Improving Adherence to Abnormal Pap Smear Follow-Up

Failure to follow up abnormal test results associated with cervical cancer in primary and ambulatory care: a systematic review

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.

Development of a text message-based intervention for follow-up colposcopy among predominately underserved Black and Hispanic/Latinx women

PURPOSE

Underserved Black and Hispanic/Latinx women show low rates of follow-up care after an abnormal Pap test, despite the fact that cervical cancer is one of the few preventable cancers if detected early. However, extant literature falls short on efficacious interventions to increase follow-up for this population. A concurrent mixed methods study was completed to evaluate the acceptability of a text message-based intervention and identify perceived barriers and facilitators to follow-up after an abnormal Pap test among underserved predominantly Black and Hispanic/Latinx women.

METHODS

Patients who completed follow-up for an abnormal Pap test were recruited to complete a cross-sectional survey, qualitative interview assessing barriers and facilitators to follow-up, and text message content evaluation (N = 28). Descriptive statistics were performed to describe background variables and to evaluate the acceptability of text messages. A directed content analysis was completed for the qualitative interviews.

RESULTS

Participants expressed interest in a text message-based intervention to increase abnormal Pap test follow-up. In the qualitative interviews, low knowledge about cervical risk and negative affect toward colposcopy/test results were identified as barriers to follow-up. Facilitators of follow-up included feeling relieved after the colposcopy and adequate social support. Participants rated the text messages as understandable, personally relevant, and culturally appropriate.

CONCLUSION

The findings suggest that underserved Black and Hispanic/Latinx women experience cognitive and emotional barriers that undermine their ability to obtain follow-up care and a text message-based intervention may help women overcome these barriers. Future research should develop and evaluate text message-based interventions to enhance follow-up after an abnormal Pap test.

Psychometric Testing of Papanicolaou Testing Barriers and Self-efficacy Scales Among Black Women

BACKGROUND

Black women face cervical cancer disparities with higher rates of morbidity and mortality compared with White women. Identifying predictors of Papanicolaou (Pap) testing is a first step to decrease morbidity and mortality from cervical cancer, with barriers and self-efficacy being constructs that should be related to Pap testing adherence. Although barriers and self-efficacy scales have been developed, they have not been validated in Black women for Pap testing.

OBJECTIVE

The purpose of this study was to modify and psychometrically test barriers and self-efficacy to Pap testing in a Black population.

INTERVENTION/METHODS

Data were collected from a minority health fair. Internal consistency reliability testing was conducted using item analysis and Cronbach's α. Construct validity was assessed by exploratory factor analysis and logistic regression. Papanicolaou testing adherence was regressed on each scale (barriers and self-efficacy) while controlling for antecedents.

RESULTS

Data demonstrated 2 reliable scales: (1) barriers (Cronbach's α = .79), item-total correlation = 0.479 to 0.628; and (2) self-efficacy (Cronbach's α = .85), item-total correlation = 0.560 to 0.697. Exploratory factor analysis supported 2 unidimensional scales. The regression models supported a relationship between each scale and Pap testing adherence.

CONCLUSIONS

The data suggested barriers and self-efficacy scales were reliable and valid among Black women. Barriers and self-efficacy could be tailored in future interventions to increase Pap testing adherence.

IMPLICATIONS FOR PRACTICE

Nurses could use responses to these scales for framing discussions about Pap testing.

Outcomes by Race Among Women Referred to an Academic Colposcopy Clinic with a Patient Navigation Program

