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Gopalani SV, Sawaya GF, Rositch AF, Dasari S, Thompson TD, Mix JM, Saraiya M. The Impact of Adjusting for Hysterectomy Prevalence on Cervical Cancer Incidence Rates and Trends Among Women Aged 30 Years and Older - United States, 2001-2019. Am J Epidemiol 2024:kwae041. [PMID: 38583940 DOI: 10.1093/aje/kwae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
Hysterectomy protects against cervical cancer when the cervix is removed. However, measures of cervical cancer incidence often fail to exclude women with a hysterectomy from the population at risk denominator, underestimating and distorting disease burden. In this study, we estimated hysterectomy prevalence from the Behavioral Risk Factor Surveillance System surveys to remove the women who were not at risk of cervical cancer from the denominator and combined these estimates with the United States Cancer Statistics data. From these data, we calculated age-specific and age-standardized incidence rates for women aged >30 years from 2001-2019, adjusted for hysterectomy prevalence. We calculated the difference between unadjusted and adjusted incidence rates and examined trends by histology, age, race and ethnicity, and geographic region using Joinpoint regression. The hysterectomy-adjusted cervical cancer incidence rate from 2001-2019 was 16.7 per 100,000 women-34.6% higher than the unadjusted rate. After adjustment, incidence rates were higher by approximately 55% among Black women, 56% among those living in the East South Central division, and 90% among women aged 70-79 and >80 years. These findings underscore the importance of adjusting for hysterectomy prevalence to avoid underestimating cervical cancer incidence rates and masking disparities by age, race, and geographic region.
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Affiliation(s)
- Sameer V Gopalani
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, United States
| | - George F Sawaya
- Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States
| | - Anne F Rositch
- Health Outcomes and Real-World Evidence, Hologic, Inc., Baltimore, Maryland, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Sabitha Dasari
- Cyberdata Technologies, Inc., Herndon, Virginia, United States
| | - Trevor D Thompson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Jacqueline M Mix
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, United States
| | - Mona Saraiya
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
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Holt HK, Martinez G, Reyes MF, Saraiya M, Qin J, Sawaya GF. Tubal Sterilization and Cervical Cancer Underscreening in the United States. J Womens Health (Larchmt) 2024. [PMID: 38502830 DOI: 10.1089/jwh.2023.0610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
Background: Tubal sterilization is more commonly utilized by racial/ethnic minority groups and has been implicated in underscreening for cervical cancer. The objective is to determine if prior tubal sterilization is a risk factor for cervical cancer underscreening. Methods: National Survey of Family Growth dataset from 2015 to 2019 used for analysis; data were weighted to represent the 72 million women in the U.S. population aged 22-49. Chi-square tests, Fisher exact tests, and logistic regression were used for analysis. The primary predictor variable was tubal sterilization which was categorized into no previous sterilization, sterilization completed <5 years ago, and sterilization completed ≥5 years ago. The outcome variable was underscreened versus not underscreened. Other predictor variables included age, household income as a percent of federal poverty level, previous live birth, primary care provider, and insurance status. Results: Prevalence of tubal sterilization completed 5 or more years ago was 12.5% and varied by most measured characteristics in univariate analyses. Approximately 8% of women were underscreened for cervical cancer. In multivariable analyses, women with a tubal sterilization 5 or more years ago had 2.64 times the odds (95% confidence interval = 1.75-4.00) of being underscreened for cervical cancer compared with women who did not have a tubal sterilization. Conclusions: Approximately 4.3 million women ages 22-49 in the United States are potentially underscreened for cervical cancer and women with previous tubal ligation ≥5 years ago are more likely to be underscreened. These results may inform the need for culturally sensitive public health messages informing people who have had these procedures about the need for continued screening.
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Affiliation(s)
- Hunter K Holt
- Department of Family and Community Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gladys Martinez
- Reproductive Statistics Branch, National Center for Health Statistics, Division of Vital Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, USA
| | - Maria F Reyes
- Department of Obstetrics, Gynecology and Reproductive Sciences, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mona Saraiya
- Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jin Qin
- Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Healthcare Value, University of California San Francisco, San Francisco, California, USA
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Dorismond VG, Saraiya M, Gopalani SV, Soman A, Kenney K, Miller J, Sawaya GF. Variation in cervical cancer screening test utilization and results in a United States-based program. Gynecol Oncol 2024; 184:96-102. [PMID: 38301312 DOI: 10.1016/j.ygyno.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/05/2024] [Accepted: 01/12/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Little is known about cervical cancer screening strategy utilization (cytology alone, cytology plus high-risk human papillomavirus [HPV] testing [cotesting], primary HPV testing) and test results in the United States. METHODS Data from the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program were analyzed for 199,578 persons aged 21-65 years screened from 2019 to 2020. Screening test utilization and results were stratified by demographic characteristics and geographic region. Age-standardized pooled HPV test positivity and genotyping test positivity were estimated within cytology result categories. RESULTS Primary HPV testing was performed in 592 persons (0.3%). Among the remaining 176,290 persons aged 30-65 years, cotesting was utilized in 72.1% (95% confidence interval [CI] 71.9-72.3%), and cytology alone was utilized in 27.9% (95% CI 27.7-28.1%). Utilization of cytology alone varied by geographic region, ranging from 18.3% (95% CI 17.4-19.1%) to 49.0% (95% CI 48.4-49.6%). HPV genotyping test utilization among those with positive pooled HPV test results was 33.9%. In persons aged ≥30 years, variations in age-adjusted test results by region were observed for pooled HPV-positive test results and for HPV genotyping-positive test results. CONCLUSIONS Cervical cancer screening strategy utilization and test results vary substantially by geographic region within a national screening program. Variation in utilization may be due to regional differences in screening test availability or the preferences of healthcare systems, screened persons and/or clinicians. Test result variations may reflect differing risk factors for HPV infections by geographic region.
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Affiliation(s)
- Vanessa G Dorismond
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California San Francisco, San Francisco, CA, USA.
| | - Mona Saraiya
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sameer V Gopalani
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | | | - Kristy Kenney
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jacqueline Miller
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
| | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California San Francisco, San Francisco, CA, USA; Center for Healthcare Value, University of California San Francisco, San Francisco, CA, USA
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Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, Huh WK, Kim JJ, Moscicki AB, Nayar R, Saraiya M, Sawaya GF, Wentzensen N, Schiffman M. 2019 ASCCP Risk-Based Management Consensus Guidelines: Updates Through 2023. J Low Genit Tract Dis 2024; 28:3-6. [PMID: 38117563 PMCID: PMC10755815 DOI: 10.1097/lgt.0000000000000788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
ABSTRACT This Research Letter summarizes all updates to the 2019 Guidelines through September 2023, including: endorsement of the 2021 Opportunistic Infections guidelines for HIV+ or immunosuppressed patients; clarification of use of human papillomavirus testing alone for patients undergoing observation for cervical intraepithelial neoplasia 2; revision of unsatisfactory cytology management; clarification that 2012 guidelines should be followed for patients aged 25 years and older screened with cytology only; management of patients for whom colposcopy was recommended but not completed; clarification that after treatment for cervical intraepithelial neoplasia 2+, 3 negative human papillomavirus tests or cotests at 6, 18, and 30 months are recommended before the patient can return to a 3-year testing interval; and clarification of postcolposcopy management of minimally abnormal results.
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Affiliation(s)
| | | | - Philip E. Castle
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - David Chelmow
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mark H. Einstein
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Francisco Garcia
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Warner K. Huh
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Jane J. Kim
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Anna-Barbara Moscicki
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Ritu Nayar
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mona Saraiya
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - George F. Sawaya
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Nicolas Wentzensen
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mark Schiffman
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - 2019 ASCCP Risk-Based Management Consensus Guidelines Committee
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
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Dorismond VG, Boscardin WJ, Sawaya GF. The association between YouTube use and knowledge of human papillomavirus-related cancers. PEC Innov 2023; 3:100186. [PMID: 37457670 PMCID: PMC10339240 DOI: 10.1016/j.pecinn.2023.100186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
Objective To examine the association between YouTube usage and HPV-related cancer knowledge (cervical, anal, oral and penile). Study design Cross-sectional study using data from the Health Information National Trends survey conducted between 2017 and 2020 (N = 16,092). Logistic regression was used to analyze the independent effect of YouTube use on cancer knowledge, controlling for sociodemographic characteristics. Results Respondents' knowledge of HPV-related cancers varied: 49.9% about cervical, 18% anal, 20.1% oral and 20.4% penile cancers. YouTube use was associated with increased knowledge for all cancers (cervical: OR 2.66, 95% CI 2.04, 3.46; anal: OR 1.83, 95% CI 1.32, 2.53; oral: OR 1.89, 95% CI 1.37, 2.61; penile OR 2.00, 95% CI 1.44, 2.77) in models adjusted for all covariates. Other independent predictors of HPV-related cancer knowledge included female gender, younger age, a higher income, and higher education. Conclusions YouTube could play an important role in educating people about HPV-related cancers and should also target other populations, such as males and those with less formal education. Innovation The study provides novel insights into the potential of YouTube as an educational tool for promoting cancer knowledge with the goal of cancer prevention.
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Affiliation(s)
- Vanessa G. Dorismond
- Department of Obstetrics and Gynecology, University of California, San Francisco, CA, USA
| | - W. John Boscardin
- Department Epidemiology & Biostatistics, University of California, San Francisco School of Medicine, 490 Illinois St, San Francisco, CA 94158, USA
| | - George F. Sawaya
- Department of Obstetrics and Gynecology, University of California, San Francisco School of Medicine, 2356 Sutter St, San Francisco, CA 94115, USA
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6
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Holt HK, Flores R, James JE, Waters C, Kaplan CP, Peterson CE, Sawaya GF. A qualitative study of primary care clinician's approach to ending cervical cancer screening in older women in the United States. Prev Med Rep 2023; 36:102500. [PMID: 38116273 PMCID: PMC10728461 DOI: 10.1016/j.pmedr.2023.102500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/18/2023] [Accepted: 11/05/2023] [Indexed: 12/21/2023] Open
Abstract
The United States Preventive Services Task Force (USPSTF) recommends that cervical cancer screening end in average-risk patients with a cervix at 65 years of age if adequate screening measures have been met, defined as having 1) at least three normal consecutive cytology (Pap) tests, or 2) two normal cytology tests and/or two negative high-risk human papillomavirus tests between ages 55-65; the last test should be performed within the prior 5 years. Up to 60 % of all women aged 65 years and older who are ending screening do not meet the criteria for adequate screening. The objective of this study was to understand the process and approach that healthcare clinicians use to determine eligibility to end cervical cancer screening. In 2021 we conducted semi-structured interviews in San Francisco, CA with twelve healthcare clinicians: two family medicine physicians, three general internal medicine physicians, two obstetrician/gynecologists and five nurse practitioners. Thematic analysis, using inductive and deductive coding, was utilized. Three major themes emerged: following guidelines, relying on self-reported data regarding prior screening, and considering sexual activity as a factor in the decision to end screening. All interviewees endorsed following the USPSTF guidelines and they utilized self-report to determine eligibility to end screening. Clinicians' approach was dependent in part on their judgement about the reliability of the patient to convey their screening history. Sexual activity of the patient was considered when making clinical recommendations. Shared decision-making was often utilized. Clinicians voiced a strong reliance on self-reported screening history to end cervical cancer screening.
