Improving compliance among women with abnormal Papanicolaou smears

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Utilization of Pap testing among women living with HIV enrolled in primary care in Baltimore, Maryland: A 10-year longitudinal study, 2005-2014

Frequent Pap testing is recommended among women living with HIV (WLWH) due to their elevated risk for cervical cancer. However, there are few recent longitudinal evaluations of utilization and determinants of Pap testing among WLWH. Medical and pathology records of WLWH seen at Johns Hopkins Hospital between 2005 and 2014 were assessed using Prentice, Williams, Peterson models. Of 554 WLWH in care for ≥ 18 months, 79% received Pap testing, however only 11% consistently received Pap testing at the recommended interval. Some women (5%) were consistently under-screened (tested at longer intervals) and 21% did not receive any Pap testing at during follow-up. WLWH with decreased likelihood of screening included older women, injection drug users, whites and those who had lived for longer with HIV. In contrast, only women with a prior abnormal Pap result were more likely to receive Pap testing. CD4 cell count and health insurance were not significant determinants. Although many WLWH in care received Pap testing, some WLWH were unscreened or underscreened. Determinants of Pap testing for WLWH include socio-demographic factors and a prior abnormal result; these present potential targets in an urban HIV care setting for closer monitoring and directed interventions to improve utilization among WLWH.

Tailored telephone counseling to improve adherence to follow-up regimens after an abnormal pap smear among minority, underserved women

OBJECTIVE

The present study explored the impact of a tailored telephone counseling intervention on increasing follow-up adherence after an abnormal Pap smear result among low-income, minority women, which may reduce cervical cancer disparity.

METHODS

Participants (N=211) were randomly assigned to receive: (1) a telephone reminder that included an assessment of barriers to adherence, as well as counseling tailored to the barriers elicited; (2) telephone reminder and barriers assessment, followed by a mailed home tailored barriers print brochure; or (3) enhanced standard care comprising telephone reminder and barriers assessment. Assessments were obtained at initial contact and 1-week later, as well as at 6- and 12-months after the initial colposcopy.

RESULTS

The telephone counseling group showed greater adherence to follow-up recommendations than did the combined other two groups (p<0.05). For the initial colposcopy, tailored telephone barriers counseling was more effective among women with a high school education or less.

CONCLUSION

Tailored telephone barriers counseling improves adherence to initial colposcopy, as well as to longer-term medical follow-up, among low-income, inner-city women.

PRACTICE IMPLICATIONS

Dissemination of barriers counseling into ongoing telephone reminder calls and contacts may decrease disparities in cancer outcomes, especially among women with less than post-secondary education.

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 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.

Integrative review of the nursing interventions used for the early detection of cervical uterine cancer

In a national program to combat cervical uterine cancer (CUC) four basic elements should exist: primary prevention, early detection, diagnosis/treatment and palliative care. Of these, early detection is the most effective modality. One of the purposes of Evidence-Based Practice (EBP) is to encourage the use of research results with the assistance provided, reinforcing the importance of research for clinical practice. This study aimed to evaluate the evidence available in the literature regarding effective nursing interventions for the early detection of CUC. The selection of articles was performed in the databases: Scopus, PubMed, CINAHL, Lilacs and Cochrane. The sample of this review consisted of seven articles, with evidence levels 1, 2 or 3. The behavioral, cognitive and social interventions, showed positive effects in the early detection of CUC, especially the interactive cognitive interventions. It is suggested, when appropriate, to use a combination of interventions in order to obtain a more effective result.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis.

MAIN RESULTS

Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials.

AUTHORS' CONCLUSIONS

There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.

Using the word 'cancer' in communication about an abnormal Pap test: finding common ground with patient-provider communication

OBJECTIVE

To investigate provider and patient views about communication regarding cervical cancer screening follow-up.

METHODS

Using qualitative analysis, we interviewed 20 providers and 10 patients from two urban clinics that serve low-income African American and Hispanic women. Semi-structured interviews and focus groups assessed familiarity with National Cancer Institute's Cancer Information Service (CIS) and reactions to a letter asking women with abnormal Pap test to telephone CIS. The letter suggested questions to ask prior to receiving follow-up.

RESULTS

No patient or provider was familiar with CIS. Providers but not patients expressed discomfort with use of the word 'cancer' in the letter and in CIS's name. Providers feared that reference to cancer would provoke fatalism and impede timely follow-up, whereas patients felt information about cancer risk was needed to prompt timely follow-up. Information providers found necessary to convey in order to accurately explain abnormal Pap tests surpassed patients' literacy levels.

CONCLUSION

Qualitative data suggest important gaps in perspective between providers and patients. There is a need to bridge the gap and overcome communication challenges to promote timely medical follow-up and have better health outcomes.

PRACTICE IMPLICATIONS

Implications and strategies for improving patient-provider education and communication about abnormal Pap test are discussed.