Background: Although minority women are at higher risk of cervical cancer in the United States, little is known about differences in rates of colposcopy and loop electrosurgical excision procedure (LEEP) by race once patients present for care. Materials and Methods: A prospective registry of patients presenting to an academic colposcopy clinic was queried from 2008 to 2018. Women with missing race or cytology results, prior hysterectomy, or prior history of cervical, vulvar, or vaginal cancer were excluded. Poisson and logistic regression models were performed to evaluate the associations between race and colposcopy, LEEP, and cancer rates, adjusting for referral Papanicolaou (Pap), human papillomavirus (HPV) result, year of visit, age, insurance, pregnancy, number of sexual partners, and smoking status. Results: A total of 4506 women were included (56.1% white and 43.9% non-white). Referral for high-grade cytology was more likely among white compared to non-white women (22.5% vs. 17.5%, p < 0.001), as well as positive HPV testing (white 7.8% vs. non-white 6.0%, p < 0.001). The colposcopy rate was slightly higher among black (incidence rate ratio [IRR]_adjusted 1.11, 95% confidence interval [CI] 1.03-1.19, p = 0.006) and Hispanic women (IRR_adjusted 1.13, 95% CI 1.06-1.21, p = 0.0003) compared to white women. Hispanic women were significantly more likely to undergo LEEP (odds ratio_adjusted 1.26, 95% CI 1.01-1.58, p = 0.04). However, no significant difference in cancer, adenocarcinoma in situ, or high-grade histology was noted by race. Conclusions: Black and Hispanic women referred for abnormal Pap or HPV results underwent a greater number of colposcopies compared to white women, and Hispanic women underwent a greater number of LEEPs. Although cancer is rare in our cohort, there was no statistical difference in rate of cancer by race.

Effects of HIV status on non-metastatic cervical cancer progression among patients in Lusaka, Zambia

INTRODUCTION

Sub-Saharan Africa has the highest global incidence of cervical cancer. Cervical cancer is the most common cause of cancer morbidity and mortality among women in Zambia. HIV increases the risk for cervical cancer and with a national Zambian adult HIV prevalence of 16%, it is important to investigate the impact of HIV on the progression of cervical cancer. We measured differences in cervical cancer progression between HIV-positive and HIV-negative patients in Zambia.

METHODS

This study included 577 stage I and II cervical cancer patients seen between January 2008 and December 2012 at the Cancer Diseases Hospital in Lusaka, Zambia. The inclusion criteria for records during the study period included known HIV status and FIGO stage I and II cervical cancer at initial date of registration in the Cancer Diseases Hospital. Medical records were abstracted for clinical and epidemiological data. Cancer databases were linked to the national HIV database to assess HIV status among cervical cancer patients. Logistic regression examined the association between HIV and progression, which was defined as metastatic or residual tumor after 3 months of initial treatment.

RESULTS

A total of 2451 cervical cancer cases were identified, and after exclusion criteria were performed the final analysis population totaled 537 patients with stage I and II cervical cancer with known HIV status (224 HIV-positive and 313 HIV-negative). HIV-positive women were, on average, 10 years younger than HIV-negative women who had a median age of 42, ranging between 25 and 72. A total of 416 (77.5%) patients received external beam radiation, and only 249 (46.4%) patients received the recommended treatment of chemotherapy, external beam radiation, and brachytherapy. Most patients were stage II (85.7%) and had squamous cell carcinoma (74.7%). HIV-positive patients were more likely to receive lower doses of external beam radiation than HIV-negative patients (47% vs 37%; P<0.05, respectively). The median total dose of external beam radiation for HIV-positive and HIV-negative patients was 46 Gy and 50 Gy, respectively. HIV positivity did not lead to tumor progression (25.4% in HIV-positive vs 23.9% in HIV-negative, OR 1.04, 95% CI [0.57, 1.92]). However, among a subset of HIV-positive patients, longer duration of infection was associated with lower odds of progression.

CONCLUSION

There was no significant impact on non-metastatic cervical cancer progression by HIV status among patients in Lusaka, Zambia. The high prevalence of HIV among cervical cancer patients suggest that HIV-positive patients should be a primary target group for HPV vaccinations, screening, and early detection.

Reimbursement Incentives to Improve Adherence to Follow-Up of Cervical Cancer Cytology Screening Results in Peru

OBJECTIVE

The purpose of this study was to determine Peruvian women's attitudes toward novel reimbursement incentives used to improve adherence to obtaining cervical cytology test results.

MATERIALS AND METHODS

Women presenting for cervical cancer screening in Peru completed a 34-item Investigational Review Board-approved questionnaire. The questionnaire determined their attitudes toward various reimbursement incentives to improve adherence to obtaining cervical cytology results. Descriptive statistics, generalized linear models, and Kruskal-Wallis tests were used in the analyses.

