Predictors of timely follow-up after abnormal cancer screening among women seeking care at urban community health centers

Patient navigation to address sociolegal barriers for patients with cancer: A comparative-effectiveness study

BACKGROUND

Sociolegal barriers to cancer care are defined as health-related social needs like affordable healthy housing, stable utility service, and food security that may be remedied by public policy, law, regulation, or programming. Legal support has not been studied in cancer care.

METHODS

The authors conducted a randomized controlled trial of patients who had newly diagnosed cancer at a safety-net medical center in Boston from 2014 through 2017, comparing standard patient navigation versus enhanced navigation partnered with legal advocates to identify and address sociolegal barriers. English-speaking, Spanish-speaking, or Haitian Creole-speaking patients with breast and lung cancer were eligible within 30 days of diagnosis. The primary outcome was timely treatment within 90 days of diagnosis. Secondary outcomes included patient-reported outcomes (distress, cancer-related needs, and satisfaction with navigation) at baseline and at 6 months.

RESULTS

In total, 201 patients with breast cancer and 19 with lung cancer enrolled (response rate, 78%). The mean patient age was 55 years, 51% of patients were Black and 22% were Hispanic, 20% spoke Spanish and 8% spoke Haitian Creole, 73% had public health insurance, 77% reported 1 or more perceived sociolegal barrier, and the most common were barriers to housing and employment. Ninety-six percent of participants with breast cancer and 73% of those with lung cancer initiated treatment within 90 days. No significant effect of enhanced navigation was observed on the receipt of timely treatment among participants with breast cancer (odds ratio, 0.88; 95% CI, 0.17-4.52) or among those with lung cancer (odds ratio, 4.00; 95% CI, 0.35-45.4). No differences in patient-reported outcomes were observed between treatment groups.

CONCLUSIONS

Navigation enhanced by access to legal consultation and support had no impact on timely treatment, patient distress, or patient needs. Although most patients reported sociolegal barriers, few required intensive legal services that could not be addressed by navigators.

LAY SUMMARY

In patients with cancer, the experience of sociolegal barriers to care, such as unstable housing, utility services, or food insecurity, is discussed. Addressing these barriers through legal information and assistance may improve care. This study compares standard patient navigation versus enhanced navigation partnered with legal advocates for patients with breast and lung cancers. Almost all patients in both navigation groups received timely care and also reported the same levels of distress, needs, and satisfaction with navigation. Although 75% of patients in the study had at least 1 sociolegal barrier identified, few required legal advocacy beyond what a navigator who received legal information and coaching could provide.

Cost-Effectiveness of Offering Cervical Cancer Screening with HPV Self-Sampling among African-American Women in the Mississippi Delta

BACKGROUND

African-American women in the United States have an elevated risk of cervical cancer incidence and mortality. In the Mississippi Delta, cervical cancer disparities are particularly stark.

METHODS

We conducted a micro-costing study alongside a group randomized trial that evaluated the efficacy of a patient-centered approach ("Choice" between self-collection at home for HPV testing or current standard of care within the public health system in Mississippi) versus the current standard of care ["Standard-of-care screening," involving cytology (i.e., Pap) and HPV co-testing at the Health Department clinics]. The interventions in both study arms were delivered by community health workers (CHW). Using cost, screening uptake, and colposcopy adherence data from the trial, we informed a mathematical model of HPV infection and cervical carcinogenesis to conduct a cost-effectiveness analysis comparing the "Choice" and "Standard-of-care screening" interventions among un/underscreened African-American women in the Mississippi Delta.

RESULTS

When each intervention was simulated every 5 years from ages 25 to 65 years, the "Standard-of-care screening" strategy reduced cancer risk by 6.4% and was not an efficient strategy; "Choice" was more effective and efficient, reducing lifetime risk of cervical cancer by 14.8% and costing $62,720 per year of life saved (YLS). Screening uptake and colposcopy adherence were key drivers of intervention cost-effectiveness.

CONCLUSIONS

Offering "Choice" to un/underscreened African-American women in the Mississippi Delta led to greater uptake than CHW-facilitated screening at the Health Department, and may be cost-effective.

IMPACT

We evaluated the cost-effectiveness of an HPV self-collection intervention to reduce disparities.

Time to diagnostic resolution after an uncertain screening mammogram in an underserved population

BACKGROUND

Screening mammography has reduced breast cancer-associated mortality worldwide. Approximately 10% of patients require further diagnostic testing after an uncertain screening mammogram (Breast imaging reporting and data system [BI-RADS] = 0), and time to diagnostic resolution varies after BI-RADS = 0 screening mammogram. There is little data about factors associated with diagnostic resolution in patients of Chinese origin ("Chinese") receiving care in the US.

METHODS

We performed a retrospective analysis to identify patterns of diagnostic resolution in an urban US hospital with a large population of Chinese patients. We evaluated whether location of primary care provider (PCP) impacted time to resolution among Chinese patients, hypothesizing that patients with a PCP outside of the hospital would have longer time to diagnostic resolution than those patients with a PCP within the institution.

RESULTS

Between 2015 and 2016, 368 patients at Tufts Medical Center (Tufts MC) had resulting BI-RADS = 0 after screening mammogram. The majority of patients (341/368, 93%) achieved diagnostic resolution with median time to resolution 27 days (Q1: 14, Q3: 40). Seven percent (27/368) never achieved resolution. Among those with diagnostic resolution, 10% of patients required >60 days to achieve resolution. Chinese origin, no previous breast cancer, subsidized insurance, and outside referring physician were associated with longer time to resolution in univariable analysis. In multivariable regression, after adjusting for age, insurance, marital status, and prior breast cancer, Chinese patients with Tufts MC PCP experienced timelier diagnostic resolution vs Chinese patients without a Tufts MC PCP (hazard ratio [HR] = 1.85, P = .02). Location of PCP did not impact time to resolution among non-Chinese patients.

