Social inequities along the cervical cancer continuum: a structured review

Cervical screening within HIV care: findings from an HIV-positive cohort in Ukraine

INTRODUCTION

HIV-positive women have an increased risk of invasive cervical cancer but cytologic screening is effective in reducing incidence. Little is known about cervical screening coverage or the prevalence of abnormal cytology among HIV-positive women in Ukraine, which has the most severe HIV epidemic in Europe.

METHODS

Poisson regression models were fitted to data from 1120 women enrolled at three sites of the Ukraine Cohort Study of HIV-infected Childbearing Women to investigate factors associated with receiving cervical screening as part of HIV care. All women had been diagnosed as HIV-positive before or during their most recent pregnancy. Prevalence of cervical abnormalities (high/low grade squamous intraepithelial lesions) among women who had been screened was estimated, and associated factors explored.

RESULTS

Overall, 30% (337/1120) of women had received a cervical screening test as part of HIV care at study enrolment (median 10 months postpartum), a third (115/334) of whom had been tested >12 months previously. In adjusted analyses, women diagnosed as HIV-positive during (vs before) their most recent pregnancy were significantly less likely to have a screening test reported, on adjusting for other potential risk factors (adjusted prevalence ratio (APR) 0.62, 95% CI 0.51-0.75 p<0.01 for 1(st)/2(nd) trimester diagnosis and APR 0.42, 95% CI 0.28-0.63 p<0.01 for 3(rd) trimester/intrapartum diagnosis). Among those with a cervical screening result reported at any time (including follow-up), 21% (68/325) had a finding of cervical abnormality. In adjusted analyses, Herpes simplex virus 2 seropositivity and a recent diagnosis of bacterial vaginosis were associated with an increased risk of abnormal cervical cytology (APR 1.83 95% CI 1.07-3.11 and APR 3.49 95% CI 2.11-5.76 respectively).

CONCLUSIONS

In this high risk population, cervical screening coverage as part of HIV care was low and could be improved by an organised cervical screening programme for HIV-positive women. Bacterial vaginosis testing and treatment may reduce vulnerability to cervical abnormalities.

Shrinking, widening, reversing, and stagnating trends in US socioeconomic inequities in cancer mortality for the total, black, and white populations: 1960-2006

OBJECTIVES OF STUDY

To test recent claims that cancer inequities are bound to increase as population health improves.

METHODS

We analyzed 1960-2006 age-standardized US county cancer mortality data, total and site-specific (lung, prostate, colorectal, breast, cervix, stomach), stratified by county income quintile for the US total, black, and white populations.

RESULTS

Between 1960 and 2006, US socioeconomic inequities in cancer mortality variously shrunk, widened, reversed, and stagnated, depending on time period and cancer site. For all cancers combined and most, but not all, sites, absolute, but not relative, socioeconomic gaps were greater for the black compared to white population. Compared to the yearly age-specific mortality rates among whites in the most affluent counties, the percent of excess cancer deaths among whites in the lower four county income quintiles first rose above 0 in 1990 and in 2006 equaled 5.4% (95% CI 4.8, 6.0); among blacks, it rose from 6.0% (95% CI 4.5, 7.4) in 1960 to 24.7% (95% CI 23.9, 25.5) in 1990 and remained at this level through 2006.

CONCLUSIONS

The hypothesis that cancer mortality inequities are bound to increase is refuted by long-term data on total and site-specific cancer mortality stratified by socioeconomic position and race/ethnicity.

Social cognitive and clinical factors associated with HPV vaccine initiation among urban, economically disadvantaged women

OBJECTIVE

To learn more about human papilloma virus (HPV) knowledge and vaccination among teens and young women age 13 to 26 years from an economically disadvantaged, urban community. Our aim was to identify common beliefs about HPV vaccine initiation and describe the relationship between attitudes, norms, perceived control, and intention to receive HPV vaccine, drawing from the theory of planned behavior (TPB).

DESIGN

Mixed method, descriptive design. Guided by the TPB, HPV vaccine beliefs were assessed through focus groups. Intention to receive the vaccine, demographic and clinical factors, and theoretical predictor variables (attitudes, norms, and control) were assessed through questionnaires.

SETTING

After recruitment, focus groups were held at a convenient date and time for our participants in a small university conference room.

PARTICIPANTS

Participants were economically disadvantaged young women, age 13 to 26 (N = 34).

METHODS

Specific behavioral, normative, and control beliefs were elicited in focus groups and analyzed using content analysis. Simple and multivariate general linear modeling with adjustment for prognostic demographic and clinical factors was completed to assess the influence of the theoretical predictor variables on the outcome of HPV vaccine initiation.

RESULTS

Influential beliefs toward vaccination were identified. Analysis indicated attitudes, norms, and perceived control toward HPV vaccine initiation were highly significant predictors of intent, as was tobacco use; all p's < .001.

CONCLUSION

Barriers to HPV vaccine initiation were identified, and strong preliminary evidence supports use of the TPB to guide programs to promote urban, economically disadvantaged young women's intent to begin the HPV vaccine.

Cervical cancer survival for patients referred to a tertiary care center in Kentucky

OBJECTIVES

To identify prognostic factors influencing cervical cancer survival for patients referred to a tertiary care center in Kentucky.

METHODS

A cohort study was performed to assess predictive survival factors of cervical cancer patients referred to the University of Kentucky from January 2001 to May 2010. Eligibility criteria included those at least 18 years-old, cervical cancer history, and no prior malignancy. Descriptive statistics were compiled and univariable and multivariable Cox proportional hazard analysis were performed.

RESULTS

381 patients met entry criteria. 95% were Caucasian (N=347) and 66% (N=243) lived in Appalachian Kentucky. The following covariates showed no evidence of a statistical association with survival: race, body mass index, residence, insurance status, months between last normal cervical cytology and diagnosis, histology, tumor grade, and location of primary radiation treatment. After controlling for identified significant variables, stage of disease was a significant predictor of overall survival, with estimated relative hazards comparing stages II, III, and IV to stage I of 3.09 (95% CI: 1.30, 7.33), 18.11 (95% CI: 7.44, 44.06), and 53.03(95% CI: 18.16, 154.87), respectively. The presence of more than two comorbid risk factors and unemployment was also correlated with overall survival [HR 4.25 (95% CI: 1.00, 18.13); HR 2.64 (95% CI 1.29, 5.42), respectively].