RESULTS

Completed questionnaires were available for 997 women. Most women (51%) would be more likely to return for their Pap result if an incentive was provided, 79% (759/956) agreed that they would pay for the Pap test, and 51% (402/859) would be willing to pay 10 Soles or less. Quechua-speaking women considered follow-up more difficult (p < .0001) but were less likely to return for their Pap results (p < .0001), pay for the Pap test (p < .0001), and afford paying more than 5 Soles (p < .0001) than women who spoke Spanish or both languages. More women who earn 1000 Soles/year or less would likely return if incentivized (p < .0001), felt the incentive would help them remember to return (p = .0047), and would be willing to pay whether there was a rebate (p = .010) as compared with women earning more money.

CONCLUSIONS

A reimbursement incentive program designed to improve follow-up of cervical cytology test results was acceptable to most Peruvian women. Such a behavioral-modifying program may improve patient follow-up after cervical cytology testing. Implementation may reduce the morbidity and mortality of cervical cancer in remote regions of the country.

Challenges to Pap Smear Follow-up among Women in the Criminal Justice System

Women involved in the United States criminal justice system face a variety of challenges in maintaining their health. Histories of sexual abuse, early initiation of sex, and substance abuse are reflected in more negative reproductive health outcomes, including cervical cancer, than those found among non-incarcerated women. Little is known about how to close this health gap. The present study assessed what incarcerated women perceived to be facilitators and inhibitors of obtaining recommended follow-up for abnormal Pap tests. In-depth individual interviews were conducted with 44 women in an urban county jail about experiences with Pap tests and how they followed-up on abnormal results. We analyzed data using the process of thematic content analysis. Four themes were found, Pap test abnormality as an all-inclusive phrase for women's health problems, unstable lives, the structural challenges of money, and competing demands. Women with criminal justice histories have numerous and complex challenges in following-up abnormal Pap test results, as well as other health problems. Understanding the context around the follow-up for abnormal Pap tests in this population may increase providers' ability to help women effectively obtain cancer prevention care that can be life-saving, as well as to more effectively provide care for other health problems.

Barriers to Follow-Up for Abnormal Papanicolaou Smears among Female Sex Workers in Lima, Peru

BACKGROUND

Cervical cancer is the most prevalent cancer among Peruvian women. Female sex workers (FSW) in Peru are at elevated risk for HPV infection, and receive annual Papanicolaou screening. The objective of this study was to identify barriers to follow-up for abnormal Pap smears among FSW in Peru.

METHODS

97 FSW attending the Alberto Barton Health Center in Lima were surveyed regarding their STI screening history. 17 women with a history of an abnormal Pap smear were interviewed about their experiences regarding follow-up care.

RESULTS

Of the 27 HPV-positive women, only 8 (30%) received follow-up treatment. Of the 19 women who did not receive follow-up, 7 (37%) had not been informed of their abnormal result. Qualitative interviews revealed that the major barrier to follow-up was lack of knowledge about HPV and potential health consequences of an abnormal Pap smear.

CONCLUSION

HPV infection is highly prevalent in Peruvian FSW, yet only 30% of FSW with abnormal Pap smears receive follow-up care. The predominant barriers to follow-up were lack of standardization in recording and communicating results and insufficient FSW knowledge regarding health consequences of HPV infection. Standardization of record-keeping and distribution of educational pamphlets have been implemented to improve follow-up for HPV.

Monitoring drug adherence

TOPIC

Medication nonadherence is prevalent in transplant recipients and is a major reason for graft loss. The present review discusses the measurement of adherence in transplant recipients and strategies to improve adherence. SOURCES REVIEWED: Since adherence research is not confined to transplant recipients, our literature review included studies relevant to transplant recipients as well as adherence to medical recommendations more generally. We reviewed manuscripts in the English language indexed in PubMed Central, as well as ancillary sources of information such as textbook chapters that are not indexed.

CONCLUSION

There is no consensus in the literature about an optimal way to monitor adherence, nor is there agreement about a preferred management strategy. Until definitive studies demonstrate the effectiveness of intervention strategies, knowledge of the monitoring as well as intervention methods that are described in this review is expected to give practitioners the initial tools to deal with nonadherence as an important aspect of patient care.

Improving the Rate of Colposcopy in an Urban Population of Patients With Known Abnormal Pap Smears

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.