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Affiliation(s)
- Hunter K. Holt
- Department of Family and Community Medicine, University of Illinois at Chicago, USA
| | - Rey Flores
- Department of Family and Community Medicine, University of Illinois at Chicago, USA
| | - Jennifer E. James
- Department of Social & Behavioral Sciences, and UCSF Bioethics, University of California, San Francisco, CA, USA
| | - Catherine Waters
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, USA
| | - Celia P. Kaplan
- Department of Medicine, Division of General Internal Medicine University of California, San Francisco, USA
| | - Caryn E. Peterson
- Department of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, USA
| | - George F. Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, USA
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7
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Sawaya GF, Dorismond VG. Avoiding Low-Value Care and Patient Financial Harm in Cervical Cancer Screening. Cancer Prev Res (Phila) 2023; 16:363-364. [PMID: 37403658 DOI: 10.1158/1940-6207.capr-23-0173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/06/2023]
Abstract
The provision of low-value care remains a significant concern in healthcare. The negative impacts resulting from low-value cervical cancer screenings are extensive at the population level and can lead to harms and substantial out-of-pocket expenses for patients. Inattention to the financial implications of screening poses a serious threat to low-income populations that depend on affordable screening services, and it may exacerbate existing healthcare disparities and inequities. Identifying and implementing strategies that promote high-value care and reduce patient out-of-pocket expenses are important to ensure that all people, regardless of their socioeconomic status, have access to effective and affordable preventive care. See related article by Rockwell et al., p. 385.
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco (UCSF), California
- UCSF Center for Healthcare Value, San Francisco, California
| | - Vanessa G Dorismond
- San Francisco Veterans Affairs Medical Center, Department of Women's Health, University of California, San Francisco, California
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Grubman J, Hawkins M, Whetstone S, Autry M, Lazar A, Sawaya GF, Jacoby V. Emergency department visits and emergency-to-inpatient admissions for abnormal uterine bleeding in the USA nationwide. Emerg Med J 2023; 40:326-332. [PMID: 36323495 DOI: 10.1136/emermed-2021-211878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/19/2022] [Indexed: 04/23/2023]
Abstract
BACKGROUND Abnormal uterine bleeding (AUB) is a common but understudied gynaecological problem, and data are lacking on emergency department (ED) visits and associated ED-to-inpatient admissions for AUB. This project aims to further understanding of the burden of AUB on patients and the healthcare system by establishing the number and characteristics of women with AUB in the ED and evaluating predictors of AUB-related inpatient hospitalisation in the USA. METHODS This is a cross-sectional study of women presenting to the ED with non-malignant AUB in the 2016 US Nationwide Emergency Department Sample (NEDS). Clinical, demographic and hospital system factors were evaluated. χ2 and Mann-Whitney tests were used to compare the proportion of visits with each characteristic, resulting in inpatient admission versus discharge from the ED. Multivariable logistic regression models were used to analyse predictors of AUB in the ED and of AUB-related hospitalisations. RESULTS There were 1.03 million AUB-related visits in the 2016 NEDS, of which 11.2% resulted in inpatient admission. Clinical as well as demographic and hospital system factors influenced ED disposition. Women with AUB tended to be of reproductive age, be underinsured, live in lower income and urban areas, and present to urban and public hospitals. However, older age, higher income, better insurance, presentation to private hospitals and rural residence predicted inpatient admission. CONCLUSIONS Our study highlights the ED as an essential place of care for women with AUB while also demonstrating the importance of access to outpatient gynaecology services as some AUB-related ED visits may be preventable with outpatient care. The significant demographic and hospital system differences, as well as expected clinical differences, between women with AUB admitted to inpatient and women discharged from the ED imply structural biases impacting AUB-related ED care and add to the deepening understanding of health disparities.
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Affiliation(s)
- Jessica Grubman
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
- Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mitzi Hawkins
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Sara Whetstone
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Meg Autry
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Ann Lazar
- Department of Epidemiology and Biostatistics, Universitty of California, San Francisco, San Francisco, California, USA
| | - George F Sawaya
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Vanessa Jacoby
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
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Sawaya GF, Saraiya M, Soman A, Gopalani SV, Kenney K, Miller J. Accelerating Cervical Cancer Screening With Human Papillomavirus Genotyping. Am J Prev Med 2023; 64:552-555. [PMID: 36935166 DOI: 10.1016/j.amepre.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/30/2022] [Accepted: 10/19/2022] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Selective utilization of human papillomavirus (HPV) genotyping in cervical cancer screening can accelerate clinical management, leading to earlier identification and treatment of precancerous lesions and cancer. Specifically, immediate colposcopy (instead of 1-year return) is recommended in persons with normal cytology and HPV genotypes 16 and/or 18, and expedited treatment (instead of colposcopy) is recommended in persons with high-grade squamous intraepithelial lesion (HSIL) cytology and HPV genotype 16. The effects of implementing HPV testing and genotyping into a screening program are largely unknown. METHODS Average-risk persons aged 30-65 years screened for cervical cancer in the National Breast and Cervical Cancer Early Detection Program from 2019 to 2020 were included (N=104,991). Percentage HPV genotyping test positivity was estimated within cytology result categories. Analyses were performed in 2022. RESULTS The most common abnormality was positive high-risk HPV testing with normal cytology, representing 40.1% (7,155/17,832) of all abnormal test result categories; HSIL cytology represented 3.0% (530/17,832) of all abnormal test result categories. In high-risk HPV‒positive persons with normal or high-grade cytology, HPV genotyping could accelerate management (immediate colposcopy and expedited treatment) in 5.4% of all persons with abnormal screening test results; if HPV genotyping had been performed in all high-risk HPV‒positive persons with normal or HSIL cytology, approximately 13.1% could have accelerated management. CONCLUSIONS HPV genotyping in human papillomavirus‒positive persons with normal or HSIL cytology could accelerate management in a sizable percentage of persons with abnormal test results and may be particularly useful in populations with challenges adhering to longitudinal follow-up.
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco (UCSF), San Francisco, California; Center for Healthcare Value, University of California San Francisco (UCSF), San Francisco, California.
| | - Mona Saraiya
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Sameer V Gopalani
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia; Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Kristy Kenney
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jacqueline Miller
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, Georgia
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10
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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: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Poncelet A, Collins S, Fiore D, Rosenbluth G, Loeser H, Sawaya GF, Teherani A, Chang A. Identifying Value Factors in Institutional Leaders' Perspectives on Investing in Health Professions Educators. JAMA Netw Open 2023; 6:e2256193. [PMID: 36795413 PMCID: PMC9936339 DOI: 10.1001/jamanetworkopen.2022.56193] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
IMPORTANCE Investing in educators, educational innovation, and scholarship is essential for excellence in health professions education and health care. Funds for education innovations and educator development remain at significant risk because they virtually never generate offsetting revenue. A broader shared framework is needed to determine the value of such investments. OBJECTIVE To explore the value factors using the value measurement methodology domains (individual, financial, operational, social or societal, strategic or political) that health professions leaders placed on educator investment programs, including intramural grants and endowed chairs. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used semi-structured interviews with participants from an urban academic health professions institution and its affiliated systems that were conducted between June and September 2019 and were audio recorded and transcribed. Thematic analysis was used to identify themes with a constructivist orientation. Participants included 31 leaders at multiple levels of the organization (eg, deans, department chairs, and health system leaders) and with a range of experience. Individuals who did not respond initially were followed up with until a sufficient representation of leader roles was achieved. MAIN OUTCOMES AND MEASURES Outcomes include value factors defined by the leaders for educator investment programs across the 5 value measurement methodology domains: individual, financial, operational, social or societal, and strategic or political. RESULTS This study included 29 leaders (5 [17%] campus or university leaders; 3 [10%] health systems leaders; 6 [21%] health professions school leaders; 15 [52%] department leaders). They identified value factors across the 5 value measurement methods domains. Individual factors emphasized the impact on faculty career, stature, and personal and professional development. Financial factors included tangible support, the ability to attract additional resources, and the importance of these investments as a monetary input rather than output. Operational factors identified educational programs and faculty recruitment or retention. Social and societal factors showcased scholarship and dissemination benefits to the external community beyond the organization and to the internal community of faculty, learners, and patients. Strategic and political factors highlighted impact on culture and symbolism, innovation, and organizational success. CONCLUSIONS AND RELEVANCE These findings suggest that health sciences and health system leaders find value in funding educator investment programs in multiple domains beyond direct financial return on investment. These value factors can inform program design and evaluation, effective feedback to leaders, and advocacy for future investments. This approach can be used by other institutions to identify context-specific value factors.