Preditores de não aderência ao seguimento preconizado para mulheres com lesão intraepitelial escamosa de alto grau (HSIL)

O câncer de colo uterino é um tumor de natureza multifatorial que persiste como um importante problema de saúde pública. Aderência à linha de cuidado é fator associado ao controle desse câncer. O objetivo deste estudo foi avaliar fatores associados à "Não aderência" ao seguimento preconizado para mulheres com lesão intraepitelial de alto grau (HSIL), atendidas em um serviço de saúde da Baixada Fluminense, no Rio de Janeiro. Este estudo do tipo coorte retrospectivo incluiu mulheres rastreadas por citologia, matriculadas entre 01/01/2002 e 31/12/2005 e submetidas à colposcopia. A coleta de dados terminou em 31/12/07. Foram revisados 1496 prontuários e identificadas 641 mulheres elegíveis com diagnóstico de HSIL obtido por excisão da zona de transformação do colo uterino. Após a aplicação dos critérios de exclusão, a população de estudo foi constituída por 537 (84%) mulheres, classificadas em dois grupos: "não aderentes" (29,4%), que abandonaram o seguimento, e "aderentes" (70,6%), que permaneceram no seguimento até a alta. A análise estatística foi realizada pelo teste do qui-quadrado, teste t e regressão logística. O modelo final incluiu as variáveis: ser fumante (OR 1,72), dona de casa (OR 1,56), ter realizado o exame com o uso do vídeo-colposcópio (OR 1,80), idade (OR 0,97) e antecedente de três ou mais gestações (OR 0,49). O estudo revelou um perfil de vulnerabilidade apontando para determinantes de ordem individual e organizacional. Estratégias para melhorar a aderência ao seguimento devem contemplar medidas dirigidas a fatores modificáveis do estilo de vida, como o tabagismo, e estruturais característicos dos serviços de saúde da região.

Defining a strategy to evaluate cervical cancer prevention and early detection in the era of HPV vaccination

OBJECTIVE

The purpose of this paper is to outline the short-, medium- and long-term requirements of a strategy to evaluate the impact of HPV immunization and to define a framework to facilitate planning and evaluation.

METHOD

This strategy was developed in Ontario from January to August 2008. Literature review was completed to assess existing material relevant to vaccine evaluation, and HPV vaccine specifically. Scientists and epidemiologists within our organization attended meetings to brainstorm and identify key requirements for vaccine evaluation. Other selected internal and external experts were consulted to review preliminary lists of potential indicators and questions for inclusion in an evaluation strategy.

RESULTS

Results are reported in three sections--literature review, proposed evaluation framework and data requirements.

CONCLUSION

The first vaccine evaluation strategy that integrates primary and secondary prevention of cervical cancer is presented. Among women who are neither screened nor immunized, customized interventions will be required to ensure that they are aware of potential risks and benefits. This evaluation strategy may serve as a useful outline for jurisdictions in Canada and elsewhere. This new paradigm of combined primary and secondary intervention will encourage cooperation for effective evaluation of an integrated approach for control of cervical cancer and other HPV-related disease.

Adherence to recommendations for follow-up to abnormal Pap tests

OBJECTIVE

To evaluate whether timely adherence rates differ by race among women with abnormal Pap tests participating in a cost-free or reduced-cost program.

METHODS

Eligible subjects included women aged 47-64 years who received a referral for follow-up care after an abnormal Pap test from 1999 to 2002 in South Carolina (n=330). Adherence was measured as days to receipt of follow-up care after an abnormal Pap test. Cox proportional hazards modeling was used to estimate risk factors associated with time to adherence within 60 and 365 days by race.

RESULTS

African-American and non-Hispanic white women had similar adherence to follow-up. Among white women, those with high-grade lesions were less likely to adhere in a timely manner relative to those with low-grade lesions (hazard ratio 0.6, 95% confidence interval [CI] 0.4-1.0). For African-American women, rural residence (hazard ratio: 0.5, 95% CI 0.2-0.9) and history of abnormal Pap tests (hazard ratio 0.6, 95% CI 0.3-1.0) were associated with decreased adherence, whereas less education (hazard ratio 2.3, 95% CI 1.3-3.9) was associated with increased adherence.

CONCLUSION

Adherence rates do not differ by race. However, risk factors for adherence within race are variable. Interventions tailored to the differential needs of racial and ethnic groups may prove effective toward increasing timely adherence rates.

LEVEL OF EVIDENCE

II.

Understanding Barriers for Adherence to Follow-Up Care for Abnormal Pap Tests

OBJECTIVE

Approximately 4000 women annually will die from preventable and treatable cervical cancer. Failure to adhere to follow-up recommendations after an abnormal Pap test can lead to development of cervical cancer. This paper summarizes the body of literature on adherence to follow-up after an abnormal Pap test in order to facilitate development of interventions to decrease morbidity and mortality due to cervical cancer.

METHODS

We conducted a comprehensive search of published literature addressing risk factors for adherence or interventions to improve adherence following an abnormal Pap test as the outcome. We included peer-reviewed original research conducted in the United States from 1990 to 2005.

RESULTS

Fourteen analytical and twelve experimental studies that met our criteria were reviewed. Lesion severity and health beliefs were consistently associated with adherence rates. Communication interventions, including telephone reminders, counseling, and educational sessions, increased follow-up compliance across intervention studies. Inconsistent evidence for associations among race, income, and age were found.

CONCLUSIONS

Further research is needed to reinforce current studies addressing health beliefs and social support. Interventions that focus on the interplay among psychological, educational, and communication barriers are necessary. These interventions should be adapted and applied across various racial/ethnic and socioeconomic groups to reach all women with a high-risk profile for invasive cervical cancer.

