Gendered experiences of unemployment, suicide and self-harm: a population-level record linkage study

BACKGROUND

Unemployment and being not in the labour force (NILF) are risk factors for suicide, but their association with self-harm is unclear, and there is continuing debate about the role of confounding by prior mental health conditions. We examine associations between employment status and self-harm and suicide in a prospective cohort, taking into account prior mental-health-related factors.

METHODS

We used linked data from the New Zealand Integrated Data Infrastructure. The outcomes were chosen to be hospital presentation for self-harm and death by suicide. The exposure was employment status, defined as employed, unemployed, or NILF, measured at the 2013 Census. Confounders included demographic factors and mental health history (use of antidepressant medication, use of mental health services, and prior self-harm). Logistic regression was used to model effects. Analyses were stratified by gender.

RESULTS

For males, unemployment was associated with an increased risk of suicide [odds ratio (OR): 1.48, 95% confidence interval (CI): 1.20-1.84] and self-harm (OR: 1.55, 95% CI: 1.45-1.68) after full adjustment for confounders. NILF was associated with an increased risk of self-harm (OR: 1.43, 95% CI: 1.32-1.55), but less of an association was seen with suicide (OR: 1.19, 95% CI: 0.94-1.49). For females, unemployment was associated with an increased risk of suicide (OR: 1.30, 95% CI: 0.93-1.80) and of self-harm (OR: 1.52, 95% CI: 1.43-1.62), and NILF was associated with a similar increase in risk for suicide (OR: 1.31, 95% CI: 0.98-1.75) and self-harm (OR: 1.32, 95% CI: 1.26-1.40).

DISCUSSION

Exclusion from employment is associated with a considerably heightened risk of suicide and self-harm for both men and women, even among those without prior mental health problems.

Exposure to discrimination and subsequent changes in self-rated health: prospective evidence from the UK's Life Opportunities Survey

OBJECTIVES

We sought to estimate risk of poor self-rated health (SRH) following exposure to disability-related and other forms of overt discrimination in a cohort of working age adults.

STUDY DESIGN

The study design is a population-based cohort survey.

METHODS

Secondary analysis of data collected in Waves 1 and 2 of the UK's Life Opportunities Survey which at Wave 2 involved the participation of 12,789 working age adults. Adjusted prevalence rate ratios were used to estimate the impact of exposure to disability and non-disability discrimination on two measures of SRH at Wave 2, controlling for SRH status at Wave 1.

RESULTS

Exposure to disability discrimination in the previous year was reported by 3.9% of working age British adults. Other forms of discrimination were reported less frequently (age: 3.7%, ethnicity: 2.5%, gender: 1.6%, religion: 0.8%, sexual orientation: 0.4%). In all analyses, there were stronger associations between exposure to disability discrimination and poor SRH at Wave 2 when compared with exposure to other forms of discrimination.

CONCLUSIONS

Disability discrimination represents a violation of human rights. It is also likely to be a major contributor to the health inequities experienced by working age adults with disability.

Disabling working environments and mental health: A commentary

Employment is a fundamental Social Determinant of Health known to have large impacts on mental health and other health outcomes. Across many countries of the world, people with disabilities are much more likely to be unemployed and looking for work than those without disabilities. The deprivation of employment opportunities is likely to have notable impacts on the health of people with disabilities. In this commentary, we outline the concept of "disabling working environments," which are defined as the range of experiences that affect the likelihood of people with disabilities in obtaining and maintaining quality employment which may then affect a disabled person's health. Disabling working environments are comprised of the following three mutually reinforcing components: 1) Differential selection into work; 2) Selection into certain types of jobs and exposure to poor psychosocial working environments when in employment, and; 3) Differential selection out of work (e.g., leaving employment at an earlier age than those who do not have a disability). We argue that policy and intervention design should consider the life course effects of employment on the mental health of people with disabilities.

