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Nonzee NJ, Thiel de Bocanegra H, Navarro S, Bastani R, Glenn BA, Kominski GF, Moscicki AB. Impact of management guidelines for abnormal cervical cytology on colposcopy procedure rates among young women. Gynecol Oncol 2024; 190:160-166. [PMID: 39197415 DOI: 10.1016/j.ygyno.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 08/05/2024] [Accepted: 08/06/2024] [Indexed: 09/01/2024]
Abstract
OBJECTIVE In 2012, updated ASCCP management guidelines for abnormal cervical cytology recommended observation rather than immediate referral to colposcopy for low-grade abnormalities in women ages 21-24. We evaluated the impact of these guidelines on changes in colposcopy procedure rates among young women. METHODS We analyzed administrative and claims data from the largest statewide family planning program between July 2011 and June 2015. Using a difference-in-differences approach, we estimated changes in colposcopy procedure rates among women ages 21-24 years before and after the 2012 ASCCP management guidelines, relative to a comparison group of women ages 25-44. RESULTS Our analysis included 333,977 women from 216 primary care provider sites. After publication of the 2012 ASCCP management guidelines, colposcopy rates significantly declined from 6.70% (95% CI 6.21-7.19) to 3.94% (95% CI 3.60-4.29) among women ages 21-24 and from 4.35% (95% CI 4.03-4.67) to 3.53% (3.25-3.80) among women over 24 years. These declines correspond to a 1.93 percentage point reduction (95% CI 1.62-2.25; p < 0.001) in colposcopy rate among women 21-24 vs. over 24 years, or a two-fold relative reduction. Among women ages 21-24, colposcopy receipt was associated with speaking primarily English vs. non-English (OR 1.46, 95% CI 1.35-1.57), having a cervical cytology test within the past year vs. not (OR 1.55, 95% CI 1.44-1.66), and receiving care from a public vs. private provider (OR 1.31, 95% CI 1.06-1.62). CONCLUSIONS Colposcopy procedure rates among young women significantly declined following publication of the 2012 management guidelines, which has implications for reducing potential harms of overtreatment.
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Affiliation(s)
- Narissa J Nonzee
- Division of Health Equities, Department of Population Sciences, City of Hope, Duarte, California, USA.
| | | | - Sandy Navarro
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Roshan Bastani
- UCLA Center for Cancer Prevention and Control Research, UCLA Kaiser Permanente Center for Health Equity, Department of Health Policy and Management, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, University of California Los Angeles, California, USA.
| | - Beth A Glenn
- UCLA Center for Cancer Prevention and Control Research, UCLA Kaiser Permanente Center for Health Equity, Department of Health Policy and Management, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, University of California Los Angeles, California, USA.
| | - Gerald F Kominski
- UCLA Center for Health Policy Research and Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA.
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, California, USA.
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Dang TH, Rieu-Werden ML, Kobrin SC, Tiro JA, Werner C, Lykken JM, Chubak J, Atlas SJ, Higashi RT, Lee SC, Haas JS, Skinner CS, Silver MI, Feldman S. Association Between Clinician Confidence and Making Guideline-Recommended Decisions in the Management of Abnormal Cervical Cancer Screening Results. J Gen Intern Med 2024:10.1007/s11606-024-08943-z. [PMID: 39060782 DOI: 10.1007/s11606-024-08943-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Guidelines for managing abnormal cervical cancer screening results are complex and adherence is challenging for clinicians. Previous studies have identified gaps in knowledge as a possible cause; few have explored the confidence clinicians have in their management decisions. Confidence in decision-making may influence management practices, particularly when guidelines are complex and evolving. OBJECTIVE Assess whether confidence in decision-making is associated with making guideline-concordant recommendations for abnormal cervical cancer screening results. DESIGN A clinician survey used vignettes to ask clinicians to make a management recommendation for different abnormal results and rate their level of confidence in their response. PARTICIPANTS Physicians and advanced practice providers (APPs) at three diverse health systems in Washington, Texas, and Massachusetts. MAIN MEASURES Correct response to each vignette based on either the 2012 or 2019 American Colposcopy and Cervical Pathology (ASCCP) management guidelines. KEY RESULTS In total, 501 clinicians completed the survey between October and December 2020 (response rate 53.7%). Overall, most clinicians made guideline-recommended management decisions for two vignettes (73.2 and 73.7%), but fewer were confident in their selection (48.3% and 46.6%, respectively). Clinicians who reported high levels of confidence were more often correct than those who reported lower levels of confidence (85.8% vs. 62.2% and 87.5% vs. 60.7%, both p<0.001). After adjusting for clinician and practice characteristics, confidence remained significantly associated with selecting the correct answer. CONCLUSIONS Clinician confidence in management decisions for abnormal cervical cancer screening results was significantly associated with knowing guideline-concordant recommendations. Given the complexity of cervical cancer management guidelines, solutions to improve clinician confidence in decision-making are needed.
