Women's understanding of the term 'Pap smear'

Cervical cancer risk and screening among women seeking assistance with basic needs

BACKGROUND

In the United States, more than half of cervical cancers occur in women who are inadequately screened. Interventions to improve access to cervical cancer preventive care is critical to reduce health inequities.

OBJECTIVE

This study aimed to evaluate the need for cervical cancer screening among women seeking assistance with basic needs and to assess best approaches to facilitate Papanicolaou test referral.

STUDY DESIGN

This study is a secondary analysis of a randomized controlled trial of low-income female callers to 2-1-1 Missouri, a helpline for local health and social services. The need for cervical cancer screening was assessed. Callers were randomized to 1 of 3 arms, each providing a Papanicolaou test referral: verbal referral only, verbal referral and tailored print reminder, or verbal referral and navigator. The primary outcome was contacting a Papanicolaou test referral 1 month following intervention. Student t tests or Mann-Whitney U tests were used to analyze significant differences in continuous variables, whereas Fisher exact or χ² tests were used for categorical variables. We stratified by number of unmet basic needs (0-1 vs ≥2) and compared success of contacting a Papanicolaou test referral among study groups (verbal referral vs tailored reminder vs navigator) using the Fisher exact test and χ² test, respectively. Multivariate logistic regression was used to assess risk factors for nonadherence for Papanicolaou test at baseline and at 1 month follow-up, adjusting for race and ethnicity, age, insurance status, self-rated health, smoking, and study group.

RESULTS

Among 932 female callers, 250 (26.8%) needed cervical cancer screening. The frequency of unmet basic needs was high, the most common being lack of money for unexpected expenses (91.2%) and necessities, such as food, shelter, and clothing (73.2%). Among those needing a Papanicolaou test, 211 women received screening referrals. Women in the navigator group (21 of 71, 29.6%) reported higher rates of contacting a Papanicolaou test referral than those exposed to verbal referral only (11/73, 15.1%) or verbal referral and tailored print reminder (9/67, 13.4%) (P=.03). Among 176 women with ≥2 unmet needs who received a Papanicolaou test referral, the provision of a navigator remained associated with contacting the referral (navigator [33.9%] vs verbal referral [17.2%] vs tailored reminder [10.2%]; P=.005). Assignment to the navigator group (adjusted odds ratio, 3.4; 95% confidence interval, 1.4-8.5) and nonwhite race (adjusted odds ratio, 2.0; 95% confidence interval, 1.5-2.8) were independent predictors of contacting a Papanicolaou test referral.

CONCLUSION

Low-income women seeking assistance with basic needs often lack cervical cancer screening. Health navigators triple the likelihood that women will make contact with Papanicolaou test services, but most 2-1-1 callers still fail to schedule Papanicolaou testing despite assistance from navigators. Interventions beyond health navigators are needed to reduce cervical cancer disparities.

Cervical Cancer Incidence Among Elderly Women in Massachusetts Compared With Younger Women

IMPORTANCE

Current cancer screening guidelines recommend cessation of cervical cancer screening at the age of 65 years for most women. To examine residual risk among elderly women, we compared cervical cancer incidence rates (IRs) in Massachusetts from 2004 to 2015 among women younger than 65 years versus 65 years and older.

MATERIALS AND METHODS

The Massachusetts Cancer Registry was used to identify all women diagnosed with cervical cancer between January 01, 2004, to December 31, 2015. Cancer incidence was calculated based on age of diagnosis (<65 years vs ≥65 years).

RESULTS

In Massachusetts, 2,418 incident cases of cervical cancer were diagnosed from 2004 to 2014, of which 571 (23.6%) were diagnosed among women 65 years and older. When compared with women diagnosed younger than 65 years, women diagnosed at the age of 65 years and older were more likely to be diagnosed with stage II or higher (71.8% vs 43.8%, p < .001). Cervical cancer IRs decreased annually for women younger than 65 years from 2004 to 2015. Among women 65 years and older, cancer IRs decreased by 3.9% annually from 2004 to 2013 (p = .0009), but 2013 to 2015 showed an increasing trend (annual percent change + 14.1%, p = .12).

CONCLUSIONS AND RELEVANCE

Women 65 years and older account for one quarter of cervical cancer diagnoses in Massachusetts and present with higher-stage disease than younger women. Upcoming planned revisions in screening and prevention guidelines should address the continued risk of cervical cancer for older women.