Life Stressors Are an Important Reason for Women Discontinuing Follow-up Care for Cervical Neoplasia

Although studies have addressed psychosocial factors associated with obtaining follow-up care for an abnormal Pap test, none have explored the effect of stressful life events in predicting the receipt of follow-up care for an abnormal Pap test. Data from a program (1995-2001) that provided free follow-up care for women with low-grade cervical lesions (n = 601) was used to determine whether life stressors increased risk of study discontinuation. Women were interviewed at baseline and offered follow-up at 4- to 6-month intervals for up to 24 months. Of the 556 women recruited and interviewed (92% response rate), 53 were referred out because they had high-grade cervical lesions and 33 had a health condition precluding follow-up. Among 470 women who began follow-up, 175 (37.2%) discontinued before completing three visits. Women who discontinued were significantly more likely to report more stressful life events in the past year [age-adjusted relative risk (aRR), 1.19; 95% confidence interval (95% CI), 1.08-1.30; 17-item scale]. Events most strongly associated with discontinuation included having a problem with a boss (aRR, 1.9; 95% CI, 1.5-2.4), severe physical partner violence (aRR, 1.7; 95% CI, 1.3-2.2), being homeless (aRR, 2.1; 95% CI, 1.6-2.8), and having an unplanned pregnancy (aRR, 1.5, 95% CI, 1.2-2.1). Life stressors may be important predictors of discontinuation of free follow-up care among women in need of immediate follow-up care to prevent lesion progression.

The effectiveness of a community outreach intervention to improve follow-up among underserved women at highest risk for cervical cancer

BACKGROUND

A disproportionate number of women diagnosed with cervical cancer are from low-income and/or ethnically diverse groups. This study was designed to evaluate the effectiveness of an outreach and counseling intervention at improving the rate of follow-up of abnormal Pap smears among women at Alameda County Medical Center, Oakland, CA.

METHODS

Between September 1, 1999 and August 31, 2001, 348 women with abnormal Pap test results were randomly assigned to intervention or usual care. The main outcome was rate of follow-up.

RESULTS

The intervention produced a significant increase in the rate of follow-up visits within 6 months. Women in the intervention group were much more likely to obtain timely follow-up at Highland Hospital than were those in the control group (61% vs. 32%, P = 0.001). The intervention was equally effective when delivered to women in the control group who had no follow-up by 6 months. Overall, we were able to contact 90% of women in the intervention group.

CONCLUSIONS

An outreach intervention is highly effective at increasing follow-up of abnormal Pap smears in a public hospital setting. Institutions offering cervical cancer screening to low-income, high-risk women should consider the use of outreach workers to reduce loss to follow-up.

Contribution of combined colposcopy and cytology in cervical pathology

AIM

The regular Papanicolaou (Pap) smear is the cornerstone of women's preventive healthcare. The introduction of the regular Pap smear as a screening tool for cervical cancer has markedly decreased the number of deaths from cervical cancer. During the past decade, however, the rate of death from cervical cancer has remained relatively static. This screening method is known to have a high percentage of false negative results. To improve the detection of cervical lesions using the Pap smear in screening, a number of adjunct procedures have been developed. The purpose of this study is to evaluate the utility of a magnified chemoluminescent screening examination (Colposcopy) combined with the Pap smear in detecting cervical abnormalities.

METHODS

We investigated a cohort of 58 subjects who have been forwarded for colposcopic evaluation due to referral cytology suggestive of persistent inflammatory process not otherwise specified, and cervical intraepithelial or invasive neoplasia, in Chania Colposcopic clinic.

RESULTS

The higher the lesion detected by cytology, the more severe the corresponding colposcopic impression viewed.

CONCLUSION

The data presented here are in harmony with previous reports and share our experience in a Regional Community Hospital Colposcopy Clinic. An integrated cytology-colposcopy program facilitates the assessment and identification of women harboring cervical pathological conditions.

Interventions to improve follow-up of abnormal findings in cancer screening

The potential reduction in morbidity and mortality through cancer screening cannot be realized without receipt of appropriate follow-up care for abnormalities identified via screening. In this paper, the authors critically examine the existing literature on correlates of receipt of appropriate follow-up care for screen-detected abnormalities, as well as the literature on interventions designed to increase rates of receipt of follow-up care. Lessons learned describe what is known and not known about factors that are related to or predict receipt of follow-up care. Similarly, effective interventions to increase follow-up are described and gaps identified. A conceptual model is developed that categorizes the health care system in the United States as comprising four levels: policy, practice, provider, and patient. Some patient-level factors that influence follow-up receipt are identified, but the lack of data severely limit the understanding of provider, practice, and policy-level correlates. The majority of intervention studies to increase follow-up receipt have focused on patient-level factors and have targeted follow-up of abnormal Papanicolaou smears. Insufficient information is available regarding the effectiveness of provider, practice, or policy-level interventions. Standard definitions of what constitutes appropriate follow-up are lacking, which severely limit comparability of findings across studies. The validity of various methods of obtaining outcome data has not been clearly established. More research is needed on interventions targeting provider, system, and policy-level factors, particularly interventions focusing on follow-up of colorectal and breast abnormalities. Standardization of definitions and measures is needed to facilitate comparisons across studies.