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Affiliation(s)
- Tin H Dang
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Meghan L Rieu-Werden
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah C Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Jasmin A Tiro
- Department of Public Health Sciences, University of Chicago Biological Sciences Division, Chicago, IL, USA
| | - Claudia Werner
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Jacquelyn M Lykken
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robin T Higashi
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Simon C Lee
- Department of Population Health, Medical Center, University of Kansas, Kansas City, KS, USA
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Celette Sugg Skinner
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Harold C Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michelle I Silver
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sarah Feldman
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Fontenot HB, Fuzzell L, Brownstein NC, Lake P, Michel A, Vadaparampil ST, Perkins RB. Health Care Provider Willingness to Recommend Self-collected Tests for Human Papillomavirus: A Mixed Methods Examination of Associated Factors. Womens Health Issues 2024:S1049-3867(24)00046-X. [PMID: 38960815 DOI: 10.1016/j.whi.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 05/03/2024] [Accepted: 05/24/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Cervical cancer disproportionately affects those who are underscreened. Human papillomavirus self-collection is a promising tool to expand screening. OBJECTIVE Study objectives were to examine 1) factors (provider characteristics and practice type) associated with and 2) attitudes (perceived benefits and concerns) toward using human papillomavirus self-collection for cervical cancer screening in clinical practice. METHODS This study had a mixed method design; prior to regulatory approval of self-collection, we conducted a national survey and interviews of health care providers who perform cervical cancer screening. Quantitative measures included provider and practice characteristics, willingness to recommend, and preferences related to self-collection. Qualitative interviews further elucidated provider perspectives. RESULTS A total of 1,251 providers completed surveys, and 56 completed interviews. Among survey respondents, 33.4% reported they were likely to offer self-collection, 28.6% were unsure, and 38.0% reported they were unlikely. Most would offer self-collection either in the clinic or at home per patient preference. Male participants, advanced practice providers, internal and family physicians, and those practicing in academic medical center, hospital, or community health settings were more likely than female participants, obstetrician-gynecologist physicians, and those in private practice to indicate they were likely to offer self-collection. Concerns expressed in both surveys and interviews included the adequacy of sample collection and the ability to follow-up. Respondents felt that self-collection would be particularly beneficial for those who did not have access to clinician-collected screening, as well as for patients who may have difficulty with pelvic examinations for any reason. CONCLUSION Providers considered human papillomavirus self-collection to be a way to expand access for patients with health care barriers and pelvic examination difficulties. They had concerns related to sample adequacy and follow-up after abnormal results.
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Affiliation(s)
- Holly B Fontenot
- University of Hawaii at Manoa, School of Nursing, Honolulu, Hawaii.
