveira
- Infectious Diseases & Global Health, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut; Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth Znamierowski
- Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jaimie P Meyer
- Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Sangini S Sheth
- Gynecologic Specialties, Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut.
| |
Collapse
|
3
|
Jetelina KK, Lee SC, Booker-Nubie QS, Obinwa UC, Zhu H, Miller ME, Sadeghi N, Dickerson U, Balasubramanian BA. Importance of primary care for underserved cancer patients with multiple chronic conditions. J Cancer Surviv 2023; 17:1276-1285. [PMID: 34984632 PMCID: PMC9320948 DOI: 10.1007/s11764-021-01159-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To understand the impact of pre-existing conditions on healthcare utilization among under- and uninsured patients in the transition from cancer treatment to post-treatment survivorship. METHODS Using electronic health record data, we constructed a cohort of patients seen in an integrated county health system between 1/1/2010 and 12/31/2016. Six hundred thirty-one adult patients diagnosed with non-metastatic breast or colorectal cancer during this period (cases) were matched 1:1 on sex and Charlson comorbidity index to non-cancer patients who had at least two chronic conditions and with at least one visit to the health system during the study period (controls). Conditional fixed effects Poisson regression models compared number of primary care and emergency department (ED) visits and completed [vs. no show or missed] appointments between cancer and non-cancer patients. RESULTS Cancer patients had significantly lower number of visits compared with non-cancer patients (N = 46,965 vs. 85,038). Cancer patients were less likely to have primary care (IRR = 0.25; 95% CI: 0.24, 0.27) and ED visits (IRR = 0.57; 95% CI: 0.50, 0.64) but more likely to complete a scheduled appointment (AOR = 4.83; 95% CI: 4.32, 5.39) compared with non-cancer patients. Cancer patients seen in primary care at a higher rate were more likely to visit the ED (IRR = 2.06; 95% CI: 1.52, 2.80) than those seen in primary care at a lower rate. CONCLUSION Health systems need to find innovative, effective solutions to increase primary care utilization among cancer patients with chronic care conditions to ensure optimal management of both chronic conditions and cancer. IMPLICATIONS FOR CANCER SURVIVORS Maintaining regular connections with primary care providers during active cancer treatment should be promoted.
Collapse
Affiliation(s)
- Katelyn K Jetelina
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA
| | - Simon Craddock Lee
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA.
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA.
| | - Quiera S Booker-Nubie
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Dallas, TX, USA
| | - Udoka C Obinwa
- Dallas Department of Health and Human Services, Dallas, TX, USA
| | - Hong Zhu
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA
| | - Michael E Miller
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA
| | - Navid Sadeghi
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA
- Department of Internal Medicine, Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health & Hospital System, Dallas, TX, USA
| | | | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA
| |
Collapse
|
4
|
Reis BS, Nogueira CM, Meneses ADFP, Mellado BH, Candido Dos Reis FJ. Experiences of women with advanced cervical cancer before starting the treatment: Systematic review of qualitative studies. Int J Gynaecol Obstet 2023; 161:8-16. [PMID: 36183310 DOI: 10.1002/ijgo.14491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Advanced stage and high mortality are characteristics of cervical cancer in developing countries. Comprehension of the diagnosis itinerary is one of the main strategies to control the disease impact. OBJECTIVES To identify reasons for the delay in diagnosing symptomatic cervical cancer according to the patient's perspectives reported in qualitative studies. We searched four databases (PubMed, Embase, CINAHL, and Web of Science). SELECTION CRITERIA We included qualitative studies of women with advanced cervical cancer that explored their experiences before treatment. We excluded unoriginal, non-qualitative, and duplicated studies. DATA COLLECTION AND ANALYSIS We selected 39 articles for a full-text reading and included 15 in the present review. We chose the Consolidated Criteria for Reporting Qualitative Research (COREQ) for quality assessment and The Model of Pathways to Treatment to guide the codifying process. MAIN RESULTS Four main themes emerged from the synthesis: (1) Health-seeking motivators; (2) Obstacles to seeking medical care; (3) Diagnosis delay; and (4) Coping with the disease. These themes were derived from patients' personal knowledge and beliefs, social relationships, socioeconomic status, and healthcare system characteristics. CONCLUSIONS Individual behavior, social factors, and healthcare organization contribute to the delay in diagnosing advanced cervical cancer.