Is the promise of cancer-screening programs being compromised? Quality of follow-up care after abnormal screening results

Cancer screening has increased dramatically in the United States, yet in some populations, particularly racial minorities or the poor, advanced disease at diagnosis remains high. One potential explanation is that follow-up of abnormal tests is suboptimal, and the benefits of screening are not being realized. The authors used a conceptual model of access to care and integrated constructs from models of provider and patient health behaviors to review published literature on follow-up care. Most studies reported that fewer than 75 percent of patients received some follow-up care, indicating that the promise of screening may be compromised. They identified pervasive barriers to follow-up at the provider, patient, and health care system levels. Interventions that address these barriers appear to be effective. Improvement of data infrastructure and reporting will be important objectives for policy makers, and further use of conceptual models by researchers may improve intervention development and, ultimately, cancer control.

Realizing the promise of breast cancer screening: clinical follow-up after abnormal screening among Black women

BACKGROUND

Delayed or incomplete follow-up after abnormal screening results may compromise the effectiveness of breast cancer screening programs, particularly in medically underserved and minority populations. This study examined the role of socioeconomic status, breast cancer risk factors, health care system barriers, and patient cognitive-attitudinal factors in the timing of diagnostic resolution after abnormal breast cancer screening exams among Black women receiving breast cancer screening at three New York city clinics.

METHODS

We identified 184 Black women as having an abnormal mammogram or clinical breast exam requiring immediate follow-up and they were interviewed and their medical records examined. Bivariate and multivariate logistic regression analyses were used to assess the association between patient and health care system factors and diagnostic resolution within 3 months of the abnormal finding.

RESULTS

Within 3 months, 39% of women were without diagnostic resolution and 28% within 6 months. Neither socioeconomic status nor system barriers were associated with timely diagnostic resolution. Timely resolution was associated with mammogram severity, patients asking questions (OR, 2.73; 95% CI, 1.25-5.96), or receiving next step information (OR, 2.6; 95% CI, 1.08-6.21) at the initial mammogram. Women with prior breast abnormalities were less likely to complete timely diagnostic resolution (OR, 0.42; 95% CI, 0.20-0.85), as were women with higher levels of cancer anxiety (OR, 0.50; 95% CI, 0.27-0.92).

CONCLUSIONS

Interventions that address a woman's prior experience with abnormal findings and improve patient/provider communication may improve timely and appropriate follow-up.

Factors affecting abnormal Pap smear follow-up among HIV-infected women

Women with HIV infection are at least 10 times more likely to have an abnormal Pap smear than women who are HIV negative. Unfortunately, many women with HIV do not return for care after an abnormal Pap smear. Through the use of focus groups and individual interviews, HIV-positive women's experiences with abnormal Pap smears and the factors that affected whether they returned for care were explored. Two thirds of the 18 participants were minority women, and the average age was 40. Using techniques of constant comparative analysis, five factors were identified that affected whether women came back for care. These factors included fear, the asymptomatic nature of the problem, life circumstances, the participant's perspectives on health, and the health care provider. The findings from this study have implications for clinical practice and future research regarding adherence and abnormal Pap smear follow-up among women with HIV.

Follow-up care of women with an abnormal cytology in a low-resource setting

STUDY PURPOSE

We ascertained the follow-up care after an abnormal cytology (Papanicolaou) screening in the San Marti;n region of Perú and assessed the status of women who had not received adequate care.

BASIC PROCEDURES

We identified women with an abnormal cytology and assessed their medical records, laboratory registries, death certificates and interviewed them at home. Re-screening, diagnosis and treatment were offered.

MAIN FINDINGS

Only 46 (25%) of the 183 women identified received appropriate follow-up care. At re-screening 31 (34%) had a normal result, 9 (10%) were diagnosed with CIN1 and 50 (56%) had CIN2 or worse.

PRINCIPAL CONCLUSIONS

In this setting, follow-up care after an abnormal cytology was very poor and could explain the lack of impact of cervical cancer screening. Women with an abnormal cytology constitute a high-risk group that should be a priority for health services.

In vitro conventional cytology historical strengths and current limitations

Despite the fact that cervical cytology screening programs have dramatically reduced the prevalence of cervical cancer in the US, women continue to develop and die from the disease. The most important observation contributing to this failing is that 60% of women with invasive cancer have not had a Pap smear in the previous 5 years (or have never had one). The most clinically effective and cost effective approach to reducing the incidence of cervical cancer is to screen the unscreened population. Recent evidence has also noted that the sensitivity of conventional cytology is also much lower than was previously believed. Much recent investigation has been directed at identifying the reasons for this low sensitivity and identifying ways to improve it. Only by improving the sensitivity of cervical cancer screening and participation in screening programs can the prevalence, morbidity, and mortality from cervical cancer be further reduced.

Effect of health beliefs on delays in care for abnormal cervical cytology in a multi-ethnic population

CONTEXT

Women from racial and ethnic minorities in the United States have higher rates of cervical cancer and present with later stage disease compared to whites. Delays in care for abnormal Papanicolaou (Pap) smears can lead to missed cases of cervical cancer or late-stage presentation and may be one explanation for these differences.

