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Roof KA, Wichmann HK, Carlton LJ, Nguyen ML, Birdsong GG, Blemur DM, Flowers LC. Factors associated with loss to follow up after abnormal cervical cancer screening in pregnancy. Gynecol Oncol 2024; 185:46-50. [PMID: 38368812 DOI: 10.1016/j.ygyno.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To assess risk factors associated with loss to follow up in patients referred for colposcopy after abnormal cervical cytology during pregnancy in a Southern safety net hospital population. METHODS An urban colposcopy center was queried for patients referred for follow up of abnormal cervical cytology during pregnancy and the postpartum period. Patients were identified through a standardized referral code in the electronic medical record. Multivariable logistic regression was used to compare patient characteristics between those who followed up for colposcopy and those lost to follow up. Independent risk factors assessed included age, parity, race, insurance, HIV status, history of mental illness, BMI, gestational age and trimester at screening, cytology at colposcopy referral, interval days until colposcopy, and biopsy histology. RESULTS 1063 patients were identified, with 40.8% of patients who completed referred colposcopy. Patient characteristics predictive for colposcopy follow up included: maternal age at referral cervical cytology >30 years (1.67; 1.27-2.20; < 0.003), gestational age < 18 weeks at abnormal cervical cytology (1.57; 1.23-2.01; <0.0002), maternal race non-African American (2.20; 1.32-3.65; <0.0024) and with high grade cervical cytology (2.42; 1.81-3.24; <0.0001). CONCLUSION In this population, inadequate follow up for abnormal cervical cytology during pregnancy is prominent, especially among those with younger maternal age, African American (AA) race, cervical cytology completed at later gestational ages of pregnancy, and low-grade initial cytology. Higher no-show rate among AA patients supports well-documented health disparities and need for further investigation and protocols to identify those at risk for loss to follow up.
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Affiliation(s)
- Kelsey A Roof
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, United States of America
| | - Hannah K Wichmann
- UPMC Magee Womens Hospital, Department of Obstetrics and Gynecology, Pittsburgh, PA, United States of America
| | - Laura J Carlton
- Mission Hospital-Asheville, Department of Obstetrics and Gynecology, Asheville, NC, United States of America
| | - Minh L Nguyen
- Emory University School of Medicine, Department of Infectious Disease, Atlanta, GA, United States of America
| | - George G Birdsong
- Emory University School of Medicine, Department of Pathology and Laboratory Medicine, Atlanta, GA, United States of America
| | - Danielle M Blemur
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, United States of America
| | - Lisa C Flowers
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, United States of America.
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Wen KY, Dayaratna S, Slamon R, Granda-Cameron C, Tagai EK, Kohler RE, Hudson SV, Miller SM. Chatbot-interfaced and cognitive-affective barrier-driven messages to improve colposcopy adherence after abnormal Pap test results in underserved urban women: A feasibility pilot study. Transl Behav Med 2024; 14:1-12. [PMID: 38014626 PMCID: PMC10782901 DOI: 10.1093/tbm/ibad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Challenges in ensuring adherence to colposcopy and follow-up recommendations, particularly within underserved communities, hinder the delivery of appropriate care. Informed by our established evidence-based program, we sought to assess the feasibility and acceptability of a novel cognitive-affective intervention delivered through a Chatbot interface, aimed to enhance colposcopy adherence within an urban inner-city population. We developed the evidence-based intervention, CervixChat, to address comprehension of colposcopy's purpose, human papillomavirus (HPV) understanding, cancer-related fatalistic beliefs, procedural concerns, and disease progression, offered in both English and Spanish. Females aged 21-65, with colposcopy appointments at an urban OBGYN clinic, were invited to participate. Enrolled patients experienced real-time counseling messages tailored via a Chatbot-driven barriers assessment, dispatched via text one week before their scheduled colposcopy. Cognitive-affective measures were assessed at baseline and through a 1-month follow-up. Participants also engaged in a brief post-intervention satisfaction survey and interview to capture their acceptance and feedback on the intervention. The primary endpoints encompassed study adherence (CervixChat response rate and follow-up survey rate) and self-evaluated intervention acceptability, with predefined feasibility benchmarks of at least 70% adherence and 80% satisfaction. Among 48 eligible women scheduled for colposcopies, 27 (56.3%) agreed, consented, and completed baseline assessments. Participants had an average age of 34 years, with 14 (52%) identifying as non-Hispanic White. Of these, 21 (77.8%) engaged with the CervixChat intervention via mobile phones. Impressively, 26 participants (96.3%) attended their diagnostic colposcopy within the specified timeframe. Moreover, 22 (81.5%) completed the follow-up survey and a brief interview. Barriers assessment revealed notable encodings in the Affect and Values/Goals domains, highlighting concerns and understanding around HPV, as well as its impact on body image and sexual matters. Persistent and relatively high intrusive thoughts and lowered risk perceptions regarding cervical cancer were reported over time, unaffected by the intervention. Post-intervention evaluations documented high satisfaction and perceived usefulness, with recommendations for incorporating additional practical and educational content. Our findings underscore the robust satisfaction and practicality of the CervixChat intervention among a diverse underserved population. Moving forward, our next step involves evaluating the intervention's efficacy through a Sequential Multiple Assignment Randomized Trial (SMART) design. Enhanced by personalized health coaching, we aim to further bolster women's risk perception, address intrusive thoughts, and streamline resources to effectively improve colposcopy screening attendance.