Collapse
Affiliation(s)
- Bruna Sena Reis
- Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Cristiane Matos Nogueira
- Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Bruna Helena Mellado
- Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | | |
Collapse
|
5
|
Chao CR, Chubak J, Beaber EF, Kamineni A, Mao C, Silverberg MJ, Tiro JA, Skinner C, Garcia M, Corley DA, Winer RL, Raine‐Bennett T, Feldman S, Wheeler CM. Gaps in the screening process for women diagnosed with cervical cancer in four diverse US health care settings. Cancer Med 2022; 12:3705-3717. [PMID: 36106421 PMCID: PMC9939213 DOI: 10.1002/cam4.5226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/08/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Chun R. Chao
- Department of Research and EvaluationKaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Elisabeth F. Beaber
- Fred Hutchinson Cancer Research Center, Public Health Sciences DivisionSeattleWashingtonUSA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Connie Mao
- Department of Obstetrics and Gynecology, University of WashingtonSeattleWashingtonUSA
| | | | - Jasmin A. Tiro
- Department of Population and Data SciencesUniversity of Texas Southwestern Medical CenterDallasTexasUSA,Harold C. Simmons Comprehensive Cancer CenterDallasTexasUSA
| | - Celette Skinner
- Department of Population and Data SciencesUniversity of Texas Southwestern Medical CenterDallasTexasUSA,Harold C. Simmons Comprehensive Cancer CenterDallasTexasUSA
| | - Michael Garcia
- Fred Hutchinson Cancer Research Center, Public Health Sciences DivisionSeattleWashingtonUSA
| | - Douglas A. Corley
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Rachel L. Winer
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWashingtonUSA
| | - Tina Raine‐Bennett
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA,Medicines360San FranciscoCaliforniaUSA
| | - Sarah Feldman
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Cosette M. Wheeler
- Center for HPV PreventionUniversity of New Mexico Comprehensive Cancer CenterAlbuquerqueNew MexicoUSA
| |
Collapse
|
6
|
Castle PE. Letter to the Editor Re: A population study of screening history and diagnostic outcomes of women with invasive cervical cancer. Cancer Med 2021; 10:7263-7264. [PMID: 34448370 PMCID: PMC8525142 DOI: 10.1002/cam4.4240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/11/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Philip E Castle
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA.,Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| |
Collapse
|
7
|
Symptomatic presentation of cervical cancer in emergency departments in California. Cancer Causes Control 2021; 32:1411-1421. [PMID: 34424442 PMCID: PMC8541957 DOI: 10.1007/s10552-021-01489-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/13/2021] [Indexed: 11/10/2022]
Abstract
Purpose Through screening and HPV vaccination, cervical cancer can mostly be prevented or detected very early, before symptoms develop. However, cervical cancer persists, and many women are diagnosed at advanced stages. Little is known about the degree to which U.S. women may begin their diagnostic workup for cervical cancer in Emergency Departments (ED). We sought to quantify the proportion of women presenting symptomatically in the ED prior to their diagnosis with cervical cancer and to describe their characteristics and outcomes. Methods We identified women diagnosed from 2006 to 2017 with cervical cancer in the California Cancer Registry. We linked this cohort to statewide ED discharge records to determine ED use and symptoms present at the encounter. Multivariable logistic regression models examined associations with ED use and multivariable Cox proportional hazards regression models examined associations with survival. Results Of the more than 16,000 women with cervical cancer in the study cohort, 28% presented symptomatically in the ED prior to diagnosis. Those presenting symptomatically were more likely to have public (odds ratio [OR] 1.16; 95% confidence interval [CI] 1.06–1.27) or no insurance (OR 4.81; CI 4.06–5.71) (vs. private), low socioeconomic status (SES) (OR 1.76; CI 1.52–2.04), late-stage disease (OR 5.29; CI 4.70–5.96), and had a 37% increased risk of death (CI 1.28–1.46). Conclusion Nearly a third of women with cervical cancer presented symptomatically, outside of a primary care setting, suggesting that many women, especially those with low SES, may not be benefiting from screening or healthcare following abnormal results.
