Variations in practice guideline adherence for abnormal cervical cytology in a county healthcare system

How follow-up rates in cervical cancer screening depend on organizational factors: A comparison of two population-based organized screening programmes

OBJECTIVES

This study compares the follow-up rates of non-normal cervical screening samples between Denmark and Flanders (Belgium) to illuminate whether organizational differences between the health systems might affect the follow-up rates, e.g. sending of reminders in Denmark since 2012 compared to Flanders with no such system in place.

METHODS

The study population included 48,082 Danish women and 22,271 Flemish women who received abnormal or inadequate primary screening results from 2014 to 2016. The participants were followed for 24 months, and the timeliness and appropriateness of the recommended follow-up, according to national guidelines, were evaluated.

RESULTS

After 18 months over 90% of the Danish women had received some form of follow-up, while in Flanders, this level is achieved only for those who test positive for human papillomavirus. The analysis also revealed that 10-28% of follow-ups were performed too early, with Danish women showing the highest proportions. In both regions, general practitioners (GPs) exhibited better follow-up rates compared to gynaecologists, with gynaecologists displaying a tendency towards earlier re-testing than recommended.

CONCLUSIONS

An important factor influencing the follow-up rate may be the sending of reminders in Denmark since 2012, as the follow-up rates in general were higher in this period. It is noteworthy that a reminder system is currently being implemented in Flanders and further studies on the potential effects should be studied. Additionally, the organization of the health system might influence the follow-up rate, as engaging the GP for screening in Denmark may have had a positive effect.

Using electronic health records to evaluate the adherence to cervical cancer prevention guidelines: A cross-sectional study

OBJECTIVE

The fight against cervical cancer requires effective screening together with optimal and on-time treatment along the care continuum. We examined the impact of cervical cancer testing and treatment guidelines on testing practices, and follow-up adherence to guidelines.

METHODS

Data from Estonian electronic health records and healthcare provision claims for 50,702 women was used. The annual rates of PAP tests, HPV tests and colposcopies during two guideline periods (2nd version 2012-2014 vs 3rd version 2016-2019) were compared. To assess the adherence to guidelines, the subjects were classified as adherent, over- or undertested based on the timing of the appropriate follow-up test.

RESULTS

The number of PAP tests decreased and HPV tests increased during the 3rd guideline period (p < 0.01). During the 3rd guideline period, among 21-29-year-old women, the adherence to guidelines ranged from 38.7% (44.4…50.1) for ASC-US to 73.4% (62.6…84.3) for HSIL and among 30-59-year-old from 49.0% (45.9…52.2) for ASC-US to 65.7% (58.8…72.7) for ASCH. The highest rate of undertested women was for ASC-US (21-29y: 25.7%; 30-59y: 21.9%). The rates of over-tested women remained below 12% for all cervical pathologies observed. There were 55.2% (95% CI 49.7…60.8) of 21-24-year-olds and 57.1% (95% CI 53.6…60.6) of 25-29-year-old women who received HPV test not adherent to guidelines.

CONCLUSIONS

Our findings highlighted some shortcomings in guideline adherence, especially among women under 30. The insights gained from this study help to improve the quality of care and, thus, reduce cervical cancer incidence and mortality.

Adherence to follow-up after the exit cervical cancer screening test at age 60-64: A nationwide register-based study

BACKGROUND

In Denmark, human papillomavirus (HPV) testing has replaced cytology in primary cervical cancer screening for women aged 60-64; at this age, women are invited for the last (exit) screening test within the national organized program.

AIM

We investigated the adherence of these women to the recommended follow-up after a non-negative (positive or inadequate) HPV test and the overall resource use during that follow-up.

MATERIALS & METHODS

We included all 2926 women aged 60-64 years with nonnegative HPV screening tests between March 2012 and December 2016. All relevant follow-up tests and procedures were retrieved until the end of 2020 from the highly complete Danish administrative health registers, and the data were linked at the individual level. We determined the extent to which the adherence patterns followed the national recommendations for follow-up and estimated the total numbers of tests and diagnostic procedures utilized during the entire process.

RESULTS

In total, only 26% of women had follow-up in accordance with the recommendations; 4% had no follow-up, 46% had insufficient follow-up, and 24% had more follow-up than recommended. We estimated that 17% of women remained in follow-up for longer than 4 years. The average numbers of diagnostic tests and procedures used after positive HPV screening were higher than expected, even among women who had insufficient follow-up, that is, those who received less invasive procedures than recommended, or experienced delays in receiving those procedures.