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Affiliation(s)
- Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Sandra Dayaratna
- Department of Obstetrics, Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, 833 Chestnut Street, Philadelphia, PA 19107, USA
| | - Rachel Slamon
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Clara Granda-Cameron
- Department of Graduate Program, College of Nursing, Thomas Jefferson University, 901 Walnut Street, Suite 703, Philadelphia, PA 19107, USA
| | - Erin K Tagai
- Department of Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Racquel E Kohler
- Cancer Health Equity Center, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Suzanne M Miller
- Department of Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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Bukowski A, Hoyo C, Vielot NA, Graff M, Kosorok MR, Brewster WR, Maguire RL, Murphy SK, Nedjai B, Ladoukakis E, North KE, Smith JS. Epigenome-wide methylation and progression to high-grade cervical intraepithelial neoplasia (CIN2+): a prospective cohort study in the United States. BMC Cancer 2023; 23:1072. [PMID: 37932662 PMCID: PMC10629205 DOI: 10.1186/s12885-023-11518-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Methylation levels may be associated with and serve as markers to predict risk of progression of precancerous cervical lesions. We conducted an epigenome-wide association study (EWAS) of CpG methylation and progression to high-grade cervical intraepithelial neoplasia (CIN2 +) following an abnormal screening test. METHODS A prospective US cohort of 289 colposcopy patients with normal or CIN1 enrollment histology was assessed. Baseline cervical sample DNA was analyzed using Illumina HumanMethylation 450K (n = 76) or EPIC 850K (n = 213) arrays. Participants returned at provider-recommended intervals and were followed up to 5 years via medical records. We assessed continuous CpG M values for 9 cervical cancer-associated genes and time-to-progression to CIN2+. We estimated CpG-specific time-to-event ratios (TTER) and hazard ratios using adjusted, interval-censored Weibull accelerated failure time models. We also conducted an exploratory EWAS to identify novel CpGs with false discovery rate (FDR) < 0.05. RESULTS At enrollment, median age was 29.2 years; 64.0% were high-risk HPV-positive, and 54.3% were non-white. During follow-up (median 24.4 months), 15 participants progressed to CIN2+. Greater methylation levels were associated with a shorter time-to-CIN2+ for CADM1 cg03505501 (TTER = 0.28; 95%CI 0.12, 0.63; FDR = 0.03) and RARB Cluster 1 (TTER = 0.46; 95% CI 0.29, 0.71; FDR = 0.01). There was evidence of similar trends for DAPK1 cg14286732, PAX1 cg07213060, and PAX1 Cluster 1. The EWAS detected 336 novel progression-associated CpGs, including those located in CpG islands associated with genes FGF22, TOX, COL18A1, GPM6A, XAB2, TIMP2, GSPT1, NR4A2, and APBB1IP. CONCLUSIONS Using prospective time-to-event data, we detected associations between CADM1-, DAPK1-, PAX1-, and RARB-related CpGs and cervical disease progression, and we identified novel progression-associated CpGs. IMPACT Methylation levels at novel CpG sites may help identify individuals with ≤CIN1 histology at higher risk of progression to CIN2+ and inform risk-based cervical cancer screening guidelines.
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Affiliation(s)
- Alexandra Bukowski
- Department of Epidemiology, University of North Carolina at Chapel Hill, 60 Bondurant Hall, Chapel Hill, NC, 27599, USA.
| | - Cathrine Hoyo
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, 27695, USA
| | - Nadja A Vielot
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Misa Graff
- Department of Epidemiology, University of North Carolina at Chapel Hill, 60 Bondurant Hall, Chapel Hill, NC, 27599, USA
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Wendy R Brewster
- Department of Epidemiology, University of North Carolina at Chapel Hill, 60 Bondurant Hall, Chapel Hill, NC, 27599, USA
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Rachel L Maguire
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, 27695, USA
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, 27701, USA
| | - Susan K Murphy
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, 27701, USA
| | - Belinda Nedjai
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Efthymios Ladoukakis
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Kari E North
- Department of Epidemiology, University of North Carolina at Chapel Hill, 60 Bondurant Hall, Chapel Hill, NC, 27599, USA
| | - Jennifer S Smith
- Department of Epidemiology, University of North Carolina at Chapel Hill, 60 Bondurant Hall, Chapel Hill, NC, 27599, USA
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, 27599, USA
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4
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Kajabwangu R, Ssedyabane F, Tusubira D, Maling S, Kakongi N, Turyakira E, Namuli A, Galiwango M, Randall TC. High Rate of Loss to Follow-Up Among Patients Undergoing Treatment for Premalignant Cervical Lesions at Mbarara Regional Referral Hospital, Southwestern Uganda: A Retrospective Cohort Study. Cureus 2023; 15:e46542. [PMID: 37927695 PMCID: PMC10625478 DOI: 10.7759/cureus.46542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND For a cervical cancer control program to be effective in reducing the incidence of the disease, there should be high compliance to treatment and follow-up of women diagnosed with precursor lesions. Screening programs in low-resource countries such as Uganda are challenged by poor adherence to follow-up following treatment for premalignant cervical lesions. This study sought to describe the burden and factors associated with loss to follow-up among women undergoing treatment for premalignant cervical lesions at a tertiary hospital in southwestern Uganda. METHODS This was a retrospective cohort study. We reviewed the registers at the Mbarara Regional Referral Hospital (MRRH) cervical cancer clinic for a period of four years from January 2017 to December 2020. Data on age, district of residence, diagnosis, date of diagnosis, date and type of initial treatment, and date of follow-up visit were collected. We also captured data on whether patients returned on the scheduled follow-up date or within three months after the scheduled follow-up date. We defined loss to follow-up as failure to return for follow-up either on the scheduled date or within three months after the scheduled date. RESULTS Out of the 298 patients who underwent treatment for premalignant cervical lesions in the study period, 227 (76.2%) did not return for follow-up at one year. At bivariate analysis, failure to attend the review visit at six weeks predicted the loss to follow-up at one year following treatment for premalignant lesions almost perfectly (risk ratio (RR)=2.84, 95% confidence interval (CI): 2.18-3.71, p<0.001). Negative HIV serostatus and receiving thermocoagulation slightly increased the risk of getting lost to follow-up, while being more than 45 years old reduced the odds. At multivariate analysis, treatment with thermocoagulation (adjusted risk ratio (aRR)=1.21, 95% CI: 1.07-1.36, p=0.03) was associated with loss to follow-up at one year. CONCLUSION The proportion of women who did not return for follow-up at one year following treatment for premalignant cervical lesions at Mbarara Regional Referral Hospital is very high. There is a need to implement strategies such as telephone-aided reminders to prompt patients to return for follow-up following treatment for premalignant cervical lesions.