Employment status and mental health among persons with and without a disability: evidence from an Australian cohort study

BACKGROUND

Unemployment and economic inactivity are associated with worse mental health in the general population, but there is limited understanding of whether these relationships are different for those persons with mental or physical disabilities. The aim of this study was to assess whether there were differences in mental health by labour force status among persons with and without disabilities.

METHOD

Over eight annual waves of the Household, Income and Labour Dynamics in Australia (HILDA) survey, a total of 2379 people with disabilities and 11 417 people without disabilities were identified. Mental health using the Mental Component Summary (MCS) from the Short Form 36 was modelled as a function of labour force status using fixed-effects regression models to control for time invariant confounding. Differences between those with and without disabilities were assessed by including an interaction term in regression models.

RESULTS

After finding evidence of effect modification, regression models were stratified by disability status. After adjustment, unemployment and economic inactivity were associated with a -1.85 (95% CI -2.96 to -0.73, p=0.001) and -2.66 (95% CI -3.46 to -1.86, p<0.001) reduction in scores of the MCS among those with a disability. For those without a disability, there were smaller declines associated with unemployment (-0.57, 95% CI -1.02 to -0.12, p=0.013) and economic inactivity (-0.34, 95% CI -0.64 to 0.05, p=0.022).

CONCLUSIONS

These results suggest a greater reduction in mental health for those persons with disabilities who were unemployed or economically inactive than those who were employed. This highlights the value of employment for people with disabilities.

Invasive breast cancers detected by screening mammography: a detailed comparison of computer-aided detection-assisted single reading and double reading

To compare double reading plus arbitration for discordance, (currently best practice, (BP)) with computer-aided-detection (CAD)-assisted single reading (CAD-R) for detection of invasive cancers detected within BreastScreen Australia. Secondarily, to examine characteristics of cancers detected/rejected using each method. Mammograms of 157 randomly selected double-read invasive cancers were mixed 1:9 with normal cancers (total 1569), all detected in a BreastScreen service. Cancers were detected by two readers or one reader (C2 and C1 cancers, ratio 70:30%) in the program. The 1569 film-screen mammograms were read by two radiologists (reader A (RA) and reader B(RB)), with findings recorded before and after CAD. Discordant findings with BP were resolved by arbitration. We compared CAD-assisted reading (CAD-RA, CAD-RB) with BP, and CAD and arbitration contribution to findings. We correlated cancer size, sensitivity and mammographic density with detection methods. BP sensitivity 90.4% compared with CAD-RA sensitivity 86.6% (P = 0.12) and CAD-RB 94.3% (P = 0.14). CAD-RB specificity was less than BP (P = 0.01). CAD sensitivity was 93%, but readers rejected most positive CAD prompts. After CAD, reader's sensitivity increased 1.9% and specificity dropped 0.2% and 0.8%. Arbitration decreased specificity 4.7%. Receiving operator curves analysis demonstrated BP accuracy better than CAD-RA, borderline significance (P = 0.07), but not CAD-RB. Secondarily, cancer size was similar for BP and CAD-R. Cancers recalled after arbitration (P = 0.01) and CAD-R (P = 0.10) were smaller. No difference in cancer size or sensitivity between reading methods was found with increasing breast density. CAD-R and BP sensitivity and cancer detection size were not significantly different. CAD-R specificity was significantly lower for one reader.

Area variation in recreational cycling in Melbourne: a compositional or contextual effect?

OBJECTIVE

To examine whether compositional and/or contextual area characteristics are associated with area socioeconomic inequalities and between-area differences in recreational cycling.

SETTING

The city of Melbourne, Australia.

PARTICIPANTS

2349 men and women residing in 50 areas (58.7% response rate).

MAIN OUTCOME MEASURE

Cycling for recreational purposes (at least once a month vs never).

DESIGN

In a cross-sectional survey participants reported their frequency of recreational cycling. Objective area characteristics were collected for their residential area by environmental audits or calculated with Geographic Information Systems software. Multilevel logistic regression models were performed to examine associations between recreational cycling, area socioeconomic level, compositional characteristics (age, sex, education, occupation) and area characteristics (design, safety, destinations or aesthetics).