CONCLUSION

To conclude, we found that the patterns of follow-up of women with nonnegative primary HPV screening tests at 60-64 often diverged from the recommendations. Addressing these inconsistencies in follow-up by providing evidence for optimal clinical management should help improve the quality of screening programs and secure an equal and reliable follow-up care service for all women.

Gaps between recommendations and their implementation: A register-based study of follow-up after abnormalities in cervical cancer screening

Follow-up after screen-detected abnormalities is crucial for the success of cervical cancer screening programs but is usually not closely monitored in official screening statistics. We determined how the follow-up deviated from the recommendations in the Danish organized program. Using Danish nationwide population-based registers, the follow-up pathways of 60,199 women aged 23-59 with non-negative screening samples from 2012 to 2014 were mapped until end of 2018. We studied the timeliness and appropriateness of follow-up tests after cervical cytology screening and the total resource use in accordance with the national recommendations. Regression analyses were used to determine variations in adherence according to age, provider type, region, and history of abnormalities. Among women referred for immediate colposcopy, 91.3% (95% CI: 90.9%-91.6%) attended within four months as recommended, whereas up to about half of the women with a recommendation for a repeat test received this test either too early or very late. Overall, only 43% (95% CI: 42.9%-43.7%) of women with non-negative screening tests received the recommended follow-up, whereas 18% (95% CI: 17.6%-18.2%) received more than was recommended, 35% (95% CI: 34.4%-35.1%) received some follow-up but less than recommended and 4% (95% CI: 3.9%-4.2%) were not followed up at all. These proportions varied by screening diagnosis, woman's age, type of health care provider, region, and history of abnormalities. On average, women underwent more tests of each type than recommended by the guidelines. Deviations from follow-up recommendations are very frequent even in organized cervical screening programs and should be routinely monitored by screening program statistics.

Granular Quality Reporting for Cervical Cytology Testing

Quality reporting for cervical cancer prevention is focused on patients with normal cervical cytology, and excludes patients with cytological abnormalities that may be at higher risk. The major obstacles for granular reporting are the complexity of surveillance guidelines and free-text data. We performed automated chart review to compare the cytology testing rates for patients with 'atypical squamous cells of undetermined significance' (ASCUS) cytology, with the rates for patients with normal cytology. We modeled the surveillance guidelines, and extracted information from free-text cytology reports, to perform this study on 28101 female patients. Our results show that patients with ASCUS cytology had significantly higher adherence rates (94.9%) than those for patients with normal cytology (90.4%). Overall our study indicates that the quality of care varies significantly between the high and average risk patients. Our study demonstrates the use of health information technology for higher granularity of reporting for cervical cytology testing.

Automated recommendation for cervical cancer screening and surveillance

Because of the complexity of cervical cancer prevention guidelines, clinicians often fail to follow best-practice recommendations. Moreover, existing clinical decision support (CDS) systems generally recommend a cervical cytology every three years for all female patients, which is inappropriate for patients with abnormal findings that require surveillance at shorter intervals. To address this problem, we developed a decision tree-based CDS system that integrates national guidelines to provide comprehensive guidance to clinicians. Validation was performed in several iterations by comparing recommendations generated by the system with those of clinicians for 333 patients. The CDS system extracted relevant patient information from the electronic health record and applied the guideline model with an overall accuracy of 87%. Providers without CDS assistance needed an average of 1 minute 39 seconds to decide on recommendations for management of abnormal findings. Overall, our work demonstrates the feasibility and potential utility of automated recommendation system for cervical cancer screening and surveillance.

Cervical Smears at Public Health Centres in Eastern Trinidad: Coverage and Follow-up, 2009-2010

BACKGROUND

The objective was to examine the cervical screening programme at selected health centres in the Eastern Regional Health Authority (ERHA), Trinidad and Tobago, specifically regarding Pap smear coverage, frequency distribution of abnormal smears and the adequacy of follow-up of abnormal smears, according to the Caribbean Frameworks for Developing National Screening and Clinical Guidelines for Cervical Cancer Prevention and Control.

METHODS

A retrospective analysis of secondary data from five health centres in the ERHA over the two-year period 2009-2010 was conducted. Data were entered into Microsoft Excel, cleaned and imported into SPSS (v 12) for analysis. Descriptive and Chi-squared analyses were carried out.