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Affiliation(s)
- Rogers Kajabwangu
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, UGA
| | - Frank Ssedyabane
- Department of Medical Laboratory Science, Mbarara University of Science and Technology, Mbarara, UGA
| | - Deusdedit Tusubira
- Department of Biochemistry, Mbarara University of Science and Technology, Mbarara, UGA
| | - Samuel Maling
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, UGA
| | - Natthan Kakongi
- Department of Biochemistry, Mbarara University of Science and Technology, Mbarara, UGA
| | - Eleanor Turyakira
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, UGA
| | - Alexcer Namuli
- Department of Obstetrics and Gynecology, Mbarara Regional Referral Hospital, Mbarara, UGA
| | - Martin Galiwango
- Department of Electrical and Electronics Engineering, Faculty of Applied Sciences and Technology, Mbarara University of Science and Technology, Mbarara, UGA
| | - Thomas C Randall
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, USA
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Kohler RE, Hemler J, Wagner RB, Sullivan B, Macenat M, Tagai EK, Miller SM, Wen KY, Ayers C, Einstein MH, Hudson SV. Confusion and anxiety in between abnormal cervical cancer screening results and colposcopy: "The land of the unknown". PATIENT EDUCATION AND COUNSELING 2023; 114:107810. [PMID: 37244133 PMCID: PMC10527466 DOI: 10.1016/j.pec.2023.107810] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Attendance to colposcopy after abnormal cervical cancer screening is essential to cervical cancer prevention. This qualitative study explored patients' understanding of screening results, their experiences of the time leading up to the colposcopy appointment, and colposcopy. METHODS We recruited women referred for colposcopy from two urban practices in an academic health system. Individual interviews (N = 15) with participants were conducted after colposcopy appointments about their cervical cancer screening histories, current results, and colposcopy experiences. A team analyzed and summarized interviews and coded transcripts in Atlas.ti. RESULTS We found that most women were confused about their screening results, did not know what a colposcopy was before being referred for one, and experienced anxiety in the interval between receiving their results and having their colposcopy. Most women searched for information online, but found "misinformation," "worst-case scenarios" and generic information that did not resolve their confusion. CONCLUSION Women had little understanding of their cervical cancer risk and experienced anxiety looking for information and waiting for the colposcopy. Educating patients about cervical precancer and colposcopy, providing tailored information about their abnormal screening test results and potential next steps, and helping women manage distress may alleviate uncertainty while waiting for follow-up appointments. PRACTICE IMPLICATIONS Interventions to manage uncertainty and distress in the interval between receiving an abnormal screening test result and attending colposcopy are needed, even among highly adherent patients.
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Affiliation(s)
- Racquel E Kohler
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA.