Collapse
|
8
|
Balasubramanian BA, Higashi RT, Rodriguez SA, Sadeghi N, Santini NO, Lee SC. Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions. JAMA Netw Open 2021; 4:e2119080. [PMID: 34387681 PMCID: PMC8363913 DOI: 10.1001/jamanetworkopen.2021.19080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
IMPORTANCE Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care. OBJECTIVE To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions. DESIGN, SETTING, AND PARTICIPANTS This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020. MAIN OUTCOMES AND MEASURES Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders. RESULTS Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions. CONCLUSIONS AND RELEVANCE Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.
Collapse
Affiliation(s)
- Bijal A. Balasubramanian
- University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Robin T. Higashi
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
| | | | - Navid Sadeghi
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | | | - Simon Craddock Lee
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
| |
Collapse
|
9
|
Benard VB, Jackson JE, Greek A, Senkomago V, Huh WK, Thomas CC, Richardson LC. A population study of screening history and diagnostic outcomes of women with invasive cervical cancer. Cancer Med 2021; 10:4127-4137. [PMID: 34018674 PMCID: PMC8209614 DOI: 10.1002/cam4.3951] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/07/2021] [Accepted: 04/15/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Despite advances to prevent and detect cervical cancer, national targets for screening have not been met in the United States. Previous studies suggested that approximately half of women who developed cervical cancer were not adequately screened. This study aimed to provide an updated examination of women's screening and diagnostic practices five years prior to an invasive cervical cancer diagnosis. METHODS The study included women age 21 years and older diagnosed with invasive cervical cancer in 2013-2016 from three population-based state cancer registries in the United States. Medical records abstraction identified screening history and diagnostic follow-up. A mailed survey provided sociodemographic data. Screening was a Pap or human papillomavirus (HPV) test between 6 months and 5 years before diagnosis. Adequate follow-up was defined per management guidelines. RESULTS Of the 376 women, 60% (n = 228) had not been screened. Among women who received an abnormal screening result (n = 122), 67% (n = 82) had adequate follow-up. Predictors of: (a) being screened were younger age, having a higher income, and having insurance; (b) adequate follow-up were having a higher income, and (c) stage 1 cervical cancer were being screened and younger age. CONCLUSION Unlike other cancer patterns of care studies, this study uses data obtained from medical records supplemented with self-report information to understand a woman's path to diagnosis, her follow-up care, and the stage of her cervical cancer diagnosis. This study provides findings that could be used to reach more unscreened or under screened women and to continue lowering cervical cancer incidence in the United States.
Collapse
Affiliation(s)
- Vicki B Benard
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - Virginia Senkomago
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Warner K Huh
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cheryll C Thomas
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
10
|
Fuzzell LN, Perkins RB, Christy SM, Lake PW, Vadaparampil ST. Cervical cancer screening in the United States: Challenges and potential solutions for underscreened groups. Prev Med 2021; 144:106400. [PMID: 33388330 DOI: 10.1016/j.ypmed.2020.106400] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/09/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022]
Abstract
Cervical cancer screening rates in the United States are generally high, yet certain groups demonstrate disparities in screening and surveillance. Individuals at greatest risk for cervical cancer are often from marginalized or underserved groups who do not participate in regular screening for a variety of reasons. Using the Population-based Research to Optimize the Screening Process (PROSPR) Trans-Organ Conceptual Model, including concepts of individual-, provider-, facility-, system-, or policy-level factors, we provide a commentary to highlight reasons for low screening participation among subgroups in the U.S. These include racial and ethnic minorities, rural residents, sexual and gender minorities, those with limited English proficiency, those with particular religious beliefs, and various health conditions. We describe barriers and offer potential solutions for each group. In addition, we discuss cross-cutting barriers to screening including difficulty interacting with the healthcare system (limited knowledge and health literacy, lack of provider recommendation/contact), financial (cost, lack of insurance), and logistical barriers (e.g., lack of usual source of care, competing demands, scheduling issues). Solutions to address these barriers are needed to improve screening rates across all underscreened groups. Changes at state and national policy levels are needed to address health insurance coverage. Mobile screening, ensuring that interpreters are available for all visits, and targeted in reach at non-gynecological visits can further overcome barriers. Employing community outreach workers can increase community demand for screening, and patient navigators can improve adherence to both screening and follow-up diagnostic evaluation. HPV self-sampling can address multiple barriers to cervical cancer screening.