Psychosocial barriers to follow-up adherence after an abnormal cervical cytology test result among low-income, inner-city women

OBJECTIVES

Low-income, inner-city women bear a disproportionate burden of cervical cancer in both incidence and mortality rates in the United States, largely because of low adherence to follow-up recommendations after an abnormal cervical cytology result in the primary care setting. The goals of the present study were to delineate the theory-based psychosocial barriers underlying these persistent low follow-up rates and their sociodemographic correlates.

METHODS

Guided by a well-validated psychosocial theory of health behaviors, this cross-sectional, correlational study assessed the barriers to follow-up adherence among underserved women (N = 210) who received an abnormal cervical cytology result. Participants were recruited through an inner-city hospital colposcopy clinic, and were assessed by telephone prior to the colposcopy appointment.

RESULTS

Participants were largely of African American race (82.2%), lower than high school completion education (58.7%), single, never married (67.3%), and without full-time employment (64.1%). Knowledge barriers were most often endorsed (68%, M = 3.22), followed by distress barriers (64%, M = 3.09), and coping barriers (36%, M = 2.36). Forty-six percent reported more than one barrier category. Less education and being unemployed were correlated with higher knowledge barriers (P < .0001 and P < .01, respectively) and more coping barriers (P < .05 and P < .05, respectively). Women who were younger than 30 years displayed greater distress barriers (P < .05).

CONCLUSION

In the primary care setting, assessing and addressing knowledge and distress barriers after feedback of an abnormal cervical cytology result may improve adherence to follow-up recommendations. The use of structured counseling protocols and referral to navigational and other resources may facilitate this process and thereby reduce disparities in cervical cancer.

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.

Evaluation of therapeutic care delay among Latina- and European-American cervical cancer survivors

OBJECTIVES

Cervical cancer (CCA) ranks among the deadliest of cancers. Globally CCA claims 275,000 lives yearly. Severe delays, in cancer diagnostic or therapeutic care, that approach ≥ 60 days negatively affect survival and survivorship outcomes. This study investigated socioeconomic and healthcare system factors influencing therapeutic care delays among cervical cancer survivors (CCS).

METHODS

291 CCS (132 European-, 50 English-proficient (EP) Latina- and 109 limited English-proficient (LEP) Latina-Americans) were recruited from cancer registries. CCS retrospectively noted the days of delay in obtaining therapeutic care and reasons for delays.

RESULTS

CCS who were LEP Latina-Americans, had lower income and education reported severe therapeutic delays (≥ 60 days). LEP Latina-Americans experienced delays due to financial issues, doctor's delay, and healthcare system issues (p < 0.001). Doctor and healthcare system delays significantly influenced therapeutic care delay in the logistic regression model.

CONCLUSIONS

Healthcare system delays are primary contributors to ethnic differences in access to appropriately-timed care observed in this study. Healthcare professionals need to develop a fuller appreciation of the multilevel factors that contribute to healthcare barriers to better inform effective interventions to increase access to life saving care.

Updates on human papillomavirus and genital warts and counseling messages from the 2010 Sexually Transmitted Diseases Treatment Guidelines

BACKGROUND

In April 2009, experts on sexually transmitted diseases (STDs) were convened to review updates on STD prevention and treatment in preparation for the revision of the Centers for Disease Control and Prevention (CDC) STD Treatment Guidelines. At this meeting, there was a discussion of important updates on human papillomavirus (HPV), genital warts, and cervical cancer screening.

METHODS

Key questions were identified with assistance from an expert panel, and systematic reviews of the literature were conducted searching the English-language literature of the PubMed computerized database (US National Library of Medicine). The available evidence was reviewed, and new information was incorporated in the 2010 CDC STD Treatment Guidelines.

RESULTS

Two HPV vaccines are now available, the quadrivalent HPV vaccine and the bivalent HPV vaccine; either vaccine is recommended routinely for girls aged 11 or 12 years. The quadrivalent HPV vaccine may be given to boys and men aged 9-26 years. A new patient-applied treatment option for genital warts, sinecatechins 15% ointment, is available and recommended for treatment of external genital warts. This product is a mixture of active ingredients (catechins) from green tea. Finally, updated counseling guidelines and messages about HPV, genital warts, and cervical cancer are included.