OBJECTIVE

To determine if race and ethnicity, health beliefs, and cancer knowledge are associated with delays in care for abnormal Pap smears.

DESIGN, PARTICIPANTS, AND SETTING

We conducted a mailed survey with telephone follow-up of all women with an abnormal Pap smear who received care at Kaiser Permanente Los Angeles Medical Center between October 1998 and October 1999 (n = 1,049).

MEASUREMENTS AND MAIN RESULTS

A delay in care was defined as not attending the first scheduled clinic visit to follow up on an abnormal Pap smear, or requiring multiple contact attempts, including a certified letter, to schedule a follow-up visit. Our response rate was 70% (n = 733) and the sample was 51% Latina. Spanish-speaking Latinas and women of Asian descent were more likely to endorse fatalistic beliefs and misconceptions about cancer. Thirteen percent of the sample delayed follow-up on their abnormal Pap smear. Women who delayed care were more fatalistic and endorsed more misconceptions about cervical cancer. Delays in care were not independently associated with race and ethnicity.

CONCLUSIONS

Health beliefs and cancer knowledge differed by race and ethnicity among women in a large managed care organization. Fatalistic health beliefs and misconceptions about cancer, but not race and ethnicity, were independently associated with delays in care.

Treatment of cervical carcinoma in situ in HIV positive women

OBJECTIVES

To evaluate the safety and effectiveness of hysterectomy vs. cone biopsy in HIV seropositive patients with carcinoma in situ of the cervix (CIS).

METHODS

We performed a retrospective case-control study of all HIV seropositive patients diagnosed with carcinoma in situ of the cervix from 1989 to 1995. A control group of HIV(-) women with CIS was also ascertained matched for date of diagnosis of CIS, race and age.

RESULTS

There were 439 patients with CIS, of which 45 were HIV seropositive (10.3%). Nine were treated by hysterectomy, 30 by cone biopsy, and six remained untreated. Overall, 63% of HIV(+) patients did not receive any follow-up Pap smear (44% of hysterectomy patients, 50% of cone biopsy patients, and 83% of untreated patients; chi(2) P=0.41). According to Pap smear results, 67% (10/15) cone biopsy patients and 60% (3/5) hysterectomy patients had an abnormal Pap smear after treatment (P=0.9). Median time to recurrence was 12 months in hysterectomy patients vs. 14 months in cone biopsy patients. Deaths occurred in 22% of hysterectomy patients, 17% of cone biopsy patients, and 50% of untreated patients, none due to cervical cancer. Median time to death from presentation was 27.5 months for hysterectomy patients, 11 months for cone biopsy patients, and 7 months for untreated patients (P<0.05). There were no complications in the hysterectomy group, however, two patients were readmitted after cone biopsy for bleeding. When compared to HIV(-) women with CIS, HIV(+) patients were more likely to be treated by hysterectomy (chi(2) P=0.01).

CONCLUSION

All patients diagnosed with CIS should be counseled regarding HIV prevention and testing because of a significant seropositive rate. Compliance with gynecologic follow-up is very poor in this patient population. Special efforts should be made to enhance compliance. Cone biopsy and hysterectomy appear to be equally safe and effective in the treatment of CIS. CIS in HIV patients is a poor prognostic indicator for death from any cause.

Effectiveness of interventions to improve follow-up after abnormal cervical cancer screening

OBJECTIVE

The purpose of this study was to determine the effectiveness of interventions designed to improve follow-up after an abnormal Pap smear.

METHODS

We performed a qualitative meta-analysis of interventions designed to improve follow-up after an abnormal Pap smear and included studies that met the following criteria: randomized or concurrently controlled study design, defined outcomes, and data available for abstraction. Interventions were classified as behavioral, cognitive, sociologic, or combined strategies (e.g., behavioral and cognitive). Abnormal Pap smears were defined as any test result requiring additional follow-up. Effectiveness was measured by the rate of compliance with recommended follow-up.

RESULTS

Twenty-two interventions in 10 studies met the inclusion criteria. Cognitive interventions utilizing interactive telephone counseling were the most effective, improving compliance by 24 to 31%. Behavioral interventions, such as patient reminders, were also effective, increasing follow-up by up to 18%. Not all of these results achieved statistical significance. The single sociologic intervention we identified used video-taped peer discussions to provide a message about abnormal Pap smears and appropriate follow-up. This intervention was not associated with increased follow-up after an abnormal test. The effectiveness of interventions using multiple types of strategies to improve follow-up was inconsistent.

CONCLUSIONS

Cognitive strategies led to the greatest improvement in compliance with follow-up of abnormal Pap smear screening tests. Extension of similar interventions to follow-up of abnormal breast and colon cancer screening, development of physician- and system-targeted interventions, and evaluation of the cost-effectiveness of these strategies are important priorities for future research.

The effectiveness of one-to-one risk communication interventions in health care: a systematic review

OBJECTIVES

To assess whether risk-communication interventions are associated with changes in patient knowledge, attitudes, and behaviors, and to identify aspects of these interventions that modify these effects.

DESIGN

Systematic review.

DATA SOURCES

96 studies from the period 1985-1996 retrieved by electronic searching of eight databases, hand searching of four journals, contacting key authors, and reference list searching.