Collapse
Affiliation(s)
- Lindsay N Fuzzell
- Moffitt Cancer Center, Department of Health Outcomes & Behavior, 12902 Magnolia Dr. Tampa, FL 33612, United States of America.
| | - Rebecca B Perkins
- Boston University School of Medicine, 85 E. Concord St., Boston, MA 02118, United States of America
| | - Shannon M Christy
- Moffitt Cancer Center, Department of Health Outcomes & Behavior, 12902 Magnolia Dr. Tampa, FL 33612, United States of America; Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 Magnolia Dr. Tampa, FL 33612, United States of America; University of South Florida, College of Medicine, 12901 Bruce B Downs Blvd., Tampa, FL 33612, United States of America
| | - Paige W Lake
- Moffitt Cancer Center, Department of Health Outcomes & Behavior, 12902 Magnolia Dr. Tampa, FL 33612, United States of America
| | - Susan T Vadaparampil
- Moffitt Cancer Center, Department of Health Outcomes & Behavior, 12902 Magnolia Dr. Tampa, FL 33612, United States of America; Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, 12902 Magnolia Dr. Tampa, FL 33612, United States of America; University of South Florida, College of Medicine, 12901 Bruce B Downs Blvd., Tampa, FL 33612, United States of America.
| |
Collapse
|
11
|
Rohner E, Edelman C, Sanusi B, Schmitt JW, Baker A, Chesko K, Faherty B, Gregory SM, Romocki LS, Sivaraman V, Nelson JAE, O'Connor S, Hudgens MG, Knittel AK, Rahangdale L, Smith JS. Extended HPV Genotyping to Compare HPV Type Distribution in Self- and Provider-Collected Samples for Cervical Cancer Screening. Cancer Epidemiol Biomarkers Prev 2020; 29:2651-2661. [PMID: 32943435 DOI: 10.1158/1055-9965.epi-20-0674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/06/2020] [Accepted: 09/10/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Primary high-risk human papillomavirus (hr-HPV) testing of self-collected cervico-vaginal swabs could increase cervical cancer screening coverage, although triage strategies are needed to reduce unnecessary colposcopies. We evaluated the use of extended hr-HPV genotyping of self-collected samples for cervical cancer screening. METHODS We recruited women ages 25-65 years at two colposcopy clinics in North Carolina between November 2016 and January 2019, and obtained self-collected cervico-vaginal samples, provider-collected cervical samples, and cervical biopsies from all enrolled women. Self- and provider-collected samples were tested for 14 hr-HPV genotypes using the Onclarity Assay (Becton Dickinson). We calculated hr-HPV genotype-specific prevalence and assessed agreement between results in self- and provider-collected samples. We ranked the hr-HPV genotypes according to their positive predictive value (PPV) for the detection of cervical intraepithelial neoplasia (CIN) grade 2 or higher (CIN2+). RESULTS A total of 314 women participated (median age, 36 years); 85 women (27%) had CIN2+. More women tested positive for any hr-HPV on self-collected (76%) than on provider-collected samples (70%; P = 0.009) with type-specific agreement ranging from substantial to almost perfect. HPV-16 was the most common genotype in self-collected (27%) and provider-collected samples (20%), and HPV-16 prevalence was higher in self- than provider-collected samples (P < 0.001). In self- and provider-collected samples, HPV-16 had the highest PPV for CIN2+ detection. CONCLUSIONS Overall sensitivity for CIN2+ detection was similar for both sample types, but the higher HPV-16 prevalence in self-collected samples could result in increased colposcopy referral rates. IMPACT Additional molecular markers might be helpful to improve the triage of women who are hr-HPV positive on self-collected samples.