CONCLUSIONS

This manuscript highlights updates to the 2010 CDC STD Treatment Guidelines for HPV and genital warts. Important additions to the 2010 STD Treatment Guidelines include information on prophylactic HPV vaccine recommendations, new patient-applied treatment options for genital warts, and counseling messages for patients on HPV, genital warts, cervical cancer screening, and HPV tests.

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.

Determinants of adequate follow-up of an abnormal Papanicolaou result among Jamaican women in Portland, Jamaica

BACKGROUND

Among Jamaican women, cervical cancer is the second leading cause of cancer mortality but factors that facilitate follow-up of women receiving abnormal Pap smear results are not known. We examined whether socio-demographic factors, factors reported by the women, and assistance received for follow-up facilitate adequate follow-up of abnormal Pap smears.

METHODS

One hundred and twenty-one women who had abnormal Pap results during June 1998-September 2005 in Portland, Jamaica were interviewed to identify determinants of adequate follow-up. Chi-square, t-test and multivariable logistic regression analysis were used to identify determinants.

RESULTS

Only half of the women in this sample sought adequate follow-up. These women had a lower number of surviving children, higher monthly income, and perceived the cost of services to be inexpensive. Advice about the timing of the follow-up activity and the next step to take by the healthcare workers were significant determinants of adequate follow-up. Women who received advice on the timing of follow-up were almost six times (adjusted OR: 5.99, 95% CI: 1.17, 30.66, p<0.05) more likely to seek adequate follow-up after adjusting for other factors.

CONCLUSIONS

Perceived low cost of services as well as assistance provided by healthcare workers regarding follow-up action helps to facilitate adequate follow-up of abnormal Pap smear results.

Factors in quality care--the case of follow-up to abnormal cancer screening tests--problems in the steps and interfaces of care

To achieve the benefit of cancer screening, appropriate follow-up of abnormal screening test results must occur. Such follow-up requires traversing the transition between screening detection and diagnosis, including several steps and interfaces in care. This article reviews factors and interventions associated with follow-up of abnormal tests for cervical, breast and colorectal cancers. We synthesized 12 reviews of descriptive and intervention studies published between 1980 and 2008. There was wide variability in definition of follow-up, setting, study population, and reported prevalence rates. Correlates of follow-up included patient characteristics (eg, knowledge and age), social support, provider characteristics, practice (eg, having reminders systems), community and professional norms (eg, quality measures), and policy (eg, federal programs). Effective interventions included patient education and support; delivery systems design changes, such as navigation; and information system changes, most notably patient tracking and physician reminders. Few studies focused explicitly on interfaces and steps of care, such as communication between primary care and specialists, or simultaneously targeted the multilevel factors that affect care. Future practice and research priorities should include development of clear operational definitions of the steps and interfaces related to patients, providers, and organizations; reflect evolving guidelines and new technologies; determine priorities for intervention testing; and improve measures and apply appropriate study designs.

Family planning provider referral, facilitation behavior, and patient follow-up for abnormal Pap smears

OBJECTIVES

Family planning (FP) clinics are important access points for cervical cancer screening and referrals for follow-up care for abnormal Papanicolaou (Pap) smears for a substantial number of U.S. women. Because little is known about referral and facilitation practices in these clinics or client action based on referrals, we sought to determine FP provider referral and facilitation practices when seeing FP clients with abnormal Pap smear results, and FP client follow-up for abnormal Pap smears due to FP provider referrals.

METHODS

We conducted a mail survey of Medicaid-enrolled FP providers in Arkansas and Alabama, and conducted a telephone survey with a sample of FP clients of those providers responding to the provider survey.

RESULTS

Major provider factors associated with referral included rural location, health department and clinic institutional setting, large Title X practice/clinic size, and high FP clinic focus. Major factors associated with facilitation included rural location, non-physician specialty, health department and clinic institutional setting, and small Title X clinic size. Of women reporting abnormal results, 62.4% reported follow-up care. Of those who received follow-up care, 40.0% received some care and a referral from their FP provider. A major factor associated with clients seeking follow-up care was being told by their FP provider where to go for follow-up care. Age was a major factor associated with clients actually obtaining follow-up care.

