Cervical cancer screening in hospitals: the efficacy of legislation in Maryland

Knowledge and practice about cervical cancer and Pap smear testing among patients at Kenyatta National Hospital, Nairobi, Kenya

Invasive cervical cancer (ICC) is the leading cause of cancer-related death among women in developing countries. Population-based cytologic screening and early treatment does reduce morbidity and mortality associated with cervical cancer. Some of the factors related to the success of such a program include awareness about cervical cancer and its screening. The objective of this study was to assess knowledge and practice about cervical cancer and Pap smear testing among cervical cancer and noncancer patients using a structured questionnaire to obtain information. Fifty-one percent of the respondents were aware of cervical cancer while 32% knew about Pap smear testing. There were no significant differences in knowledge between cervical cancer and noncancer patients. Health care providers were the principal source of information about Pap testing (82%). Only 22% of all patients had had a Pap smear test in the past. Patients aware of cervical cancer were more likely to have had a Pap smear test in the past. The level of knowledge is low among ICC and noncancer patients. There is need to increase the level of knowledge and awareness about ICC and screening among Kenyan women to increase uptake of the currently available hospital screening facilities.

Effectiveness of screening for cervical cancer in an inpatient hospital setting

OBJECTIVE

To estimate the effectiveness of an inpatient, hospital-based cervical cancer screening program at a single institution.

METHODS

Between January 1999 and December 2002, 1,117 women admitted to the Johns Hopkins Hospital underwent Papanicolaou (Pap) test screening during their hospital stay. In that time period, 111,933 women were screened at all of the combined Hopkins outpatient clinics. We compared rates of abnormal Pap tests in these cohorts (retrospective cohort study). Our main outcome measure was the prevalence of abnormal Pap tests among the screening population by age group, ethnicity, and insurance status compared between our outpatient and inpatient populations.

RESULTS

The prevalence of abnormal Pap tests in the inpatient cohort was twice as high as that in the outpatient setting (15.5% versus 7%). The prevalence of high-grade squamous intraepithelial lesions (HSIL), the immediate precursor lesion to cervical cancer, was nearly 5-fold higher in the inpatient cohort compared with the outpatient cohort (3% versus 0.7%). In multivariable models, younger women had greater risk for all types of abnormal Pap tests, and black women had greater risk for HSIL. Previous abnormal Pap and human immunodeficiency virus-positive status were associated with all abnormal tests and with HSIL results.

CONCLUSIONS

A hospital-based, inpatient Pap test program is an efficient strategy for targeting limited screening funds toward women at high risk of invasive cervical cancer.

LEVEL OF EVIDENCE

II-2

Improving cervical cancer screening in hospital settings

BACKGROUND

Identifying opportunities to offer cervical cancer screening to underscreened women is important for increasing early detection. Maryland law mandates offering Pap tests during hospital admissions. We examined organizational and physician attitudes and practices regarding inpatient screening, to identify mechanisms for increasing the law's effectiveness.

METHODS

We analyzed state admission data, a hospital administrators telephone survey, and a mailed survey of Maryland primary and specialty care physicians, to identify overall patterns and subgroup differences regarding screening.

RESULTS

Overall, we found significant concern regarding cancer, and evidence of policies and procedures for screening. However, most hospitals and providers offered screening without assessing clinical need or including persuasive recommendations. Providers with significantly less engagement in preventive assessment and screening included medical and surgical subspecialists and non-primary care providers. Providers to African-American and Medical Assistance women were also less likely to have knowledge, attitudes, and practices conducive to inpatient screening.

CONCLUSIONS

Adequate support and infrastructure for preventive screening exist within hospitals. Adding clinical assessment and persuasive education could in crease the impact of these mechanisms, and improve prevention among underscreened inpatient populations.

A review of cervical cancer screening intervention research: implications for public health programs and future research

In this paper we review the published literature with respect to cervical cancer screening intervention research. Mass media campaigns appear to work best in promoting cervical cancer screening when multiple media are used, when they promote specific screening programs that eliminate or reduce access barriers, or when they are used in combination with other strategies. Many positive examples of using outreach staff to promote cervical cancer screening, as well as using mobile examination rooms in the community, were found. Substantial evidence that letters mailed to patient populations are efficacious was found, especially in promoting interval screening; however, bulk mailings to nonpatient populations have generally not been successful. Both physician and patient prompts have shown promise as well as opportunistic screenings in both the outpatient and the inpatient settings. In addition, several strategies for reducing loss to follow-up among women with abnormal test results were identified, including telephone follow-up, educational mailouts, audiovisual programs, clinic-based educational presentations and workshops, transportation incentives, and economic vouchers. Of special note is the success of other countries in establishing centralized recall systems to promote interval screening for cervical cancer. Ultimately, such systems could replace the need for opportunistic screening in underserved populations and perhaps many community outreach efforts. It is argued that health departments represent a logical starting point for developing a network of recall systems in the United States for underserved women.

Attitudes to Papanicolaou smears

Preventive health behavior has been defined as behavior aimed at the prevention or detection of disease in an asymptomatic state. When cervical cancer is discovered and treated in the premalignant stage, the cure rate is 95% or higher. The success of the screening program for cervical cancer depends at least partially on women's acceptance of and compliance with the service. Compliance is related to women's underlying motivation and attitudes to cervical cancer and health and illness in general. The following paper provides an overview of the literature and examines who participates in cervical screening, the participant's feelings about the test and the place of testing, who are unlikely to participate and the reasons for this noncompliance. It is hoped that this overview will indicate possible ways of improving women's acceptance of this screening, whilst identifying negative attitudes and experiences which impede participation.