Impact of Patient-Directed Cytology Results Correspondence Program on Follow-Up of High-Grade Pap Tests

OBJECTIVE

Proper follow-up of high-grade (HG) Pap tests is critical to the prevention of cervical cancer. This study evaluated the impact of a patient-directed cytology results correspondence program on follow-up of HG Pap tests among at-risk women aged 21 to 69 in Ontario.

METHODS

A cohort study with a historical control was used to investigate the impact of a result letter on adherence to follow-up after an HG Pap test. Analyses were conducted on an intention-to-treat basis. The intervention group was defined as women with an HG Pap test in 2014-2016, and the control group included women with an HG Pap test in 2010-2012. Follow-up was defined as a colposcopy or related treatments within 6 months of an HG Pap test. Factors that could influence adherence to follow-up were included as covariates in a multivariable logistic regression model (Canadian Task Force Classification II-2).

RESULTS

The study population comprised 7088 women in the intervention group and 6887 women in the non-intervention group. The follow-up rate in the intervention group was 86.2% compared with 81.0% in the non-intervention group. Controlling for covariates, women in the intervention group were more likely to have a follow-up (adjusted odds ratio 1.5; 95% confidence interval 1.3-1.6). Other significant factors included being registered to a family physician and the physician's gender.

CONCLUSIONS

A patient-directed correspondence program that provides Pap test results directly to the woman may reduce loss to follow-up for an HG abnormality, with an increased likelihood that these women will seek and complete a colposcopy and related treatment.

Treating Second Breast Events After Breast-Conserving Surgery for Ductal Carcinoma in Situ

Background: Because of screening mammography, the number of ductal carcinoma in situ (DCIS) survivors has increased dramatically. DCIS survivors may face excess risk of second breast events (SBEs). However, little is known about SBE treatment or its relationship to initial DCIS care. Methods: Among a prospective cohort of women who underwent breast-conserving surgery (BCS) for DCIS from 1997 to 2008 at institutions participating in the NCCN Outcomes Database, we identified SBEs, described patterns of care for SBEs, and examined the association between DCIS treatment choice and SBE care. Using multivariable regression, we identified features associated with use of mastectomy, radiation therapy (RT), or antiestrogen therapy (AET) for SBEs. Results: Of 2,939 women who underwent BCS for DCIS, 83% received RT and 40% received AET. During the median follow-up of 4.2 years, 200 women (6.8%) developed an SBE (55% ipsilateral, 45% invasive). SBEs occurred in 6% of women who underwent RT for their initial DCIS versus 11% who did not. Local treatment for these events included BCS (10%), BCS/RT (30%), mastectomy (53%), or none (6%); only 28% of patients received AET. Independent predictors of RT or mastectomy for SBEs included younger age, shorter time to SBE diagnosis, and RT or AET for the initial DCIS. Conclusions: A sizable proportion of patients with SBEs were treated with mastectomy, most especially those who previously received RT for their initial DCIS and those who developed an ipsilateral SBE. Despite the occurrence of an SBE, relatively few patients received AET. Future studies should investigate optimal treatment approaches for SBEs, including the benefit of mastectomy versus lumpectomy for an ipsilateral SBE and the benefit of AET for a hormone-receptor-positive SBE contingent on AET use for the initial DCIS diagnosis.

Comparing treatment and outcomes of ductal carcinoma in situ among women in Missouri by race

PURPOSE

To investigate whether treatment (surgery, radiation therapy, and endocrine therapy) contributes to racial disparities in outcomes of ductal carcinoma in situ (DCIS).

PATIENTS AND METHODS

The analysis included 8184 non-Hispanic White and 954 non-Hispanic Black women diagnosed with DCIS between 1996 and 2011 and identified in the Missouri Cancer Registry. Logistic regression models were used to estimate odds ratios (ORs) of treatment for race. We used Cox proportional hazards regression models to estimate hazard ratios (HRs) of ipsilateral breast tumor (IBT) and contralateral breast tumor (CBT) for race.

RESULTS

There was no significant difference between Black and White women in utilization of mastectomy (OR 1.16; 95 % CI 0.99-1.35) or endocrine therapy (OR 1.19; 95 % CI 0.94-1.51). Despite no significant difference in underutilization of radiation therapy (OR 1.14; 95 % CI 0.92-1.42), Black women had higher odds of radiation delay, defined as at least 8 weeks between surgery and radiation (OR 1.92; 95 % CI 1.55-2.37). Among 9138 patients, 184 had IBTs and 326 had CBTs. Black women had a higher risk of IBTs (HR 1.69; 95 % CI 1.15-2.50) and a comparable risk of CBTs (HR 1.19; 95 % CI 0.84-1.68), which were independent of pathological features and treatment.

CONCLUSION

Racial differences in DCIS treatment and outcomes exist in Missouri. This study could not completely explain the higher risk of IBTs in Black women. Future studies should identify differences in timely initiation and completion of treatment, which may contribute to the racial difference in IBTs after DCIS.