MAIN OUTCOME MEASURES

The effect size of the principal outcome was identified from each study. Outcomes measuring behavioral change were preferred; if these were not available, knowledge, anxiety, or risk perceptions were used, according to the focus of the study. Data were available to calculate the principal effect sizes for 82 of the studies.

ANALYSIS

Meta-regression.

RESULTS

The methodologic qualities of the studies varied. Nevertheless, risk-communication interventions generally had positive (beneficial) effects. Interventions addressing treatment choices were associated with larger effects than were those in other contexts, such as prevention or screening. Interventions using individual risk estimates were associated with larger effects than were those using more general risk information. Two design variables were identified as effect modifiers: randomized controlled trials were associated with smaller effects than other designs, and dichotomous outcomes were associated with larger effects than continuous outcomes.

CONCLUSIONS

Risk communication interventions may be most productive if they include individual risk estimates in the discussion between professional and patient. Patient decisions about treatment appear more amenable to change by these interventions than attendance for screening or modification of risky behavior.

Adolescents' knowledge of human papillomavirus and cervical dysplasia

STUDY OBJECTIVE

This study examined adolescents' knowledge of human papillomavirus (HPV) and cervical dysplasia (CD). Factors associated with knowledge and self-reported change in health-related behaviors were identified.

DESIGN

Interviews were conducted at an average of 2.5 years following the diagnosis of HPV/CD. Medical charts were reviewed.

SETTING

The study was conducted at a university-based adolescent dysplasia clinic.

PARTICIPANTS

Fifty females, ages 15-23 participated in the study: 88% African-American, 12% Caucasian.

RESULTS

On average, participants responded correctly to 86% of the questions regarding HPV/CD. However, the following key points were routinely missed: 52% did not know cigarette smoking increased the risk for cervical cancer; 42% believed that HPV/CD was always symptomatic; and 22% did not know condoms decreased the transmission of HPV. According to participants, their health care provider explained the diagnosis and treatment of HPV/CD using words they understood "some" or "most of the time." Higher academic skills significantly correlated with greater knowledge of HPV/CD. Forty-one percent of participants with a smoking history reportedly increased their smoking since the diagnosis, and only 40% used condoms "most of the time." However, 90% had maintained or increased their frequency of Pap tests.

CONCLUSIONS

Adolescent girls had knowledge of most factors related to HPV/CD, but many did not understand the risks of cigarette smoking and failure to use condoms. To improve understanding and compliance, health care providers should tailor educational strategies to the functional level of adolescents.

How should effectiveness of risk communication to aid patients' decisions be judged? A review of the literature

Risk-communication interventions are associated with benefits at both the individual and the public health level. However, the types of outcomes used to assess the effectiveness of risk-communication interventions vary greatly. This makes synthesis of the research in systematic review difficult, and limits both the implementation of advances in clinical practice and further research. This article reviews the outcomes used in risk-communication publications, particularly those addressing individual decisions about treatment. From the traditional cognitive and behavioral research outcomes of patient knowledge, risk perception, and compliance, the emphasis has shifted towards more affective outcomes, including satisfaction, assessment of the information provided and the decision-making process, and certainty about whether the best option has been chosen. These affective outcomes may be more specific and sensitive measures for risk-communication research. Further development and validation of measurement scales to address these issues is needed.

A review of a prison cervical cancer screening program in British Columbia

OBJECTIVE

To review a 1995 Pap smear screening program at Burnaby Correctional Centre for Women (BCCW).

METHOD

129 inmates (15%), were screened in BCCW in 1995. General population data were obtained from the British Columbia Cervical Cytology Screening Program (BC CCSP) Registry.

RESULTS

BCCW inmates aged 25-29 years were 11 times more likely to have high grade cytologic abnormalities on Pap smear screening compared with age-matched general population (p < 10(-10). In the 20-34 year age group, 47% of BCCW inmates had received at least one Pap smear in 1992-1994, compared with 87% of the general population (p < 0.001). There was no relationship between Pap smear results and BCCW inmate ethnicity (p = 0.85).

CONCLUSIONS

Prison inmates presented with more severe abnormalities on Pap smear screening at a younger age, and had received Pap smear screening less frequently, compared with the general population.

Reducing loss-to-follow-up among women with abnormal Pap smears. Results from a randomized trial testing an intensive follow-up protocol and economic incentives

OBJECTIVES

This study evaluates the efficacy of two interventions designed to reduce loss-to-follow-up among women with abnormal Pap smears.

METHODS

The two interventions were evaluated in two large public hospitals using a randomized 2 x 2 factorial design. One intervention involved an intensive follow-up protocol that relied on multiple attempts (mail and telephone) to contact the patient. The second intervention provided patients with economic vouchers to offset out-of-pocket expenses associated with the follow-up visits. Loss-to-follow-up was addressed by medical chart reviews and telephone interviews.