RESULTS

After adjustment for compositional characteristics, residents of deprived areas were less likely to cycle for recreation (OR 0.66; 95% CI 0.43 to 1.00), and significant between-area differences in recreational cycling were found (median odds ratio 1.48 (95% credibility interval 1.24 to 1.78). Aesthetic characteristics tended to be worse in deprived areas and were the only group of area characteristics that explained some of the area deprivation differences. Safety characteristics explained the largest proportion of between-area variation in recreational cycling.

CONCLUSION

Creating supportive environments with respect to safety and aesthetic area characteristics may decrease between-area differences and area deprivation inequalities in recreational cycling, respectively.

Determinants of false positive recall in an Australian mammographic screening program

We conducted a case-control study (n=30128) to assess the importance of clinical (e.g., family history, age, hormone replacement therapy (HRT) use and duration) and service-related characteristics (e.g., time since introduction of Kodak MINR2000 film, year of screen) for false positive (FP) recall at BreastScreen Victoria, Australia. There was an age-adjusted upward trend in FP recall rates with year of screen at first (odds ratio (OR) 1.11, 95% confidence interval (95% CI) 1.08-1.13) and subsequent rounds (OR 1.04, 95% CI 1.01-1.06). In the multivariate analysis, the upward trend only remained for first round and age and family history also remained statistically significant at first round. At subsequent rounds the time since introduction of MINR2000, age, strong family history of breast cancer, use of HRT, recall at previous screen and previous screen at more than 27 months were all important predictors of FP recall. The rise in FP rates with year of screen at first round screening is of concern and may require further training of radiologists to improve confidence when viewing films when there a no films for comparison.

Weight and place: a multilevel cross-sectional survey of area-level social disadvantage and overweight/obesity in Australia

OBJECTIVE

To estimate variation between small areas in adult body mass index (BMI), and assess the importance of area level socioeconomic disadvantage in predicting BMI.

METHODS

We identified all census collector districts (CCDs) in the 20 innermost Local Government Areas in metropolitan Melbourne, Australia, and ranked them by the percentage of low income households (< dollar 400/week). In all, 50 CCDs were randomly selected from the least, middle and most disadvantaged septiles of the ranked list and 4913 residents (61.4% participation rate) completed one of two surveys. Multilevel linear regression was used to estimate area level variance in BMI and the importance of area level socioeconomic disadvantage in predicting BMI.

RESULTS

There were significant variations in BMI between CCDs for women, even after adjustment for individual and area SES (P = 0.012); significant area variation was not found for men. Living in the most versus least disadvantaged areas was associated with an average difference in BMI of 1.08 kg/m2 (95% CI: 0.48-1.68 kg/m2) for women, and of 0.93 kg/m2 (95% CI: 0.32-1.55 kg/m2) for men. Living in the mid versus least disadvantaged areas were associated with an average difference in BMI of 0.67 kg/m2 (95% CI: 0.09-1.26 kg/m2) for women, and 0.43 kg/m2 for men (95% CI: -0.16-1.01).

CONCLUSION

These findings suggest that area disadvantage is an important predictor of adult BMI, and support the need to focus on improving local environments to reduce socioeconomic inequalities in overweight and obesity.

Use of hormone replacement therapy (HRT) and survival following breast cancer diagnosis

Although hormone replacement therapy (HRT) use has been associated with breast cancers that have better prognostic features, it is not clear whether this leads to improved survival. We studied a cohort of 4022 postmenopausal women diagnosed with breast cancer between 1993 and 2000, who attended a mammographic screening program, among whom 312 deaths subsequently occurred. Proportional hazards models were used to examine survival from breast cancer and all-causes among HRT users and non-users. The multivariate hazard ratio for HRT use was 0.64 (95% CI: 0.41-1.00) for breast cancer deaths and 0.69 (95% CI: 0.49-0.96) for all-cause mortality. This was attenuated by grade (HR 0.71; 95% CI: 0.45-1.10). HRT use at diagnosis was associated with modestly improved survival from breast cancer that appeared in part to be explained by the influence of HRT on tumour grade, although we cannot exclude the possibility of confounding by factors associated with the choice to use HRT.