Challenges to Pap Smear Follow-up among Women in the Criminal Justice System

Women involved in the United States criminal justice system face a variety of challenges in maintaining their health. Histories of sexual abuse, early initiation of sex, and substance abuse are reflected in more negative reproductive health outcomes, including cervical cancer, than those found among non-incarcerated women. Little is known about how to close this health gap. The present study assessed what incarcerated women perceived to be facilitators and inhibitors of obtaining recommended follow-up for abnormal Pap tests. In-depth individual interviews were conducted with 44 women in an urban county jail about experiences with Pap tests and how they followed-up on abnormal results. We analyzed data using the process of thematic content analysis. Four themes were found, Pap test abnormality as an all-inclusive phrase for women's health problems, unstable lives, the structural challenges of money, and competing demands. Women with criminal justice histories have numerous and complex challenges in following-up abnormal Pap test results, as well as other health problems. Understanding the context around the follow-up for abnormal Pap tests in this population may increase providers' ability to help women effectively obtain cancer prevention care that can be life-saving, as well as to more effectively provide care for other health problems.

Roles of Health Care Providers and Patients in Initiation of Unnecessary Papanicolaou Testing After Total Hysterectomy

OBJECTIVES

To assess Papanicolaou (Pap) testing use among US adult women with a history of a total hysterectomy for a benign condition and the roles of health care providers and patients in the initiation of screening Pap tests.

METHODS

We used 2000 to 2013 data from the National Health Interview Survey on women aged 20 years or older who had undergone a hysterectomy (n = 11 616) to estimate unnecessary Pap test use.

RESULTS

The percentage of self-reported Pap testing in the preceding 3 years among women who had undergone a hysterectomy decreased from 72.2% in 2000 to 53.3% in 2013. In 2013, 42.4% of women who had undergone a hysterectomy reported receiving recommendations for screening from a health care provider in the past year (32% of which were unnecessary), and 32.1% reported undergoing Pap tests in the preceding year (22.1% of which were unnecessary). Although the majority of Pap tests were performed at a clinician's recommendation, approximately one fourth were initiated by patients without clinician recommendations.

CONCLUSIONS

Health care providers should advise women who have had a total hysterectomy for a benign condition on appropriate use of screening services.

Women's Understanding of the Term 'Pap smear': A Comparison of Spanish-Speaking Versus English-Speaking Women

Objective To compare the understanding of the term 'Pap smear' among Spanish-speaking women, as compared to their English-speaking counterparts. Methods Surveys were distributed to English and Spanish speaking female patients in an urban Obstetrics and Gynecology clinic. Patients were at least 18 years old or they were less than 18 years old and pregnant. Results A majority of participants (77.3 % English-speaking vs. 74.1 % Spanish-speaking, respectively) were able to identify at least one correct descriptor for the term Pap smear. However, Spanish-speaking women were significantly less likely to choose incorrect descriptors. Spanish-speaking women were much less likely to say that a Pap smear was the same as a Pelvic exam (45.7 vs. 78.8 %; p = 0.001), or a test for a sexually transmitted disease (25 vs. 60.6 %; p = 0.001). Conclusions for Practice Compared to English-speaking women, Spanish-speaking women are much less likely to conflate a pelvic exam with a Pap smear. Overall understanding was suboptimal, regardless of primary language, indicating that major efforts are still needed to improve functional health literacy with respect to cervical cancer screening.

Cervical cancer screening among women ≥70 years of age in the United States-A referral problem or patient choice

OBJECTIVE

Clinical guidelines recommend that women with a history of adequate screening and not otherwise at high risk may discontinue cervical cancer screening after 65 years of age. However, screening remains common among US women over 65 years old. This study was conducted to examine whether overutilization was attributable to provider's recommendation or patient choice.

METHOD

This cross-sectional study used data from 1752 female participants (70+ years) from the 2013 National Health Interview Survey (NHIS). We quantitatively assessed the proportions of provider-recommended and patient self-initiated Pap smears.

RESULTS

Among female respondents, 40.8% had a Pap smear within the past 3 years, 19.4% had a Pap smear in the last year, and 39.7% reported receiving a recommendation for a Pap smear from their provider in the past year. Among women who received a recommendation to obtain a Pap smear, 39.8% did so within the past 12 months compared to 5.9% of women who did not receive a recommendation (adjusted odds ratio 10.5, 95% confidence interval 7.39-15.0). About 70% of women who visited an obstetrician/gynecologist and reported receiving a recommendation to have a Pap smear did so in the past year, while 32.3% of women who visited an obstetrician/gynecologist but did not receive a recommendation obtained one.

CONCLUSION

Pap smears were common among women ≥70 years of age. Health care providers may need additional education on current guidelines regarding indications for Pap smears in this age group to help reduce screening of patients who may not benefit.