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Affiliation(s)
- Ann Poncelet
- University of California, San Francisco, San Francisco, California
| | - Sally Collins
- University of California, San Francisco, San Francisco, California
| | - Darren Fiore
- University of California, San Francisco, San Francisco, California
| | - Glenn Rosenbluth
- University of California, San Francisco, San Francisco, California
| | - Helen Loeser
- University of California, San Francisco, San Francisco, California
| | - George F. Sawaya
- University of California, San Francisco, San Francisco, California
| | - Arianne Teherani
- University of California, San Francisco, School of Medicine, San Francisco, California
| | - Anna Chang
- University of California, San Francisco, San Francisco, California
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12
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Qin J, Holt HK, Richards TB, Saraiya M, Sawaya GF. Use Trends and Recent Expenditures for Cervical Cancer Screening-Associated Services in Medicare Fee-for-Service Beneficiaries Older Than 65 Years. JAMA Intern Med 2023; 183:11-20. [PMID: 36409511 PMCID: PMC9679959 DOI: 10.1001/jamainternmed.2022.5261] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/19/2022] [Indexed: 11/23/2022]
Abstract
Importance Since 1996, the US Preventive Services Task Force has recommended against cervical cancer screening in average-risk women 65 years or older with adequate prior screening. Little is known about the use of cervical cancer screening-associated services in this age group. Objective To examine annual use trends in cervical cancer screening-associated services, specifically cytology and human papillomavirus (HPV) tests, colposcopy, and cervical procedures (loop electrosurgical excision procedure, cone biopsy, and ablation) in Medicare fee-for-service beneficiaries during January 1, 1999, to December 31, 2019, and estimate expenditures for services performed in 2019. Design, Setting, and Participants This population-based, cross-sectional analysis included health service use data across 21 years for women aged 65 to 114 years with Medicare fee-for-service coverage (15-16 million women per year). Data analysis was conducted between July 2021 and April 2022. Main Outcomes and Measures Proportion of testing modalities (cytology alone, cytology plus HPV testing [cotesting], HPV testing alone); annual use rate per 100 000 women of cytology and HPV testing, colposcopy, and cervical procedures from 1999 to 2019; Medicare expenditure for these services in 2019. Results There were 15 323 635 women 65 years and older with Medicare fee-for-service coverage in 1999 and 15 298 656 in 2019. In 2019, the mean (SD) age of study population was 76.2 (8.1) years, 5.1% were Hispanic, 0.5% were non-Hispanic American Indian/Alaska Native, 3.0% were non-Hispanic Asian/Pacific Islander, 7.4% were non-Hispanic Black, and 82.0% were non-Hispanic White. From 1999 to 2019, the percentage of women who received at least 1 cytology or HPV test decreased from 18.9% (2.9 million women) in 1999 to 8.5% (1.3 million women) in 2019, a reduction of 55.3%; use rates of colposcopy and cervical procedures decreased 43.2% and 64.4%, respectively. Trend analyses showed a 4.6% average annual reduction in use of cytology or HPV testing during 1999 to 2019 (P < .001). Use rates of colposcopy and cervical procedures decreased before 2015 then plateaued during 2015 to 2019. The total Medicare expenditure for all services rendered in 2019 was about $83.5 million. About 3% of women older than 80 years received at least 1 service at a cost of $7.4 million in 2019. Conclusions and Relevance The results of this cross-sectional study suggest that while annual use of cervical cancer screening-associated services in the Medicare fee-for-service population older than 65 years has decreased during the last 2 decades, more than 1.3 million women received these services in 2019 at substantial costs.
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Affiliation(s)
- Jin Qin
- Division of Cancer Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hunter K. Holt
- Department of Family and Community Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Thomas B. Richards
- Division of Cancer Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mona Saraiya
- Division of Cancer Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - George F. Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
- UCSF Center for Healthcare Value, San Francisco, California
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13
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Schrier E, Holt HK, Kuppermann M, Sawaya GF. Changing Preferences for a Cervical Cancer Screening Strategy: Moving Away from Annual Testing. Womens Health Rep (New Rochelle) 2022; 3:709-717. [PMID: 36147829 PMCID: PMC9436266 DOI: 10.1089/whr.2022.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 11/12/2022]
Abstract
Background While annual cytology has not been recommended for many years, it remains many patients' preferred screening strategy for cervical cancer. Patient education and provider recommendations have been found effective in aligning professional society guidelines with patient preferences. We assessed whether an educational video with value elicitation exercises (utility assessments) changed screening strategy preferences among patients who had an initial preference for annual screening. Materials and Methods We conducted an interventional study of English- or Spanish-speaking women 21-65 years of age, recruited from two women's health clinics in San Francisco, California (n = 262). Participants were asked about their preferred method of screening before viewing a 7-minute educational video and using a computerized tool that elicited values for 23 different health states related to cervical cancer screening. Directly afterward, they were again asked about their preferred screening strategy. Multivariable regression analysis was utilized to identify independent predictors of changing preferences. Results Of 246 enrollees, 62.6% (154/246) had an initial preference for annual cytology; after viewing the video and completing the values elicitation exercises, about half (72/154, 47%) preferred a strategy other than annual screening. Having attended college and being screened every 3 to 5 years in the recent past were independent predictors of changing preferences away from annual screening. In sensitivity analyses, 53.2% of average-risk participants changed preferences away from annual cytology (p < 0.01). Conclusions Viewing an educational video and conducting a series of value elicitation exercises were associated with a substantially decreased likelihood of preferring annual screening. These findings underscore the importance of patient-centered education to help support informed patient preferences.
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Affiliation(s)
- Elizabeth Schrier
- School of Medicine, University of California, San Francisco, San Francisco, California, USA.,Address correspondence to: Elizabeth Schrier, BA, School of Medicine, University of California, San Francisco, San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Hunter K. Holt
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California, USA.,Department of Family and Community Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - George F. Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA.,Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA
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14
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Saraiya M, Colbert J, Bhat GL, Almonte R, Winters DW, Sebastian S, O'Hanlon M, Meadows G, Nosal MR, Richards TB, Michaels M, Townsend JS, Miller JW, Perkins RB, Sawaya GF, Wentzensen N, White MC, Richardson LC. Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity. J Womens Health (Larchmt) 2022; 31:462-468. [PMID: 35467443 PMCID: PMC9206487 DOI: 10.1089/jwh.2022.0100] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cervical cancer is highly preventable when precancerous lesions are detected early and appropriately managed. However, the complexity of and frequent updates to existing evidence-based clinical guidelines make it challenging for clinicians to stay abreast of the latest recommendations. In addition, limited availability and accessibility to information technology (IT) decision supports make it difficult for groups who are medically underserved to receive screening or receive the appropriate follow-up care. The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC), is leading a multiyear initiative to develop computer-interpretable ("computable") version of already existing evidence-based guidelines to support clinician awareness and adoption of the most up-to-date cervical cancer screening and management guidelines. DCPC is collaborating with the MITRE Corporation, leading scientists from the National Cancer Institute, and other CDC subject matter experts to translate existing narrative guidelines into computable format and develop clinical decision support tools for integration into health IT systems such as electronic health records with the ultimate goal of improving patient outcomes and decreasing disparities in cervical cancer outcomes among populations that are medically underserved. This initiative meets the challenges and opportunities highlighted by the President's Cancer Panel and the President's Cancer Moonshot 2.0 to nearly eliminate cervical cancer.
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Affiliation(s)
- Mona Saraiya
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jean Colbert
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Geeta L Bhat
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Rose Almonte
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - David W Winters
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Sharon Sebastian
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Michael O'Hanlon
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Ginny Meadows
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Michael R Nosal
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Thomas B Richards
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maria Michaels
- Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Julie S Townsend
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jacqueline W Miller
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rebecca B Perkins
- Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - George F Sawaya
- UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA.,Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Mary C White
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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15
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Sawaya GF, Holt HK, Lamar R, Perron-Burdick M, Smith-McCune K. Prioritizing cervical cancer screening services during the COVID-19 pandemic: Response of an academic medical center and a public safety net hospital in California. Prev Med 2021; 151:106569. [PMID: 34217411 PMCID: PMC8241652 DOI: 10.1016/j.ypmed.2021.106569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/16/2021] [Accepted: 04/18/2021] [Indexed: 12/17/2022]
Abstract
The expeditious diagnosis and treatment of high-grade cervical precancers are fundamental to cervical cancer prevention. However, during the COVID-19 pandemic healthcare systems have at times restricted in-person visits to those deemed urgent. Professional societies provided some guidance to clinicians regarding ways in which traditional cervical cancer screening might be modified, but many gaps remained. To address these gaps, leaders of screening programs at an academic medical center and an urban safety net hospital in California formed a rapid-action committee to provide guidance to its practitioners. Patients were divided into 6 categories corresponding to various stages in the screening process and ranked by risk of underlying high-grade cervical precancer and cancer. Tiers corresponding to the intensity of the local pandemic were constructed, and clinical delays were lengthened for the lowest-risk patients as tiers escalated. The final product was a management grid designed to escalate and de-escalate with changes in the local epidemiology of the COVID-19 pandemic. While this effort resulted in substantial delays in clinical screening services as mandated by the healthcare systems, the population effects of delaying on both cervical cancer outcomes as well as the beneficial effects related to decreasing transmission of severe acute respiratory coronavirus 2 have yet to be elucidated.
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco (UCSF), United States of America; Obstetrics, Midwifery and Gynecology Clinic, Zuckerberg San Francisco General Hospital and Trauma Center, United States of America.
| | - Hunter K Holt
- Department of Family and Community Medicine, UCSF, United States of America
| | - Robyn Lamar
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco (UCSF), United States of America
| | - Misa Perron-Burdick
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco (UCSF), United States of America; Obstetrics, Midwifery and Gynecology Clinic, Zuckerberg San Francisco General Hospital and Trauma Center, United States of America
| | - Karen Smith-McCune
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco (UCSF), United States of America
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16
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Qin J, Shahangian S, Saraiya M, Holt H, Gagnon M, Sawaya GF. Trends in the use of cervical cancer screening tests in a large medical claims database, United States, 2013-2019. Gynecol Oncol 2021; 163:378-384. [PMID: 34507826 DOI: 10.1016/j.ygyno.2021.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To examine trends in the use of cervical cancer screening tests during 2013-2019 among commercially insured women. METHODS The study population included women of all ages with continuous enrollment each year in the IBM MarketScan commercial or Medicare supplemental databases and without known history of cervical cancer or precancer (range = 6.9-9.8 million women per year). Annual cervical cancer screening test use was examined by three modalities: cytology alone, cytology plus HPV testing (cotesting), and HPV testing alone. Trends were assessed using 2-sided Poisson regression. RESULTS Use of cytology alone decreased from 34.2% in 2013 to 26.4% in 2019 among women aged 21-29 years (P < .0001). Among women aged 30-64 years, use of cytology alone decreased from 18.9% in 2013 to 8.6% in 2019 (P < .0001), whereas cotesting use increased from 14.9% in 2013 to 19.3% in 2019 (P < .0001). Annual test use for HPV testing alone was below 0.5% in all age groups throughout the study period. Annually, 8.7%-13.6% of women aged 18-20 years received cervical cancer screening. There were persistent differences in screening test use by metropolitan residence and census regions despite similar temporal trends. CONCLUSIONS Temporal changes in the use of cervical cancer screening tests among commercially insured women track changes in clinical guidelines. Screening test use among individuals younger than 21 years shows that many young women are inappropriately screened for cervical cancer.