CONCLUSION

We identified patterns of diagnostic resolution in an urban hospital with a large historically underserved population. We found that Chinese patients without integrated primary care within the institution are at risk for delayed diagnostic resolution. Future interventions need to target at-risk patients to prevent loss of follow-up after uncertain screening mammogram.

Cervical Cancer Burden and Opportunities for Prevention in a Safety-Net Healthcare System

BACKGROUND

The high prevalence of cervical cancer at safety-net health systems requires careful analysis to best inform prevention and quality improvement efforts. We characterized cervical cancer burden and identified opportunities for prevention in a U.S. safety-net system.

METHODS

We reviewed tumor registry and electronic health record (EHR) data of women with invasive cervical cancer with ages 18+, diagnosed between 2010 and 2015, in a large, integrated urban safety-net. We developed an algorithm to: (i) classify whether women had been engaged in care (≥1 clinical encounter between 6 months and 5 years before cancer diagnosis); and (ii) identify missed opportunities (no screening, no follow-up, failure of a test to detect cancer, and treatment failure) and associated factors among engaged patients.

RESULTS

Of 419 women with cervical cancer, more than half (58%) were stage 2B or higher at diagnosis and 40% were uninsured. Most (69%) had no prior healthcare system contact; 47% were diagnosed elsewhere. Among 122 engaged in care prior to diagnosis, failure to screen was most common (63%), followed by lack of follow-up (21%), and failure of test to detect cancer (16%). Tumor stage, patient characteristics, and healthcare utilization differed across groups.

CONCLUSIONS

Safety-net healthcare systems face a high cervical cancer burden, mainly from women with no prior contact with the system. To prevent or detect cancer early, community-based efforts should encourage uninsured women to use safety-nets for primary care and preventive services.

IMPACT

Among engaged patients, strategies to increase screening and follow-up of abnormal screening tests could prevent over 80% of cervical cancer cases.

Social Network Structures of Breast Cancer Patients and the Contributing Role of Patient Navigators

BACKGROUND

Minority women in the U.S. continue to experience inferior breast cancer outcomes compared with white women, in part due to delays in care delivery. Emerging cancer care delivery models like patient navigation focus on social barriers, but evidence demonstrating how these models increase social capital is lacking. This pilot study describes the social networks of newly diagnosed breast cancer patients and explores the contributing role of patient navigators.

MATERIALS AND METHODS

Twenty-five women completed a one hour interview about their social networks related to cancer care support. Network metrics identified important structural attributes and influential individuals. Bivariate associations between network metrics, type of network, and whether the network included a navigator were measured. Secondary analyses explored associations between network structures and clinical outcomes.

RESULTS

We identified three types of networks: kin-based, role and/or affect-based, or heterogeneous. Network metrics did not vary significantly by network type. There was a low prevalence of navigators included in the support networks (25%). Network density scores were significantly higher in those networks without a navigator. Network metrics were not predictive of clinical outcomes in multivariate models.

CONCLUSION

Patient navigators were not frequently included in support networks, but provided distinctive types of support. If navigators can identify patients with poorly integrated (less dense) social networks, or who have unmet tangible support needs, the intensity of navigation services could be tailored. Services and systems that address gaps and variations in patient social networks should be explored for their potential to reduce cancer health disparities.

IMPLICATIONS FOR PRACTICE

This study used a new method to identify the breadth and strength of social support following a diagnosis of breast cancer, especially examining the role of patient navigators in providing support. While navigators were only included in one quarter of patient support networks, they did provide essential supports to some individuals. Health care providers and systems need to better understand the contributions of social supports both within and outside of health care to design and tailor interventions that seek to reduce health care disparities and improve cancer outcomes.

Follow-Up of Abnormal Breast and Colorectal Cancer Screening by Race/Ethnicity

INTRODUCTION

Timely follow-up of abnormal tests is critical to the effectiveness of cancer screening, but may vary by screening test, healthcare system, and sociodemographic group.

METHODS

Timely follow-up of abnormal mammogram and fecal occult blood testing or fecal immunochemical tests (FOBT/FIT) were compared by race/ethnicity using Population-Based Research Optimizing Screening through Personalized Regimens consortium data. Participants were women with an abnormal mammogram (aged 40-75 years) or FOBT/FIT (aged 50-75 years) in 2010-2012. Analyses were performed in 2015. Timely follow-up was defined as colonoscopy ≤3 months following positive FOBT/FIT; additional imaging or biopsy ≤3 months following Breast Imaging Reporting and Data System Category 0, 4, or 5 mammograms; or ≤9 months following Category 3 mammograms. Logistic regression was used to model receipt of timely follow-up adjusting for study site, age, year, insurance, and income.

RESULTS

Among 166,602 mammograms, 10.7% were abnormal; among 566,781 FOBT/FITs, 4.3% were abnormal. Nearly 96% of patients with abnormal mammograms received timely follow-up versus 68% with abnormal FOBT/FIT. There was greater variability in receipt of follow-up across healthcare systems for positive FOBT/FIT than for abnormal mammograms. For mammography, black women were less likely than whites to receive timely follow-up (91.8% vs 96.0%, OR=0.71, 95% CI=0.51, 0.97). For FOBT/FIT, Hispanics were more likely than whites to receive timely follow-up than whites (70.0% vs 67.6%, OR=1.12, 95% CI=1.04, 1.21).

CONCLUSIONS

Timely follow-up among women was more likely for abnormal mammograms than FOBT/FITs, with small variations in follow-up rates by race/ethnicity and larger variation across healthcare systems.

Racial and ethnic differences in patient navigation: Results from the Patient Navigation Research Program

BACKGROUND

Patient navigation was developed to address barriers to timely care and reduce cancer disparities. The current study explored navigation and racial and ethnic differences in time to the diagnostic resolution of a cancer screening abnormality.

METHODS

The authors conducted an analysis of the multisite Patient Navigation Research Program. Participants with an abnormal cancer screening test were allocated to either navigation or control. The unadjusted median time to resolution was calculated for each racial and ethnic group by navigation and control. Multivariable Cox proportional hazards models were fit, adjusting for sex, age, cancer abnormality type, and health insurance and stratifying by center of care.