Predictors of non-attendance for second round mammography in an Australian mammographic screening programme

OBJECTIVE

To determine the socioeconomic, cultural, and clinical predictors of non-attendance for second round mammography.

DESIGN/PARTICIPANTS

Retrospective cohort study of 121 889 women aged 50-69 years who attended for first mammography screening in the BreastScreen Victoria programme in 1995/1996 and who were recommended to be invited for routine biennial mammography. Women were considered to be non-attenders if they had not attended for rescreening within 27 months of their initial screening. Relative risk (RR) was used to compare categories for non-attendance for second screening, and a multivariate model was fitted to adjust for possible confounding.

SETTING

BreastScreen Victoria, a population based mammographic screening programme, which offers free biennial mammography to all women 40 years and older. The programme specifically targets women aged 50-69 years.

RESULTS

In the multivariate analysis, women from non-English speaking backgrounds were more likely not to attend for second round screening (RR ranged from 1.18 to 1.77). Indigenous women (RR 2.02, 95% confidence interval (CI) 1.61 to 2.54) and women who reported either significant symptoms (RR 1.90, 95% CI 1.76 to 2.05) or other breast symptoms (RR 2.25, 95% CI 2.15 to 2.36) at the time of first round screening were also more likely not to attend for second round screening.

CONCLUSIONS

Women from non-English speaking backgrounds, indigenous women, and women who report symptoms at the time of first screening are more likely to not attend for second round screening. It is important to investigate why these women do not attend for second round screening so that services can be more appropriately tailored to their needs.

Radiological review of interval cancers in an Australian mammographic screening programme. Radiology Quality Assurance Group of BreastScreen Victoria

OBJECTIVES

To determine the proportion and features of invasive interval cancers that could be considered detectable at the time of the previous screen and the proportion of cases that could be classified as true intervals, false negatives, minimal signs, or radiographically occult lesions.

SETTING

BreastScreen Victoria, the Victorian component of the BreastScreen Australia mammography screening programme.

METHODS

Two separate review methodologies were adopted. Firstly a blinded review of interval, screen detected, and normal cases was undertaken, followed by a confirmation exercise to determine the proportion of invasive interval cancers that could be considered detectable at the time of the previous screen. Secondly, an unblinded review was performed to classify interval cases as true interval, false negative, minimal signs, or radiographically occult.

RESULTS

From the blinded review, it was estimated that 38% of interval cases may be considered "potentially detectable" at the time of screening. Comparison of the characteristics of interval and screen detected cases indicates that interval cases are more likely to be smaller, equivocal, ill defined masses. In the unblinded exercise, 41% of interval cases were classified as false negatives and a further 16% as minimal signs, 33% true intervals, and 10% radiographically occult. Of the interval cancers considered potentially detectable at screening, 97% were classified as false negatives in the unblinded review.

CONCLUSIONS

This study highlights the importance of adopting staged review methods with both blinded and unblinded components. The blinded review and confirmation exercise allows the determination of the proportion of interval cases that could be considered potentially detectable at screening. The unblinded review provides an active important opportunity for professional development and review and a mechanism to link into the blinded review through further classification of interval cases.

The sensitivity, specificity, and positive predictive value of screening mammography and symptomatic status

OBJECTIVE

To examine whether the accuracy of screening mammography varies according to symptomatic status reported at the time of screening.

SETTING

Victoria, Australia, where free biennial screening is provided to women aged 40 and older.

METHODS

We examined the sensitivity, specificity, and the positive predictive value of screening mammography by symptom status in 106,826 women from Victoria, who attended for first round mammography in 1994 and who did not have a personal history of breast cancer. Symptomatic status was divided into the following categories: asymptomatic; significant symptoms, if the woman reported a breast lump and/or blood stained or watery nipple discharge; and other symptoms, if reported. Unconditional logistic regression modelling was used to adjust for age, use of hormone replacement therapy (HRT), and family history.