CONCLUSIONS

Where follow-up care is not available at the FP site, referrals are critical and are a major factor associated with whether women seek care for the condition. Interventions to increase follow-up rates should focus on provider and system features, rather than clients.

Adherence characteristics after abnormal screening results between mammogram and Papanicolaou test groups

The purpose of this study was to evaluate whether the adherence concerns related to follow-up were different between groups of women after abnormal screening results of mammography (Mam) and Papanicolaou (Pap) test. Taiwanese women with abnormal Mam screening results (n = 42) and abnormal Pap test results (n = 109) provided data via a self-administered survey. Data were collected in 2005. After providing informed consent, women completed the AFAR, an 18 item questionnaire that measured the Adherence concerns of Follow-up after Abnormal screening Results. The results showed that (1) for both Mam and Pap test groups, the most important adherence concern for clinical follow-up after abnormal screening results is disease related, followed by others' response and resource accessibility; and (2) in these 2 clinical follow-up groups, women in the Mam group were more likely to be concerned with all of the 18 adherence factors than those in the Pap test group (OR, 2.46-9.86). The most important adherence concern on clinical follow-up after abnormal screening results for Mam and Pap test women is disease related. Mammography women considered significantly more adherence concerns than Pap test women. These differences imply that improving follow-up after Mam or Pap screen may require different interventions.

Male partner involvement in reducing loss to follow-up after cervical cancer screening in Uganda

OBJECTIVE

To evaluate the efficacy of male partner involvement in reducing loss to follow-up among women in Uganda referred for colposcopy after a positive cervical cancer-screening test.

METHODS

In 2 family-planning/postnatal clinics at Mulago Hospital, Kampala, Uganda, 5094 women were screened for cervical lesions. Those who screened positive were referred for colposcopy; half were allocated to the intervention group and half to the control group. In the intervention group, information about the screening findings and a request to assist their partner in attending the next examination were sent to male partners. In the control group, a standard service was provided, which did not include a letter to the male partner. Logistic regression models were applied to calculate the probability of women returning for colposcopy.

RESULTS

Of the 834 women referred, 209 (25%) did not return for colposcopy: 143/419 (34%) from the control group and 66/415 (16%) from the intervention group. Women in the intervention group were more likely to return (odds ratio 2.8; 95% confidence interval, 1.9-3.9).

CONCLUSION

Male partner involvement significantly reduced loss to follow-up among women referred for colposcopy.

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.

Impact of targeted financial incentives on personal health behavior: a review of the literature

Over the past decade, there has been a substantial increase in the use of financial incentives by private employers and public programs to encourage healthy behaviors, wellness activities, and use of preventive services. The research evidence regarding the effectiveness of this approach is reviewed, summarizing relevant findings from literature reviews and from recent evaluations. The article concludes that financial incentives, even relatively small incentives, can influence individuals' health-related behaviors. However, the findings regarding health promotion and wellness are based primarily on analyses of a limited number of private sector initiatives, whereas the evidence regarding preventive services is based on evaluations of initiatives sponsored predominantly by public programs and directed at low-income populations. In either case, there are several important limitations in the ability of the published findings to provide clear guidance for public program administrators or private purchasers seeking to design and implement effective incentive programs.

Three-year follow-up study of women who participated in a cervical cancer screening intervention while in prison

OBJECTIVE

This study describes rescreening following a prison cervical cancer screening intervention: the numbers of women who received rescreening during the three-year follow-up period; their timing of rescreening in relationship to intervention follow-up recommendations; and socio-demographic factors associated with rescreening.

METHODS

Socio-demographic information was collected from Corrections Branch records. Clinical and risk factor information was obtained by a self-administered questionnaire. Pap screening histories were collected from Cervical Cancer Screening Program (CCSP) client records using the client ID number for Pap smears taken during the intervention period, during the three-year follow-up period, and during the 30-month period preceding the intervention period. Results were entered in Excel and responses summarized with frequency tables; bivariate analysis of categoric variables was done using chi-square tests of independence.

RESULTS

During the three-year follow-up period, only 28 (21%) of 138 women who participated in a prison cervical cancer screening intervention were rescreened within 6 months of the recommendation received at intervention Pap test. Women with fewer than 5 multiple names (aliases) were more likely to be rescreened (p = 0.02). Educational level approached statistical significance (p = 0.05), with women with least education receiving highest rescreening. There was no relationship between rescreening and ethnicity, injection drug use, having borne children and current methadone treatment.