| | - Jennifer Hemler
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Rachel B Wagner
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Brittany Sullivan
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Myneka Macenat
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Erin K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Suzanne M Miller
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Charletta Ayers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ 08901, USA
| | - Mark H Einstein
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Shawna V Hudson
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA; Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
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6
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Martinez-Gutierrez J, Chima S, Boyd L, Sherwani A, Drosdowsky A, Karnchanachari N, Luong V, Reece JC, Emery J. Failure to follow up abnormal test results associated with cervical cancer in primary and ambulatory care: a systematic review. BMC Cancer 2023; 23:653. [PMID: 37438686 DOI: 10.1186/s12885-023-11082-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 06/17/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Cervical cancer is a preventable and treatable form of cancer yet continues to be the fourth most common cancer among women globally. Primary care is the first point of contact most patients have with health services and is where most cancer prevention and early detection occur. Inadequate follow-up of abnormal test results for cervical abnormalities in primary care can lead to suboptimal patient outcomes including higher mortality and decreased quality of life. AIMS To explore the magnitude of and factors associated with, inadequate follow-up of test results for cervical abnormalities in primary and ambulatory care. METHODS MEDLINE, Embase, Cochrane Library and CINAHL were searched for peer-reviewed literature from 2000-2022, excluding case-studies, grey literature, and systematic reviews. Studies were included if they reported on patients aged ≥ 18 years with no previous cancer diagnosis, in a primary care/ambulatory setting. Risk of bias was assessed using the Joanna Briggs Institute Critical appraisal checklists, appropriate to the study design. A segregated methodology was used to perform a narrative synthesis, maintaining the distinction between quantitative and qualitative research. RESULTS We included 27 publications reporting on 26 studies in our review; all were conducted in high-income countries. They included 265,041 participants from a variety of ambulatory settings such as family medicine, primary care, women's services, and colposcopy clinics. Rates of inadequate follow-up ranged from 4 to 75%. Studies reported 41 different factors associated with inadequate follow-up. Personal factors associated with inadequate follow-up included younger age, lower education, and socioeconomic status. Psychological factors were reported by only 3/26 studies and 2/3 found no significant association. System protective factors included the presence of a regular primary care provider and direct notification of abnormal test results. DISCUSSION This review describes inadequate follow-up of abnormal cervical abnormalities in primary care. Prevalence varied and the evidence about causal factors is unclear. Most interventions evaluated were effective in decreasing inadequate follow-up. Examples of effective interventions were appointment reminders via telephone, direct notification of laboratory results, and HPV self-sampling. Even though rates of cervical cancer have decreased over the years, there is a lack of information on factors affecting follow-up in primary care and ambulatory settings, particularly in low and middle-income countries. This information is crucial if we are to achieve WHO's interim targets by 2030, and hope to avert 62 million cervical cancer deaths by 2120. TRIAL REGISTRATION PROSPERO ID CRD42021250136.
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Affiliation(s)
- Javiera Martinez-Gutierrez
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia.
- Department of Family Medicine. Pontificia, Universidad Católica de Chile, Santiago, Chile.
| | - Sophie Chima
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Lucy Boyd
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia
- Melbourne School of Population and Global Health, Centre for Health Policy, The University of Melbourne, Melbourne, Australia
| | - Asma Sherwani
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Allison Drosdowsky
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Napin Karnchanachari
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Vivien Luong
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Jeanette C Reece
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia
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Holt HK, Peterson CE, MacLaughlan David S, Abdelaziz A, Sawaya GF, Guadamuz JS, Calip GS. Mediation of Racial and Ethnic Inequities in the Diagnosis of Advanced-Stage Cervical Cancer by Insurance Status. JAMA Netw Open 2023; 6:e232985. [PMID: 36897588 PMCID: PMC10726717 DOI: 10.1001/jamanetworkopen.2023.2985] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Importance Black and Hispanic or Latina women are more likely than White women to receive a diagnosis of and to die of cervical cancer. Health insurance coverage is associated with diagnosis at an earlier stage of cervical cancer. Objective To evaluate the extent to which racial and ethnic differences in the diagnosis of advanced-stage cervical cancer are mediated by insurance status. Design, Setting, and Participants This retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results (SEER) program on an analytic cohort of 23 942 women aged 21 to 64 years who received a diagnosis of cervical cancer between January 1, 2007, and December 31, 2016. Statistical analysis was performed from February 24, 2022, to January 18, 2023. Exposures Health inusurance status (private or Medicare insurance vs Medicaid or uninsured). Main Outcomes and Measures The primary outcome was a diagnosis of advanced-stage cervical cancer (regional or distant stage). Mediation analyses were performed to assess the proportion of observed racial and ethnic differences in the stage at diagnosis that were mediated by health insurance status. Results A total of 23 942 women (median age at diagnosis, 45 years [IQR, 37-54 years]; 12.9% were Black, 24.5% were Hispanic or Latina, and 52.9% were White) were included in the study. A total of 59.4% of the cohort had private or Medicare insurance. Compared with White women, patients of all other racial and ethnic groups had a lower proportion with a diagnosis of early-stage cervical cancer (localized) (American Indian or Alaska Native, 48.7%; Asian or Pacific Islander, 49.9%; Black, 41.7%; Hispanic or Latina, 51.6%; and White, 53.3%). A larger proportion of women with private or Medicare insurance compared with women with Medicaid or uninsured received a diagnosis of an early-stage cancer (57.8% [8082 of 13 964] vs 41.1% [3916 of 9528]). In models adjusting for age, year of diagnosis, histologic type, area-level socioeconomic status, and insurance status, Black women had higher odds of receiving a diagnosis of advanced-stage cervical cancer compared with White women (odds ratio, 1.18 [95% CI, 1.08-1.29]). Health insurance was associated with mediation of more than half (ranging from 51.3% [95% CI, 51.0%-51.6%] for Black women to 55.1% [95% CI, 53.9%-56.3%] for Hispanic or Latina women) the racial and ethnic inequities in the diagnosis of advanced-stage cervical cancer across all racial and ethnic minority groups compared with White women. Conclusions and Relevance This cross-sectional study of SEER data suggests that insurance status was a substantial mediator of racial and ethnic inequities in advanced-stage cervical cancer diagnoses. Expanding access to care and improving the quality of services rendered for uninsured patients and those covered by Medicaid may mitigate the known inequities in cervical cancer diagnosis and related outcomes.