RESULTS

Among a sample of 7514 participants, 29% were non-Hispanic white, 43% were Hispanic, and 28% were black. In the control group, black individuals were found to have a longer median time to diagnostic resolution (108 days) compared with non-Hispanic white individuals (65 days) or Hispanic individuals (68 days) (P<.0001). In the navigated groups, black individuals had a reduction in the median time to diagnostic resolution (97 days) (P<.0001). In the multivariable models, among controls, black race was found to be associated with an increased delay to diagnostic resolution (hazard ratio, 0.77; 95% confidence interval, 0.69-0.84) compared with non-Hispanic white individuals, which was reduced in the navigated arm (hazard ratio, 0.85; 95% confidence interval, 0.77-0.94).

CONCLUSIONS

Patient navigation appears to have the greatest impact among black patients, who had the greatest delays in care. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2715-2722. © 2016 American Cancer Society.

Variation in Screening Abnormality Rates and Follow-Up of Breast, Cervical and Colorectal Cancer Screening within the PROSPR Consortium

BACKGROUND

Primary care providers and health systems have prominent roles in guiding effective cancer screening.

OBJECTIVE

To characterize variation in screening abnormality rates and timely initial follow-up for common cancer screening tests.

DESIGN

Population-based cohort undergoing screening in 2011, 2012, or 2013 at seven research centers comprising the National Cancer Institute-sponsored Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

PARTICIPANTS

Adults undergoing mammography with or without digital breast tomosynthesis (n = 97,683 ages 40-75 years), fecal occult blood or fecal immunochemical tests (n = 759,553 ages 50-75 years), or Papanicolaou with or without human papillomavirus tests (n = 167,330 ages 21-65 years).

INTERVENTION

Breast, colorectal, or cervical cancer screening.

MAIN MEASURES

Abnormality rates per 1000 screens; percentage with timely initial follow-up (within 90 days, except 9-month window for BI-RADS 3). Primary care clinic-level variation in percentage with screening abnormality and percentage with timely initial follow-up.

KEY RESULTS

There were 10,248/97,683 (104.9 per 1000) abnormal breast cancer screens, 35,847/759,553 (47.2 per 1000) FOBT/FIT-positive colorectal cancer screens, and 13,266/167,330 (79.3 per 1000) abnormal cervical cancer screens. The percentage with timely follow-up was 93.2 to 96.7 % for breast centers, 46.8 to 68.7  % for colorectal centers, and 46.6 % for the cervical cancer screening center (low-grade squamous intraepithelial lesions or higher). The primary care clinic variation (25th to 75th percentile) was smaller for the percentage with an abnormal screen (breast, 8.5-10.3 %; colorectal, 3.0-4.8 %; cervical, 6.3-9.9 %) than for the percentage with follow-up within 90 days (breast, 90.2-95.8 %; colorectal, 43.4-52.0 %; cervical, 29.6-61.4 %).

CONCLUSIONS

Variation in both the rate of screening abnormalities and their initial follow-up was evident across organ sites and primary care clinics. This highlights an opportunity for improving the delivery of cancer screening through focused study of patient, provider, clinic, and health system characteristics associated with timely follow-up of screening abnormalities.

Racial/Ethnic Disparities in Time to a Breast Cancer Diagnosis: The Mediating Effects of Health Care Facility Factors

BACKGROUND

Racial/ethnic disparities exist along the breast cancer continuum, including time to a diagnosis. Previous research has largely focused on patient-level factors, and less is known about the role that health care facilities may play in delayed breast cancer care.

OBJECTIVES

We examined racial/ethnic disparities in delayed diagnosis for breast cancer in the Breast Cancer Care in Chicago Study and estimated the potential mediating effects of facility factors.

RESEARCH DESIGN AND SUBJECTS

Breast cancer patients (N=606) contributed interview and medical record data as part of a population-based study.

MEASURES

Race/ethnicity was self-reported at interview. Diagnostic delay was defined as an excess of 60 days between medical presentation and a definitive diagnosis. Facility factors included the facility of medical presentation with respect to: (1) accreditation through the National Consortium of Breast Centers; (2) certification as a Breast Imaging Center of Excellence through the American College of Radiology; and (3) status as a disproportionate share hospital through the state of Illinois as well as the number of facilities used between presentation and diagnosis.

RESULTS

Relative to non-Hispanic whites, minorities were more likely to experience a diagnostic delay, present at a nonaccredited facility and at a disproportionate share hospital, and involve multiple facilities in their diagnosis. Together, facility factors accounted for 43% of the disparity in diagnostic delay (P<0.0001).

CONCLUSIONS

Initial presentation of breast cancer at higher resourced facilities can reduce diagnostic delays. Disparities in delay are partly due to a disproportionate presentation at lower resourced facilities by minorities.

Delays in Cancer Care Among Low-Income Minorities Despite Access

INTRODUCTION

Narrowing the racial/ethnic and socioeconomic disparities in breast and cervical cancer requires an in-depth understanding of motivation for adherence to cancer screening and follow-up care. To inform patient-centered interventions, this study aimed to identify reasons why low-income women adhered to or delayed breast or cervical cancer screening, follow-up and treatment despite access to cancer care-related services.

METHODS

Semistructured qualitative interviews were conducted among women with access to cancer care-related services receiving care at an academic cancer center, federally qualified health centers, or free clinics in the Chicago metropolitan area. Transcripts were coded and analyzed for themes related to rationales for adherence.

RESULTS

Among 138 participants, most were African American (46%) or Hispanic (36%), English speaking (70%), and between ages 41 and 65 years (64%). Primary drivers of nonadherence included lack of knowledge of resources, denial or fear, competing obligations, and embarrassment. Facilitators included abnormality identification, patient activation, provider-initiated actions, and motivation from family or friends.