CONCLUSION

Only 50% of women who participated in a specifically designed prison screening intervention were rescreened during the subsequent three years. Further work is needed to design, implement and evaluate follow-up initiatives of community cervical cancer screening programs for women who are at higher risk of developing cervical dysplasia.

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.

Frequency of Gynecologic Follow-Up and Cervical Cancer Screening in the Swiss HIV Cohort Study

BACKGROUND

According to current recommendations, HIV-infected women should have at least 1 gynecologic examination per year.

OBJECTIVES

To analyze factors associated with frequency of gynecologic follow-up and cervical cancer screening among HIV-infected women followed in the Swiss HIV Cohort Study (SHCS).

METHODS

Half-yearly questionnaires between April 2001 and December 2004. At every follow-up visit, the women were asked if they had had a gynecologic examination and a cervical smear since their last visit. Longitudinal models were fitted with these variables as outcomes.

RESULTS

A total of 2186 women were included in the analysis. Of the 1146 women with complete follow-up in the SHCS, 35.3% had a gynecologic examination in each time period, whereas 7.4% had never gone to a gynecologist. Factors associated with a poor gynecologic follow-up were older age, nonwhite ethnicity, less education, underweight, obesity, being sexually inactive, intravenous drug use, smoking, having a private infectious disease specialist as a care provider, HIV viral load <400 copies/mL, and no previous cervical dysplasia. No association was seen for living alone, CD4 cell count, and positive serology for syphilis.

CONCLUSIONS

Gynecologic care among well-followed HIV-positive women is poor and needs to be improved.

The health care costs of cervical human papillomavirus--related disease

OBJECTIVE

The purpose of this study was to examine the health care costs of cervical human papillomavirus-related disease in a US health care setting.

STUDY DESIGN

We conducted an observational cohort study using 1997 through 2002 administrative and laboratory records from 103,476 female enrollees of the Kaiser Permanente Northwest health plan (Portland, Ore). We examined the cost per case and annual cost per 1000 enrollees for cervical human papillomavirus-related events.

RESULTS

A cervical examination with a normal routine papanicolaou smear incurred costs of 57 dollars (95% CI, 57-57). Costs that were associated with abnormal routine screening diagnoses ranged from 299 dollars for atypical squamous cells (95% CI, 245-352) to 2349 dollars for high-grade squamous intraepithelial lesion (95% CI, 1,047-3,650). The costs of histologically confirmed cervical intraepithelial neoplasia ranged from 1026 dollars for cervical intraepithelial neoplasia 1 (95% CI, 862-1191) to 3235 dollars for cervical intraepithelial neoplasia 3 (95% CI, 2051-4419); a cost of 376 dollars (95% CI, 315-436) was associated with false-positive test results. At the level of the health plan, overall annual cervical cancer prevention and treatment costs were 26,415 dollars per 1000 female enrollees, with routine cervical cancer screening accounting for expenditures of 16,746 dollars per 1000 female enrollees, cervical intraepithelial neoplasia accounting for expenditures of 4535 dollars per 1000 female enrollees, cervical cancer accounting for expenditures of 2629 dollars per 1000 female enrollees, and false-positive test results accounting for expenditures of 2394 dollars per 1000 female enrollees.

CONCLUSION

These are the first direct estimates of both individual and population level costs of cervical human papillomavirus-related disease in a general US health care setting. Routine cervical cancer screening comprises nearly two thirds of total annual cervical human papillomavirus-related health care costs, with 10% of expenditures dedicated to the treatment of invasive cervical cancer, 17% to the management of cervical precancers, and 9% to dealing with false-positive Papanicolaou test results.

Perceived barriers and benefits to cervical cancer screening in Latin America

BACKGROUND

This article describes the results of studies on the barriers and benefits of cervical cancer screening from the perspective of women, men, and health providers in five Latin American countries and compares them to other findings from the literature.

METHODS

Five separate qualitative studies (focus groups and interviews) were conducted among low-income women in Venezuela, Ecuador, Mexico, El Salvador, and Peru regarding barriers and benefits of cervical cancer screening. Views from health providers and men were also included.