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Affiliation(s)
- Hunter K Holt
- Department of Family and Community Medicine, University of Illinois at Chicago, Chicago
| | - Caryn E Peterson
- Department of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago
| | | | - Abdullah Abdelaziz
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago
| | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Jenny S Guadamuz
- Flatiron Health, New York, New York
- Program on Medicines and Public Health, University of Southern California, Los Angeles
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago
- Flatiron Health, New York, New York
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8
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Sudhakaran S, Bhatla N, Mathur SR, Mahey R, Vashist S, Natarajan J, Kachhawa G, Kumari R, Tanwar P. Evaluation of cervical cancer screening during pregnancy in India: Human papillomavirus testing can change the paradigm. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 36:17-21. [PMID: 37615134 DOI: 10.25259/nmji_768_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Background The World Health Organization's call for elimination of cervical cancer envisages 70% screening coverage of women aged 35 and 45 years by an effective test. In India, this target seems unrealistic as awareness and access to cancer prevention services are poor. However, the institutional delivery rate is now >80%. We evaluated the acceptability and feasibility of human papillomavirus (HPV) testing and its role in screening during pregnancy. Methods This observational study recruited 275 pregnant women aged >25 years between 12 and 34 weeks of gestation for screening by cytology and HPV testing. Colposcopy was advised if either test was positive. Acceptability and feasibility were assessed by a questionnaire. Results Cytology and HPV reports were available for 269 subjects. The median age was 28 years and median parity was two. Only 98 (36.4%) had heard about carcinoma cervix. Awareness improved with education (p < 0.001). On cytology, only 4 (1.5%) were abnormal (atypical squamous cells of undetermined significance 3; low-grade squamous intraepithelial lesion 1). The prevalence of high-risk HPV infection was 8.2% (22/269). On colposcopy, all had the Swede score <5. No high-grade cervical intraepithelial neoplasia or carcinoma was detected. Pre-procedure, 183 (68.0%) subjects expressed apprehension, post-procedure 114 (42.4%) of them had realized that their apprehensions were unfounded. Women found screening to be more uncomfortable after 28 weeks of gestation (n=26/68; 38.2%; p<0.001). Physicians found the cervix more difficult to visualize after 20 weeks of gestation (p<0.001). Conclusions HPV screening at 16-20 weeks of pregnancy is acceptable, feasible, and can greatly improve screening coverage in resource-limited settings. Pregnancy is a good opportunity to improve awareness of the screening programmes.
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Affiliation(s)
- Surabhi Sudhakaran
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Neerja Bhatla
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Sandeep R Mathur
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Reeta Mahey
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Shachi Vashist
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Jayashree Natarajan
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Garima Kachhawa
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Rajesh Kumari
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Pranay Tanwar
- Department of Laboratory Oncology, Dr BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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Muacevic A, Adler JR. Patient Adherence to Follow-Up Recommendations Following Cryotherapy for Treatment of High-Grade Cervical Dysplasia. Cureus 2022; 14:e30154. [PMID: 36397919 PMCID: PMC9646447 DOI: 10.7759/cureus.30154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 01/25/2023] Open
Abstract
Objective Determine the rate of patient adherence to follow-up recommendations after cryotherapy for high-grade cervical lesions, and identify patient characteristics associated with adherence to follow-up. Methods This is a retrospective case series from May 2016 to June 2018 of patients who underwent cryotherapy for high-grade dysplasia at a single academic safety-net hospital. Patient demographics and clinical information were abstracted from the electronic medical record. All patients were recommended to follow up with Pap and high-risk human papillomavirus (HPV) testing 12 months after their procedure. The primary outcome was patient adherence to these recommendations. Descriptive statistics and statistical testing were utilized to compare adherence by demographic and clinical characteristics. A multivariable logistic model was used to preliminarily look at potential factors associated with increased odds of adherence. We further described the proportion of follow-up testing among those patients who adhered to recommendations. Results One hundred and forty-three patients met the inclusion criteria. The adherence percentage was 60.1% (95% CI: 51.6, 68.2). Only employment was associated with follow-up among demographic variables reviewed (p=0.039). Of those who were adherent with follow-up, 4.7% (4/86) had high-grade findings on follow-up Pap testing, and 56.9% (49/86) had negative cytology and negative HPV testing. Conclusion Adherence to follow-up recommendations for the following cryotherapy for high-grade dysplasia within our system was poor, and demographic factors were generally not associated with adherence to follow-up. Given these findings, cryotherapy should be used with caution.
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10
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Butler EN, Umar A, Heckman-Stoddard BM, Kundrod KA, Signorello LB, Castle PE. Redefining precision cancer prevention to promote health equity. Trends Cancer 2022; 8:295-302. [PMID: 35181273 DOI: 10.1016/j.trecan.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 11/15/2022]
Abstract
Precision cancer prevention as it is currently envisioned is a targeted, molecular-based approach to intercept carcinogenesis before cancer develops or before it becomes untreatable. Unfortunately, due to systemic biases, current precision cancer prevention interventions might not be effective in all populations, especially in minoritized communities. In addition, not all cancer risk is attributable to genetic or even biological factors, but includes social determinants of health (SDH). Here, we propose a broader framework for precision cancer prevention, anchored in optimizing the benefits to harms for all people. We propose that precision cancer prevention considers not only what is being delivered, but also for whom, where, and how, with a goal of achieving cancer prevention health equity.
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Affiliation(s)
- Eboneé N Butler
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD, USA; Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Asad Umar
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Brandy M Heckman-Stoddard
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Kathryn A Kundrod
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Lisa B Signorello
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Philip E Castle
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD, USA; Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA.