RESULTS

Sensitivity was lower for women with other symptoms (60.0%) than asymptomatic women (75.6%), or women with significant symptoms (80.8%). Specificity was lower for women with significant symptoms (73.7%) than asymptomatic women (94.9%), or women with other symptoms (95.4%). Among women who had invasive cancer detected during screening interval, women with other symptoms were more likely to get a false negative result (odds ratio 1.79, 95% confidence interval 1.03 to 3.04) than asymptomatic women, after adjusting for age, use of HRT, and family history.

CONCLUSION

The lower sensitivity in women with other symptoms requires further investigation. Possible explanations include increased breast density and poor image quality. The high sensitivity in women with significant symptoms is probably due to more cautious radiological practice, which has also resulted in low specificity in this group.

Management of women with minor abnormalities of the cervix detected on screening: a qualitative study

OBJECTIVE

To examine the consistency of decisions by pathology staff and general practitioners in managing women in whom minor cervical abnormalities are detected by screening, with current National Health and Medical Research (NHMRC) Council guidelines, and to look at reasons for inconsistencies.

DESIGN

Qualitative interview study.

PARTICIPANTS

14 pathology staff (12 pathologists and two cytoscientists) from 10 of the 17 laboratories providing cervical cytology services in Victoria, and a sample of 22 GPs from metropolitan and rural locations in Victoria.

MAIN OUTCOME MEASURES

Comparison of management practice with NHMRC guidelines; reasons for current decision-making practice.

RESULTS

Most pathologists provided more cautious recommendations for minor abnormalities of the cervix than the NHMRC recommendations in all reporting categories except human papillomavirus. Pathologists had concerns about the appropriateness of the NHMRC recommendations, particularly for glandular atypia, lack of an endocervical component and inflammatory smears, where they believed that the NHMRC recommendations were not well supported by evidence. GPs generally followed the recommendations of their laboratories. Medicolegal concerns were a major influence on clinical decisions for both pathologists and GPs, and have contributed to the development of cautious management practice. Reporting and management practice of pathologists and GPs reflects the ambiguity of minor cervical abnormalities that the NHMRC guidelines fail to highlight.

CONCLUSION

Many pathologists and GPs are reluctant to follow NHMRC guidelines because they believe they are inadequate for some minor cervical abnormalities. The cervical screening guidelines should be reviewed according to the NHMRC guidelines for developing clinical practice guidelines, to promote consistent practice based on an up-to-date, accurate evidence base.

Invasive lobular carcinoma: sonographic features of cancers detected in a BreastScreen Program

Sixty-two screen-detected invasive lobular carcinomas (ILC) were studied for sonographic, mammographic, clinical and histological findings. Ultrasound (US) features were compared with 60 invasive duct cancers (IDC). Size and axillary lymph node status in ILC were compared with all other cancers detected. In 41 ILC examined with US, 36 were found as masses (87.8% sensitivity; 95% CI 77.8-97.8%). Some US features of ILC and IDC differed: ILC were 9.94 times more likely to be hyperechoic (odds ratio, OR, 9.94; 95% CI 3.28-31.74) and 77% less likely to be taller than wide (OR 0.23; 95% CI 0.18-0.62). Thirty-three ILC showed typical malignant features of spiculate margins and acoustic shadowing. invasive lobular carcinomas had a greater mean diameter (20.4 mm; n = 60) than other invasive cancers (14.4 mm; n = 322) (P < 0.001). Ultrasound-guided needle biopsy was the method of diagnosis in 26 of 41 impalpable ILC (63%). Ultrasound has high sensitivity in characterizing screen-detected ILC, which may have atypical sonographic features including hyperechogenicity and a wider than tall shape. Ultrasound was an important contributor to diagnosis.

Hormone replacement therapy and accuracy of mammographic screening

BACKGROUND

Hormone replacement therapy (HRT) is commonly used and may affect the accuracy of mammographic screening.