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Affiliation(s)
- Jin Qin
- Division of Cancer Prevention and Control, CDC, USA.
| | | | - Mona Saraiya
- Division of Cancer Prevention and Control, CDC, USA
| | - Hunter Holt
- Department of Family and Community Medicine, University of California, San Francisco, USA
| | | | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, USA
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17
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Holt HK, Sawaya GF, El Ayadi AM, Henderson JT, Rocca CH, Westhoff CL, Harper CC. Delayed Visits for Contraception Due to Concerns Regarding Pelvic Examination Among Women with History of Intimate Partner Violence. J Gen Intern Med 2021; 36:1883-1889. [PMID: 33145695 PMCID: PMC8298732 DOI: 10.1007/s11606-020-06334-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 10/21/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Concern regarding pelvic examinations may be more common among women experiencing intimate partner violence. OBJECTIVE We examined women's attitudes towards pelvic examination with history of intimate partner violence (pressured to have sex, or verbal, or physical abuse). DESIGN Secondary analysis of data from a cluster randomized trial on contraceptive access. PARTICIPANTS Women aged 18-25 were recruited at 40 reproductive health centers across the USA (2011-2013). MAIN MEASURES Delays in clinic visits for contraception and preference to avoid pelvic examinations, by history of ever experiencing pressured sex, verbal, or physical abuse from a sexual partner, reported by frequency (never, rarely, sometimes, often). We used multivariable logistic regression with generalized estimating equations for clustered data. KEY RESULTS A total of 1490 women were included. Ever experiencing pressured sex was reported by 32.4% of participants, with 16.5% reporting it rarely, 12.1% reporting it sometimes, and 3.8% reporting it often. Ever experiencing verbal abuse was reported by 19.4% and physical abuse by 10.2% of participants. Overall, 13.2% of participants reported ever having delayed going to the clinic for contraception to avoid having a pelvic examination, and 38.2% reported a preference to avoid pelvic examinations. In multivariable analysis, women reporting that they experienced pressured sex often had significantly higher odds of delaying a clinic visit for birth control (aOR 3.10 95% CI 1.39-6.84) and for reporting a preference to avoid pelvic examinations (aOR 2.91 95% CI 1.57-5.40). We found no associations between delay of clinic visits or preferences to avoid a pelvic examination and verbal or physical abuse. CONCLUSIONS History of pressured sex from an intimate partner is common. Among women who have experienced pressured sex, concern regarding pelvic examinations is a potential barrier to contraception. Communicating that routine pelvic examinations are no longer recommended by professional societies could potentially reduce barriers and increase preventive healthcare visits.
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Affiliation(s)
- Hunter K Holt
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA.
| | - George F Sawaya
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Alison M El Ayadi
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Jillian T Henderson
- Kaiser Permanente Center for Health Research, Northwest, Portland, Oregon, USA
| | - Corinne H Rocca
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
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Perkins RB, Guido RL, Saraiya M, Sawaya GF, Wentzensen N, Schiffman M, Feldman S. Summary of Current Guidelines for Cervical Cancer Screening and Management of Abnormal Test Results: 2016-2020. J Womens Health (Larchmt) 2021; 30:5-13. [PMID: 33464997 DOI: 10.1089/jwh.2020.8918] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Cervical cancer can be prevented through routine screening and follow-up of abnormal results. Several guidelines have been published in the last 4 years from various medical societies and organizations. These guidelines aim to personalize screening and management, reducing unnecessary testing in low-risk patients and managing high-risk patients with more intensive follow-up. However, the resulting complexity can lead to confusion among providers. The CDC, NCI, and obstetrician-gynecologists involved in guideline development summarized current screening and management guidelines. For screening, guidelines for average-risk and high-risk populations are summarized and presented. For management, differences between the 2012 and 2019 consensus guidelines for managing abnormal cervical cancer screening tests and cancer precursors are summarized. Current screening guidelines for average-risk individuals have minor differences, but are evolving toward an HPV-based strategy. For management, HPV testing is preferred to cytology because it is a more sensitive test for cancer precursor detection and also allows for precise risk stratification. Current risk-based screening and management strategies can improve care by reducing unnecessary tests and procedures in low-risk patients and focusing resources on high-risk patients. Knowledge of screening and management guidelines is important to improve adherence and avoid both over- and under-use of screening and colposcopy.
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Affiliation(s)
- Rebecca B Perkins
- Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - Richard L Guido
- University of Pittsburgh/Magee-Women's Hospital, Pittsburgh, Pennsylvania, USA
| | - Mona Saraiya
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Sarah Feldman
- Department of Obstetrics/Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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19
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
- Center for Healthcare Value, University of California, San Francisco
| | - Robyn Lamar
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Rebecca B Perkins
- Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
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20
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Holt HK, Kulasingam S, Sanstead EC, Alarid-Escudero F, Smith-McCune K, Gregorich SE, Silverberg MJ, Huchko MJ, Kuppermann M, Sawaya GF. Discussing Cervical Cancer Screening Options: Outcomes to Guide Conversations Between Patients and Providers. MDM Policy Pract 2020; 5:2381468320952409. [PMID: 32885045 PMCID: PMC7440733 DOI: 10.1177/2381468320952409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/27/2020] [Indexed: 11/15/2022] Open
Abstract
Purpose. In 2018, the US Preventive Services Task Force (USPSTF) endorsed three strategies for cervical cancer screening in women ages 30 to 65: cytology every 3 years, testing for high-risk types of human papillomavirus (hrHPV) every 5 years, and cytology plus hrHPV testing (co-testing) every 5 years. It further recommended that women discuss with health care providers which testing strategy is best for them. To inform such discussions, we used decision analysis to estimate outcomes of screening strategies recommended for women at age 30. Methods. We constructed a Markov decision model using estimates of the natural history of HPV and cervical neoplasia. We evaluated the three USPSTF-endorsed strategies, hrHPV testing every 3 years and no screening. Outcomes included colposcopies with biopsy, false-positive testing (a colposcopy in which no cervical intraepithelial neoplasia grade 2 or worse was found), treatments, cancers, and cancer mortality expressed per 10,000 women over a shorter-than-lifetime horizon (15-year). Results. All strategies resulted in substantially lower cancer and cancer death rates compared with no screening. Strategies with the lowest likelihood of cancer and cancer death generally had higher likelihood of colposcopy and false-positive testing. Conclusions. The screening strategies we evaluated involved tradeoffs in terms of benefits and harms. Because individual women may place different weights on these projected outcomes, the optimal choice for each woman may best be discerned through shared decision making.
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Affiliation(s)
- Hunter K Holt
- Department of Family and Community Medicine, University of California, San Francisco, California
| | - Shalini Kulasingam
- Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Erinn C Sanstead
- Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Fernando Alarid-Escudero
- Drug Policy Program, Center for Research and Teaching in Economics (CIDE), Aguascalientes, Mexico
| | - Karen Smith-McCune
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
| | - Steven E Gregorich
- Department of Medicine, University of California, San Francisco, California
| | | | - Megan J Huchko
- Obstetrics & Gynecology and Global Health, Duke University, Durham, North Carolina
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
| | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
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21
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Silverberg MJ, Leyden WA, Lam JO, Chao CR, Gregorich SE, Huchko MJ, Kulasingam S, Kuppermann M, Smith-McCune KK, Sawaya GF. Effectiveness of 'catch-up' human papillomavirus vaccination to prevent cervical neoplasia in immunosuppressed and non-immunosuppressed women. Vaccine 2020; 38:4520-4523. [PMID: 32446836 DOI: 10.1016/j.vaccine.2020.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 11/27/2022]
Abstract
It is unknown whether the HPV vaccine is effective in immunocompromised women during catch-up ages. We performed a case-control study of 4,357 women with incident CIN2+ (cases) and 5:1 age-matched, incidence-density selected controls (N = 21,773) enrolled in an integrated health care system from 2006 to 2014. Vaccine effectiveness was estimated from multivariable conditional logistic regression models, with results stratified by immunosuppression history, defined as prior HIV infection, solid organ transplant history, or recently prescribed immunosuppressive medications. HPV vaccination resulted in a 19% reduction in CIN2+ rates for women without an immunosuppression history but a nonsignificant 4% reduction for women with an immunosuppression history. Further research is needed to evaluate whether catch-up HPV vaccine effectiveness varies by immunosuppression status, especially given the recent approval of the HPV vaccine for adults up to 45 years of age.
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Affiliation(s)
| | - Wendy A Leyden
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jennifer O Lam
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chun R Chao
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Steven E Gregorich
- Department of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - Megan J Huchko
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California at San Francisco, San Francisco, CA, USA; Department of Obstetrics and Gynecology, Global Health Institute, Duke University, Durham, NC, USA
| | - Shalini Kulasingam
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California at San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, USA
| | - Karen K Smith-McCune
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California at San Francisco, San Francisco, CA, USA
| | - George F Sawaya
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California at San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, USA
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22
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Qin J, Saraiya M, Martinez G, Sawaya GF. Prevalence of Potentially Unnecessary Bimanual Pelvic Examinations and Papanicolaou Tests Among Adolescent Girls and Young Women Aged 15-20 Years in the United States. JAMA Intern Med 2020; 180:274-280. [PMID: 31904768 PMCID: PMC7028301 DOI: 10.1001/jamainternmed.2019.5727] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Pelvic examination is no longer recommended for asymptomatic, nonpregnant women and may cause harms such as false-positive test results, overdiagnosis, anxiety, and unnecessary costs. The bimanual pelvic examination (BPE) is an invasive and controversial examination component. Cervical cancer screening is not recommended for women younger than 21 years. OBJECTIVES To estimate prevalence of potentially unnecessary BPE and Papanicolaou (Pap) tests performed among adolescent girls and women younger than 21 years (hereinafter referred to as young women) in the United States and to identify factors associated with receiving these examinations. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of the National Survey of Family Growth from September 2011 through September 2017 focused on a population-based sample of young women aged 15 to 20 years (n = 3410). The analysis used survey weights to estimate prevalence and the number of people represented in the US population. Data were analyzed from December 21, 2018, through September 3, 2019. MAIN OUTCOMES AND MEASURES Receipt of a BPE or a Pap test in the last 12 months and the proportion of potentially unnecessary examinations and tests. RESULTS Responses from 3410 young women aged 15 to 20 years were included in the analysis with 6-year sampling weights applied. Among US young women aged 15 to 20 years represented during the 2011-2017 study period, 4.8% (95% CI, 3.9%-5.9%) were pregnant, 22.3% (95% CI, 20.1%-24.6%) had undergone STI testing, and 4.5% (95% CI, 3.6%-5.5%) received treatment or medication for an STI in the past 12 months (Table 1). Only 2.0% (95% CI, 1.4%-2.9%) reported using an IUD, and 33.5% (95% CI, 30.8%-36.4%) used at least 1 other type of hormonal contraception in the past 12 months. Among US young women aged 15 to 20 years who were surveyed in the years 2011 through 2017, approximately 2.6 million (22.9%; 95% CI, 20.7%-25.3%) reported having received a BPE in the last 12 months. Approximately half of these examinations (54.4%; 95% CI, 48.8%-59.9%) were potentially unnecessary, representing an estimated 1.4 million individuals. Receipt of a BPE was associated with having a Pap test (adjusted prevalence ratio [aPR], 7.12; 95% CI, 5.56-9.12), testing for sexually transmitted infections (aPR, 1.60; 95% CI, 1.34-1.90), and using hormonal contraception other than an intrauterine device (aPR, 1.31; 95% CI, 1.11-1.54). In addition, an estimated 2.2 million young women (19.2%; 95% CI, 17.2%-21.4%) reported having received a Pap test in the past 12 months, and 71.9% (95% CI, 66.0%-77.1%) of these tests were potentially unnecessary. CONCLUSIONS AND RELEVANCE This analysis found that more than half of BPEs and almost three-quarters of Pap tests performed among young women aged 15 to 20 years during the years 2011 through 2017 were potentially unnecessary, exposing women to preventable harms. The results suggest that compliance with the current professional guidelines regarding the appropriate use of these examinations and tests may be lacking.