RESULTS

The cumulative cervical screening coverage for the years 2009 and 2010 was 2600 Pap smears for a population of 28 811 women (9% coverage). The proportion of cervical smears done per age group ranged from 1.6% to 8.6% in 2009 and from 1.9% to 12.9% in 2010. The proportion of Pap smears for the target population, 25-49 years, stood at 11% in 2009 and 13.2% in 2010. The distribution of abnormal Pap smears (n = 155) was: atypical squamous cell of undetermined significance (ASCUS), 68.4%; low-grade squamous intra-epithelial lesion (LSIL), 14.2%; atypical squamous cells - high-grade squamous intra-epithelial lesion cannot be excluded (ASC-H), 4.5%; atypical glandular cells of undetermined significance (AGUS), 1.3% and invasive squamous cervical carcinoma, 0.6%. Human papillomavirus was detected in 7.7% of the study population. More than half of the women with abnormal smears did not follow-up on recommendations for further care and there was a significant loss to follow-up especially among the women who were referred for repeat Pap smear. The significant predictor to whether follow-up care occurred or not was age (p < 0.05).

CONCLUSION

The cervical screening services in the ERHA in Trinidad did not provide adequate coverage to the target population or adequate follow-up care for women with abnormal smears in 2009 and 2010.

Diagnostic imaging and biopsy use among elderly medicare beneficiaries with hepatocellular carcinoma

PURPOSE

Diagnostic imaging is effective for evaluating patients suspected of having hepatocellular carcinoma (HCC). Although the diagnosis can be established with imaging alone, diagnostic biopsy may be useful for patients with tumors measuring 1 to 2 cm. To date, biopsy and imaging use among patients with HCC has not been evaluated in the general community.

PATIENTS AND METHODS

This cohort study used Surveillance, Epidemiology, and End Results (SEER) -Medicare data (2002-2005) evaluating biopsy, imaging modalities (ultrasound, computed tomography [CT] scan, and/or magnetic resonance imaging [MRI]), and HCC risk factors.

RESULTS

Of 3,696 patients, 1,197 (32.4%) underwent one or more biopsies, with no change in yearly biopsy rate (trend test, P = .64). Patients with tumors > 5 cm were most likely to receive biopsies (35.3%), with increasing rates of biopsy for larger tumors (P = .001). Patients who received biopsies underwent more imaging than those who did not (P < .001) and were more likely to have an HCC risk factor. Tumor size > 5 cm in the setting of a concurrent HCC risk factor increased the odds of biopsy. In 47.8% of patients, the diagnostic sequence was not consistent with contemporary evidence-based guidelines.

CONCLUSIONS

Despite widespread availability and use of CT scan and MRI, one third of HCC patients undergo biopsy, suggesting a problem with the performance and/or quality of diagnostic imaging or that providers do not believe imaging alone is sufficient to establish the diagnosis. Understanding factors that drive biopsy use may help improve the care of patients with HCC.

Intensity-modulated radiation therapy versus para-aortic field radiotherapy to treat para-aortic lymph node metastasis in cervical cancer: prospective study

AIM

To compare dosimetry, efficacy, and toxicity of intensity-modulated radiation therapy (IMRT) with para-aortic field radiotherapy in patients with para-aortic lymph node (PALN) metastasis of cervical cancer.

METHODS

This prospective study examined 60 patients with cervical cancer with PALN metastasis who underwent whole-pelvis radiotherapy followed by brachytherapy between November 1, 2004 and May 31, 2008. After 3 cycles of chemotherapy, patients were serially allocated into two groups and treated with IMRT or para-aortic field RT at doses of 58-68 Gy and 45-50 Gy, respectively. Treatment response was evaluated and toxicities were assessed. Patients in the IMRT group were treated with both para-aortic field RT and IMRT in order to compare the exposure dose of organs at risk.

RESULTS

In the IMRT group, the mean dose delivered to the planning target volume was 67.5 Gy. At least 99% of the gross tumor volume received effective coverage and radical dose (median, 63.5 Gy; range, 54.5-66) during treatment. IMRT plans yielded better dose conformity to the target and better sparing of the spinal cord and small intestine than para-aortic field RT. The IMRT patients experienced less acute and chronic toxicities. The IMRT group also had higher 2- and 3-year survival rates than the para-aortic RT group (2-year, 58.8% vs 25.0%, P = 0.019; 3-year, 36.4% vs 15.6%, P = 0.016). However, no significant difference was found in 1-year survival (67.7% vs 51.3%, P =0.201). The median survival in the IMRT group was 25 months (range, 3 to 37 months). The actuarial overall survival, disease-free survival, and locoregional control rates at 2 years were 67%, 77%, and 88%, respectively, in the IMRT group.

CONCLUSIONS

IMRT provides better clinical outcomes than para-aortic field radiotherapy in patients with PALN metastasis. However, cervical local and distal recurrence remain a problem. Long-term follow-up and studies involving more patients are needed to confirm our results.