METHODS

We examined the sensitivity, specificity, and small-cancer detection rate according to HRT use in 103,770 women in Victoria, Australia, who attended first-round screening in 1994 and who did not have a personal history of breast cancer or a breast lump or a bloodstained or watery nipple discharge at the time of screening. BreastScreen Victoria provides mammography to women aged 40 years and older every 2 years. Unconditional logistic modelling was used to adjust for age, family history, and symptom status.

FINDINGS

The sensitivity of screening mammography for a 2-year screening interval was lower in HRT users (64.8% [95% CI 58-72]) than non-users (77.3% [74-81]). In the target group (50-69 years), the sensitivity was 64.3% (57-72) in HRT users and 79.8% (76-84) in non-users. Among women who were diagnosed with cancer during the 2-year screening interval, HRT users were more likely to have a false negative result than non-users (odds ratio 1.60 [1.04-2.21]) after adjusting for potential confounding factors. Specificity was 0.6% lower in HRT users compared with non-users. Among women who did not have cancer diagnosed in the interval, HRT users were more likely to have a false positive result (adjusted odds ratio 1.12 [1.05-1.19]).

INTERPRETATION

We show that HRT use reduces the sensitivity of mammographic screening. In countries where HRT use is widespread, the reduction in sensitivity with HRT use may undermine the capacity of population-based mammographic-screening programmes to realise their potential mortality benefit.

Monitoring interval cancers in an Australian mammographic screening programme

OBJECTIVE

To report the interval cancer rate for BreastScreen Victoria.

DESIGN

Electronic linkage of Breast Screen Victoria records with those of the Victorian Cancer Registry. Interval cancers were expressed as a proportion of the underlying incidence (proportional incidence), and the sensitivity as the number of screen detected invasive breast cancers divided by the total number of invasive breast cancers diagnosed in the screening interval.

SETTING

Victoria, Australia where biennial screening is provided to women aged 40 and older.

SUBJECTS

Victorian women aged 40-79 who attended first round screening in 1994 (103,023 women) and 1995 (107,057 women).

RESULTS

The sensitivity of screening mammography for the two year interval increased with age (p for trend < 0.001) and was 49.4% in women aged 40-49, 68.6% in 50-59 year old women, 80.7% in 60-69 year old women, and 85.2% in women aged 70-79. The proportional incidence in the first year after screening was 59% in 40-49 year old women and 27% in women aged 50-69. In the second year the proportional incidence was 93% in 40-49 year old women and 54% in women aged 50-69.

CONCLUSIONS

Interval cancers comprise such a large proportion of the expected number of cancers in 40-49 year old women that the benefit of screening is likely to be low. For women aged 50-69, the proportional incidence found in this study was similar to those found in the UK programmes.

Evaluation of breast cancer incidence: is the increase due entirely to mammographic screening?

OBJECTIVES

To examine the trends in the incidence rates of breast cancer in a population with mammographic screening and in the unscreened women within that population.

METHODS

Data consisted of incident cases of breast cancer notified to the Victorian Cancer Registry in Victoria, Australia, between 1988 and 1996 and cases detected in the population-based BreastScreen Program. These data were grouped by age (25-39, 40-49, 50-59, 60-69 and > or = 70 years of age) and size of tumor (< or =10 mm, > 10-< or =15 mm, and > 15 mm). Poisson regression modeling was used to examine trends by age, tumor size, calendar year and availability of screening.

RESULTS

The incidence rate of breast cancer in the total population increased between 1988 and 1996. The greatest increase was seen after 1993 when population-based screening became available. In unscreened women, modeling demonstrated a statistically significant (p < 0.01) 1.5% annual increase in the incidence rate. The annual increase in this rate differed by size of tumor and was approximately 8% (p < 0.01) for small tumors (< or = 10 mm) but not significant for tumors > 10 mm. The greatest increase was in small tumors for women > or = 50 years of age.

CONCLUSION

The incidence of breast cancer has increased since population-based mammographic screening was introduced in 1994. The rate in unscreened women also showed a significant increase. This was greatest in small tumors for women > or = 50 years of age. Whether this will translate into an increase in mortality is uncertain and long-term monitoring is required to determine if cohort and period effects impact on the underlying incidence of breast cancer in Victoria.