CONCLUSIONS

Residence and location of treatment center are not an important factor in cervical cancer survival when a tertiary cancer center can oversee and coordinate care; however, comorbid risk factors influence survival and further exploration of disease comorbidity related to cervical cancer survival is warranted.

Survival of a cohort of women with cervical cancer diagnosed in a Brazilian cancer center

OBJECTIVE: To assess overall survival of women with cervical cancer and describe prognostic factors associated. METHODS: A total of 3,341 cases of invasive cervical cancer diagnosed at the Brazilian Cancer Institute, Rio de Janeiro, southeastern Brazil, between 1999 and 2004 were selected. Clinical and pathological characteristics and follow-up data were collected. There were performed a survival analysis using Kaplan-Meier curves and a multivariate analysis through Cox model. RESULTS: Of all cases analyzed, 68.3% had locally advanced disease at the time of diagnosis. The 5-year overall survival was 48%. After multivariate analysis, tumor staging at diagnosis was the single variable significantly associated with prognosis (p<0.001). There was seen a dose-response relationship between mortality and clinical staging, ranging from 27.8 to 749.6 per 1,000 cases-year in women stage I and IV, respectively. CONCLUSIONS: The study showed that early detection through prevention programs is crucial to increase cervical cancer survival.

Dynamics of HPV vaccination initiation in Flanders (Belgium) 2007-2009: a Cox regression model

Background

We investigated dynamic patterns and predictors of HPV vaccination initiation in Flanders (Belgium) by girls aged 12 to 18, between 2007 and 2009, the period immediately after the introduction of the HPV vaccines on the Belgian market. During this period the initiative for vaccination was taken by the girl, her family or the general practitioner/pediatrician/gynecologist.

Methods

We used a Cox regression model with time constant and time varying predictors to model hazard rates of HPV vaccination initiation. The sample existed of 117,151 female members of the National Alliance of Christian Mutualities, the largest sickness fund in Flanders.

Results

The study showed that the hazard of HPV vaccination initiation was higher (1) for older girls, (2) for girls with a more favorable socio-economic background, (3) under more generous reimbursement regimes (with this effect being more pronounced for girls with weak socioeconomic backgrounds), (4) for girls that were informed personally about the reimbursement rules.

Conclusions

When the initiative for HPV vaccination lies with the girls, their families or the physicians (no organized setting) the uptake of the vaccines is affected by both individual and organizational factors.

Examining barriers to cervical cancer screening and treatment in Florida through a socio-ecological lens

Cervical cancer incidence and mortality have declined in the U.S. over the past 50 years because of broad screening efforts; however, some states continue to bear a greater burden due to under-screened and -treated populations. The purpose of this study was to utilize the socio-ecological model to examine barriers to cervical cancer screening and treatment in Florida. A qualitative semi-structured interview guide was used to conduct telephone interviews with 21 purposively sampled health care professionals from 13 high-risk counties. Interviews were transcribed and coded using themes identified a priori based on levels of the socio-ecological model. Investigators identified barriers to cervical cancer screening and treatment in Florida across four levels: (1) regulations and funding issues at the policy level are inconsistent between federal, state and local levels; (2) community level barriers range from cultural differences and fear of deportation, to transportation issues; (3) institutional level barriers complicate the administration of screening and treatment services; and (4) individual beliefs, behaviors, and stressors due to poverty hinder women's ability to access services. Many of our findings are consistent with previous studies that identified constraints to screening and treatment of cervical cancer, such as poverty and lack of access to care. This study adds to the literature by examining barriers from the viewpoint of service providers and program coordinators, and through the utilization of the socio-ecological model to provide a comprehensive framework for identifying and understanding these challenges.

Mothers' support for voluntary provision of HPV vaccine in schools

HPV vaccination rates among adolescents in the United States lag behind some other developed countries, many of which routinely offer the vaccine in schools. We sought to assess mothers' willingness to have their adolescent daughters receive HPV vaccine at school. A national sample of mothers of adolescent females ages 11-14 completed our internet survey (response rate=66%). The final sample (n=496) excluded mothers who did not intend to have their daughters receive HPV vaccine in the next year. Overall, 67% of mothers who intended to vaccinate their daughters or had vaccinated their daughters reported being willing to have their daughters receive HPV vaccine at school. Mothers were more willing to allow their daughters to receive HPV vaccine in schools if they had not yet initiated the vaccine series for their daughters or resided in the Midwest or West (all p<.05). The two concerns about voluntary school-based provision of HPV vaccine that mothers most frequently cited were that their daughters' doctors should keep track of her shots (64%) and that they wished to be present when their daughters were vaccinated (40%). Our study suggests that most mothers who support adolescent vaccination for HPV find school-based HPV vaccination an acceptable option. Ensuring communication of immunization records with doctors and allowing parents to be present during immunization may increase parental support.

Evaluating a County-Sponsored Social Marketing Campaign to Increase Mothers' Initiation of HPV Vaccine for their Pre-teen Daughters in a Primarily Rural Area

Routine vaccination against human papillomavirus (HPV), the main cause of cervical cancer, is recommended for 11-12 year old girls, yet vaccine uptake is low. This study evaluates a social marketing campaign initiated by 13 North Carolina counties to raise awareness among parents and reduce barriers to accessing the vaccine in a primarily rural area. The 3-month campaign targeted mothers of girls ages 11-12 and healthcare practices serving pre-teen girls in four counties. Principles of social marketing were: product (recommended vaccine against HPV), price (cost, perception of safety and efficacy, and access), promotion (posters, brochures, website, news releases, doctor's recommendation), and place (doctors' offices, retail outlets). We analyzed (1) website traffic, hotline calls, and media placement; (2) cross-sectional surveys of mothers and providers; and (3) HPV immunization rates in intervention versus non-intervention counties. Of respondent mothers (n=225), 82% heard or saw campaign messages or materials. Of respondent providers (n=35), 94% used campaign brochures regularly or occasionally in conversations with parents. HPV vaccination rates within six months of campaign launch were 2% higher for 9-13 year old girls in two of the four intervention counties compared to 96 non-intervention counties. This evaluation supports campaign use in other primarily rural and underserved areas.