CONCLUSIONS

Interventions targeting increased adherence to care among low-income and ethnic minority women should direct efforts to proactive, culturally and patient-informed education that enables patients to access resources and use the health care system, address misconceptions about cancer, ensure health care providers' communication of screening guidelines, and leverage the patient's social support network.

The impact of health insurance reform on insurance instability

We investigated the impact of the 2006 Massachusetts health care reform on insurance coverage and stability among minority and underserved women. We examined 36 months of insurance claims among 1,946 women who had abnormal cancer screening at six community health centers pre-(2004-2005) and post-(2007-2008) insurance reform. We examined frequency of switches in insurance coverage as measures of longitudinal insurance instability. On the date of their abnormal cancer screening test, 36% of subjects were publicly insured and 31% were uninsured. Post-reform, the percent ever uninsured declined from 39% to 29% (p .001) and those consistently uninsured declined from 23% to 16%. To assess if insurance instability changed between the pre- and post-reform periods, we conducted Poisson regression models, adjusted for patient demographics and length of time in care. These revealed no significant differences from the pre- to post-reform period in annual rates of insurance switches, incident rate ratio 0.98 (95%- CI 0.88-1.09). Our analysis is limited by changes in the populations in the pre- and post-reform period and inability to capture care outside of the health system network. Insurance reform increased stability as measured by decreasing uninsured rates without increasing insurance switches.

Unifying screening processes within the PROSPR consortium: a conceptual model for breast, cervical, and colorectal cancer screening

General frameworks of the cancer screening process are available, but none directly compare the process in detail across different organ sites. This limits the ability of medical and public health professionals to develop and evaluate coordinated screening programs that apply resources and population management strategies available for one cancer site to other sites. We present a trans-organ conceptual model that incorporates a single screening episode for breast, cervical, and colorectal cancers into a unified framework based on clinical guidelines and protocols; the model concepts could be expanded to other organ sites. The model covers four types of care in the screening process: risk assessment, detection, diagnosis, and treatment. Interfaces between different provider teams (eg, primary care and specialty care), including communication and transfer of responsibility, may occur when transitioning between types of care. Our model highlights across each organ site similarities and differences in steps, interfaces, and transitions in the screening process and documents the conclusion of a screening episode. This model was developed within the National Cancer Institute-funded consortium Population-based Research Optimizing Screening through Personalized Regimens (PROSPR). PROSPR aims to optimize the screening process for breast, cervical, and colorectal cancer and includes seven research centers and a statistical coordinating center. Given current health care reform initiatives in the United States, this conceptual model can facilitate the development of comprehensive quality metrics for cancer screening and promote trans-organ comparative cancer screening research. PROSPR findings will support the design of interventions that improve screening outcomes across multiple cancer sites.

Multiple barriers delay care among women with abnormal cancer screening despite patient navigation

BACKGROUND

While there is widespread dissemination of patient navigation programs in an effort to reduce delays in cancer care, little is known about the impact of barriers to care on timely outcomes.

METHODS

We conducted a secondary analysis of the Boston Patient Navigation Research Program (PNRP) to examine the effect that the presence of barriers had on time to diagnostic resolution of abnormal breast or cervical cancer screening tests. We used multivariable Cox proportional hazards regression with time to diagnostic resolution as the outcome to examine the effect of the number of barriers, controlling for demographic covariates and clustered by patients' primary navigator.

RESULTS

There were 1481 women who received navigation; mean age was 39 years; 32% were White, 27% Black, and 31% Hispanic; 28% had private health insurance; and 38% did not speak English. Overall, half (n=745, 50%) had documentation of one or more barriers to care. Women with barriers were more likely to be older, non-White, non-English language speakers, and on public or no health insurance compared with women without barriers. In multivariable analyses, we found less timely diagnostic resolution as the number of barriers increased (one barrier, adjusted hazard ratio [aHR] 0.81 [95% CI 0.56-1.17], p=0.26; two barriers, aHR 0.55 [95% CI 0.37-0.81], p=0.0025; three or more barriers, aHR 0.31 [95% CI 0.21-0.46], p<0.0001)].

CONCLUSION

Within a patient navigation program proven to reduce delays in care, we found that navigated patients with documented barriers to care experience less timely resolution of abnormal cancer screening tests.

Follow-up to abnormal cancer screening tests: considering the multilevel context of care

The call for multilevel interventions to improve the quality of follow-up to abnormal cancer screening has been out for a decade, but published work emphasizes individual approaches, and conceptualizations differ regarding the definition of levels. To investigate the scope and methods being undertaken in this focused area of follow-up to abnormal tests (breast, colon, cervical), we reviewed recent literature and grants (2007-2012) funded by the National Cancer Institute. A structured search yielded 16 grants with varying definitions of "follow-up" (e.g., completion of recommended tests, time to diagnosis); most included minority racial/ethnic group participants. Ten grants concentrated on measurement/intervention development and 13 piloted or tested interventions (categories not mutually exclusive). All studies considered patient-level factors and effects. Although some directed interventions at provider levels, few measured group characteristics and effects of interventions on the providers or levels other than the patient. Multilevel interventions are being proposed, but clarity about endpoints, definition of levels, and measures is needed. The differences in the conceptualization of levels and factors that affect practice need empirical exploration, and we need to measure their salient characteristics to advance our understanding of how context affects cancer care delivery in a changing practice and policy environment.

Urban and rural safety net health care system clinics: no disparity in HPV4 vaccine completion rates

OBJECTIVE

Safety net health care centers in the US serve vulnerable and underinsured females. The primary aim of this work was to determine if HPV4 dosing compliance differs between females who receive doses at rural vs. urban core safety net health care locations.

METHODS

Females exclusively receiving health care in the Truman Medical Center (TMC) safety net system at the urban core and rural locations were identified by their HPV4 vaccine records. Dates and number of HPV4 doses as well as age, gravidity, parity and race/ethnicity were recorded from the electronic medical record (EMR). Appropriate HPV4 dosing intervals were referenced from the literature.