| | - Lindsay Fuzzell
- H. Lee Moffitt Cancer Center & Research Institute, Department of health Outcomes and Behavior, Tampa, Florida
| | - Naomi C Brownstein
- Medical University of South Carolina, Public Health Sciences, Charleston, South Carolina
| | - Paige Lake
- H. Lee Moffitt Cancer Center & Research Institute, Department of health Outcomes and Behavior, Tampa, Florida
| | - Alexandra Michel
- Rosalind Franklin University College of Nursing, North Chicago, Illinois
| | - Susan T Vadaparampil
- H. Lee Moffitt Cancer Center & Research Institute, Department of health Outcomes and Behavior, Tampa, Florida
| | - Rebecca B Perkins
- Boston University, Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
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4
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Cheng D, Rieu-Werden ML, Lykken JM, Werner CL, Feldman S, Silver MI, Atlas SJ, Tiro JA, Haas JS, Kamineni A. Assessing Management of Abnormal Cervical Cancer Screening Results and Concordance with Guideline Recommendations in Three US Healthcare Settings. Cancer Epidemiol Biomarkers Prev 2024; 33:912-922. [PMID: 38652505 DOI: 10.1158/1055-9965.epi-23-1564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/04/2024] [Accepted: 04/10/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Follow-up of abnormal results is essential to cervical cancer screening, but data on adherence to follow-up are limited. We describe patterns of follow-up after screening abnormalities and identify predictors of guideline-concordant follow-up. METHODS We identified the index screening abnormality (positive human papillomavirus test or atypical squamous cells of undetermined significance or more severe cytology) among women of ages 25 to 65 years at three US healthcare systems during 2010 to 2019. We estimated the cumulative incidence of surveillance testing, colposcopy, or treatment after the index abnormality and initial colposcopy. Logistic regressions were fit to identify predictors of guideline-concordant follow-up according to contemporaneous guidelines. RESULTS Among 43,007 patients with an index abnormality, the cumulative incidence of any follow-up was 49.6% by 4 years for those with atypical squamous cells of undetermined significance/human papillomavirus-negative and higher for abnormalities warranting immediate colposcopy. The 1-year cumulative incidence of any follow-up after colposcopy was 70% for patients with normal results or cervical intraepithelial neoplasia I and 90% for patients with cervical intraepithelial neoplasia II+. Rates of concordant follow-up after screening and colposcopy were 52% and 47%, respectively. Discordant follow-up was associated with factors including age, race/ethnicity, overweight/obese body mass index, and specific types of public payor coverage or being uninsured. CONCLUSIONS Adherence to the recommended follow-up of cytologic and histopathologic abnormalities is inconsistent in clinical practice. Concordance was poor for mild abnormalities and improved, although suboptimal, for more severe abnormalities. IMPACT There remain gaps in the cervical cancer screening process in clinical practice. Further study is needed to understand the barriers to the appropriate management of cervical abnormalities.
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Affiliation(s)
- David Cheng
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Meghan L Rieu-Werden
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacquelyn M Lykken
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Claudia L Werner
- Department of Obstetrics and Gynecology, University of Southwestern Medical Center, Dallas, Texas
- Parkland Health, Dallas, Texas
| | - Sarah Feldman
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michelle I Silver
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jasmin A Tiro
- Department of Public Health Sciences, University of Chicago-Biological Sciences Division, Chicago, Illinois
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Michel AD, Fontenot HB, Fuzzell L, Brownstein NC, Lake P, Vadaparampil ST, Perkins RB. Attitudes toward the American Cancer Society's 2020 cervical cancer screening guidelines: A qualitative study of a national sample of US clinicians. Cancer 2024; 130:2325-2338. [PMID: 38436396 DOI: 10.1002/cncr.35269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND The 2020 American Cancer Society (ACS) guidelines are the most recent national guidelines for cervical cancer screening. These guidelines propose two major changes from current practice: initiating screening at age 25 years and using primary human papillomavirus (HPV) testing. Adoption of guidelines often occurs slowly, and therefore understanding clinician attitudes is important to facilitate practice change. METHODS Interviews with a national sample of clinicians who perform cervical cancer screening in a variety of settings explored attitudes toward the two major changes from the 2020 ACS cervical cancer screening guidelines. Clinicians participated in 30- to 60-min interviews exploring their attitudes toward various aspects of cervical cancer screening. Qualitative analysis was performed. RESULTS Seventy clinicians participated from across the United States. Few respondents were initiating screening at age 25 years, and none were using primary HPV testing. However, over half would be willing to adopt these practices if supported by scientific evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional societies, lack of laboratory availability and insurance coverage, limited autonomy within large health care systems, and concerns related to missed disease. CONCLUSIONS Few clinicians have adopted screening initiation or primary HPV testing, as recommended by the 2020 ACS guidelines, but over half were open to adopting these changes. Implementation may be facilitated via professional organization endorsement, clinician education, and laboratory, health care system, and insurance support. PLAIN LANGUAGE SUMMARY In 2020, the American Cancer Society (ACS) released updated guidelines for cervical cancer screening. The main changes to current practices were to initiate screening at age 25 years instead of age 21 years and to screen using primary human papillomavirus (HPV) testing rather than cytology alone or in combination with HPV testing. We performed in-depth interviews with 70 obstetrics and gynecology, family medicine, and internal medicine physicians and advanced practice providers about their attitudes toward these guidelines. Few clinicians are following the 2020 ACS guidelines, but over half were open to changing practice if the changes were supported by evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional medical organizations, logistical issues, and concerns about missed disease.