Examining the effect of minority status and neighborhood characteristics on cervical cancer survival outcomes

OBJECTIVE

Understanding the factors that contribute to mortality and survival is central to health outcome research. The purpose of this study was to investigate the following: (1) differences in survival status by ethnicity and neighborhood median income level; and (2) individual- and neighborhood-level factors influencing cervical cancer survival.

METHODS

This study was based on data from 1811 cervical cancer cases obtained through the California Cancer Surveillance Program. The dependent variable was days of survival from date of cancer diagnosis. Zip code-based neighborhood-level variables were obtained from Census 2000 data.

RESULTS

Ethnicity was significantly associated with survival (χ²=20.58; p<0.001), with African-Americans showing the shortest survival. The 5-year survival rates of European-, African-, Latino-, and Asian-American patients for all stages combined were 85%, 75%, 85%, and 84%, respectively. Differences in survival between high- and low-income regions were not observed. However, when ethnicity was considered, Asian-Americans who lived in high-income regions showed longer survival than their low-income community counterparts (χ²=4.531; p<0.05). The multilevel model demonstrated ethnicity, age at diagnosis, and cancer stage stratified by surgery to be significantly associated with cervical cancer survival at the individual level. At the neighborhood level, residing in neighborhoods with a high proportion of African-Americans increased the risk of death by 1%.

CONCLUSIONS

The neighborhood context may be an influential contributor to survival for Asian- and African-Americans specifically. These findings necessitate closer examination of the unique contribution of ethnicity and neighborhood on cancer survival to disentangle the role of ethnic group membership, socio-ecological contexts and stress, and medical factors on disease outcomes.

HPV AWARENESS AMONG LATINA IMMIGRANTS AND ANGLO AMERICAN WOMEN IN THE SOUTHERN U.S.: CULTURAL MODELS OF CERVICAL CANCER RISK FACTORS AND BELIEFS

Latinas have higher cervical cancer age-adjusted incidence and mortality rates, and present with more advanced disease compared to non-Latino whites. This study used a cross-sectional mixed methods survey design, exploring knowledge, attitudes, and beliefs regarding the human papillomavirus (HPV), the HPV vaccine, and cervical cancer screening with four groups of women (Mexican, Honduran, Puerto-Rican, Anglo American; n=80) attending low-income health clinics along with one group of Latina health care workers (n=17). Data analyses included univariate frequency distributions and one-way ANOVA tests for quantitative data, thematic and content analysis of qualitative data, and cultural consensus analysis using the covariance method to compare groups. Results indicate overall cultural consensus for the five subgroups for both the agree/disagree questions and rankings on cervical cancer risk factors. However, differences were found between Latina women compared to Anglo American patients and health care clinic workers around birth control practices as possible causal factors for cervical cancer. Other findings suggested greater awareness of HPV and the HPV vaccine among Anglo American and Puerto Rican women compared to Mexican and Honduran women. Mexican and Honduran women were less likely to be aware of HPV and the HPV vaccine, and more likely to be uninsured and without a regular health care provider. Results point to the need to assess knowledge, attitudes, and beliefs in specific subgroups experiencing cervical cancer disparities to identify target areas for health education. Study findings will be used to inform the development and pilot testing of health education curriculum modules for cervical cancer prevention.

Human papillomavirus health policy

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and the leading cause of cervical cancer. The Food and Drug Administration approved the first human papillomavirus vaccine and has recommended routine vaccination of 11 to 12 year old girls with catch-up vaccination for females 13 to 26 years of age. This primary prevention tool for cervical cancer could significantly reduce cervical cancer, but broad vaccination coverage will be required. Health care providers are in a position to educate parents and teens about the benefits of receiving the recommended HPV vaccine. Mandating the HPV vaccine can be effective in increasing vaccine rates, reducing disease disparities, and decreasing rates of cervical cancer.

Health locus of control and assimilation of cervical cancer information in Deaf women

This study assessed the relationship between Deaf women's internal health locus of control (IHLC) and their cervical cancer knowledge acquisition and retention. A blind, randomized trial evaluated Deaf women's (N = 130) baseline cancer knowledge and knowledge gained and retained from an educational intervention, in relation to their IHLC. The Multidimensional Health Locus of Control scales measured baseline IHLC, and a cervical cancer knowledge survey evaluated baseline to post-intervention knowledge change. Women's IHLC did not significantly predict greater cervical cancer knowledge at baseline or over time. IHLC does not appear to be a characteristic that must be considered when creating Deaf women's cancer education programs.

Determinants of adequate follow-up of an abnormal Papanicolaou result among Jamaican women in Portland, Jamaica

BACKGROUND

Among Jamaican women, cervical cancer is the second leading cause of cancer mortality but factors that facilitate follow-up of women receiving abnormal Pap smear results are not known. We examined whether socio-demographic factors, factors reported by the women, and assistance received for follow-up facilitate adequate follow-up of abnormal Pap smears.

METHODS

One hundred and twenty-one women who had abnormal Pap results during June 1998-September 2005 in Portland, Jamaica were interviewed to identify determinants of adequate follow-up. Chi-square, t-test and multivariable logistic regression analysis were used to identify determinants.

RESULTS

Only half of the women in this sample sought adequate follow-up. These women had a lower number of surviving children, higher monthly income, and perceived the cost of services to be inexpensive. Advice about the timing of the follow-up activity and the next step to take by the healthcare workers were significant determinants of adequate follow-up. Women who received advice on the timing of follow-up were almost six times (adjusted OR: 5.99, 95% CI: 1.17, 30.66, p<0.05) more likely to seek adequate follow-up after adjusting for other factors.

CONCLUSIONS

Perceived low cost of services as well as assistance provided by healthcare workers regarding follow-up action helps to facilitate adequate follow-up of abnormal Pap smear results.

The roles of social domains, behavioral risk, health care resources, and chlamydia in spatial clusters of US cervical cancer mortality: not all the clusters are the same

BACKGROUND

While high-risk geographic clusters of cervical cancer mortality have previously been assessed, factors associated with this geographic patterning have not been well studied. Once these factors are identified, etiologic hypotheses and targeted population-based interventions may be developed and lead to a reduction in geographic disparities in cervical cancer mortality.