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Affiliation(s)
- Jin Qin
- Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mona Saraiya
- Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gladys Martinez
- Reproductive Statistics Branch, National Center for Health Statistics, Division of Vital Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco.,Center for Healthcare Value, University of California, San Francisco
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23
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Nguyen C, Sawaya GF, Hoffman A. Effect of cost exposure on medical students' preferred mammography screening strategies: A randomized comparison. Med Teach 2019; 41:1293-1297. [PMID: 31339438 DOI: 10.1080/0142159x.2019.1636954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Introduction: Many high value care educational interventions have focused on shaping clinical decision-making for individual patients. Few have investigated how trainees integrate cost information into recommendations within a public health context. Methods: Third-year medical students at the University of California San Francisco participated in a small group on benefits and harms of breast cancer screening. We randomly assigned half of small groups to view estimated total costs of different screening strategies. Students selected a screening strategy for coverage by a publicly funded program and one they would recommend to a hypothetical patient. We used the chi-square test for independence and chi-square test for trend to compare proportions. Results: A total of 267 third-year medical students participated. Exposure to costs was associated with selection of significantly less intensive screening strategies for coverage by a publicly funded program (p < 0.05). We found no significant differences in perspectives that involved recommendations for individual patients. Discussion: Students weigh cost considerations more heavily when making decisions about populations, rather than individual hypothetical patients. We suggest that it may be easier for students to relate cost considerations to populations. Initial curricular activities can be framed from this perspective with subsequent activities focusing on individual patient care.
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Affiliation(s)
- Clarice Nguyen
- University of California San Francisco School of Medicine (UCSF) , San Francisco , CA , USA
| | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine (UCSF) , San Francisco , CA , USA
- UCSF Center for Healthcare Value , San Francisco , CA , USA
| | - Ari Hoffman
- UCSF Center for Healthcare Value , San Francisco , CA , USA
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco School of Medicine (UCSF) , San Francisco , CA , USA
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24
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Sawaya GF, Sanstead E, Alarid-Escudero F, Smith-McCune K, Gregorich SE, Silverberg MJ, Leyden W, Huchko MJ, Kuppermann M, Kulasingam S. Estimated Quality of Life and Economic Outcomes Associated With 12 Cervical Cancer Screening Strategies: A Cost-effectiveness Analysis. JAMA Intern Med 2019; 179:867-878. [PMID: 31081851 PMCID: PMC6515585 DOI: 10.1001/jamainternmed.2019.0299] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Many cervical cancer screening strategies are now recommended in the United States, but the benefits, harms, and costs of each option are unclear. OBJECTIVE To estimate the cost-effectiveness of 12 cervical cancer screening strategies. DESIGN, SETTING, AND PARTICIPANTS The cross-sectional portion of this study enrolled a convenience sample of 451 English-speaking or Spanish-speaking women aged 21 to 65 years from September 22, 2014, to June 16, 2016, identified at women's health clinics in San Francisco. In this group, utilities (preferences) were measured for 23 cervical cancer screening-associated health states and were applied to a decision model of type-specific high-risk human papillomavirus (hrHPV)-induced cervical carcinogenesis. Test accuracy estimates were abstracted from systematic reviews. The evaluated strategies were cytologic testing every 3 years for women aged 21 to 65 years with either repeat cytologic testing in 1 year or immediate hrHPV triage for atypical squamous cells of undetermined significance (ASC-US), cytologic testing every 3 years for women age 21 to 29 years followed by cytologic testing plus hrHPV testing (cotesting), or primary hrHPV testing alone for women aged 30 to 65 years. Screening frequency, abnormal test result management, and the age to switch from cytologic testing to hrHPV testing (25 or 30 years) were varied. Analyses were conducted from both the societal and health care sector perspectives. MAIN OUTCOMES AND MEASURES Utilities for 23 cervical cancer screening-associated health states (cross-sectional study) and quality-adjusted life-years (QALYs) and total costs for each strategy. RESULTS Utilities were measured in a sociodemographically diverse group of 451 women (mean [SD] age, 38.2 [10.7] years; 258 nonwhite [57.2%]). Cytologic testing every 3 years with repeat cytologic testing for ASC-US yielded the most lifetime QALYs and conferred more QALYs at higher costs ($2166 per QALY) than the lowest-cost strategy (cytologic testing every 3 years with hrHPV triage of ASC-US). All cytologic testing plus hrHPV testing (cotesting) and primary hrHPV testing strategies provided fewer QALYs at higher costs. Adding indirect costs did not change the conclusions. In sensitivity analyses, hrHPV testing every 5 years with genotyping triage beginning at age 30 years was the lowest-cost strategy when hrHPV test sensitivity was markedly higher than cytologic test sensitivity or when hrHPV test cost was equated to the lowest reported cytologic test cost ($14). CONCLUSIONS AND RELEVANCE Cytologic testing every 3 years for women aged 21 to 29 years with either continued cytologic testing every 3 years or switching to a low-cost hrHPV test every 5 years confers a reasonable balance of benefits, harms, and costs. Comparative modeling is needed to confirm the association of these novel utilities with cost-effectiveness.
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco.,University of California, San Francisco Center for Healthcare Value, San Francisco
| | - Erinn Sanstead
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
| | - Fernando Alarid-Escudero
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis.,now at Drug Policy Program, Center for Research and Teaching in Economics, Aguascalientes, Aguascalientes, Mexico
| | - Karen Smith-McCune
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | | | | | - Wendy Leyden
- Division of Research, Kaiser Permanente, Oakland, California
| | - Megan J Huchko
- Department of Obstetrics and Gynecology, Global Health Institute, Duke University, Durham, North Carolina
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Shalini Kulasingam
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
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Martinez GM, Qin J, Saraiya M, Sawaya GF. Receipt of Pelvic Examinations Among Women Aged 15-44 in the United States, 1988-2017. NCHS Data Brief 2019:1-8. [PMID: 31442190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pelvic examination has been commonly performed as part of a physical examination for women in the United States. However, the value of routine pelvic examinations has been questioned recently (1,2). In 2012, the American College of Obstetricians and Gynecologists (ACOG) recommended annual pelvic examinations for women aged 21 and over as part of the well-woman visit (3). In 2018, ACOG advised that pelvic examinations be performed when indicated by medical history or symptoms (4). Using National Survey of Family Growth (NSFG) data through 2017 for women aged 15-44, this report describes trends overall and by age since 1988 in the receipt of pelvic examinations in the past year, and differences by Hispanic origin and race, education, poverty status, and health insurance status for 2015-2017.
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
- UCSF Center for Healthcare Value, San Francisco, California
| | - Karen Smith-McCune
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco.,Department of Epidemiology & Biostatistics, University of California, San Francisco.,Center for Healthcare Value, University of California, San Francisco
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Affiliation(s)
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston Medical Center/Boston University School of Medicine, Boston, MA
| | - George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, Department of Epidemiology & Biostatistics, UCSF Center for Healthcare Value, University of California, San Francisco, CA
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29
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Averbach S, Silverberg MJ, Leyden W, Smith-McCune K, Raine-Bennett T, Sawaya GF. Recent intrauterine device use and the risk of precancerous cervical lesions and cervical cancer. Contraception 2018; 98:S0010-7824(18)30144-6. [PMID: 29673740 PMCID: PMC6192861 DOI: 10.1016/j.contraception.2018.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Understanding the effect of contraceptives on the development of precancerous lesions of the cervix and cervical cancer may provide information that is valuable to women in contraceptive decision-making. The purpose of this study was to evaluate the association between recent intrauterine device (IUD) use (by type) and cervical intraepithelial neoplasia 2, 3, adenocarcinoma in situ or cancer (CIN2+ or CIN3+). STUDY DESIGN Case-control study of 17,559 women age 18-49 with incident CIN2+ cases and 5:1 age-matched, incidence-density selected controls (N=87,378) who were members of Kaiser Permanente Northern California Healthcare System from 1996 to 2014. Recent IUD use, within 18 months prior to index, was the exposure of interest. RESULTS We identified 1,657 IUD users among the cases and 7,925 IUD users among controls. After adjusting for sexually transmitted infection testing, smoking, HPV vaccination, hormonal contraceptive use, parity, race and number of outpatient healthcare system visits, IUD use was associated with an increased rate of CIN2+ [rate ratio (RR) 1.12, 95% confidence interval (1.05-1.18), p<0.001] but not CIN3+ [RR 1.02 (0.93-1.11), p=0.71]. Levonorgestrel-IUD use was associated with an increased rate of CIN2+ [RR 1.18 (1.08-1.30), p<0.001] but not CIN3+ [RR 1.05 (0.91-1.21), p=0.48]. Copper-IUD use was not associated with CIN2+ [RR 0.88 (0.75-1.04), p=0.13] or CIN3+ [RR 0.81 (0.64-1.02), p=0.07]. CONCLUSION Recent IUD use had variable weak associations with CIN2+ but was not associated with increased risk of CIN3+. IMPLICATIONS Recent levonorgestrel-IUD use may be associated with CIN2, a lesion with a high rate of regression, but not CIN3, which is considered a true pre-cancerous lesion. The observed association between levonorgestrel-IUDs and CIN2+ was modest but warrants further investigation. It may have clinical importance for contraceptive counseling if this finding is shown to be consistent across other studies and other populations.