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11
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Adherence to follow-up in women with cervical intraepithelial neoplasia grade 1. Taiwan J Obstet Gynecol 2021; 60:56-59. [PMID: 33495009 DOI: 10.1016/j.tjog.2020.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Adherence to follow-up is crucial for cervical intraepithelial neoplasia grade 1 (CIN1) because these women have a chance of progression to high-grade premalignant cervical lesions and cervical cancer. This study aimed to evaluate the rate of adherence to follow-up in women who were initially diagnosed with CIN 1 over a period of 24 months and to evaluate the regression and progression rate of CIN 1. MATERIAL AND METHODS Of 1050 women who visited a colposcopy clinic from October 2013 through March 2017, 138 with histologically proven as CIN 1 were recruited. Adherence to follow-up, the regression and progression rate of CIN 1 were retrospectively assessed. RESULTS Of the 138 women, 86 (62.3%) followed regularly until the study endpoint at 24 months. During the study period, 10 women received ablative treatment. The regression rate in women who had surveillance with cervical cytology was 69.7%, persistent disease of 18.4%, and progression to CIN 2-3 of 11.8%. In contrast, 80% of women who received ablative treatment had regression, 20% of them had persistent disease but none had progression. CONCLUSIONS Nearly 40% of women with CIN 1 were lost to follow-up at 24 months. Adherence to the follow-up should be emphasized to all women. Intensive interventions to improve adherence and clinical outcome might be an option, particularly among women with poor compliance.
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12
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Affordable Care Act and cancer stage at diagnosis in an underserved population. Prev Med 2019; 126:105748. [PMID: 31195020 DOI: 10.1016/j.ypmed.2019.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/06/2019] [Accepted: 06/04/2019] [Indexed: 11/20/2022]
Abstract
The Patient Protection and Affordable Care Act (ACA) has increased insurance coverage among underserved individuals, but the effect of ACA on cancer diagnosis is currently debated, particularly in Medicaid non-expansion states. Therefore, we aimed to assess the effect of ACA implementation on stage at diagnosis among underserved cancer patients in Texas, a Medicaid non-expansion state. We used data from the institutional registry of the JPS Center for Cancer Care, which serves an urban population of underserved cancer patients. Eligible individuals were aged 18 to 64 years and diagnosed with a first primary invasive solid tumor between 2008 and 2015. We used a natural experiment framework and interrupted time-series analysis to assess level (i.e. immediate) and slope (over time) changes in insurance coverage and cancer stage at diagnosis between pre- and post-ACA periods. Our study population comprised 4808 underserved cancer patients, of whom 51% were racial/ethnic minorities. The prevalence of uninsured cancer patients did not immediately change after ACA implementation but modestly decreased over time (PR = 0.94; 95% CL: 0.90, 0.98). The prevalence of early- and advanced-stage diagnosis did not appreciably change overall or when stratified by screen-detectable cancers. Our results suggest that ACA implementation decreased the prevalence of uninsured cancer patients but had little effect on cancer stage at diagnosis in an underserved population. Given that Texas is a Medicaid non-expansion state, Medicaid expansion and alternative approaches may need to be further explored to improve earlier cancer diagnosis among underserved individuals.
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13
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Miller SM, Tagai EK, Wen KY, Lee M, Hui SKA, Kurtz D, Scarpato J, Hernandez E. Predictors of adherence to follow-up recommendations after an abnormal Pap smear among underserved inner-city women. PATIENT EDUCATION AND COUNSELING 2017; 100:1353-1359. [PMID: 28190541 PMCID: PMC5466500 DOI: 10.1016/j.pec.2017.01.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 01/04/2017] [Accepted: 01/30/2017] [Indexed: 05/14/2023]
Abstract
OBJECTIVES This study aimed to identify cognitive-affective predictors of adherence to initial diagnostic colposcopy and 6-month follow-up recommendations among underserved women. METHODS A secondary data analysis was completed of a randomized clinical trial assessing tailored telephone counseling for colposcopy adherence after an abnormal screening Pap smear among 210 underserved inner-city women. RESULTS Adherence to initial diagnostic colposcopy was significantly associated with greater self-efficacy (OR=1.504, 95% CI 1.021-2.216). Women with lower monitoring attentional style had significantly greater adherence to 6-month follow-up recommendations compared to women with higher monitoring scores (OR=0.785, 95% CI 0.659-0.935). CONCLUSION Increasing cervical cancer-related self-efficacy and tailoring cervical cancer risk communication to monitoring attentional style may help improve adherence to follow-up recommendations after an abnormal Pap smear test result. PRACTICE IMPLICATIONS Future research is needed to develop and implement psychosocial approaches to improving adherence to diagnostic colposcopy and follow-up recommendations adherence among underserved women.