METHODS

The authors linked multiple data sets at the county level to assess the effects of social domains, behavioral risk factors, local physician and hospital availability, and Chlamydia trachomatis infection on overall spatial clustering and on individual clusters of cervical cancer mortality rates in 2000-2004 among 3,105 US counties in the 48 states and the District of Columbia.

RESULTS

During the study period, a total of 19,898 cervical cancer deaths occurred in women aged 20 and older. The distributions of county-level characteristics indicated wide ranges in social domains measured by demographics and socioeconomic status, local health care resources, and the rate of chlamydial infection. We found that overall geographic clustering of increased cervical cancer mortality was related to the high proportion of black population, low socioeconomic status, low Papanicolaou test rate, low health care coverage, and the high chlamydia rate; however, unique characteristics existed for each individual cluster, and the Appalachian cluster was not related to a high proportion of black population or to chlamydia rates.

DISCUSSION

This study indicates that local social domains, behavioral risk, and health care sources are associated with geographic disparities in cervical cancer mortality rates. The association between the chlamydia rate and the cervical cancer mortality rate may be confounded by other factors known to be a risk for cervical cancer mortality, such as the infection with human papillomavirus. The findings will help cancer researchers examine etiologic hypotheses and develop tailored, cluster-specific interventions to reduce cervical cancer disparities.

Racial/ethnic and socioeconomic disparities in mortality among women diagnosed with cervical cancer in New York City, 1995-2006

BACKGROUND

Though cervical cancer rates have declined due to Pap screening, racial and socioeconomic disparities in cervical cancer incidence and mortality persist. This study assesses the relative impact of race/ethnicity and neighborhood poverty on cervical cancer incidence and mortality in New York City (NYC).

METHODS

Invasive cervical cancer cases in NYC from 1995 to 2006 were identified along with demographic and socioeconomic measures. Odds ratios (OR) of late stage diagnosis were estimated using logistic regression. Hazard ratios (HR) of death were calculated using Cox proportional hazards regression.

RESULTS

From 1995 to 2006 cervical cancer incidence and mortality rates decreased in NYC, though black and Hispanic women had higher incidence and mortality rates than white women. Puerto Ricans (OR = 1.55, 95% CI = 1.20-2.01) and blacks (OR = 1.34, 95% CI = 1.15-1.57) were more likely to be diagnosed with late stage disease than whites. In multivariate analysis, blacks had similar mortality risk (HR 1.07, 95% CI = 0.95-1.20) to whites while Puerto Ricans had increased risk (HR = 1.31, 95% CI = 1.10-1.55), and non-Puerto Rican Hispanics (HR = 0.54, 95% CI = 0.45-0.63) and Asian/PIs (HR = 0.64, 95% CI = 0.52-0.78) had reduced risk. Women living in high poverty neighborhoods had higher mortality than women in higher income neighborhoods (HR = 1.32, 95% CI = 1.16-1.52).

CONCLUSIONS

Black and Puerto Rican women in NYC are at greatest risk of dying from cervical cancer. Race/ethnicity is predictive of late stage diagnosis, while both race/ethnicity and neighborhood poverty are important predictors of cervical cancer mortality.

Innovation in cervical cancer prevention and control in Mexico

Disparities related to cervical cancer continue to exist in Mexico, including insufficient screening coverage, problems with quality control and a resulting greater risk of mortality among women from marginalized areas. A lack of opportunities and requirements for continuing education and accreditation of healthcare personnel involved in the screening program is also an issue. HPV DNA testing and HPV vaccines are recent technological innovations that offer a potential solution to the continued negative impact of cervical cancer among Mexican women. This essay attempts to answer questions such as: Why should HPV testing be integrated into the early detection program in Mexico? How can HPV testing best be integrated into the program in Mexico? How-from a public health perspective that seeks to reduce disparities-can HPV vaccination best be implemented in Mexico? HPV testing allows increased positive predictive value while also reducing costly and unnecessary overtreatment of low-grade abnormalities, and HPV vaccines offer the possibility of primary prevention of cervical cancer. The strategy proposed for Mexico includes primary prevention with HPV vaccination for girls aged between 12 and 16 years (before sexual initiation), Pap testing with excellent quality control for women 24-34 years of age and high-risk HPV DNA testing for women 35 years and older. HPV samples would be either clinically collected or self-collected and women with positive HPV test results would receive follow-up high-quality Pap testing. This approach is creative and focuses on reducing disparities and providing high-quality care that is also cost effective.

Preventing cervical cancer in the Latina population

Cervical cancer causes great morbidity and mortality worldwide and in the United States. Infection with oncogenic human papillomavirus (HPV), the etiological agent of almost all cervical cancer cases, is common among sexually active women in the United States. Over the past 5 decades, the implementation of Papanicolaou screening programs in the United States has led to a significant decrease in cervical cancer cases. However, notable disparities in the incidence and mortality of cervical cancer and cervical screening rates among Hispanics in the United States remain. If current disparities persist without intervention, the Latina population in the United States may remain at a higher risk of developing and dying from cervical cancer. We discuss disparities in cervical cancer screening, incidence, and mortality among the Latina population, as well as the barriers that may propagate these disparities. We also address how these barriers can be overcome through the coordination of outreach programs and widespread prophylactic HPV vaccination to reduce cervical cancer disparities in Latinas.

Breast and cervical cancer screening specific effects of depression and obesity

BACKGROUND

Obesity and depression may each be associated with lower rates of cervical and breast cancer screening. Studies have examined obesity or depression alone, but not together, despite the established link between them.

PURPOSE

This article aims to disentangle the effects of depression and obesity on receipt of breast and cervical cancer screening.

METHODS

A stratified sampling design was used to recruit women aged 40-65 years with information on BMI from an integrated health plan in Washington State in 2003-2005. A telephone survey included the Patient Health Questionnaire-9 for depression, weight, and height. Automated data assessed Paps for 3097 women over a 3-year period and screening mammograms over a 2-year period for 2163 women aged > or =51 years. Logistic regression models (conducted in 2008) examined the association between obesity and depression and receipt of screening tests.