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Affiliation(s)
- Alexandra D Michel
- College of Nursing, Rosalind Franklin University, North Chicago, Illinois, USA
| | - Holly B Fontenot
- School of Nursing, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Lindsay Fuzzell
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Naomi C Brownstein
- Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Paige Lake
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Susan T Vadaparampil
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Rebecca B Perkins
- Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts, USA
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Lu Y, Wu H, Fu K, Shen Y, Li L, Liao Z, Liu Y, Kang Y, Zhang Y. PAX1 methylation as a robust predictor: developing and validating a nomogram for assessing endocervical curettage (ECC) necessity in human papillomavirus16/18-positive women undergoing colposcopy. Clin Epigenetics 2024; 16:77. [PMID: 38849868 PMCID: PMC11157736 DOI: 10.1186/s13148-024-01691-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 06/03/2024] [Indexed: 06/09/2024] Open
Abstract
OBJECTIVE The major challenge in routine endocervical curettage (ECC) among Human Papillomavirus (HPV) 16/18-positive patients is that only a small fraction benefit. Nevertheless, current reported models often overestimate the validity and necessity of ECC, making it difficult to improve benefits for patients. This research hypothesized that assessing paired boxed gene 1 methylation levels (PAX1m) and clinical characteristics could enhance the predictive accuracy of detecting additional high-grade squamous intraepithelial lesions or worse (HSIL +) through ECC that were not identified by colposcopy-directed biopsy (CDB). METHODS Data from 134 women with HPV16/18 positivity undergoing CDB and ECC between April 2018 and April 2022 were collected and analyzed. Quantitative methylation-specific polymerase chain reaction (qMSP) was utilized to measure PAX1m, expressed as ΔCp. Univariate and multivariate regression analyses were conducted to screen variables and select predictive factors. A nomogram was constructed using multivariate logistic regression to predict additional HSIL + detected by ECC. The discrimination, calibration, and clinical utility of the nomogram were evaluated using receiver operating characteristic curves (ROC) and the calibration plot. RESULTS Age (odds ratio [OR], 5.654; 95% confidence interval [CI], 1.131-37.700), cytology (OR, 24.978; 95% CI, 3.085-540.236), and PAX1 methylation levels by grade (PAX1m grade) (OR, 7.801; 95% CI, 1.548-44.828) were independent predictive factors for additional detection of HSIL + by ECC. In HPV16/18-positive women, the likelihood of additional detection of HSIL + through ECC increased with the severity of cytological abnormalities, peaking at 43.8% for high-grade cytological lesions. Moreover, when cytological findings indicated low-grade lesions, PAX1 methylation levels were positively correlated with the additional detection of HSIL + by ECC (P value < 0.001). A nomogram prediction model was developed (area under curve (AUC) = 0.946; 95% CI, 0.901-0.991), demonstrating high sensitivity (90.9%) and specificity (90.5%) at the optimal cutoff point of 107. Calibration analysis confirmed the model's strong agreement between predicted and observed probabilities. CONCLUSION The clinical nomogram presented promising predictive performance for the additional detection of HSIL + through ECC among women with HPV16/18 infection. PAX1 methylation level could serve as a valuable tool in guiding individualized clinical decisions regarding ECC for patients with HPV 16/18 infection, particularly in cases of low-grade cytological findings.