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Affiliation(s)
- Suzanne M Miller
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University School of Medicine, 3500 N. Broad Street, Philadelphia, PA, 19140, USA.
| | - Erin K Tagai
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Kuang-Yi Wen
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Minsun Lee
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Siu-Kuen Azor Hui
- Research & Evaluation Group, Public Health Management Corporation, 1500 Market Street, Suite 1500, Philadelphia, PA, 19102, USA
| | - Deirdre Kurtz
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - John Scarpato
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Enrique Hernandez
- Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University School of Medicine, 3500 N. Broad Street, Philadelphia, PA, 19140, USA
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14
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Patient compliance with cervical smear surveillance in a shared-care setting. Int J Gynaecol Obstet 2016; 135:177-181. [DOI: 10.1016/j.ijgo.2016.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/26/2016] [Accepted: 06/27/2016] [Indexed: 11/18/2022]
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Luckett R, Feldman S. Impact of 2-, 4- and 9-valent HPV vaccines on morbidity and mortality from cervical cancer. Hum Vaccin Immunother 2016; 12:1332-42. [PMID: 26588179 PMCID: PMC4964711 DOI: 10.1080/21645515.2015.1108500] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 09/21/2015] [Accepted: 10/10/2015] [Indexed: 01/08/2023] Open
Abstract
Cervical cancer causes significant morbidity and mortality worldwide. Most cervical cancers are associated with oncogenic human papillomavirus (HPV), and vaccination with any of 3 available HPV vaccines is anticipated to greatly reduce the burden of cervical cancer. This review provides an overview of the burden of HPV, the efficacy and clinical effectiveness of the bivalent (HPV 16, 18), quadrivalent (HPV 6, 11, 16, 18) and 9vHPV (HPV 6, 11, 16, 1831, 33, 45, 52, 58) vaccines in order to assess the anticipated impact on cervical cancer. All three vaccines show high efficacy in prevention of vaccine-specific HPV-type infection and associated high-grade cervical dysplasia in HPV-naïve women. Early clinical effectiveness data for the bivalent and quadrivalent vaccine demonstrate reduced rates of HPV 16 and 18 prevalence in vaccinated cohorts; data evaluating cervical dysplasia and cervical procedures as outcomes will shed further light on the clinical effectiveness of both vaccines. The bivalent vaccine has demonstrated cross-protection to non-vaccine HPV types, including the types in the 9vHPV vaccine. No clinical effectiveness data is yet available for the 9vHPV vaccine. While HPV vaccination has great promise to reduce cervical cancer morbidity and mortality, estimated benefits are largely theoretical at present. Large population-based clinical effectiveness studies will provide long-term immunogenicity and effectiveness, as well as assessment of cervical cancer as an endpoint, particularly as young vaccinated women enter the appropriate age range to initiate screening for cervical cancer. Strengthening screening and treatment programs will likely have the greatest impact in the short-term on cervical cancer morbidity and mortality.
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Affiliation(s)
- Rebecca Luckett
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sarah Feldman
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Adherence to Management Recommendations in Patients Diagnosed With Cervical Intraepithelial Neoplasia 2 or 3. J Low Genit Tract Dis 2015; 20:44-6. [PMID: 26461230 DOI: 10.1097/lgt.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the rate of patient adherence to provider recommendations for biopsy proven cervical intraepithelial neoplasia (CIN) 2 or 3 in an academic safety-net hospital. MATERIALS AND METHODS This is a case series of patients with biopsy-proven CIN 2 or 3 identified via pathology records between January 1, 2008 to December 31, 2012 at a single academic safety-net hospital. Patients with human immunodeficiency virus, lupus, or pregnancy were excluded. Patient demographics, recommended management, and patient adherence were extracted from the patient chart. Complete adherence was defined as completion of follow-up recommendations within 6 months of the recommended follow-up date. The primary outcome was rate of complete adherence to management recommendations. Descriptive statistics, univariate analysis, and multivariable logistic regression were performed. RESULTS Six hundred eighty-four patients met inclusion and exclusion criteria. The complete adherence rate was 89% (n = 606). In multivariable analyses, those who completed follow-up were older (mean = 31 vs 29 years; p = .031), more likely to use a long-acting reversible contraceptive or sterilization for contraception (92% vs 87%; p = .036) and more likely to have been recommended excision (90% vs 83%; p = .009). In multivariable analysis, using a long-acting reversible contraceptive or sterilization (odds ratio = 1.75; CI = 1.02-3.0) and the recommendation of any kind of treatment as opposed to expectant management (odds ratio = 3.89; CI = 1.96-7.70) remained significantly associated with complete follow-up. CONCLUSIONS Patients were overall highly adherent to management recommendations when diagnosed with CIN 2 or 3. Those patients recommended to undergo treatment as opposed to observation were more likely to follow up.
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Perinatal High-Grade Cervical Cytology: A Case Series From a Safety Net Institution. J Low Genit Tract Dis 2015; 19:329-32. [PMID: 26247258 DOI: 10.1097/lgt.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the outcomes of women with high-grade cervical cytology in pregnancy and to identify factors that predict completion of appropriate postpartum follow-up. METHODS We describe a case series of all patients with high-grade cervical cytology collected during pregnancy between 2007 and 2011 at a single institution. Patients were considered adherent with follow-up if they received any kind of postpartum evaluation or treatment for their cervical dysplasia at our institution within 9 months of delivery. RESULTS Of 138 women with high-grade cervical cytology in pregnancy, 87 (63%) had high-grade squamous intraepithelial lesion, 47 (34%) had atypical squamous cells that cannot rule out high-grade (ASC-H), and 4 (3%) had atypical glandular cells (AGC). Most patients (81%) underwent colposcopy during pregnancy. A total of 48 patients (43%) had biopsies performed, 26 (54%) were CIN 2 or 3, and one (2%) was adenocarcinoma in situ (AIS). A total of 97 (70%) of 138 patients completed recommended postpartum follow-up, resulting in the detection of one additional case of AIS and one case of invasive adenocarcinoma. Hispanic ethnicity (odds ratio [OR], 3.6; confidence interval [CI], 1.4-9.1), being married (OR, 4.5; CI, 1.6-12.4), being employed (OR, 3.7; CI, 1.3-10.5), and CIN2 or 3 on antenatal biopsy (OR, 9.8; CI, 2.0-47.9) were all significantly associated with completion of postpartum follow-up. CONCLUSION Colposcopy during pregnancy resulted in the detection of one case of AIS. Postpartum evaluation and treatment detected an additional case of AIS as well as one case of invasive cervical adenocarcinoma. Whereas certain demographic characteristics were associated with completion of recommended follow-up, the strongest association is with a high-grade biopsy during pregnancy.