RESULTS

In univariate logistic regression models, women were less likely to receive a Pap if they were obese (OR=0.53, 95% CI=0.41, 0.69) or depressed (OR=0.60, 95% CI=0.42, 0.87). Further, women were less likely to receive a screening mammogram if they were depressed (OR=0.45, 95% CI=0.30, 0.67). In multivariable models, only obesity remained significantly associated with a lower likelihood of Pap screening (OR=0.67, 95% CI=0.0.49, 0.93), and only depression remained significantly associated with lower rates of screening mammography (OR=0.49, 95% CI=0.31, 0.76). Obesity and depression did not interact significantly in either model.

CONCLUSIONS

Obesity and depression appear to have specific effects on receipt of different cancer-screening tests.

Association of area socioeconomic status and breast, cervical, and colorectal cancer screening: a systematic review

BACKGROUND

Although numerous studies have examined the association of area socioeconomic status (SES) and cancer screening after controlling for individual SES, findings have been inconsistent. A systematic review of existing studies is timely to identify conceptual and methodologic limitations and to provide a basis for future research directions and policy.

OBJECTIVE

The objectives were to (a) describe the study designs, constructs, methods, and measures; (b) describe the independent association of area SES and cancer screening; and (c) identify neglected areas of research.

METHODS

We searched six electronic databases and manually searched cited and citing articles. Eligible studies were published before 2008 in peer-reviewed journals in English, represented primary data on individuals ages > or = 18 years from developed countries, and measured the association of area and individual SES with breast, cervical, or colorectal cancer screening.

RESULTS

Of 19 eligible studies, most measured breast cancer screening. Studies varied widely in research design, definitions, and measures of SES, cancer screening behaviors, and covariates. Eight employed multilevel logistic regression, whereas the remainder analyzed data with standard single-level logistic regression. The majority measured one or two indicators of area and individual SES; common indicators at both levels were poverty, income, and education. There was no consistent pattern in the association between area SES and cancer screening.

DISCUSSION

The gaps and conceptual and methodologic heterogeneity in the literature to date limit definitive conclusions about an underlying association between area SES and cancer screening. We identify five areas of research deserving greater attention in the literature.

A brief history of economic evaluation for human papillomavirus vaccination policy

Background: This commentary discusses key issues for health economic evaluation and modelling, applied to human papillomavirus (HPV) vaccine programs. Methods: We outline some of the specific features of HPV disease and vaccination, and associated policy questions in light of a literature search for economic evaluations on HPV vaccination. Results: We observe that some policy questions could not be reliably addressed by many of the 43 published economic evaluations we found. Despite this, policy making on universal HPV vaccination followed shortly after vaccine licensure in many developed countries, so the role economic evaluation played in informing these decisions (pre-dating 2008) seems to have been fairly limited. For more recent decisions, however, economic evaluation is likely to have been used more widely and more intensively. Conclusions: We expect future cost-effectiveness analyses to be more instrumental in policy making regarding vaccines covering more HPV types, therapeutic HPV vaccines, and novel diagnostic tests for biomarkers of HPV infection and disease integrated with cervical screening programs.

Incidence Rates of Cervical Carcinoma Among First- and Second-Generation Women of North African Origin in Israel

Objectives:

To evaluate the incidence rates of cervical cancer by ethnic origins and compare these rates between first- and second-generation women of North African origin.

Methods:

Data of all cervical carcinoma of Jewish women during 2000 to 2005 were obtained from the National Cancer Registry. Standardized incidence ratios for each ethnic origin category were calculated and compared using Poisson regression.

Results:

During the study period, 938 patients were examined. The standardized incidence ratios of North African-born women and of Israeli-born women of North African descent were significantly higher compared with those of women of other origins.

Conclusions:

The persistence of a higher risk of cervical cancer in Israeli Jewish women of North African descent compared with those of other origins may suggest that genetic factors are involved in the etiology of this neoplasm.

Daughter-initiated health advice to mothers: perceptions of African-American and Latina daughters

The prevailing paradigm of health exchange within the family is for health advice to flow from parent to child. Consistent with this pattern of exchange, most research has focused on the one-directional influence of the parent on the child and there is thus an absence of literature that explores the ability of adolescents to influence their parents' health behaviors. This qualitative study addressed this gap by exploring the feasibility of daughters providing health advice to their mothers. Twelve focus groups were conducted with 78 African-American and Latina daughters between the ages of 12 and 17 from low-income neighborhoods in a Mid-Western city in the United States. This study utilized a grounded theory approach to examine the focus group data. The findings indicate that many daughters report that they are already giving their mothers a wide spectrum of advice, including health advice. Differences were found in the reported willingness of African-American daughters when compared to Latina daughters to provide their mothers with specific cancer advice. These data suggest that some of these daughters have the potential to be valuable health education conveyers in the family.

Understanding barriers to cervical cancer screening among Hispanic women

OBJECTIVE

We investigated issues affecting Papanicolaou smear screening access, health services utilization, acculturation, social networking, and media venues most conducive to acquiring health information among Hispanics.

STUDY DESIGN

Self-identified Hispanics were surveyed. Participants were stratified based on age, time living in the United States, and Papanicolaou screening frequency.

RESULTS

Of 318 participants, Hispanics aged 30 years or older and living in the United States less than 5 years prefer speaking Spanish. Women with 5 or more lifetime Papanicolaou smears were 1.610 times more likely to have lived in the United States 5 or more years, 1.706 times more likely to speak a second language, and 1.712 times less likely to need a translator during their health care encounter.

CONCLUSION

Age and years living in the United States may be independent risk factors for participation in Papanicolaou screening programs. Social difficulties inherent to acculturation inform health behavior and translate to health disparity among Hispanics. Our results may help design federally funded and community-level programs.

Parents' health beliefs and HPV vaccination of their adolescent daughters

Though many studies have documented correlates of HPV vaccine acceptability, our study is one of the first to examine correlates of vaccine initiation. The current study aimed to identify modifiable correlates of HPV vaccine initiation among adolescent girls in high risk communities and whether correlates varied by race and urban/rural status. In 2007, we conducted a cross-sectional survey of 889 parents of adolescent girls aged 10-18 living in areas of North Carolina, USA with high cervical cancer rates. We analyzed data using logistic regression. Health Belief Model constructs were associated with HPV vaccine initiation in multivariate analyses, including doctor's recommendation to get HPV vaccine, perceived barriers to obtaining HPV vaccine, and perceived potential vaccine harms. While exploratory stratified analyses suggested that many of the same parent beliefs were important correlates of HPV vaccine initiation regardless of racial group or urban/rural status, a few differences did exist. These potentially modifiable beliefs offer well-defined targets for future interventions designed to increase HPV vaccine coverage. However, the beliefs' relative importance may differ between racial groups and regions.

