Screening for Cervical Cancer

Reflections of Homeless Women and Women with Mental Health Challenges on Breast and Cervical Cancer Screening Decisions: Power, Trust, and Communication with Care Providers

This study conducted in Toronto, Canada, explored the perceptions of women living in homeless shelters and women with severe mental health challenges about the factors influencing their decision-making processes regarding breast and cervical cancer screening. Twenty-six in-depth qualitative interviews were conducted. The objectives of this research were (i) to provide new insights about women's decision-making processes, (ii) to describe the barriers to and facilitators for breast and cervical cancer screening, and (iii) to offer recommendations for future outreach, education, and screening initiatives developed specifically for under/never-screened marginalized women living in urban centers. This exploratory study utilized thematic analysis to broaden our understanding about women's decision-making processes. A constructed ontology was used in an attempt to understand and describe participants' constructed realities. The epistemological framework was subjective and reflected co-created knowledge. The approach was hegemonic, values-based, and context-specific. The aim of the analysis was to focus on meanings and actions with a broader view to identify the interplay between participants' narratives and social structures, medical praxis, and policy implications. Results from 26 qualitative interviews conducted in 2013-2014 provided insights on both positive and negative prior cancer screening experiences, the role of power and trust in women's decision-making, and areas for improvement in health care provider/patient interactions. Outcomes of this investigation contribute to the future development of appropriately designed intervention programs for marginalized women, as well as for sensitivity training for health care providers. Tailored and effective health promotion strategies leading to life-long cancer screening behaviors among marginalized women may improve clinical outcomes, decrease treatment costs, and save lives.

Inequities in cervical cancer screening among Colombian women: a multilevel analysis of a nationwide survey

OBJECTIVES

To identify factors associated with whether women in Colombia have had a Pap test, evaluate differences in risk factors between rural and urban residence, and evaluate the contextual effect of the lack of education on having ever had a Pap test.

METHOD

Data used were from the 2010 Colombian National Demographic and Health Survey; 40,392 women reported whether they have had a Pap test. A multilevel mixed logistic regression model was developed with random intercepts to account for clustering by neighbourhood and municipality. The model evaluated whether having a rural/urban area of residence modified the effect of identified risk factors and if the prevalence of no education at the neighbourhood level acted as a contextual effect.

RESULTS

Most women (87.3%) reported having at least one Pap test. Women from lower socioeconomic quintiles (p=0.002), who were unemployed (p<0.001), and whose final health decisions depended on others (p<0.001) were less likely to have had a Pap test. Women with children were more likely to have had the test (p<0.001), and the effects of education (p=0.03), type of health insurance (p=0.01), age (p<0.001), and region (p<0.001) varied with having a rural/urban area of residence. Women living in rural areas (specifically younger ones, with no health insurance, living in the Atlantic and Amazon-Orinoquía regions, and with no education) were less likely to have had a Pap test when compared to those living in urban areas. Furthermore, women living in a neighbourhood with a higher prevalence of no education were less likely to have ever had a Pap test (p=0.005).

CONCLUSIONS

In Colombia, the probability of having had a Pap test is associated with personal attributes, area of residence, and prevalence of no education in the neighbourhood. Efforts to improve access to cervical cancer screening should focus on disadvantaged women with limited education, low socioeconomic status, and no health insurance or subsidised insurance, especially those in rural/isolated areas.

Colposcopic management of abnormal cervical cytology and histology

OBJECTIVE

To provide a guideline for managing abnormal cytology results after screening for cervical cancer, to clarify the appropriate algorithms for follow-up after treatment, and to promote the best possible care for women while ensuring efficient use of available resources.

OUTCOMES

Women with abnormal cytology are at risk of developing cervical cancer; appropriate triage and treatment will reduce this risk. This guideline will facilitate implementation of common standards across Canada, moving away from the current trend of individual guidelines in each province and territory.

EVIDENCE

Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in October 2008 using appropriate controlled vocabulary (e.g., colposcopy, cervical dysplasia) and key words (e.g., colposcopy management, CIN, AGC, cervical dysplasia, LEEP, LLETZ, HPV testing, cervical dysplasia triage). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to July 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. Expert opinion from published peer-reviewed literature and evidence from clinical trials is summarized. Consensus opinion is outlined when evidence is insufficient.

VALUES

The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1).

VALIDATION

This guideline has been reviewed for accuracy from content experts in cytology, pathology, and cervical screening programs. Guideline content was also compared with similar documents from other organizations including the American Society for Colposcopy and Cervical Pathology, the British Society for Colposcopy and Cervical Pathology, and the European Cancer Network.

Optimizing technology for cervical cancer screening in high-resource settings

Although historically successful in reducing the burden of cervical cancer, Papanicolaou (Pap) testing faces numerous limitations. A growing body of evidence suggests that modern screening practice will benefit from primary screening for high-risk human papillomavirus (HPV) infection, the causative agent of cervical cancer. Molecular tests detecting the presence of HPV nucleic acids consistently demonstrate high sensitivity relative to Pap testing, and provide reliable, dichotomous results. Pap cytology is ideally suited to triage HPV-positive cases owing to its high test specificity, and the accuracy of cytological readings will be maximized in high-prevalence conditions. This algorithm of primary HPV testing with Pap triage has been shown to maintain the high sensitivity of HPV testing without compromising Pap cytology's strong ability to rule out falsely positive diagnoses. Given the anticipated decline of high-risk HPV-16 and -18 infections in the emergent post-HPV vaccination era, highly sensitive primary HPV testing is especially warranted. Novel screening technologies that identify HPV viral gene expression continue to emerge and seek to complement current HPV testing by identifying those women who may be at risk of progressive disease. How to best incorporate these new technologies into clinical practice presents our next great challenge. Implementation of novel algorithms for cervical screening is not a trivial task. Avoidance of exceedingly complex screening algorithms is an important priority.

Immigrant women's experiences of receiving care in a mobile health clinic

AIM

This paper is a report of a study of the experiences of Portuguese-speaking immigrant women who used a mobile health clinic for their reproductive health care.

BACKGROUND

Upon arrival in Canada, immigrant women often are in better health than their Canadian-born counterparts; however, this health status tends to deteriorate over time. One reason for this change is limited access to services.

METHOD

Data collection during 2004 and 2005 involved individual interviews with seven Portuguese-speaking women who received care in a mobile health clinic in Toronto, Canada, and with four clinic care providers. Non-participant observation of the interaction between clients and care providers was also conducted. Interviews conducted in Portuguese were translated into English and transcribed, along with those conducted in English. Interview transcripts were read and re-read in the context of observational notes to develop codes. Emerging codes were grouped together to develop subcategories and categories.

FINDINGS

Participants' experiences of accessing and receiving care in the mobile health clinic were shaped by their perceptions of health, which included physical, mental, social and spiritual aspects, and their pre- and postmigration care experiences. As an alternative model of care delivery, the mobile health clinic was perceived by participants to address their care needs and to help overcome postmigration barriers by providing accessible, holistic, and linguistically and culturally appropriate care.

CONCLUSION

Mobile health clinics should be considered as an alternative care delivery model for immigrant women who may be at a disadvantage because of their socio-economic, cultural, and racialized statuses.