RESULTS

The main barriers identified by all participants are accessibility and availability of quality services, facilities that lack comfort and privacy, costs, and courtesy of providers, which interact with poor service delivery. Barriers that pertain to women's beliefs are anxiety borne by women awaiting test results, associated with negligence and fear of cancer (although not to a particular cancer or a particular procedure). Benefits of screening are peace of mind and being in control of their health, which then enable other life activities to continue unhindered.

CONCLUSIONS

Except for the accessibility and availability of quality services, these results are consistent with findings from other studies in developed and developing countries. Barriers could be lifted if health service delivery was enhanced, for instance, through quality improvement techniques that are available at low cost. Women's anxiety over test results still needs to be further assessed to devise risk communication strategies that take into account broader cultural frameworks. It is to be noted that such strategies should permeate the way health services are provided for cervical cancer prevention regardless of the specific test used. Vulnerability perceived by low-income women with respect to their capacity to cope with diseases and trust the health services and how this affects their perceptions of risk and their behaviors have not been studied as yet.

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.

Management of women with cervical cancer precursor lesions

An understanding of the natural history of HPV-induced precancer and cancer, and of the immune response to HPV and to these lesions, has significantly changed the management of lower genital tract neoplasia. New management guidelines incorporate this understanding, providing a more rational approach to diagnosis and treatment. Understanding that low-grade HPV-induced lesions are not true cervical cancer precursor has fostered expectant management of women with these lesions; however, management approaches are still hampered by the inability to better predict who is at risk for high-grade intraepithelial neoplasia and cancer and who is not; this is particularly problematic in the expectant management of CIN 1. In addition, the decision whether or not to treat these low-grade lesions may depend on a number of complex factors that take into account the woman's preferences and reliability for follow-up, as well as a host of issues related to costs and the reliability of the original diagnosis and the tests used for follow-up. Management options for high-grade cervical cancer precursor lesions are much more definitive, because the option of expectant management is given except in pregnancy and for adolescents with CIN 2. New markers that better predict which women with high-risk HPV are at highest risk for subsequent development of a true cervical cancer precursor lesion appear to be on the horizon and may make the management of low-grade lesions as clear as present guide lines for their high-grade cousins. Until that time, understanding all the issues involved in expectant and in active management of cervical HPV-induced lesions will help provide women with the best care possible.

Barreras percibidas por el personal de salud para la toma de la citología cervical en mujeres zapotecas de Juchitán, Oaxaca

Antecedentes: El cáncer cervicouterino (CaCU) representa un problema de salud pública en México. Las mujeres indígenas presentan mayor riesgo de morir por esta enfermedad. El estudio sobre las barreras que afronta la población indígena mexicana para la toma de la citología cervical es escaso. Propósitos: Objetivo: Identificar las barreras estructurales, psicosociales y culturales percibidas por el personal de salud para la toma de la citología cervical en mujeres juchitecas. Método: Tipo de estudio: exploratorio-descriptivo de corte cualitativo. Se aplicaron entrevistas semiestructuradas a personal sanitario de centros de salud públicos y privados de Juchitán. Muestreo intencional por cuotas, 9 participantes, 7 clínicas elegidas al azar. Se realizó análisis de contenido. Resultados: Se identificaron barreras estructurales, psicosociales y culturales. Las principales: tardanza en entrega de resultados, falta de material, espacios para la toma y recursos humanos, alto nivel de desinformación sobre la prueba y la enfermedad, miedo a tener algo “malo” y al dolor, el tabú de la sexualidad, la actitud de la pareja hacia la prueba, prejuicios y falta de traductores que apoyen en la comunicación entre las mujeres y el personal del sistema de salud. Conclusiones: Existe desinformación sobre el CaCu y su detección oportuna en esta población; hay múltiples barreras de tipo estructural, prejuicios y mitos rodean la enfermedad. Se detectó desinterés por parte del sistema de salud en la promoción de programas preventivos del CaCu. Informar a la población en su lengua, cuidar y ser empáticos ante la exposición del cuerpo y diseñar políticas de salud incluyentes, son aspectos fundamentales a considerar y desarrollar en programas locales.