RESULTS

The study population (n = 1453) was primarily Hispanic, married or otherwise living with a significant other, relatively young in age, and with no source of payment for health care. Overall, 30% of the total sample was loss-to-follow-up (i.e., no return visits). Among patients assigned to the control condition, loss-to-follow-up was 36.1% compared with 27.8% for the intensive follow-up condition, 28.8% for the voucher condition, and 29.0% for the intensive follow-up plus voucher condition. Both intervention conditions significantly improved follow-up rates. The odds ratio for intensive follow-up was 1.56 compared with 1.50 for the voucher intervention. The combined intervention condition (intensive follow-up x voucher program) did not have a significant effect after taking into account the main effects of the two interventions. Correlates of loss-to-follow-up included age (younger women had lower return rates), race/ethnicity (African American women had lower return rates), live-in relationship (women who were not married or living as married had lower return rates), and severity of the abnormal Pap smear (less severe abnormalities were associated with lower return rates).

CONCLUSIONS

Both interventions were associated with moderate reductions in loss-to-follow-up in this underserved population. The implications of these findings are discussed relative to implementing cervical cancer control programs within state and local health departments.

A review of cervical cancer screening intervention research: implications for public health programs and future research

In this paper we review the published literature with respect to cervical cancer screening intervention research. Mass media campaigns appear to work best in promoting cervical cancer screening when multiple media are used, when they promote specific screening programs that eliminate or reduce access barriers, or when they are used in combination with other strategies. Many positive examples of using outreach staff to promote cervical cancer screening, as well as using mobile examination rooms in the community, were found. Substantial evidence that letters mailed to patient populations are efficacious was found, especially in promoting interval screening; however, bulk mailings to nonpatient populations have generally not been successful. Both physician and patient prompts have shown promise as well as opportunistic screenings in both the outpatient and the inpatient settings. In addition, several strategies for reducing loss to follow-up among women with abnormal test results were identified, including telephone follow-up, educational mailouts, audiovisual programs, clinic-based educational presentations and workshops, transportation incentives, and economic vouchers. Of special note is the success of other countries in establishing centralized recall systems to promote interval screening for cervical cancer. Ultimately, such systems could replace the need for opportunistic screening in underserved populations and perhaps many community outreach efforts. It is argued that health departments represent a logical starting point for developing a network of recall systems in the United States for underserved women.

Follow-up of abnormal Papanicolaou smears in a hospital-based adolescent clinic

STUDY OBJECTIVE

To present data on the spectrum of abnormal Papanicolaou (PAP) smears in adolescents and to determine factors that influence compliance with recommendations to return for repeat PAP smears or for colposcopic examination.

DESIGN

Retrospective chart review with follow-up telephone calls to patients who did not follow recommendations for colposcopy.

SETTING

Adolescents receiving health care in a hospital-based adolescent clinic.

PARTICIPANTS

Patients with abnormal PAP smears between July 1, 1994 and June 30, 1995.

MAIN OUTCOME MEASURES

Compliance with follow-up for abnormal PAP smears including referral to the colposcopy clinic, and the results of repeat PAP smears and colposcopy.

RESULTS

Of 888 adolescents undergoing PAP smear evaluation 119 (13.4%) had an abnormal PAP smear during the study year (index PAP). The results of the index PAP were 97 (81.5%) atypia and 22 (18.5%) squamous intraepithelial lesion low grade (SIL LG). The index PAP was the first abnormal PAP smear for 92 of the patients (77%); 27 had one or more previous abnormal PAP smears (18 atypia, 7 SIL LG, 2 SIL high grade [HG]), and 13 had been referred for colposcopy in the past. For 76 of 92 patients with atypia on index PAP (84%), the index PAP was the first abnormal PAP smear. Of these 76 patients, 51 had a second PAP smear: 27 (53%) were normal, 13 (25%) atypia, and 11 (22%) SIL LG. Sixty patients were referred to the colposcopy clinic, but only 37 actually kept the colposcopy appointment despite outreach. The only significant factor for obtaining colposcopy was a visit to the Adolescent Clinic after notification of the abnormal PAP smear result and before the colposcopy appointment; 79% of those who had a visit obtained colposcopy compared with 45% of those who did not have such a visit (p = 0.007). There were no significant differences by race, insurance status, age, PAP smear result, previous referral for colposcopy, or number of reminders with compliance with recommendations for repeat PAP smears or colposcopy.

CONCLUSIONS

Although a sizable proportion of adolescents with abnormal PAP smears have significant pathology on repeat PAP smears, adolescents with abnormal PAP smears have a high failure rate in keeping appointments for follow-up PAP smears and colposcopy. Interventions that target all adolescents with abnormal PAP smears need to be designed and tested to aid follow-up.

Enhancing adherence following abnormal Pap smears among low-income minority women: a preventive telephone counseling strategy

BACKGROUND

Although the incidence of precancerous conditions of the cervix has recently been increasing, prompt initial and long-term follow-up care can effectively reduce unnecessary morbidity and mortality. For example, the 4-year survival rates among those individuals at greatest risk for cervical cancer (i.e., minority women of low socioeconomic status) approach 95% with early detection. Women who present with advanced disease have a much poorer outlook (0%-39% survival). Yet, high-risk individuals are least likely to adhere to recommended diagnostic regimens.

PURPOSE

We tested the effectiveness of a brief telephone counseling intervention directed to low-income, inner-city women after they had received an abnormal Pap smear result. The women were counseled on the importance of having an initial and 6-month repeat follow-up diagnostic procedure (i.e., colposcopic examination of the cervix).