RESULTS

1259 females, 10-26 years of age, received HPV4 vaccination at either the rural (23%) or urban core location (77%). At the rural location, 23% received three doses on time, equal to the 24% at the urban core. Females seen in the urban core were more likely to receive on-time doublet dosing than on-time triplet dosing (82% vs. 67%, p<0.001). Mistimed doses occurred equally often among females receiving only two doses, as well as those receiving three doses.

CONCLUSIONS

Compliance with on-time HPV4 triplet dose completion was low at rural and urban core safety net health clinics, but did not differ by location.

Barriers reported among patients with breast and cervical abnormalities in the patient navigation research program: impact on timely care

BACKGROUND

Patient navigation (PN) is a system-level strategy to decrease cancer mortality rates by reducing barriers to cancer care. Barriers to resolution among participants in the PN intervention arm with a breast or cervical abnormality in the Patient Navigation Research Program and navigators' actions to address those barriers were examined.

METHODS

Data from seven institutions (2005-2010) included 1,995 breast and 1,194 cervical patients. A stratified Cox proportional hazards regression model was used to examine the effects of barriers on time to resolution of an abnormal screening test or clinical finding.

FINDINGS

The range of unique barriers was 0 to 12 and 0 to 7 among participants with breast and cervical abnormalities, respectively. About two thirds of breast and one half of cervical participants had at least one barrier resulting in longer time to diagnostic resolution among breast (adjusted hazard ratio [HR], 0.744; p < .001) and cervical (adjusted HR, 0.792; p < .001) participants. Patient- and system-level barriers were most common. Frequent navigator actions were making arrangements, scheduling appointments, referrals, and education.

CONCLUSIONS

Having a barrier resulted in a delay in diagnostic resolution of an abnormal screening test or clinical finding. Health care systems can use these findings to improve existing PN programs or when developing new programs.

Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study

Time delay after an abnormal screening mammogram may have a critical impact on tumor size, stage at diagnosis, treatment, prognosis, and survival of subsequent breast cancer. This study was undertaken to evaluate disparities between Latina and non-Hispanic white (NHW) women in time to definitive diagnosis of breast cancer after an abnormal screening mammogram, as well as factors contributing to such disparities. As part of the activities of the National Cancer Institute (NCI)-funded Redes En Acción research network, clinical records of 186 Latinas and 74 NHWs who received abnormal screening mammogram results were reviewed to determine the time to obtain a definitive diagnosis. Data was obtained from participating clinics in six U.S. cities and included demographics, clinical history, and mammogram characteristics. Kaplan-Meier estimates and Cox proportional hazards models were used to test differences in median time to definitive diagnosis by ethnicity after adjusting for clinic site, demographics, and clinical characteristics. Time-to-event analysis showed that Latinas took 2.2 times longer to reach 50% definitively diagnosed with breast cancer relative to NHWs, and three times longer to reach 80% diagnosed (p=0.001). Latinas' median time to definitive diagnosis was 60 days compared to 27 for NHWs, a 59% gap in diagnosis rates (adjusted Hazard Ratio [aHR] = 1.59, 95% CI = 1.09, 2.31; p=0.015). BI-RADS-4/5 women's diagnosis rate was more than twice that of BI-RADS-3 (aHR = 2.11, 95% CI = 1.18, 3.78; p=0.011). Disparities in time between receipt of abnormal screening result and definitive diagnosis adversely affect Latinas compared to NHWs, and remain significant after adjusting for demographic and clinical variables. With cancer now the leading cause of mortality among Latinos, a greater need exists for ethnically and culturally appropriate interventions like patient navigation to facilitate Latinas' successful entry into, and progression through, the cancer care system.

Invasive cervical cancer risk among HIV-infected women: a North American multicohort collaboration prospective study

OBJECTIVE

HIV infection and low CD4+ T-cell count are associated with an increased risk of persistent oncogenic human papillomavirus infection-the major risk factor for cervical cancer. Few reported prospective cohort studies have characterized the incidence of invasive cervical cancer (ICC) in HIV-infected women.

METHODS

Data were obtained from HIV-infected and -uninfected female participants in the North American AIDS Cohort Collaboration on Research and Design with no history of ICC at enrollment. Participants were followed from study entry or January 1996 through ICC, loss to follow-up, or December 2010. The relationship of HIV infection and CD4+ T-cell count with risk of ICC was assessed using age-adjusted Poisson regression models and standardized incidence ratios. All cases were confirmed by cancer registry records and/or pathology reports. Cervical cytology screening history was assessed through medical record abstraction.

RESULTS

A total of 13,690 HIV-infected and 12,021 HIV-uninfected women contributed 66,249 and 70,815 person-years of observation, respectively. Incident ICC was diagnosed in 17 HIV-infected and 4 HIV-uninfected women (incidence rate of 26 and 6 per 100,000 person-years, respectively). HIV-infected women with baseline CD4+ T-cells of ≥350, 200-349, and <200 cells per microliter had a 2.3, 3.0, and 7.7 times increase in ICC incidence, respectively, compared with HIV-uninfected women (P(trend) = 0.001). Of the 17 HIV-infected women, medical records for the 5 years before diagnosis showed that 6 had no documented screening, 5 had screening with low-grade or normal results, and 6 had high-grade results.

CONCLUSIONS

This study found elevated incidence of ICC in HIV-infected compared with -uninfected women, and these rates increased with immunosuppression.

Cervical cancer screening among Michigan women: 'The Special Cancer Behavioral Risk Factor Survey', 2004-2008

The burden of cervical cancer remains greater among minority women. The purpose of this study was to evaluate racial/ethnic disparities in cervical cancer screening among minority women in Michigan. Data from 8,023 women (≥ 40 years) surveyed in the 2004-2008 Michigan Special Cancer Behavioral Risk Factor Survey were used to assess racial/ethnic differences in cervical cancer screening, knowledge and beliefs. Unexpectedly, African-American and Hispanic women reported being screened for cervical cancer at rates similar to, or higher than, Whites. Women demonstrated limited knowledge of cervical cancer risk factors and its signs/symptoms. Most minority women were more likely than Whites to believe in the importance of cervical screening, with Hispanic women more likely to support HPV vaccination. Differential utilisation of screening does not explain the disproportionately high rates of cervical cancer among minorities. Future research should examine disparities in the follow-up of abnormal cervical results and receipt of treatment.