Screening endoscopy and risk of colorectal cancer in United States men

OBJECTIVES

The purpose of this study was to describe the effect of screening endoscopy (sigmoidoscopy or colonoscopy) on colorectal cancer incidence and mortality.

METHODS

We used data from a prospective cohort study of 24,744 men aged 40 to 75 years in 1986, free from cancer and colon polyps, followed until 1994. The outcomes are diagnosis of colorectal cancer and death from colorectal cancer.

RESULTS

Screening endoscopy in 1986-87 was associated with a lower risk of all colorectal cancer (multivariate relative risk [RR] = 0.58, 95 percent confidence interval [CI] = 0.36-0.96); cancer in the distal colon or rectum (multivariate RR = 0.40, CI = 0.19-0.84); Dukes stage A&B (multivariate RR = 0.66, CI = 0.35-1.25); and Dukes stage C&D (multivariate RR = 0.50, CI = 0.20-1.26) colorectal cancer; and death from colorectal cancer (multivariate RR = 0.56, CI = 0.20-1.60), after adjusting for age and a wide range of colon cancer risk factors. Screening endoscopy in 1988-87 appeared to provide strong protection against distal stage C&D cancers (age-adjusted RR = 0.16, CI = 0.02-1.23) but no protection against proximal stage C&D cancers (age-adjusted RR = 0.96, CI = 0.32-2.91).

CONCLUSIONS

This study provides strong evidence for a protective effect of screening sigmoidoscopy on colorectal cancer incidence and mortality and supports recommendations for screening sigmoidoscopy as an approach to colon cancer prevention.

The short-term financial costs of abnormal Pap smears to women and government in Australia

Using data collected from a private Canberra colposcopy service, we examined the direct costs, to women and government, of the gynaecological care of women with cervical cytological abnormalities and determine the potential savings of implementing the Commonwealth recommendations for the clinical care of women with screen-detected abnormalities. We performed a case note audit of 502 women who first attended a gynaecologist because of an abnormal Pap smear between 1 January 1989 and 30 April 1990. The smear resulting in their referral--their presenting smear--was categorised as No CIN (showing no evidence of cervical intraepithelial neoplasia), CIN 1, CIN 2 and CIN 3. The average costs to government (p for trend < 0.001) and women (p for trend = 0.006) increase as the presenting smear increases in severity; the median costs to government (p for trend < 0.001) and women (p for trend < 0.001) also rose with increasing cytological severity. Treatment of CIN 1 and No CIN accounted for half the costs incurred by government and women. Although costs increase with increasing severity of cytological abnormality, adherence to new Australian guidelines for the gynaecological care of women with screen-detected cervical abnormalities could result in substantial short-term savings to government and women.

Embodied risk: my body, myself?

Risk has become a dominant way to interpret who gets sick and why. A distinction has been drawn between two categories of risk: those arising from the environment, and those resulting from an individual's lifestyle. We identify a third category that might be called corporeal or embodied risk which has received little scholarly attention. Embodied risks are so called because they are located in the body of the person said to be "at risk". Environmental risks are due to something that happens to a person; lifestyle risks occur because of something a person does or does not do, while embodied risks say something about who the person is. To investigate how people experience health risks--especially risks identified as characteristics of their bodies--we conducted detailed interviews with 29 women who were told they had an abnormal Pap smear. All health risks pose problems for people who are diagnosed as "at risk": They must translate probabilistic statements about populations into terms that have personal meaning; they must cope with uncertainty; they must consider what it means to be in danger of developing an illness even though most have no symptoms; and they must mobilise appropriate surveillance and perhaps risk reduction. However, limiting attention to environmental and lifestyle risk (and the distinction between them) neglects the additional challenges posed by corporeal risks: the simultaneous presence of disease now and the possibility of more consequential disease in the future; the necessity to submit to ongoing medical surveillance; a tendency to exacerbate the cartesian split between body and self; and the absence of medical or popular discourses through which to interpret and respond to embodied risk. We call upon medicine and public health practitioners to work together with people who are at risk to formulate languages and approaches that can reflect both scientific accuracy (as it is currently understood), and the needs of people to integrate health threats into their daily personal lives.