Collapse
Affiliation(s)
- Eliane Rohner
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Claire Edelman
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Busola Sanusi
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - John W Schmitt
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Anna Baker
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | | | | | | | - LaHoma S Romocki
- Department of Public Health Education, North Carolina Central University, Durham, North Carolina
| | - Vijay Sivaraman
- Department of Biological and Biomedical Sciences, North Carolina Central University, Durham, North Carolina
| | - Julie A E Nelson
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Siobhan O'Connor
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Andrea K Knittel
- Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lisa Rahangdale
- Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer S Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina. .,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
12
|
Rohner E, McGuire FH, Liu Y, Li Q, Miele K, Desai SA, Schmitt JW, Knittel A, Nelson JAE, Edelman C, Sivaraman V, Baker A, Romocki LS, Rahangdale L, Smith JS. Racial and Ethnic Differences in Acceptability of Urine and Cervico-Vaginal Sample Self-Collection for HPV-Based Cervical Cancer Screening. J Womens Health (Larchmt) 2020; 29:971-979. [PMID: 32212991 DOI: 10.1089/jwh.2019.8132] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: We compared women's acceptability of urine and cervico-vaginal sample self-collection for high-risk (oncogenic) human papillomavirus (hrHPV) testing and assessed whether acceptability varied across racial/ethnic groups. Methods: As part of a test accuracy study of urine-based hrHPV testing, we recruited a convenience sample of women 25-65 years of age at two colposcopy clinics in North Carolina between November 2016 and January 2019. After self-collection of urine and cervico-vaginal samples, women completed a questionnaire on the acceptability of the sample collection methods. We coded open-ended questions inductively. All results are presented stratified by racial/ethnic group. Results: We included 410 women (119 Hispanic, 115 non-Hispanic Black, 154 non-Hispanic White, and 22 women with other racial identities). Most women (79%, 95% confidence interval [CI] = 76%-83%) had positive feelings about urine-based hrHPV testing. Women generally preferred urine (78%, 95% CI = 74%-82%) over cervico-vaginal self-collection (18%, 95% CI = 14%-22%), but the degree differed by racial/ethnic group, increasing from 75% in non-Hispanic Black to 82% in Hispanic women (p = 0.011). Most women reported at least one positive aspect of urine (89%) and cervico-vaginal self-collection (85%) for hrHPV testing with the most common positive aspect being easy sample collection, although 16% of women were concerned about performing the cervico-vaginal self-collection correctly. Conclusions: Self-collection for hrHPV-based cervical cancer screening is highly acceptable to women across different racial/ethnic groups in the United States, and most women in our study would be more likely to attend future cervical cancer screening appointments if screening were urine based. Urine-based hrHPV testing is a promising approach to improve cervical cancer screening coverage.