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Affiliation(s)
- Yingnan Lu
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Haiyue Wu
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Kun Fu
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - YuFei Shen
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Lucia Li
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Zexi Liao
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yingzhen Liu
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yanan Kang
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
| | - Yu Zhang
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
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7
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Kucera CW, Chappell NP, Tian C, Richardson MT, Tarney CM, Hamilton CA, Chan JK, Kapp DS, Leath CA, Casablanca Y, Rojas C, Sitler CA, Wenzel L, Klopp A, Jones NL, Rocconi RP, Farley JH, O'Connor TD, Shriver CD, Bateman NW, Conrads TP, Phippen NT, Maxwell GL, Darcy KM. Survival disparities in non-Hispanic Black and White cervical cancer patients vary by histology and are largely explained by modifiable factors. Gynecol Oncol 2024; 184:224-235. [PMID: 38340648 PMCID: PMC11361276 DOI: 10.1016/j.ygyno.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/30/2024] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Abstract
PURPOSE We investigated racial disparities in survival by histology in cervical cancer and examined the factors contributing to these disparities. METHODS Non-Hispanic Black and non-Hispanic White (hereafter known as Black and White) patients with stage I-IV cervical carcinoma diagnosed between 2004 and 2017 in the National Cancer Database were studied. Survival differences were compared using Cox modeling to estimate hazard ratio (HR) or adjusted HR (AHR) and 95% confidence interval (CI). The contribution of demographic, socioeconomic and clinical factors to the Black vs White differences in survival was estimated after applying propensity score weighting in patients with squamous cell carcinoma (SCC) or adenocarcinoma (AC). RESULTS This study included 10,111 Black and 43,252 White patients with cervical cancer. Black patients had worse survival than White cervical cancer patients (HR = 1.40, 95% CI = 1.35-1.45). Survival disparities between Black and White patients varied significantly by histology (HR = 1.20, 95% CI = 1.15-1.24 for SCC; HR = 2.32, 95% CI = 2.12-2.54 for AC, interaction p < 0.0001). After balancing the selected demographic, socioeconomic and clinical factors, survival in Black vs. White patients was no longer different in those with SCC (AHR = 1.01, 95% CI 0.97-1.06) or AC (AHR = 1.09, 95% CI = 0.96-1.24). In SCC, the largest contributors to survival disparities were neighborhood income and insurance. In AC, age was the most significant contributor followed by neighborhood income, insurance, and stage. Diagnosis of AC (but not SCC) at ≥65 years old was more common in Black vs. White patients (26% vs. 13%, respectively). CONCLUSIONS Histology matters in survival disparities and diagnosis at ≥65 years old between Black and White cervical cancer patients. These disparities were largely explained by modifiable factors.
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Affiliation(s)
- Calen W Kucera
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Nicole P Chappell
- George Washington Medical Faculty Associates, George Washington Cancer Center, Washington, DC, USA
| | - Chunqiao Tian
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Michael T Richardson
- Department of Obstetrics and Gynecology, University of California, Los Angeles School of Medicine, Los Angeles, CA. USA
| | - Christopher M Tarney
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Chad A Hamilton
- Gynecologic Oncology Section, Women's Services and The Ochsner Cancer Institute, Ochsner Health, New Orleans, LA, USA
| | - John K Chan
- Palo Alto Medical Foundation / California Pacific Medical Center /Sutter Health, San Francisco, CA, USA
| | - Daniel S Kapp
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Charles A Leath
- Division of Gynecologic Oncology, University of Alabama at Birmingham, O'Neal Comprehensive Cancer Center, Birmingham, AL, USA
| | - Yovanni Casablanca
- Division of Gynecologic Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Christine Rojas
- Division of Gynecologic Oncology, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - Collin A Sitler
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Lari Wenzel
- School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Ann Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nathaniel L Jones
- Division of Gynecologic Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA
| | - Rodney P Rocconi
- Division of Gynecologic Oncology, Cancer Center & Research Institute, the University of Mississippi Medical Center, Jackson, MS, USA
| | - John H Farley
- Division of Gynecologic Oncology, Center for Women's Health, Cancer Institute, Dignity Health St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Timothy D O'Connor
- Institute for Genome Sciences, Department of Medicine and Program in Personalized and Genomic Medicine, and Program in Health Equity and Population Health, University of Maryland School of Medicine, Baltimore, MD, USA; University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Nicholas W Bateman
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Thomas P Conrads
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Women's Health Integrated Research Center, Inova Women's Service Line, Inova Health System, Falls Church, VA, USA
| | - Neil T Phippen
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - G Larry Maxwell
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Women's Health Integrated Research Center, Inova Women's Service Line, Inova Health System, Falls Church, VA, USA
| | - Kathleen M Darcy
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.