Women's understanding of abnormal cervical smear test results: a qualitative interview study

OBJECTIVE

To describe how women interpret their experiences of diagnosis and treatment of a cervical abnormality and how healthcare services for such women can be improved.

DESIGN

Qualitative study using detailed individual interviews.

SETTING

Australian gynaecology clinics.

SUBJECTS

29 Women who had a cervical cytological abnormality and who attended a gynaecologist.

MAIN OUTCOME MEASURES

Women's views on their diagnosis and their information needs.

RESULTS

Most women wanted to participate in decisions about their care but found it difficult to get the information they required from doctors because they were confused by what their doctors told them and felt unable to ask questions in the consultation. Medical terms such as wart virus and precancer were difficult to understand. Not being able to see their cervix also made it hard for women to understand what their abnormality meant and what treatment entailed. Most women tried to make sense of their abnormality in the context of their everyday lives. For some women their gynaecological care was not consistent with the way they understood their abnormality.

CONCLUSIONS

The inherent power structure of medical practice combined with time pressures often make it difficult for doctors to give the detailed information and reassurance patients need when a diagnosis is distressing or when investigation and treatment are strange and upsetting.

Predicting nonattendance for colposcopy clinic follow-up after referral for an abnormal Pap smear

This is retrospective cohort study of women who were recommended for further assessment or treatment after their first visit to a gynaecologist for an abnormal Pap smear. The sample included women who first attended a private outpatient colposcopy service in Canberra between 1 January 1989 and 30 April 1990. Only women who had never previously seen a gynaecologist for an abnormal Pap smear were included in the sample. The nonattendance rate was 2.2 women per 100 women-months (n = 493). Cox proportional hazards modelling was used to examine the relationships between sociodemographic and clinic variables and nonattendance. After adjusting for age and the degree of abnormality on presenting smear, women without private health insurance and women who had had treatment were less likely to continue attending. The current focus on identifying barriers to screening services needs to be broadened to consider attendance at all points along the screening pathway.

Consequences of current patterns of Pap smear and colposcopy use

OBJECTIVES - To describe age specific frequencies of Pap smear and colposcopy use in the Australian Capital Territory (ACT) and to estimate the cumulative effects of current patterns of use. SETTING - Frequencies of Pap smear and colposcopy use were estimated for the financial year from 1 July 1989 to 30 June 1990. Eligible women were between the ages of 15 and 74, living in the ACT. METHODS - Data collected from a 10% sample of subjects enrolled with Medicare and from the only public pathology laboratory in the ACT were used to estimate age specific frequencies. The expected number of deaths from cervical cancer in the ACT in the absence of a screening programme was estimated by applying Australian age specific mortality rates for cervical cancer between 1960 and 1964 to the 1989 ACT population. A life table approach was used to simulate the cumulative risk of colposcopy - given current age specific rates - on a hypothetical cohort of 1000, 15 year old women. RESULTS - Forty four per cent (95% confidence interval (CI) 42.9 to 44.9) of women had a Pap smear and 2.5% had colposcopy (95% CI 2.4 to 2.6). Two and a half percent of 15 to 24 year old women had colposcopy (95% CI 1.9 to 3.1). The ratio of women having Pap smears to women having colposcopy was 17-8:1 (95% CI 17.7 to 17.9). An estimated 247 women had colposcopy for every cervical cancer death; in the 15 to 24 year old age group this ratio was 47900:1. A 15 year old woman exposed to current rates of colposcopy (adjusted for hysterectomy) has a 76.8% chance of having a colposcopy during her life time. CONCLUSIONS - Many more women will have colposcopy than will develop cervical cancer, which undermines the cost effectiveness of Australia's cervical cancer screening programme.