Improving cervical cancer screening in hospital settings

Influence of primary care on breast cancer outcomes among Medicare beneficiaries

PURPOSE

We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to explore the association between primary care and breast cancer outcomes.

METHODS

Using a retrospective cohort study of 105,105 female Medicare beneficiaries with a diagnosis of breast cancer in SEER registries during the years 1994-2005, we examined the total number of office visits to primary care physicians and non-primary care physicians in a 24-month period before cancer diagnosis. For women with invasive cancers, we examined the odds of diagnosis of late-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages III and IV vs stages I and II), and survival (breast cancer specific and all cause) using logistic regression and proportional hazards models, respectively. We also explored whether including noninvasive cancers, such as ductal carcinoma in situ (DCIS), would alter results and whether prior mammography was a potential mediator of associations.

RESULTS

Primary care physician visits were associated with improved breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower breast cancer and overall mortality. Prior mammography (and resultant earlier stage diagnosis) mediated these associations in part, but not completely. Similar results were seen for non-primary care physician visits. Results were similar when women with DCIS were included in the analysis.

CONCLUSIONS

Medicare beneficiaries with breast cancer had better outcomes if they made greater use of a primary care physician's ambulatory services. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.

The 'hows', 'whos', and 'whens' of screening: gynaecologists' perspectives on cervical cancer screening in urban Sweden

Population-based screening has contributed to decreased mortality in cervical cancer. However, the 'hows', 'whos' and 'whens' of screening still concern health professionals and policy makers. As part of a research project aimed at examining a population-based cervical cancer screening program (PCCSP) from different stakeholders' perspectives, the aim of this qualitative interview study was to elucidate the views of gynaecologists, working in both public and private settings, as stakeholders in the PCCSP in the county of Stockholm, Sweden. Results from semi structured interviews with 17 physicians indicate ambiguity in their descriptions of the purpose of both the PCCSP and smear testing in general, leading to different views about appropriate time intervals for Pap-smear testing. The gynaecologists also described experiencing a number of dilemmas related to information content and provision-both prior to screening and in relation to test results. In addition, the gynaecologists tended to differentiate morally through choice of language between women who participate in some form of screening and non-attendees of the PCCSP. There also appeared to be distinctions in how these gynaecologists conceptualised and discussed women receiving Pap-smears, dependent on whether they were regarded as within the category of 'my patients' (seen by the gynaecologist in a private or public setting) or 'the population' (women unknown to the gynaecologist). This study indicates the importance of comprehensively analysing the context of professionals' work when attempting to understand professional attitudes. Seeming disparities in attitudes as well as varying practices may be explained by the simultaneous existence of multiple value systems, applied to different patient populations, as found in this study.

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

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

Effectiveness of screening for cervical cancer in an inpatient hospital setting

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

II-2