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Affiliation(s)
- Sarah Averbach
- University of California, San Diego, Department of Obstetrics, Gynecology and Reproductive Sciences, San Diego, CA; University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA.
| | | | - Wendy Leyden
- Kaiser Permanente Northern California (KPNC), Division of Research, Oakland, CA
| | - Karen Smith-McCune
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA
| | - Tina Raine-Bennett
- Kaiser Permanente Northern California (KPNC), Division of Research, Oakland, CA
| | - George F Sawaya
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA
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Abstract
IMPORTANCE Ovarian cancer is relatively rare but the fifth-leading cause of cancer mortality among United States women. OBJECTIVE To systematically review evidence on benefits and harms of ovarian cancer screening among average-risk women to inform the United States Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, Cochrane Collaboration Registry of Controlled Trials; studies published in English from January 1, 2003, through January 31, 2017; ongoing surveillance in targeted publications through November 22, 2017. STUDY SELECTION Randomized clinical trials of ovarian cancer screening in average-risk women that reported mortality or quality-of-life outcomes. Interventions included transvaginal ultrasound, cancer antigen 125 (CA-125) testing, or their combination. Comparators were usual care or no screening. DATA EXTRACTION AND SYNTHESIS Independent critical appraisal and data abstraction by 2 reviewers. Meta-analytic pooling of results was not conducted because of the small number of studies and heterogeneity of interventions. MAIN OUTCOMES AND MEASURES Ovarian cancer mortality, false-positive screening results and surgery, surgical complications, and psychological effects of screening. RESULTS Four trials (N = 293 587) were included; of these, 3 (n = 293 038) assessed ovarian cancer mortality, and 1 (n = 549) reported only on psychological outcomes. Evaluated screening interventions included transvaginal ultrasound alone, transvaginal ultrasound plus CA-125 testing, and CA-125 testing alone. Test positivity for CA-125 was defined by a fixed serum level cutpoint or by a proprietary risk algorithm based on CA-125 level, change in CA-125 level over time, and age (risk of ovarian cancer algorithm [ROCA]). No trial found a significant difference in ovarian cancer mortality with screening. In the 2 large screening trials (PLCO and UKCTOCS, n = 271 103), there was not a statistically significant difference in complete intention-to-screen analyses of ovarian, fallopian, and peritoneal cancer cases associated with screening (PLCO: rate ratio, 1.18 [95% CI, 0.82-1.71]; UKCTOCS: hazard ratio [HR], 0.91 [95% CI, 0.76-1.09] for transvaginal ultrasound and HR, 0.89 [95% CI, 0.74-1.08] for CA-125 ROCA). Within these 2 trials, screening led to surgery for suspected ovarian cancer in 1% of women without cancer for CA-125 ROCA and in 3% for transvaginal ultrasound with or without CA-125 screening, with major complications occurring among 3% to 15% of surgery. Evidence on psychological harms was limited but nonsignificant except in the case of repeat follow-up scans and tests, which increased the risk of psychological morbidity in a subsample of UKCTOCS participants based on the General Health Questionnaire 12 (score ≥4) (odds ratio, 1.28 [95% CI, 1.18-1.39]). CONCLUSIONS AND RELEVANCE In randomized trials conducted among average-risk, asymptomatic women, ovarian cancer mortality did not significantly differ between screened women and those with no screening or in usual care. Screening harms included surgery (with major surgical complications) in women found to not have cancer. Further research is needed to identify effective approaches for reducing ovarian cancer incidence and mortality.
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Affiliation(s)
- Jillian T Henderson
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Elizabeth M Webber
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
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Craig AD, Khan MJ, Singhrao R, Sawaya GF, Bae S, Kamali D, Huh W, Smith-McCune KK. Focal treatment for high-grade cervical intraepithelial neoplasia: a pilot study. Gynecol Oncol 2017. [DOI: 10.1016/j.ygyno.2017.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sawaya GF, Smith-McCune KK, Gregorich SE, Moghadassi M, Kuppermann M. Effect of professional society recommendations on women's desire for a routine pelvic examination. Am J Obstet Gynecol 2017; 217:338.e1-338.e7. [PMID: 28528899 DOI: 10.1016/j.ajog.2017.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 04/15/2017] [Accepted: 05/04/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The American College of Physicians strongly recommends against performing pelvic examinations in asymptomatic, nonpregnant women, citing evidence of harm (false-positive testing, unnecessary surgery) and no evidence of benefit. In contrast, the American Congress of Obstetricians and Gynecologists recommends pelvic examinations in asymptomatic women beginning at age 21 years, citing expert opinion. OBJECTIVE We sought to evaluate if providing women with professional societies' conflicting statements about pelvic examinations (recommendations and rationales) would influence their desire for a routine examination. STUDY DESIGN We recruited 452 women ages 21-65 years from 2 women's clinics to participate in a 50-minute face-to-face interview about cervical cancer screening that included a 2-phase study related to pelvic examinations. In the first phase, 262 women were asked about their desire for the examination without being provided information about professional societies' recommendations. In the second phase, 190 women were randomized to review summaries of the American College of Physicians or American Congress of Obstetricians and Gynecologists statement followed by an interview. RESULTS First-phase participants served as the referent: 79% (208/262) indicated they would want a routine examination if given a choice. In the second phase, a similar percentage of women randomized to the American Congress of Obstetricians and Gynecologists summary had this desire (82%: 80/97; adjusted odds ratio, 1.37; 95% confidence interval, 0.69-2.70). Women randomized to the American College of Physicians summary, however, were less likely to indicate they would opt for an examination (39%: 36/93; adjusted odds ratio, 0.12; 95% confidence interval, 0.06-0.21). Overall, 94% (179/190) believed the potential benefits and harms should be discussed prior to the examination. CONCLUSION Providing women with a professional society's recommendation advising against routine pelvic examinations substantially reduced their desire to have one. Educational materials are needed to ensure women's informed preferences and values are reflected in decisions about pelvic examinations.
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; Center for Healthcare Value, University of California, San Francisco, San Francisco, CA.
| | - Karen K Smith-McCune
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Steven E Gregorich
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Michelle Moghadassi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
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Norrell LL, Kuppermann M, Moghadassi MN, Sawaya GF. Women's beliefs about the purpose and value of routine pelvic examinations. Am J Obstet Gynecol 2017; 217:86.e1-86.e6. [PMID: 28040449 DOI: 10.1016/j.ajog.2016.12.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 12/15/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The American Congress of Obstetricians and Gynecologists recommends that a pelvic examination be offered to asymptomatic women after an informed discussion with their provider. Although the adverse health outcomes that the examination averts were not delineated, the organization stated that it helps establish open communication between patients and physicians. Recent surveys have focused on obstetrician-gynecologists' attitudes and beliefs about the examination, but the perspectives of women have not been well-characterized. OBJECTIVE The purpose of this study was to better understand women's beliefs about the purpose and value of routine pelvic examinations. STUDY DESIGN We completed structured interviews with 262 women who were 21-65 years old who agreed to participate in a 50-minute interview about cervical cancer screening. Recruitment took place in outpatient women's clinics at a public hospital and an academic medical center in San Francisco, CA. Women were shown an illustration of a bimanual pelvic examination and asked a series of closed-ended questions: if they knew why it was performed, if it reassured them of their health, and if they believed it helped establish open communication with their provider. Women were asked an open-ended question about their perception of the examination's purpose. Multivariable logistic regression analysis was used to identify demographic predictors of responses. RESULTS Approximately one-half of the participants (56%) stated that they knew the examination's purpose. The most frequently cited reason was assurance of normalcy. Most of participants (82%) believed that the examination reassured them of their health. Approximately two-thirds of the participants (62%) believed that the examination helps establish open communication with their provider. In multivariate analyses, older age (≥45 years) independently predicted a higher likelihood of a belief that they knew the examination's purpose (odds ratio, 2.9; 95% confidence interval, 1.5-5.6) and a belief that it facilitates open communication (odds ratio, 2.1; 95% confidence interval, 1.1-3.9). Non-white race also was associated with a belief that the examination helps facilitate open communication between patients and providers (odds ratio, 1.9; 95% confidence interval, 1.1-3.1). CONCLUSION Approximately one-half of the women who participated in our study reported not knowing the purpose of the pelvic examination, yet most of them believed it to be of some value, especially reassurance of health. To achieve shared, informed decision-making, clinicians will need to communicate better to their patients the examination's purpose.
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Abstract
Cervical cancer screening in the United States has accompanied profound decreases in cancer incidence and mortality over the last half century. Two screening strategies are currently endorsed by US-based guideline groups: (1) triennial cytology for women aged 21 to 65 years, and (2) triennial cytology for women aged 21 to 29 years followed by cytology plus testing for high-risk human papillomavirus types every 5 years for women aged 30 years and older. Providing women with affordable, easily accessible screening, follow-up of abnormal tests, and timely treatment will result in the greatest impact of screening on cervical cancer incidence and mortality.
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 550 16th Street, Floor 7, San Francisco, CA 94143, USA; Department of Epidemiology & Biostatistics, University of California, San Francisco, 550 16th Street, Floor 7, San Francisco, CA 94143, USA.
| | - Megan J Huchko
- Department of Obstetrics and Gynecology, Global Health Institute, Duke University, 310 Trent Drive, Box 90519, Durham, NC, 27708, USA
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Affiliation(s)
- George F Sawaya
- UCSF Center for Healthcare Value, San Francisco, California2Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco3Department of Epidemiology and Biostatistics, University of California, San Francisco
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Abstract
Several important lessons have been learnt from our experiences in screening for various cancers. Screening programmes for cervical and colorectal cancers have had the greatest success, probably because these cancers are relatively homogenous, slow-growing, and have identifiable precursors that can be detected and removed; however, identifying the true obligate precursors of invasive disease remains a challenge. With regard to screening for breast cancer and for prostate cancer, which focus on early detection of invasive cancer, preferential detection of slower-growing, localized cancers has occurred, which has led to concerns about overdiagnosis and overtreatment; programmes for early detection of invasive lung cancers are emerging, and have faced similar challenges. A crucial consideration in screening for breast, prostate, and lung cancers is their remarkable phenotypic heterogeneity, ranging from indolent to highly aggressive. Efforts have been made to address the limitations of cancer-screening programmes, providing an opportunity for cross-disciplinary learning and further advancement of the science. Current innovations are aimed at identifying the individuals who are most likely to benefit from screening, increasing the yield of consequential cancers on screening and biopsy, and using molecular tests to improve our understanding of disease biology and to tailor treatment. We discuss each of these concepts and outline a dynamic framework for continuous improvements in the field of cancer screening.