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Perkins RB, Fuzzell L, Lake P, Brownstein NC, Fontenot HB, Michel A, Whitmer A, Vadaparampil ST. Factors Associated With Guideline-concordant and Excessive Cervical Cancer Screening: A Mixed Methods Study. Womens Health Issues 2024; 34:257-267. [PMID: 38383228 DOI: 10.1016/j.whi.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/21/2023] [Accepted: 01/09/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION National guidelines recommend cervical cancer screening with Papanicolaou (Pap) testing at 3-year intervals or with human papillomavirus (HPV) testing alone or HPV/Pap cotesting at 5-year intervals for average-risk individuals aged 30-65 years. METHODS We explored factors associated with clinician-reported guideline-concordant screening, as well as facilitators and barriers to appropriate cervical cancer screening. RESULTS A national sample of clinicians (N = 1,251) completed surveys; a subset (n = 55) completed interviews. Most (94%) reported that they screened average-risk patients aged 30-65 years with cotesting. Nearly all clinicians who were categorized as nonadherent to national guidelines were overscreening (98%). Guideline concordant screening was reported by 47% and 82% of those using cotesting and HPV testing, respectively (5-year intervals), and by 62% of those using Pap testing only (3-year intervals). Concordant screening was reported more often by clinicians who were aged <40 years, non-Hispanic, and practicing in the West or Midwest, and less often by obstetrician-gynecologists and private practice physicians. Concordant screening was facilitated by beliefs that updated guidelines were evidence-based and reduced harms, health care system dissemination of guidelines, and electronic medical record prompts. Barriers to concordant screening included using outdated guidelines, relying on personal judgment, concern about missing cancers, inappropriate patient risk assessment, and lack of support for guideline adoption through health care systems or electronic medical records. CONCLUSIONS Most clinicians screened with Pap/HPV cotesting and approximately one-half endorsed a 5-year screening interval. Clinician knowledge gaps include understanding the evidence underlying 5-year intervals and appropriate risk assessment to determine which patients should be screened more frequently. Education and tracking systems can promote guideline-concordant screening.
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Affiliation(s)
- Rebecca B Perkins
- Boston University, Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts.
| | - Lindsay Fuzzell
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and Behavior, Office of Community Outreach, Engagement, and Equity, Tampa, Florida
| | - Paige Lake
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and Behavior, Office of Community Outreach, Engagement, and Equity, Tampa, Florida
| | - Naomi C Brownstein
- Medical University of South Carolina, Public Health Sciences, Charleston, South Carolina
| | | | | | - Ashley Whitmer
- Boston University, Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Susan T Vadaparampil
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and Behavior, Office of Community Outreach, Engagement, and Equity, Tampa, Florida
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Fuzzell L, Brownstein NC, Fontenot HB, Lake PW, Michel A, Whitmer A, Rossi SL, McIntyre M, Vadaparampil ST, Perkins RB. Examining the association of clinician characteristics with perceived changes in cervical cancer screening and colposcopy practice during the COVID-19 pandemic: a mixed methods assessment. eLife 2023; 12:e85682. [PMID: 37656169 PMCID: PMC10473834 DOI: 10.7554/elife.85682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
Background The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed method study we explored perceived pandemic-related practice changes to cervical cancer screenings and colposcopies. Methods In 2021, a national sample of 1251 clinicians completed surveys, including 675 clinicians who performed colposcopy; a subset (n=55) of clinicians completed qualitative interviews. Results Nearly half of all clinicians reported they were currently performing fewer cervical cancer screenings (47%) and colposcopies (44% of those who perform the procedure) than before the pandemic. About one-fifth (18.6%) of colposcopists reported performing fewer LEEPs than prior to the pandemic. Binomial regression analyses indicated that older, as well as internal medicine and family medicine clinicians (compared to OB-GYNs), and those practicing in community health centers (compared to private practice) had higher odds of reporting reduced screening. Among colposcopists, internal medicine physicians and those practicing in community health centers had higher odds of reporting reduced colposcopies. Qualitative interviews highlighted pandemic-related care disruptions and lack of tracking systems to identify overdue screenings. Conclusions Reductions in cervical cancer screening and colposcopy among nearly half of clinicians more than 1 year into the pandemic raise concerns that inadequate screening and follow-up will lead to future increases in preventable cancers. Funding This study was funded by the American Cancer Society, who had no role in the study's design, conduct, or reporting.
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Affiliation(s)
- Lindsay Fuzzell
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
| | | | - Holly B Fontenot
- University of Hawaii at Manoa, Nancy Atmospera-Walch School of NursingHonoluluUnited States
| | - Paige W Lake
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
| | - Alexandra Michel
- University of Hawaii at Manoa, Nancy Atmospera-Walch School of NursingHonoluluUnited States
| | - Ashley Whitmer
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
| | - Sarah L Rossi
- Boston University, Chobanian & Avedisian School of MedicineBostonUnited States
| | - McKenzie McIntyre
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
| | - Susan T Vadaparampil
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
- H. Lee Moffitt Cancer Center & Research Institute, Office of Community Outreach, Engagement, and EquityTampaUnited States
| | - Rebecca B Perkins
- Boston University, Chobanian & Avedisian School of MedicineBostonUnited States
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