Client satisfaction in a breast and cervical cancer early detection program: the influence of ethnicity and language, health, resources, and barriers

OBJECTIVES

Satisfaction is a critical outcome for the healthcare system and an important influence on subsequent interactions with that system, yet findings have been inconsistent. This paper examined satisfaction as a multidimensional construct and focused on the interrelated influences of ethnicity and language, the potential confounding effects of economic resources and health status, and the possible role of perceived barriers to service delivery.

METHODS

The study was based on a phone survey conducted in 2005 of a stratified random sample of 207 Massachusetts patients in the National Breast and Cervical Cancer Early Detection Program, which used case managers to increase the rates of diagnostic testing among uninsured women at risk of breast or cervical cancer. Ethnicity, primary language, economic resources, and health status were each related to particular dimensions of patient satisfaction, but mostly independent of perceived barriers to program participation.

RESULTS

The findings indicated that adequate evaluation of public health programs must conceptualize and measure satisfaction as multidimensional and supported the prediction of "segmented assimilation theory" that satisfaction can decline with time in the U.S.

Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis

We examined socioeconomic inequalities in cancer survival in New Zealand among 132,006 people ages 15 to 99 years who had a cancer registered (1994-2003) and were followed up to 2004. Relative survival rates (RSR) were calculated using deprivation-specific life tables. A census-based measure of socioeconomic position (New Zealand deprivation based on the 1996 census) based on residence at the time of cancer registration was used. All RSRs were age-standardized, and further standardization was used to investigate the effect of extent of disease at diagnosis on survival. Weighted linear regression was used to estimate the deprivation gap (slope index of inequality) between the most and least deprived cases. Socioeconomic inequalities in cancer survival were evident for all of the major cancer sites, with the deprivation gap being particularly high for prostate (-0.15), kidney and uterus (both -0.14), bladder (-0.12), colorectum (-0.10), and brain (+0.10). Accounting for extent of disease explained some of the inequalities in survival from breast and colorectal cancer and melanoma and all of the deprivation gaps in survival of cervical cancer; however, it did not affect RSRs for cancers of the kidney, uterus, and brain. No substantial differences between the total compared with the non-Māori population were found, indicating that the findings were not due to confounding by ethnicity. In summary, socioeconomic disparities in survival were consistent for nearly all cancer sites, persisted in ethnic-specific analyses, and were only partially explained by differential extent of disease at diagnosis. Further investigation of reasons for persisting inequalities is required.

Health-related quality of life in cervical cancer survivors: a population-based survey

PURPOSE

In a population-based sample of cervical cancer survivors, health-related quality of life (HRQoL) was assessed 2-10 years postdiagnosis.

METHODS AND MATERIALS

All patients given a diagnosis of cervical cancer in 1995-2003 in the Eindhoven region, The Netherlands, and alive after Jan 2006 were identified through the cancer registry. Generic HRQoL (36-Item Short-Form Health Survey, EQ-5D), cervical cancer-specific HRQoL (European Organization for Research and Treatment of Cancer Quality-of-Life questionnaire cervical cancer module), and anxiety (6-item State Trait Anxiety Inventory) were assessed and compared with a reference population (n = 349). Data for tumor characteristics at diagnosis and disease progression were available.

RESULTS

A total of 291 women responded (69%), with a mean age of 53 +/- 13 (SD) years (range, 31-88 years). Treatment had consisted of surgery (n = 195) or a combination of therapies (n = 75); one woman had not been treated. Of all women, 85% were clinically disease free, 2% had a recurrence/metastasis, and in 13%, this was unknown. After controlling for background characteristics (age, education, job and marital status, having children, and country of birth), generic HRQoL scale scores were similar to the reference population, except for worse mental health in survivors. The most frequent symptoms were crampy pain in the abdomen or belly (17%), urinary leakage (15%), menopausal symptoms (18%), and problems with sexual activity. Compared with the 6-10-year survivors, more sexual worry and worse body image were reported by the 2-5-year survivors. Compared with surgery only, especially primary radiotherapy was associated with an increased frequency of treatment-related side effects, also after controlling for age and disease stage at diagnosis and follow-up.

CONCLUSIONS

Most cervical cancer survivors were coping well, although their mental health was worse than in the reference population. Even after 2-10 years, radiotherapy was associated with an increased frequency of treatment-related side effects.

The disparity of cervical cancer in diverse populations

Significant disparities in cervical cancer incidence and mortality rates among minority groups have been documented in the United States, despite an overall decline in these rates for the population as a whole. Differences in cervical cancer screening practices have been suggested as an explanation for these disparities, as have differences in treatment among various racial and ethnic groups. A number of factors are attributed to these observed differences. As minority populations continue to grow in size over the next 50 years, persistent disparities will place an ever increasing burden on these populations and on the national healthcare system. Strategies to reduce cervical cancer disparities need to be employed in order to reverse these trends.

Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities

Emmanuela Gakidou and colleagues find that coverage of cervical cancer screening in developing countries is on average 19% compared to 63% in developed countries.

Lesbians and cancer: an overlooked health disparity

OBJECTIVE

To evaluate the breast, cervical, ovarian, lung, and colorectal cancer literatures using a novel application of the cancer disparities grid to identify disparities along domains of the cancer continuum focusing on lesbians as a minority population.

METHODS

Computerized databases were searched for articles published from 1981 to present. Cumulative search results identified 51 articles related to lesbians and disparities, which were classified by domain.

RESULTS

The majority of articles identified were related to breast and cervical cancer screening. Barriers to adequate screening for both cancers include personal factors, poor patient-provider communication, and health care system factors. Tailored risk counseling has been successful in increasing lesbian's mammography and Pap screening. Ovarian, lung, and colorectal cancer have been virtually unexplored in this population. An "Adjustment to Illness/Quality of Life" domain was added to capture literature on psychosocial aspects of cancer.