Collapse
Affiliation(s)
- Eliane Rohner
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - F Hunter McGuire
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Yutong Liu
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Quefeng Li
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Kate Miele
- Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Samveg A Desai
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - John W Schmitt
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Andrea Knittel
- Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Julie A E Nelson
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Claire Edelman
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Vijay Sivaraman
- Department of Biological and Biomedical Sciences, North Carolina Central University, Durham, North Carolina
| | - Anna Baker
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - LaHoma S Romocki
- Department of Public Health Education, North Carolina Central University, Durham, North Carolina
| | - Lisa Rahangdale
- Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer S Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
13
|
Rohner E, Rahangdale L, Sanusi B, Knittel AK, Vaughan L, Chesko K, Faherty B, Tulenko SE, Schmitt JW, Romocki LS, Sivaraman V, Nelson JAE, Smith JS. Test Accuracy of Human Papillomavirus in Urine for Detection of Cervical Intraepithelial Neoplasia. J Clin Microbiol 2020; 58:e01443-19. [PMID: 31896666 PMCID: PMC7041584 DOI: 10.1128/jcm.01443-19] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/12/2019] [Indexed: 01/22/2023] Open
Abstract
The objective was to assess the diagnostic test accuracy of high-risk human papillomavirus (hrHPV) testing of self-collected urine and cervicovaginal samples for the detection of cervical intraepithelial neoplasia grade 2 or higher (CIN2+). We recruited a convenience sample of women 25 to 65 years of age who were undergoing clinically indicated colposcopy at two medical centers in North Carolina between November 2016 and January 2019. Women with normal cytology results and positive hrHPV results were also recruited. Urine samples, self-collected cervicovaginal samples, provider-collected cervical samples, and cervical biopsy samples were obtained from all enrolled women. Samples were tested for hrHPV DNA using the Onclarity assay (Becton Dickinson, Sparks, MD). Biopsy samples were histologically graded as CIN2+ or
Collapse
Affiliation(s)
- Eliane Rohner
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Busola Sanusi
- Department of Biostatistics, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Andrea K Knittel
- Department of Obstetrics and Gynecology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Kirsty Chesko
- Becton, Dickinson and Company, Sparks, Maryland, USA
| | - Brian Faherty
- Becton, Dickinson and Company, Sparks, Maryland, USA
| | - Samantha E Tulenko
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - John W Schmitt
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - LaHoma S Romocki
- Department of Public Health Education, North Carolina Central University, Durham, North Carolina, USA
| | - Vijay Sivaraman
- Department of Biological and Biomedical Sciences, North Carolina Central University, Durham, North Carolina, USA
| | - Julie A E Nelson
- Department of Microbiology and Immunology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer S Smith
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
14
|
Castle PE, Silva VRS, Consolaro MEL, Kienen N, Bittencourt L, Pelloso SM, Partridge EE, Pierz A, Dartibale CB, Uchimura NS, Scarinci IC. Participation in Cervical Screening by Self-collection, Pap, or a Choice of Either in Brazil. Cancer Prev Res (Phila) 2019; 12:159-170. [PMID: 30651294 DOI: 10.1158/1940-6207.capr-18-0419] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/10/2019] [Accepted: 01/11/2019] [Indexed: 11/16/2022]
Abstract
Most cervical cancers occur in women who do not participate in cervical-cancer screening. We therefore evaluated adherence to screening for clinic-based Pap testing, self-collected sampling for HPV testing, and choice of the 2 among 483 unscreened/underscreened women in Brazil. Three public Basic Health Units (BHU) were each randomly assigned to three arms: (i) Pap testing at the BHU (N = 160), (ii) "Self&HPV" (self-collection for HPV testing) (N = 161), and (iii) "Choice" between self-collection and HPV testing and Pap test at the local BHU (N = 162). The theory-based (PEN-3 and Health Belief Model) intervention in all three arms was implemented by trained Community Health Workers (CHW) at participants' home. With the first invitation, 60.0% in the Pap arm, 95.1% [154 of 161 (95.7%) who selected Self&HPV and 0 of 1 (0.0%) who selected Pap] in the Choice arm, and 100% in the Self&HPV arm completed screening. By the second invitation to choose a method of screening in the Choice arm, 100% completed screening. After three invitations, 75.0% of women in the Pap arm completed screening. Adherence to screening differed by study arm (P < 0.001). In conclusion, Self&HPV testing is a promising strategy for unscreened/underscreened women who are recalcitrant or unable to undergo clinic-based cervical screening to complement the screening modality used in the general population. In Brazil, where Pap testing is recommended for routine cervical screening, training CHWs in behavior change strategies and offering Self&HPV or Choice could greatly improve screening population coverage by reaching the unscreened/underscreened populations.
Collapse
Affiliation(s)
| | | | | | - Nádia Kienen
- Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | | | | | | | - Amanda Pierz
- Albert Einstein College of Medicine, Bronx, New York
| | | | | | | |
Collapse
|