Patient barriers to follow-up care for breast and cervical cancer abnormalities

BACKGROUND

Women with breast or cervical cancer abnormalities can experience barriers to timely follow-up care, resulting in delays in cancer diagnosis. Patient navigation programs that identify and remove barriers to ensure timely receipt of care are proliferating nationally. The study used a systematic framework to describe barriers, including differences between African American and Latina women; to determine recurrence of barriers; and to examine factors associated with barriers to follow-up care.

METHODS

Data originated from 250 women in the intervention arm of the Chicago Patient Navigation Research Program (PNRP). The women had abnormal cancer screening findings and navigator encounters. Women were recruited from a community health center and a publicly owned medical center. After describing proportions of African American and Latina women experiencing particular barriers, logistic regression was used to explore associations between patient characteristics, such as race/ethnicity, and type of barriers.

RESULTS

The most frequent barriers occurred at the intrapersonal level (e.g., insurance issues and fear), while institutional-level barriers such as system problems with scheduling care were the most commonly recurring over time (29%). The majority of barriers (58%) were reported in the first navigator encounter. Latinas (81%) reported barriers more often than African American women (19%). Differences in race/ethnicity and employment status were associated with types of barriers. Compared to African American women, Latinas were more likely to report an intrapersonal level barrier. Unemployed women were more likely to report an institutional level barrier.

CONCLUSION

In a sample of highly vulnerable women, there is no single characteristic (e.g., uninsured) that predicts what kinds of barriers a woman is likely to have. Nevertheless, navigators appear able to easily resolve intrapersonal-level barriers, but ongoing navigation is needed to address system-level barriers. Patient navigation programs can adopt the PNRP barriers framework to assist their efforts in assuring timely follow-up care.

Factors influencing time to diagnosis after abnormal mammography in diverse women

BACKGROUND

Abnormal mammograms are common, and the risk of false positives is high. We surveyed women in order to understand the factors influencing the efficiency of the evaluation of an abnormal mammogram.

METHODS

Women aged 40-80 years, identified from lists with Breast Imaging Reporting and Data System (BIRADS) classifications of 0, 3, 4, or 5, were surveyed. Telephone surveys asked about the process of evaluation, and medical records were reviewed for tests and timing of evaluation.

RESULTS

In this study, 970 women were surveyed, and 951 had chart reviews. Overall, 36% were college graduates, 68% were members of a group model health plan, 18% were Latinas, 25% were African Americans, 15% were Asian, and 43% were white. Of the 352 women who underwent biopsies, 151 were diagnosed with cancer (93 invasive). Median time to diagnosis was 183 days for BIRADS 3 compared to 29 days for BIRADS 4/5 and 27 days for BIRADS 0. At 60 days, 84% of BIRADS 4/5 women had a diagnosis. Being African American (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.49-0.97, p=0.03), income < $10,000 (HR 0.55, 95% CI 0.31-0.98, p<0.04), perceived discrimination (HR 0.22, 95% CI 0.09-0.52, p<0.001), not fully understanding the results of the index mammogram (HR 0.49, 95% CI 0.32-0.75, p=0.001), and being notified by letter (HR 0.66, 95% CI 0.48-0.90, p=0.01) or telephone (HR 0.62, 95% CI 0.42-0.92, p=0.02) rather than in person were all associated with significant delays in diagnosis.

CONCLUSIONS

Evaluation of BIRADS 0, 4, or 5 abnormal mammograms was completed in most women within the recommended 60 days. Even within effective systems, correctible communication factors may adversely affect time to diagnosis.

Follow-up and timeliness after an abnormal cancer screening among underserved, urban women in a patient navigation program

BACKGROUND

We evaluated the efficacy of a Chicago-based cancer patient navigation program developed to increase the proportion of patients reaching diagnostic resolution and reduce the time from abnormal screening test to definitive diagnostic resolution.

METHODS

Women with an abnormal breast (n = 352) or cervical (n = 545) cancer screening test were recruited for the quasi-experimental study. Navigation subjects originated from five federally qualified health center sites and one safety net hospital. Records-based concurrent control subjects were selected from 20 sites. Control sites had similar characteristics to the navigated sites in terms of patient volume, racial/ethnic composition, and payor mix. Mixed-effects logistic regression and Cox proportional hazard regression analyses were conducted to compare navigation and control patients reaching diagnostic resolution by 60 days and time to resolution, adjusting for demographic covariates and site.

RESULTS

Compared with controls, the breast navigation group had shorter time to diagnostic resolution (aHR = 1.65, CI = 1.20-2.28) and the cervical navigation group had shorter time to diagnostic resolution for those who resolved after 30 days (aHR = 2.31, CI = 1.75-3.06), with no difference before 30 days (aHR = 1.42, CI = 0.83-2.43). Variables significantly associated with longer time to resolution for breast cancer screening abnormalities were being older, never partnered, abnormal mammogram and BI-RADS 3, and being younger and Black for cervical abnormalities.

CONCLUSIONS

Patient navigation reduces time from abnormal cancer finding to definitive diagnosis in underserved women.

IMPACT

Results support efforts to use patient navigation as a strategy to reduce cancer disparities among socioeconomically disadvantaged women.

Boston Patient Navigation Research Program: the impact of navigation on time to diagnostic resolution after abnormal cancer screening

BACKGROUND

There is a need for controlled studies to assess the impact of patient navigation in vulnerable cancer populations.