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Affiliation(s)
- Yiwey Shieh
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, 1545 Divisadero Street, San Francisco, California 94115, USA
| | - Martin Eklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 17177 Stockholm, Sweden
| | - George F Sawaya
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, California 94158, USA
| | - William C Black
- Department of Radiology, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, USA
| | - Barnett S Kramer
- Division of Cancer Prevention, National Cancer Institute, 9609 Medical Center Drive, Bethesda, Maryland 20892, USA
| | - Laura J Esserman
- Departments of Surgery and Radiology, University of California, San Francisco, 1600 Divisadero Street, Box 1710, San Francisco, California 94115, USA
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Hsu A, Henderson JT, Harper CC, Sawaya GF. Obstetrician-Gynecologist Practices and Beliefs Regarding External Genitalia Inspection and Speculum Examinations in Healthy Older Asymptomatic Women. J Am Geriatr Soc 2016; 64:293-8. [PMID: 26805728 DOI: 10.1111/jgs.13954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To understand obstetrician-gynecologist perceptions of the value of external genitalia inspection and speculum examinations in older and younger healthy women across the life span. DESIGN National survey from May 2010 to January 2011 asking obstetrician-gynecologists about the need for and importance of external inspection and speculum examination in four scenarios of asymptomatic healthy women aged 70, 55, 35, and 18 who present for routine health visits. Separate questions asked about the importance of various reasons for these examinations. SETTING Mail-in survey of a national sample of obstetrician-gynecologists. PARTICIPANTS Probability sample of obstetrician-gynecologists from the American Medical Association Physician Masterfile (N = 521). MEASUREMENTS Proportion of obstetrician-gynecologists who would perform external inspection and speculum examinations and consider these examinations to be very important. RESULTS The response rate was 62%. In a healthy 70-year-old woman, 98% of respondents would perform external inspection, and 86% would perform a speculum examination. Ninety percent would perform a speculum examination in a healthy 55-year-old woman after removal of her uterus, cervix, and ovaries. Respondents more often indicated that the external examination was very important in the 70-year-old (63%) than in younger women (46-53%). Reasons rated as very important included identifying cancers and benign lesions, reassuring women of their health, and adhering to standard of care. CONCLUSION Obstetrician-gynecologists would commonly perform external and speculum examinations in asymptomatic women and believe the external examination to be particularly important in older women for cancer detection. Clinicians should discuss limitations of screening pelvic examination guidelines and elicit health goals from older women to provide more person-centered gynecological care.
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Affiliation(s)
- Amy Hsu
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
| | | | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Francisco, San Francisco, California
| | - George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Francisco, San Francisco, California
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Cooper CP, Saraiya M, Sawaya GF. Acceptable and Preferred Cervical Cancer Screening Intervals Among U.S. Women. Am J Prev Med 2015; 49:e99-107. [PMID: 26141914 PMCID: PMC4656074 DOI: 10.1016/j.amepre.2015.04.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 04/02/2015] [Accepted: 04/23/2015] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Current U.S. cervical cancer screening guidelines recommend a 3- or 5-year screening interval depending on age and screening modality. However, many women continue to be screened annually. The purpose of this study is to investigate U.S. women's self-reported frequency of cervical cancer screening, acceptance of an extended screening interval (once every 3-5 years), and preferred screening options. METHODS Data from a 2012 web-based survey of U.S. women aged ≥18 years who had not undergone a hysterectomy or been diagnosed with cervical cancer (N=1,380) were analyzed in 2014. Logistic regression models of extended screening interval use, acceptance, and preference were developed. RESULTS Annual Pap testing was the most widely used (48.5%), accepted (61.0%), and preferred (51.1%) screening option. More than one third of respondents (34.4%) indicated that an extended screening interval would be acceptable, but only 6.3% reported that they were currently screened on an extended interval. Women who preferred an extended screening interval (32.9% of those willing to accept regular screening) were more likely to report no primary care visits during the last 12 months (AOR=2.05, p<0.003), no history of abnormal Pap test results (AOR=1.71, p=0.013), and that their last Pap test was performed by an internist/family practitioner rather than an obstetrician-gynecologist (AOR=2.03, p<0.001). CONCLUSIONS U.S. women's acceptance of and preference for an extended cervical cancer screening interval appears to be more widespread than utilization. Strategies to educate women about the reasoning behind recommendations for less-than-annual testing and to foster informed preferences should be devised and evaluated.
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Affiliation(s)
| | - Mona Saraiya
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia.
| | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Epidemiology and Biostatistics, University of California, San Francisco, California
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Schneider A, Henderson JT, Harper CC, Hsu A, Saraiya M, Sawaya GF. Obstetrician-gynecologists' beliefs about performing less cervical cancer screening: the pendulum swings. Am J Obstet Gynecol 2015; 213:744-5. [PMID: 26184779 DOI: 10.1016/j.ajog.2015.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
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Sawaya GF, Kulasingam S, Denberg TD, Qaseem A. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015; 162:851-9. [PMID: 25928075 DOI: 10.7326/m14-2426] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION The purpose of this best practice advice article is to describe the indications for screening for cervical cancer in asymptomatic, average-risk women aged 21 years or older. METHODS The evidence reviewed in this work is a distillation of relevant publications (including systematic reviews) used to support current guidelines. BEST PRACTICE ADVICE 1 Clinicians should not screen average-risk women younger than 21 years for cervical cancer. BEST PRACTICE ADVICE 2 Clinicians should start screening average-risk women for cervical cancer at age 21 years once every 3 years with cytology (cytologic tests without human papillomavirus [HPV] tests). BEST PRACTICE ADVICE 3 Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years. BEST PRACTICE ADVICE 4 Clinicians may use a combination of cytology and HPV testing once every 5 years in average-risk women aged 30 years or older who prefer screening less often than every 3 years. BEST PRACTICE ADVICE 5 Clinicians should not perform HPV testing in average-risk women younger than 30 years. BEST PRACTICE ADVICE 6 Clinicians should stop screening average-risk women older than 65 years for cervical cancer if they have had 3 consecutive negative cytology results or 2 consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years. BEST PRACTICE ADVICE 7 Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.
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Affiliation(s)
- George F. Sawaya
- From the University of California, San Francisco, Center for Healthcare Value, San Francisco, California; University of Minnesota School of Public Health, Minneapolis, Minnesota; Carilion Clinic, Roanoke, Virginia; and American College of Physicians, Philadelphia, Pennsylvania
| | - Shalini Kulasingam
- From the University of California, San Francisco, Center for Healthcare Value, San Francisco, California; University of Minnesota School of Public Health, Minneapolis, Minnesota; Carilion Clinic, Roanoke, Virginia; and American College of Physicians, Philadelphia, Pennsylvania
| | - Thomas D. Denberg
- From the University of California, San Francisco, Center for Healthcare Value, San Francisco, California; University of Minnesota School of Public Health, Minneapolis, Minnesota; Carilion Clinic, Roanoke, Virginia; and American College of Physicians, Philadelphia, Pennsylvania
| | - Amir Qaseem
- From the University of California, San Francisco, Center for Healthcare Value, San Francisco, California; University of Minnesota School of Public Health, Minneapolis, Minnesota; Carilion Clinic, Roanoke, Virginia; and American College of Physicians, Philadelphia, Pennsylvania
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Moriates C, Dohan D, Spetz J, Sawaya GF. Defining competencies for education in health care value: recommendations from the University of California, San Francisco Center for Healthcare Value Training Initiative. Acad Med 2015; 90:421-424. [PMID: 25354077 DOI: 10.1097/acm.0000000000000545] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Leaders in medical education have increasingly called for the incorporation of cost awareness and health care value into health professions curricula. Emerging efforts have thus far focused on physicians, but foundational competencies need to be defined related to health care value that span all health professions and stages of training. The University of California, San Francisco (UCSF) Center for Healthcare Value launched an initiative in 2012 that engaged a group of educators from all four health professions schools at UCSF: Dentistry, Medicine, Nursing, and Pharmacy. This group created and agreed on a multidisciplinary set of comprehensive competencies related to health care value. The term "competency" was used to describe components within the larger domain of providing high-value care. The group then classified the competencies as beginner, proficient, or expert level through an iterative process and group consensus. The group articulated 21 competencies. The beginner competencies include basic principles of health policy, health care delivery, health costs, and insurance. Proficient competencies include real-world applications of concepts to clinical situations, primarily related to the care of individual patients. The expert competencies focus primarily on systems-level design, advocacy, mentorship, and policy. These competencies aim to identify a standard that may help inform the development of curricula across health professions training. These competencies could be translated into the learning objectives and evaluation methods of resources to teach health care value, and they should be considered in educational settings for health care professionals at all levels of training and across a variety of specialties.
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Affiliation(s)
- Christopher Moriates
- Dr. Moriates is assistant clinical professor of medicine, University of California, San Francisco School of Medicine, San Francisco, California. Dr. Dohan is professor of health policy and social medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco School of Medicine, San Francisco, California. Dr. Spetz is professor of health policy, Philip R. Lee Institute for Health Policy Studies, and associate director for research strategy, Center for the Health Professions, University of California, San Francisco School of Medicine, San Francisco, California. Dr. Sawaya is professor of obstetrics, gynecology and reproductive science, and of epidemiology and biostatistics, University of California, San Francisco School of Medicine, San Francisco, California
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Affiliation(s)
- Miriam Kuppermann
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
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Saraiya M, Benard VB, Greek AA, Steinau M, Patel S, Massad LS, Sawaya GF, Unger ER. Type-specific HPV and Pap test results among low-income, underserved women: providing insights into management strategies. Am J Obstet Gynecol 2014; 211:354.e1-6. [PMID: 24813971 DOI: 10.1016/j.ajog.2014.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 03/31/2014] [Accepted: 05/04/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The primary cervical cancer screening strategy for women over age 30 is high-risk human papillomavirus (HPV) testing combined with Papanicolaou (Pap) testing (cotesting) every 5 years. This combination strategy is a preventive service that is required by the Affordable Care Act to be covered with no cost-sharing by most health insurance plans. The cotesting recommendation was made based entirely on prospective data from an insured population that may have a lower proportion of women with HPV positive and Pap negative results (ie, discordant results). The discordant group represents a very difficult group to manage. If the frequency of discordant results among underserved women is higher, health care providers may perceive the cotesting strategy to be a less favorable screening strategy than traditional Pap testing every 3 years. STUDY DESIGN The Centers for Disease Control and Prevention's Cervical Cancer Study was conducted at 15 clinics in 6 federally qualified health centers across Illinois. Providers at these clinics were given the option of cotesting for routine cervical cancer screening. Type-specific HPV detection was performed on residual extracts using linear array. RESULTS Pap test results were abnormal in 6.0% and HPV was positive in 7.2% of the underserved women screened in this study (mean age, 45.1 years). HPV prevalence decreased with age, from 10.3% among 30- to 39-year-olds to 4.5% among 50- to 60-year-olds. About 5% of the women had a combination of a positive HPV test and normal Pap test results; HPV 16/18 was identified in 14% of discordant women. CONCLUSION The rate of discordant results among underserved women was similar to those reported throughout the US in a variety of populations. Typing for HPV 16/18 appears to assist in the management in a small proportion of women with discordant results.