CONCLUSIONS

This review revealed a lack of research for specific cancers and for specific aspects of the cancer continuum. The limited number of studies identified focused on issues related to screening/prevention in cervical and breast cancers, with almost no attention to incidence, etiology, diagnosis, treatment, survival, morbidity, or mortality. We present implications for social and public health policy, research, and prevention.

Insurance and quality of life in men with prostate cancer: data from the Cancer of the Prostate Strategic Urological Research Endeavor

OBJECTIVE

To evaluate the effect of medical insurance coverage on health-related quality of life (HRQoL) outcomes in men newly diagnosed with prostate cancer, as insurance status has been shown to be related to clinical presentation, and types of treatments received for localized prostate cancer, but the relationship of insurance and QoL has not been explored sufficiently.

PATIENTS AND METHODS

Data from the Cancer of the Prostate Strategic Urological Research Endeavor (CaPSURE), a national longitudinal database registry of men with prostate cancer, were used for this study. Men who were newly diagnosed at entry to CaPSURE and completed one questionnaire before treatment, and one or more afterwards, were included. Insurance groups specific to age distribution of the study population were assessed, i.e. Medicare, preferred provider organizations (PPOs), health maintenance organizations (HMOs), fee for service (FFS), and the Veterans Administration (VA) for the younger group, and Medicare only, Medicare plus supplement (+S), and HMO/PPO for the older group. Associations between patients' clinical and sociodemographic characteristics and insurance status were evaluated by chi-square and analysis of variance. Relationships between insurance status and HRQoL outcomes over time were evaluated by multivariate mixed model.

RESULTS

Of 2258 men who met the study criteria, 1259 were younger and 999 were older than 65 years. More than half of the younger patients belonged to an HMO or PPO (42.2% and 32.5%, respectively), with the remainder distributed between Medicare, FFS and VA. In the older group most men belonged to Medicare only and the Medicare +S groups (22.4% and 58.8%, respectively). There was greater variation in clinical risk categories at presentation by insurance groups in the younger group. In the multivariate analysis, insurance status was significantly associated with changes in most HRQoL outcomes over time in the younger group, while in the older patients the effect of insurance diminished. Men in the VA and Medicare systems had lower scores at baseline and a steeper decline in Physical Function, Role Physical, Role Emotional, Social Function, Bodily Pain, Vitality, and General Health domains over time, controlling for type of initial treatment received, timing of HRQoL assessment, number of comorbidities, clinical risk at presentation, and income.

CONCLUSION

Insurance was independently related to changes in a wide range of HRQoL outcomes in men aged <65 years treated for prostate cancer. With the latest advances in early diagnosis and treatment of prostate cancer, clinicians and researchers should be aware of the specific groups of patients who are more vulnerable to the adverse effects of treatment and subsequent decline in functioning. The present findings could provide important tools for understanding the process of recovery after treatment for prostate cancer, and identifying needs for specific services.

A healthy mistrust: how worldview relates to attitudes about breast cancer screening in a cross-sectional survey of low-income women

BACKGROUND

Perceived racial discrimination is one factor which may discourage ethnic minorities from using healthcare. However, existing research only partially explains why some persons do accept health promotion messages and use preventive care, while others do not. This analysis explores 1) the psychosocial characteristics of those, within disadvantaged groups, who identify their previous experiences as racially discriminatory, 2) the extent to which perceived racism is associated with broader perspectives on societal racism and powerlessness, and 3) how these views relate to disadvantaged groups' expectation of mistreatment in healthcare, feelings of mistrust, and motivation to use care.

METHODS

Using survey data from 576 African-American women, we explored the prevalence and predictors of beliefs and experiences related to social disengagement, racial discrimination, desired and actual racial concordance with medical providers, and fear of medical research. We then used both sociodemographic characteristics, and experiences and attitudes about disadvantage, to model respondents' scores on an index of personal motivation to receive breast cancer screening, measuring screening knowledge, rejection of fatalistic explanatory models of cancer, and belief in early detection, and in collaborative models of patient-provider responsibility.

RESULTS

Age was associated with lower motivation to screen, as were depressive symptoms, anomie, and fear of medical research. Motivation was low among those more comfortable with African-American providers, regardless of current provider race. However, greater awareness of societal racism positively predicted motivation, as did talking to others when experiencing discrimination. Talking was most useful for women with depressive symptoms.

CONCLUSION

Supporting the Durkheimian concepts of both anomic and altruistic suicide, both disengagement (depression, anomie, vulnerability to victimization, and discomfort with non-Black physicians) as well as over-acceptance (low awareness of discrimination in society) predict poor health maintenance attitudes in disadvantaged women. Women who recognize their connection to other African-American women, and who talk about negative experiences, appear most motivated to protect their health.

Racial and ethnic disparities in cervical cancer incidence rates in the United States, 1992-2003

OBJECTIVE

Differences in cervical cancer incidence rates by race/ethnicity persist in the United States. We examined these differences by histologic type and by various patient and socioeconomic characteristics.

METHODS

Thirteen U.S. cancer registries were used to identify women 20-79 years of age diagnosed from 1992 to 2003 with invasive cervical cancer. Age-adjusted incidence rates and annual percent changes were calculated for four different races/ethnicities (Non-Hispanic whites, Hispanic whites, African-Americans, and Asians/Pacific Islanders) for cervical cancer overall, squamous cell carcinoma (SCC), and adenocarcinoma (AC).

RESULTS

Hispanic whites had the highest incidence rate of cervical cancer overall (24.2/100,000), SCC (18.3/100,000), and AC (4.6/100,000). Non-Hispanic whites had the lowest rates of cervical cancer overall (10.8/100,000) and SCC (7.2/100,000), while African-Americans had the lowest rate of AC (2.3/100,000). Incidence rates of cervical cancer overall and SCC declined across all racial/ethnic groups. Numerous variations in incidence rates and annual percent changes were observed when analyses were stratified by county level socioeconomic characteristics.

CONCLUSIONS

Variations in screening utilization and socioeconomic status may account for the majority of racial/ethnic disparities in cervical cancer incidence. Targeting groups with the greatest burdens of cervical cancer is of public health importance, particularly as we enter the human papillomavirus vaccine era.

Predictors of HPV vaccine acceptability: a theory-informed, systematic review

OBJECTIVE

To inform future human papillomavirus (HPV) vaccination programs, we systematically reviewed studies of HPV-related beliefs and HPV vaccine acceptability, organizing the findings using health behavior theory and cervical cancer risk factors.