METHODS

Boston Patient Navigation Research Program conducted a quasi-experimental patient navigation intervention across six federally qualified inner-city community health centers, three assigned to a breast cancer navigation intervention and three assigned to a cervical cancer navigation intervention; each group then served as the control for the other. Eligible women had an abnormal breast or cervical cancer screening test conducted at one of the participating health centers during a baseline (2004-2005) or intervention period (2007-2008). Kaplan-Meier survival curves and proportional hazards regression examined the effect of patient navigation on time to definitive diagnosis, adjusting for covariates, clustering by clinic and differences between the baseline and intervention period.

RESULTS

We enrolled 997 subjects in the baseline period and 3,041 subjects during the intervention period, of whom 1,497 were in the navigated arm, and 1,544 in the control arm. There was a significant decrease in time to diagnosis for subjects in the navigated group compared with controls among those with a cervical screening abnormality [aHR 1.46; 95% confidence interval (CI), 1.1-1.9]; and among those with a breast cancer screening abnormality that resolved after 60 days (aHR 1.40; 95% CI, 1.1-1.9), with no differences before 60 days.

CONCLUSIONS

This study documents a benefit of patient navigation on time to diagnosis among a racially/ethnically diverse inner city population.

IMPACT

Patient navigation may address cancer health disparities by reducing time to diagnosis following an abnormal cancer-screening event.

Correlates of human papillomavirus vaccination rates in low-income, minority adolescents: a multicenter study

BACKGROUND

Low rates of human papillomavirus (HPV) vaccination in low-income, minority adolescents may exacerbate racial disparities in cervical cancer incidence.

METHODS

Using electronic medical record data and chart abstraction, we examined correlates of HPV vaccine series initiation and completion among 7702 low-income and minority adolescents aged 11-21 receiving primary care at one of seven medical centers between May 1, 2007, and June 30, 2009. Our population included 61% African Americans, 13% Caucasians, 15% Latinas, and 11% other races; 90% receive public insurance (e.g., Medicaid). We used logistic regression to estimate the associations between vaccine initiation and completion and age, race/ethnicity, number of contacts with the healthcare system, provider documentation, and clinical site of care.

RESULTS

Of the 41% of adolescent girls who initiated HPV vaccination, 20% completed the series. A higher proportion of girls aged 11-<13 (46%) and 13-<18 (47%) initiated vaccination than those aged 18-21 (28%). In adjusted analyses, receipt of other recommended adolescent vaccines was associated with vaccine initiation, and increased contact with the medical system was associated with both initiation and completion of the series. Conversely, provider failure to document risky health behaviors predicted nonvaccination. Manual review of a subset of unvaccinated patients' charts revealed no documentation of vaccine discussions in 67% of cases.

CONCLUSIONS

Fewer than half of low-income and minority adolescents receiving health maintenance services initiated HPV vaccination, and only 20% completed the series. Provider failure to discuss vaccination with their patients appears to be an important contributor to nonvaccination. Future research should focus on improving both initiation and completion of HPV vaccination in high-risk adolescents.

Age-specific trends in black-white disparities in cervical cancer incidence in the United States: 1975-2009

BACKGROUND

Although overall cervical cancer incidence rates have decreased in both black and white women in the U.S. since the mid 1950s due to widespread screening, rates continue to be higher among blacks than among whites. However, whether this pattern differs by age is unknown.

METHODS

Cervical cancer cases (1975-2009, N=36,503) were obtained from nine Surveillance, Epidemiology, and End Results (SEER) Program registries. Age-standardized incidence rates for white and black women were calculated from 1975-1979 through 2005-2009 by age group (<50, 50-64, and ≥65 years). Rate ratios (RRs) and 95% confidence intervals (CIs) evaluated differences in rates for blacks vs. whites by age group and stage at diagnosis during 1975-1979 and 2005-2009.

RESULTS

Among women aged <50 years, the black-to-white disparity RR decreased from nearly two-fold (RR, 1.9; 95% CI, 1.7-2.1) during 1975-1979 to unity during 2005-2009 (RR, 0.9; 95% CI, 0.8-1.0). In contrast, rates remained significantly elevated for blacks vs. whites aged 50-64 years (RR, 2.4; 95% CI, 2.1-2.7 and 1.7; 95% CI, 1.5-2.0), and for those aged ≥65 years (RR, 3.3; 95% CI, 2.9-3.8 and 2.2; 95% CI, 1.9-2.7) during both time periods, although the disparities decreased over time. Similar disparities persisted for older black women with cervical cancer of all stages.

CONCLUSION

Disparities in cervical cancer incidence rates were eliminated for younger blacks vs. whites but persisted for blacks aged 50 years and older. Additional strategies are needed to increase follow-up and treatment of precancerous lesions among middle-aged and older black women.

Evaluation of therapeutic care delay among Latina- and European-American cervical cancer survivors

OBJECTIVES

Cervical cancer (CCA) ranks among the deadliest of cancers. Globally CCA claims 275,000 lives yearly. Severe delays, in cancer diagnostic or therapeutic care, that approach ≥ 60 days negatively affect survival and survivorship outcomes. This study investigated socioeconomic and healthcare system factors influencing therapeutic care delays among cervical cancer survivors (CCS).

METHODS

291 CCS (132 European-, 50 English-proficient (EP) Latina- and 109 limited English-proficient (LEP) Latina-Americans) were recruited from cancer registries. CCS retrospectively noted the days of delay in obtaining therapeutic care and reasons for delays.

RESULTS

CCS who were LEP Latina-Americans, had lower income and education reported severe therapeutic delays (≥ 60 days). LEP Latina-Americans experienced delays due to financial issues, doctor's delay, and healthcare system issues (p < 0.001). Doctor and healthcare system delays significantly influenced therapeutic care delay in the logistic regression model.

CONCLUSIONS

Healthcare system delays are primary contributors to ethnic differences in access to appropriately-timed care observed in this study. Healthcare professionals need to develop a fuller appreciation of the multilevel factors that contribute to healthcare barriers to better inform effective interventions to increase access to life saving care.