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Affiliation(s)
- Mona Saraiya
- Division of Cancer Prevention and Control, Epidemiology and Applied Research Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Vicki B Benard
- Division of Cancer Prevention and Control, Epidemiology and Applied Research Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Martin Steinau
- Division of High-Consequence Pathogens and Pathology, Chronic Viral Diseases Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sonya Patel
- Division of High-Consequence Pathogens and Pathology, Chronic Viral Diseases Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - L Stewart Massad
- Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, School of Medicine, San Francisco, CA
| | - Elizabeth R Unger
- Division of High-Consequence Pathogens and Pathology, Chronic Viral Diseases Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
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Affiliation(s)
- Analía R Stormo
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, George
| | - Mona Saraiya
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, George
| | - Esther Hing
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | | | - George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Epidemiology and Biostatistics, University of California, San Francisco
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Henderson JT, Yu JM, Harper CC, Sawaya GF. U.S. clinicians' perspectives on less frequent routine gynecologic examinations. Prev Med 2014; 62:49-53. [PMID: 24518004 DOI: 10.1016/j.ypmed.2014.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 01/31/2014] [Accepted: 02/01/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE With newer recommendations for less frequent cervical cancer screening, longer intervals between routine gynecologic examinations might also be considered. METHODS A nationally representative mailed survey of U.S. obstetrician-gynecologists (n=521, response rate 62%) was conducted in 2010-11. Clinicians were asked their views on annual gynecologic examinations and on the consequences of extending the interval from annually to every 3 years for asymptomatic patients. RESULTS Over two-thirds considered annual gynecologic examination very important for women in their reproductive years (69%); fewer consider it very important for women in menopause (55%). Most anticipated that shifting examinations to every 3 years would result in lower patient satisfaction (78%), contraceptive provision (74%), and patient health and well-being (74%). Decreases in clinic volume (93%) and financial reimbursement (78%) were also expected. Anticipated effects of longer intervals varied by provider characteristics, geography, and practice setting. CONCLUSION Obstetrician-gynecologists in the U.S. believed that longer intervals between routine examinations would have negative repercussions for patients and medical practice, but there were differences by region, practice, and personal characteristics. Redefining annual gynecologic visits as contraceptive counseling and health maintenance visits could address financial and patient volume concerns, and perspectives from patients and other providers might reveal possible benefits of less frequent gynecologic examinations.
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Affiliation(s)
- Jillian T Henderson
- Kaiser Permanente Center for Health Research, Northwest, 3800 N. Interstate Avenue, Portland, OR 97227, USA; Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA.
| | - Jean M Yu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
| | - George F Sawaya
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
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Woo VG, Liegler T, Cohen CR, Sawaya GF, Smith-McCune K, Bukusi EA, Huchko MJ. Association of cervical biopsy with HIV type 1 genital shedding among women on highly active antiretroviral therapy. AIDS Res Hum Retroviruses 2013; 29:1000-5. [PMID: 23594240 DOI: 10.1089/aid.2012.0341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
HIV-1 genital shedding is associated with increased HIV-1 transmission risk. Inflammation and ulceration are associated with increased shedding, while highly active antiretroviral therapy (HAART) has been shown to have a protective effect. We sought to examine the impact of cervical biopsies, a routine component of cervical cancer screening, on HIV-1 genital RNA levels in HIV-infected women on HAART. We enrolled HIV-1-infected women undergoing cervical biopsy for diagnosis of cervical intraepithelial neoplasia (CIN) 2/3 in this prospective cohort study. All were stable on HAART for at least 3 months. Clinical and demographic information as well as plasma HIV-1 viral load were collected at the baseline visit. Specimens for cervical HIV-1 RNA were collected immediately prior to biopsy, and 2 and 7 days afterward. Quantitative PCR determined HIV-1 concentration in cervical specimens at each time point to a lower limit of detection of 40 copies/specimen. Among the 30 participants, five (16.6%) women had detectable cervical HIV-1 RNA at baseline, of whom four (80%) had detectable HIV-1 RNA after cervical biopsy, with no significant increase in viral load in the follow-up specimens. Only one woman (3.3%) with undetectable baseline cervical HIV-1 RNA had detection postbiopsy. Detectable plasma HIV-1 RNA was the only factor associated with baseline cervical HIV-1 RNA. In women on HAART, an increase in cervical HIV-1 RNA detection or concentration was not associated with cervical biopsy. These findings help provide safety data regarding cervical cancer screening and diagnosis in HIV-infected women and inform postprocedure counseling.
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Affiliation(s)
- Victoria G. Woo
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
- Doris Duke Clinical Research Fellow, University of California, San Francisco, San Francisco, California
| | - Teri Liegler
- Department of Medicine, HIV/AIDS, University of California, San Francisco, San Francisco, California
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - George F. Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Karen Smith-McCune
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Megan J. Huchko
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
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Huchko MJ, Woo VG, Liegler T, Leslie H, Smith-McCune K, Sawaya GF, Bukusi EA, Cohen CR. Impact of loop electrosurgical excision procedure for cervical intraepithelial neoplasia on HIV-1 genital shedding: a prospective cohort study. BJOG 2013; 120:1233-9. [PMID: 23647852 DOI: 10.1111/1471-0528.12258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We sought to examine the impact of the loop electrosurgical excision procedure (LEEP) on the rate and magnitude of HIV-1 genital shedding among women undergoing treatment for cervical intraepithelial neoplasia 2/3 (CIN2/3). DESIGN Prospective cohort study. POPULATION Women infected with HIV-1 undergoing LEEP for CIN2/3 in Kisumu, Kenya. METHODS Participants underwent specimen collection for HIV-1 RNA prior to LEEP and at 1, 2, 4, 6, 10, and 14 weeks post-LEEP. HIV-1 viral load was measured in cervical and plasma specimens using commercial real-time polymerase chain reaction (PCR) assays, to a lower limit of detection of 40 copies per specimen. MAIN OUTCOME MEASURES Presence and magnitude of HIV-1 RNA (copies per specimen or cps) in post-LEEP specimens, compared with baseline. RESULTS Among women on highly active antiretroviral therapy (HAART), we found a statistically significant increase in cervical HIV-1 RNA concentration at week 2, with a mean increase of 0.43 log10 cps (95% CI 0.03-0.82) from baseline. Similarly, among women not receiving HAART, we found a statistically significant increase in HIV-1 shedding at week 2 (1.26 log10 cps, 95% CI 0.79-1.74). No other statistically significant increase in concentration or detection of cervical HIV-1 RNA at any of the remaining study visits were noted. CONCLUSIONS In women infected with HIV undergoing LEEP, an increase in genital HIV shedding was observed at 2 but not at 4 weeks post-procedure. The current recommendation for women to abstain from vaginal intercourse for 4 weeks seems adequate to reduce the theoretical increased risk of HIV transmission following LEEP.
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Affiliation(s)
- M J Huchko
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California-San Francisco, CA 94105, USA.
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Weitlauf J, Jones S, Xu X, Finney JW, Moos RH, Sawaya GF, Frayne SM. Receipt of cervical cancer screening in female veterans: impact of posttraumatic stress disorder and depression. Womens Health Issues 2013; 23:e153-9. [PMID: 23660429 PMCID: PMC3704317 DOI: 10.1016/j.whi.2013.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 03/16/2013] [Accepted: 03/20/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE We evaluated receipt of cervical cancer screening in a national sample of 34,213 women veterans using Veteran Health Administration facilities between 2003 and 2007 and diagnosed with 1) posttraumatic stress disorder (PTSD), or 2) depression, or 3) no psychiatric illness. METHODS Our study featured a cross-sectional design in which logistic regression analyses compared receipt of recommended cervical cancer screening for all three diagnostic groups. RESULTS Cervical cancer screening rates varied minimally by diagnostic group: 77% of women with PTSD versus 75% with depression versus 75% without psychiatric illness were screened during the study observation period (p < .001). However, primary care use was associated with differential odds of screening in women with versus without psychiatric illness (PTSD or depression), even after adjustment for age, income and physical comorbidities (Wald Chi-square (2): 126.59; p < .0001). Specifically, among low users of primary care services, women with PTSD or depression were more likely than those with no psychiatric diagnoses to receive screening. Among high users of primary care services, they were less likely to receive screening. CONCLUSION Psychiatric illness (PTSD or depression) had little to no effect on receipt of cervical cancer screening. Our finding that high use of primary care services was not associated with comparable odds of screening in women with versus without psychiatric illness suggests that providers caring for women with PTSD or depression and high use of primary care services should be especially attentive to their preventive healthcare needs.
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Affiliation(s)
- Julie Weitlauf
- Veterans Affairs Palo Alto Health Care System - Center for Health Care Evaluation, Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford Cancer Institute, 795 Willow Road (152 MPD) Menlo Park, CA 94024, Phone: 650 493 5000 x 23420
| | - Surai Jones
- Veterans Affairs Palo Alto Health Care System - Center for Health Care Evaluation, 795 Willow Road (152 MPD) Menlo Park, CA 94024, Phone: 650 493 5000 x 27907
| | - Xiangyan Xu
- Veterans Affairs Palo Alto Health Care System – Sierra Pacific MIRECC, 3801 Miranda Ave (151Y) Palo Alto, CA 94304, Phone: 650 493 5000 x 69964
| | - John W. Finney
- Veterans Affairs Palo Alto Health Care System - Center for Health Care Evaluation, Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 795 Willow Road (152 MPD) Menlo Park, CA 94024, Phone: 650 493 5000 x 22848
| | - Rudolf H. Moos
- Veterans Affairs Palo Alto Health Care System - Center for Health Care Evaluation, Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 795 Willow Road (152 MPD) Menlo Park, CA 94024, Phone: 650-614-9892
| | - George F. Sawaya
- University of California, San Francisco, Departments of Obstetrics, Gynecology and Reproductive Sciences and Epidemiology and Biostatistics, 3333 California Street, Suite 335, San Francisco, CA 94143-0856, Phone 415 502 4090
| | - Susan M. Frayne
- Veterans Affairs Palo Alto Health Care System - Center for Health Care Evaluation, Stanford University School of Medicine, Department of Medicine, Division of General Internal Medicine, 795 Willow Road (152 MPD) Menlo Park, CA 94024, Phone: 650 493 5000 x 23369
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