METHODS

A randomized trial design was used to compare the effects on these women of telephone counseling with (n = 192) or without (n = 203) a booster counseling telephone call prior to the appointment for a repeat colposcopy 6 months later, with a telephone appointment confirmation/reminder call (n = 216) and with standard care (i.e., no telephone contact) (n = 217). The telephone counseling protocol probed for and addressed three psychologic barriers to adherence (i.e., attendance at appointment for colposcopy examination): 1) encoding/expectancy (e.g., did the patient understand her risk of developing cervical cancer?); 2) affective/emotional (e.g., was the woman worried about the condition and its consequences?); and 3) self-regulatory/practical (e.g., was the woman likely to forget medical appointments?). Logistic regression was used to analyze the effects of the intervention group and the type of psychologic barriers elicited on colposcopy adherence.

RESULTS

The results of logistic regression analysis (using those who received an appointment confirmation/reminder telephone call as the comparison group) revealed that telephone counseling produced significantly higher adherence rates to the initial colposcopy visit compared with telephone confirmation (300 [76%] of 395 women versus 147 [68%] of 216; odds ratio [OR] = 1.50; 95% confidence interval [CI] = 1.04-2.17). Additionally, standard care resulted in significantly lower adherence rates than did telephone confirmation (109 [50%] of 217 women versus 147 [68%] of 216; OR = 0.47; 95% CI = 0.32-0.73). Regarding attendance at the 6-month repeat colposcopy appointments, the 80 patients who had received telephone counseling prior to the initial visit (and were recommended for follow-up colposcopy) were significantly more likely to adhere than were the 47 patients who had received telephone confirmation (49 [61%] of 80 women versus 17 [36.2%] of 47; OR = 2.70; 95% CI = 1.15-6.51). The 6-month adherence rates for patients in the telephone confirmation group and the standard care group (n = 30) were low and did not differ significantly (17 [36.2%] of 47 women versus nine [30.0%] of 30; OR = 1.08; 95% CI = 0.40-2.89). Forgetting medical appointments (OR = 0.31; 95% CI = 0.19-0.51) and having scheduling conflicts (OR = 0.45; 95% CI = 0.28-0.72) were also associated with lower rates of adherence.

CONCLUSION

The use of telephone counseling appears to be an effective strategy for enhancing initial and long-term adherence to a follow-up cervical diagnostic procedure in a traditionally underserved population. Patients who respond to a positive Pap test result with a particular profile of psychologic barriers may require more intensive and targeted counseling interventions.

Positive screening tests for gonorrhea and chlamydial infection fail to lead consistently to treatment of patients attending a sexually transmitted disease clinic

BACKGROUND AND OBJECTIVES

Patients attending sexually transmitted disease (STD) clinics are frequently screened for gonorrhea and chlamydial infection. To determine the efficiency of these screening efforts as a component of STD control, we evaluated treatment outcomes of patients with positive cultures who had not received presumptive treatment at their initial visit.

GOALS

To determine the treatment outcomes of patients screened for STDs who have positive test results.

STUDY DESIGN

Retrospective chart review of the computerized medical record.

RESULTS

Between January 1, 1994 and June 30, 1995, 24,823 patients were tested for gonorrhea, of whom 19.3% (4791) had positive cultures. Of patients with positive gonorrhea cultures, 564 (11.8%) had positive screening cultures and did not receive therapy at the time of evaluation. Similarly, screening chlamydial cultures were positive in 1539 (10.9%) of 14,162 patients screened for chlamydial infection. Forty-four percent (677) of these did not receive presumptive treatment for chlamydial infection at their initial visit. Overall, 20% of patients with positive cultures failed to return to the clinic for treatment within 30 days of screening. Of those who did return, 30% did so only after at least 2 weeks had elapsed.

CONCLUSIONS

A substantial proportion of patients with positive screening tests for gonorrhea and chlamydial infection fail to comply with follow-up recommendations and thus are likely to remain infectious. Methods must be sought to enhance patient compliance with follow-up of test results and treatment if indicated.

Colposcopic and cytologic findings among adolescents referred to two urban teaching hospitals

STUDY OBJECTIVE

To determine colposcopic findings among adolescents and to determine compliance with management recommendations.

DESIGN

Retrospective review of colposcopy logs and patient charts.

SETTING

Two urban resident colposcopy clinics.

PARTICIPANTS

Low-income, predominantly minority girls 16 years of age or younger referred for evaluation of abnormal cervical cytology.

INTERVENTION

Colposcopy with directed biopsy.

MAIN OUTCOME MEASURES

Histologic findings in colposcopic biopsies and compliance with management recommendations.

RESULTS

Of 62 adolescents evaluated, 17 (27%) had biopsies showing atypia or koilocytosis and 13 (21%) had dysplasia, with grade 2 cervical intraepithelial neoplasia (CIN 2) in 5 (8%). No biopsy showed CIN 3 or invasive cancer. None of 31 endocervical curettings contained dysplasia. Forty-one adolescents (66%) failed to comply with recommendations for surveillance or treatment.

CONCLUSIONS

The prevalence of dysplasia among adolescents referred for colposcopy is substantial, and better strategies are needed to ensure proper follow-up.