METHODS

We searched Medline, CINAHL, and PsycINFO from 1995 to January, 2007 for studies of HPV beliefs and HPV vaccine acceptability among adolescents, young adults, and parents of adolescents in the United States.

RESULTS

We identified 28 studies. Most were small, cross-sectional studies of parents and adults. Most parents reacted positively to the possibility of vaccinating their daughters against HPV. Vaccination acceptability was higher when people believed the vaccine was effective, a physician would recommend it, and HPV infection was likely. Cost and, for 6% to 12% of parents, concerns that vaccination would promote adolescent sexual behavior were barriers to vaccination. African American, Hispanic, and white respondents were equally accepting of the HPV vaccine. Parents with lower levels of education reported higher vaccine acceptability. Many studies inadequately reported on other variables associated with cervical cancer mortality.

CONCLUSIONS

HPV vaccine programs in the United States should emphasize high vaccine effectiveness, the high likelihood of HPV infection, and physicians' recommendations, and address barriers to vaccination.

Racial/ethnic disparities in breast and gynecologic cancer treatment and outcomes

PURPOSE OF REVIEW

To review recent research in racial/ethnic disparities in breast and gynecologic cancers, focusing on disparities occurring postdiagnosis.

RECENT FINDINGS

Mortality statistics show that of the cancers under study, breast cancer has the greatest impact, and of racial/ethnic groups, African Americans suffer the greatest disparities, with highest mortality rates for breast, uterine and cervical cancers, and second highest for ovarian cancer. Recent studies demonstrated that black breast cancer patients suffer more underuse of appropriate adjuvant therapy, and greater delays in diagnosis and institution of treatments, and blacks and Hispanics suffered greater postsurgical pain and symptomatology. Data indicate that the biology of some breast cancers in blacks is unique and more aggressive. One study demonstrated that more black breast cancer patients died of nonbreast cancer causes and that excessive comorbidity in blacks explained substantial amounts of survival disparity. Research is beginning to identify important disparities in nonblack minority racial/ethnic groups, including Hispanics and South Asian Americans.

SUMMARY

Research is continuing to identify and explain an important group of disparities - African American disparities in breast cancer outcomes. Disparities in other minority racial/ethnic groups, and in ovarian, uterine and cervical cancers, are at an emerging stage. Continuing efforts at all fronts are needed.

Advances in primary and secondary interventions for cervical cancer: human papillomavirus prophylactic vaccines and testing

Cytologic screening has greatly reduced the incidence of invasive cervical cancer in many industrialized nations. State-of-the-art cervical cancer prevention is costly, however, and includes cytologic screening at repeat intervals, confirmation of abnormalities by colposcopic biopsy, and treatment of precancerous lesions. In resource-limited settings, accessibility to prevention programs for cervical cancer is often poor, or such programs are simply unavailable or inadequately supported. This disease, therefore, remains a leading form of cancer among women living in low-resource regions, and over 250,000 women worldwide die from cervical cancer each year. Persistent cervical infection with one of approximately 15 carcinogenic human papillomavirus (HPV) types causes virtually all invasive cervical cancer and its precursor abnormalities, which can be detected by cytologic screening. Genital HPV infections are primarily transmitted via sexual intercourse. One promising prophylactic HPV vaccine is available and others continue in development as primary cervical cancer prevention strategies in younger women. As secondary interventions, HPV tests are simultaneously evolving for use in cervical cancer screening programs, including routine screening of older women. HPV testing is more sensitive and reproducible than cytology with colposcopy for the detection of cervical precancer and cancer. This article presents current advances and perspectives on HPV vaccines and HPV testing.

Key informants' perspectives prior to beginning a cervical cancer study in Ohio Appalachia

Higher-than-average cervical cancer incidence and mortality rates occur in Ohio Appalachia. Little is known, however, about societal norms and social determinants that affect these rates. To examine county-level sociocultural environments to plan a cervical cancer prevention program, the authors interviewed key informants from 17 of 29 Ohio Appalachia counties. Findings include the perceived offensiveness of the term Appalachia, the importance of long-standing family ties, urban and rural areas within counties, use and acceptability of tobacco, the view that cancer is a death sentence, and the stigmatization of people with cancer. Barriers to screening included cost, lack of insurance, transportation problems, fear, embarrassment, and privacy issues. These findings highlight the important role of geography, social environment, and culture on health behaviors and health outcomes. The interviews provided information about the unique characteristics of this population that are important when developing effective strategies to address cancer-related health behaviors in this medically underserved population.

Patient navigation and case management following an abnormal mammogram: a randomized clinical trial

BACKGROUND

A high rate of low-income, ethnic minority women delay or fail to keep appointments following abnormal mammograms. This study was designed to test the effectiveness of a structured counseling and patient navigation intervention for improving follow-up rates at a large public sector medical center.

METHODS

This randomized clinical trial, conducted in Los Angeles 2001-2002, included 204 women with abnormal mammograms referred for follow-up who were then assigned to intervention or usual care. The primary outcome was the rate of follow-up through diagnostic resolution within eight months.

RESULTS

The intervention resulted in a significant increase in the rate of adherence to follow-up through diagnostic resolution. The intervention group was much more likely to be adherent through diagnostic resolution than the control group (90% vs. 66%, OR=4.48, p<0.001) and were more likely to experience timely adherence than UC patients (77% vs. 57%, OR=2.5, p=0.01). Intervention effectiveness was not significantly different for women assigned to different levels of service intensity.

CONCLUSIONS

Patient navigation and counseling driven by a structured clinical algorithm are highly effective strategies to improve diagnostic resolution follow-up among low-income, ethnic minority women with abnormal mammograms. The intervention algorithm and available training materials can be adapted for diverse care systems serving high-risk women to decrease loss to follow-up.

The promise of the human papillomavirus vaccine does not confer immunity against ethical reflection

The recent announcement of an experimental vaccine against human papillomavirus (HPV) has raised great hopes and expectations. Promising trial results, however, should not obscure ethical issues related to a vaccine's ultimate dissemination. Although lay media might view an HPV vaccine as a panacea, a more complicated ethical reality exists, touching upon public knowledge, health care disparities, and parental consent for childhood vaccination.