Prevention of invasive cervical cancer in the United States: past, present, and future

Over the past several decades, invasive cervical cancer (ICC) incidence in the United States has declined dramatically. Much of this decline has been attributed to widespread use of cytology screening followed by treatment of precancerous lesions. Despite available technologies to prevent ICC and screening programs targeting high-risk women, certain populations in the United States experience disproportionately high rates of ICC (e.g., racial/ethnic minorities and rural women). Limited access to and use of screening/follow-up services underlie this disparity. The licensure of the human papillomavirus (HPV) vaccine in 2006 introduced an additional method of ICC prevention. Unfortunately, dissemination of the vaccine to age-eligible females has been lower than expected (32% have received all 3 recommended doses). Decreasing the burden of HPV infection and HPV-related diseases in the United States will require greater dissemination of the HPV vaccine to adolescents and young adults, along with successful implementation of revised ICC screening guidelines that incorporate HPV and cytology cotesting. While a future without ICC is possible, we will need a comprehensive national health care program and innovative approaches to reduce ICC burden and disparities.

Adherence to conservative management recommendations for abnormal pap test results in adolescents

OBJECTIVE

To investigate whether the 2006 American Society for Colposcopy and Cervical Pathology guidelines for conservative management of minimally abnormal Pap test results (atypical squamous cells of undetermined significance, human papillomavirus-positive, and low-grade squamous intraepithelial lesions) and moderate dysplasia (cervical intraepithelial neoplasia 2) in adolescents 1) resulted in fewer colposcopies and loop electrosurgical excision procedures (LEEPs) in adolescents or 2) resulted in unintended treatment changes in older age groups.

METHODS

We analyzed data from 1,806 women aged 18 years and older attending one of six community health centers who were diagnosed with abnormal Pap test results between January 1, 2004, and December 31, 2008. We used multivariable logistic regression to examine treatment differences in women with minimally abnormal Pap test results before and after guideline changes. Variables included date of abnormality, site of care, race or ethnicity, language, and insurance type. We used Fisher exact tests to examine rates of LEEP in patients with moderate dysplasia before and after guideline publication.

RESULTS

Among 206 women aged 18-20 years, rates of colposcopy after a minimally abnormal Pap test result decreased from 78% (n=102) to 45% (n=34) after guideline changes (P<.001). Colposcopy among women over age 21 (n=1,542) remained unchanged (greater than 90%). Multivariable logistic regression indicated that both date of abnormality and site of care were associated with colposcopy referral. After guideline changes, management of moderate dysplasia with LEEP in women aged 18-23 decreased from 55% to 18% (P=.04); rates remained stable in women ages 24 and older (70% compared with 74%; P=.72).

CONCLUSION

Health care providers quickly adopted new conservative management guidelines for low-income, minority adolescents, which may reduce preterm deliveries in these high-risk populations.

LEVEL OF EVIDENCE

II.

What affects human papillomavirus vaccination rates? A qualitative analysis of providers' perceptions

PURPOSE

To define factors that providers perceive as affecting their administration of human papillomavirus (HPV) vaccination in their clinical practices.

METHODS

We conducted in-depth, qualitative interviews with 34 pediatric and family medicine providers in four community health centers to explore providers' perceptions of factors that either enabled or impeded their ability to vaccinate their patients against HPV.

RESULTS

Providers' self-reported vaccination rates ranged from 25 to 95% (median, 75%) of the 11- to 26-year-old females in their practices. Factors that enabled vaccination included providers' beliefs that HPV vaccines were safe and would provide important health benefits, structured visits that promoted vaccination, and coadministration of HPV with other recommended vaccines. Factors that impeded vaccination included safety concerns, a low perceived severity of HPV disease, lack of school mandates, and policies against coadministration of HPV and meningococcal vaccines. Providers who described more enabling factors than impeding factors reported vaccinating more of their patients.

CONCLUSIONS

Provider perceptions around the ease or difficulty of providing HPV vaccination may influence their behavior when offering HPV vaccines to their patients.

Depression and anxiety diagnoses are not associated with delayed resolution of abnormal mammograms and pap tests among vulnerable women

BACKGROUND

Delays in care after abnormal cancer screening contribute to disparities in cancer outcomes. Women with psychiatric disorders are less likely to receive cancer screening and may also have delays in diagnostic resolution after an abnormal screening test.

OBJECTIVE

To determine if depression and anxiety are associated with delays in resolution after abnormal mammograms and Pap tests in a vulnerable population of urban women.

DESIGN

We conducted retrospective chart reviews of electronic medical records to identify women who had a diagnosis of depression or anxiety in the year prior to the abnormal mammogram or Pap test. We used time-to-event analysis to analyze the outcome of time to resolution after abnormal cancer screening, and Cox proportional hazards regression modeling to control for confounding.

PARTICIPANTS

Women receiving care in six Boston-area community health centers 2004-2005: 523 with abnormal mammograms, 474 with abnormal Pap tests.

RESULTS

Of the women with abnormal mammogram and pap tests, 19% and 16%, respectively, had co-morbid depression. There was no difference in time to diagnostic resolution between depressed and not-depressed women for those with abnormal mammograms (aHR = 0.9, 95 CI 0.7,1.1) or Pap tests (aHR = 0.9, 95 CI 0.7,1.3).

CONCLUSIONS

An active diagnosis of depression and/or anxiety in the year prior to an abnormal mammogram or Pap test was not associated with a prolonged time to diagnostic resolution. Our findings imply that documented mood disorders do not identify an additional barrier to resolution after abnormal cancer screening in a vulnerable population of women.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Referrals among cancer services organizations serving underserved cancer patients in an urban area

Significant racial, socioeconomic, and geographic disparities exist nationwide in cancer screenings, treatments, and outcomes. Differences in health and social service provision and utilization may contribute to or exacerbate these disparities. We evaluated the composition and structure of a referral network of organizations providing services to underserved cancer patients in an urban area in 2007. We observed a need for increased awareness building among provider organizations, broader geographic coverage among organizations, and increased utilization of tobacco cessation and financial assistance services.

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

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