Access of Black, Hispanic, and nonprivately insured women to liquid-based cytology, human papillomavirus DNA testing, and on-site colposcopy in the United States

Factors associated with high-risk human papillomavirus test utilization and infection: a population-based study of uninsured and underinsured women

Background

Current cervical cancer screening guidelines recommend a Pap test every 3 years for women age 21–65 years, or for women 30–65 years who want to lengthen the screening interval, a combination of Pap test and high-risk human papilloma virus testing (co-testing) every 5 years. Little population-based data are available on human papilloma virus test utilization and human papilloma virus infection rates. The objective of this study was to examine the patient-level, cervical cancer screening, and area-level factors associated with human papilloma virus testing and infection among a diverse sample of uninsured and underinsured women enrolled in the New Jersey Cancer Early Education and Detection (NJCEED) Program.

Methods

We used data for a sample of 50,510 uninsured/underinsured women, age ≥ 29 years, who screened for cervical cancer through NJCEED between January 1, 2009 and December 31, 2015. Multivariable logistic regression models were used to estimate associations between ever having a human papilloma virus test or a positive test result, and individual- (age, race/ethnicity, birthplace) and area-level covariates (% below federal poverty level, % minority, % uninsured), and number of screening visits.

Results

Only 26.6% (13,440) of the sample had at least one human papilloma virus test. Among women who underwent testing, 13.3% (1792) tested positive for human papilloma virus. Most women who were positive for human papilloma virus (99.4%) had their first test as a co-test. Human papilloma virus test utilization and infection were significantly associated with age, race/ethnicity, birthplace (country), and residential area-level poverty. Rates of human papilloma virus testing and infection also differed significantly across counties in the state of New Jersey.

Conclusions

These findings suggest that despite access to no-cost cervical cancer screening for eligible women, human papilloma virus test utilization was relatively low among diverse, uninsured and underinsured women in New Jersey, and test utilization and infection were associated with individual-level and area-level factors.

Diagnostic colposcopic accuracy by the gynocular and a stationary colposcope

OBJECTIVES

The aim of this study was to evaluate the diagnostic accuracy of sensitivity and specificity of cervical lesions by the low-cost, portable Gynocular colposcope and a stationary colposcope, in women referred for colposcopy with abnormal cervical cytology.

METHODS

A randomized cross-over clinical trial for evaluating the diagnostic accuracy in detecting cervical lesions by the Gynocular and a stationary colposcope. The Swede score systematic colposcopy system was used for evaluation of colposcopic abnormalities. Directed punch biopsy and excisional cone biopsy were used as the "gold-standard" by histologically confirmed high grade cervical lesions CIN2+ (CIN2, CIN3, CIN3+). In total, 123 women referred for colposcopy due to abnormal cervical cytology were recruited at the Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden. The percentage agreement and the kappa statistic were calculated for Swede score by the Gynocular and a stationary colposcope. Swede scores were compared with the results from directed punch biopsy and excisional cone biopsy.

RESULTS

The Gynocular and the stationary colposcope had a high agreement of Swede scores with a Kappa statistic of 0.947, p < .0001. Punch biopsy diagnosed CIN2+ (CIN2, CIN3, and invasive cancer) in 44 (35.7 percent) women while cytology detected CIN2+ in 34 (27.6 percent) women. There were no significant differences of the sensitivity and specificity for different Swede scores by the Gynocular or a stationary colposcope in detecting CIN 2+.

CONCLUSIONS

There were no significant differences in sensitivity or specificity in detecting cervical lesions by the Gynocular or stationary colposcope. The Gynocular is as accurate in diagnosing cervical lesions as a stationary colposcope.

Changes to cervical cancer prevention guidelines: effects on screening among U.S. women ages 15-29

OBJECTIVE

A shift toward later initiation of cervical cancer screening for women began in 2002. We generated national estimates of screening prevalence rates and guideline-consistent screening among U.S. women ages 15-29 before and after the first evidence-based recommendations for reduced cervical cancer screening.

METHOD

We used National Survey of Family Growth data to compare self-reported cervical cancer screening in 2002 and 2006-2008, stratified by age (15-17, 18-20, 21-29) and sexual activity. We also assessed receipt of guideline-consistent screening by selected demographic variables.

RESULTS

Among females ages 15-17, the proportion screened decreased from 23% to 12%, and screening was significantly more likely to be guideline-consistent. Among females ages 18-20, 24% were screened too early in 2006-2008, but among those not yet sexually active, screening declined to 8%, appropriately reflecting new guidelines. In multivariable analysis, private health insurance, pregnancy, and hormonal contraceptive use were associated with guideline-consistent screening among sexually-active women.

CONCLUSION

Fewer adolescents were being screened before sexual initiation, representing newer guidelines. However, sexually-active young adult women also should have later screening initiation. Factors related to health care access contribute to receipt of screening. Monitoring and provider education are needed to improve guideline-consistent screening, as newer guidelines call for less screening.