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Luckett R, Pena N, Vitonis A, Bernstein MR, Feldman S. Effect of patient navigator program on no-show rates at an academic referral colposcopy clinic. J Womens Health (Larchmt) 2015; 24:608-15. [PMID: 26173000 DOI: 10.1089/jwh.2014.5111] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patient navigators have been used successfully to guide vulnerable patients through barriers to cancer care and reduce disparities in cancer outcomes. This study evaluated the effect of a patient navigator program on no-show rates at a tertiary care referral colposcopy center and explored factors associated with missed appointments. METHODS No-show rates prior and subsequent to implementation of the intervention were compared by chi-square test. We compared patient demographic, lifestyle, and diagnostic characteristics between patients who had ever and never missed appointments. We described patient-reported barriers to care. RESULTS Of 4,199 women evaluated in our clinic from January 2006 to December 2013, 2,441 (58%) had at least one missed appointment. African American, Hispanic, and publicly insured women tended to miss appointments more frequently than did white and privately insured women (p<0.0001). Patients who missed appointments tended to have more abnormal cytology (p<0.0001), cervical pathology (p=0.007), and vulvar pathology (p=0.001). No-show rates declined from 49.7% to 29.5% after implementation of the patient navigator program (p<0.0001). We found that 45% of patient no-shows were anticipated or a result of patient misunderstanding and could be mediated with targeted education by the patient navigator. CONCLUSIONS Patient navigator programs at referral centers reduce no-show rates, thus improving patient follow-up, which may reduce disparities in cervical cancer screening and treatment.
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Affiliation(s)
- Rebecca Luckett
- 1 Department of Obstetrics and Gynecology, Brigham and Women's Hospital , Boston, Massachusetts
| | - Nancy Pena
- 2 Department of Gynecologic Oncology, Dana Farber Cancer Institute , Harvard Medical School, Boston, Massachusetts
| | - Allison Vitonis
- 1 Department of Obstetrics and Gynecology, Brigham and Women's Hospital , Boston, Massachusetts
| | - Marilyn R Bernstein
- 2 Department of Gynecologic Oncology, Dana Farber Cancer Institute , Harvard Medical School, Boston, Massachusetts
| | - Sarah Feldman
- 1 Department of Obstetrics and Gynecology, Brigham and Women's Hospital , Boston, Massachusetts
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Montella JM, Pelegano JF. Improving the Rate of Colposcopy in an Urban Population of Patients With Known Abnormal Pap Smears. Am J Med Qual 2015; 31:233-9. [PMID: 25614512 DOI: 10.1177/1062860614568648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This project was designed to improve the colposcopy rate in an urban patient population with known abnormal Pap smears within 75 days of the test to rapidly identify and treat premalignant lesions. Using Plan-Do-Study-Act cycles, Lean techniques, and the electronic health record, the authors created a protocol to verify all Pap smears, then created a process whereby a phone-triage team contacted patients with abnormal Pap smears to educate them and schedule colposcopy. As a result, 100% of Pap smears were verified, compared with 95% prior to plan implementation. The mean time from Pap to colposcopy was 38.5 days, with 85% of patients having colposcopy performed after plan implementation, compared with 50% prior-a 70% improvement. If patients with medical contraindications were excluded, the percentage rose to 91%-an 82% improvement. Patient and provider satisfaction improved, staff and provider workload did not increase, and there was the potential for substantial economic savings.
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Affiliation(s)
- Joseph M Montella
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | - James F Pelegano
- Jefferson School of Population Health of Thomas Jefferson University, Philadelphia, PA
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Miller SM, Hui SKA, Wen KY, Scarpato J, Zhu F, Buzaglo J, Hernandez EE. Tailored telephone counseling to improve adherence to follow-up regimens after an abnormal pap smear among minority, underserved women. PATIENT EDUCATION AND COUNSELING 2013; 93:488-95. [PMID: 24007767 PMCID: PMC3852173 DOI: 10.1016/j.pec.2013.08.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 07/25/2013] [Accepted: 08/11/2013] [Indexed: 05/03/2023]
Abstract
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.
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Affiliation(s)
- Suzanne M Miller
- Department of Psychosocial and Behavioral Medicine, Fox Chase Cancer Center/Temple University Health System, USA.
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Factors affecting compliance in the first year of postcolposcopy surveillance among women with a high incidence of cervical cancer. Int J Gynaecol Obstet 2013; 124:160-3. [DOI: 10.1016/j.ijgo.2013.07.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/18/2013] [Accepted: 10/02/2013] [Indexed: 11/22/2022]
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