Relationship between Pap smear performance and physician ordering a mammogram.

BACKGROUND. Although Pap smear screening for cervical cancer in general has been successfully implemented, mammography screening for breast cancer remains relatively underused. Patients having one screening test are more likely to have other screening tests performed. The objective of this study was to determine whether visits by women for Pap smears serve as opportunities for physicians to order a screening mammogram. METHODS. A matched case-control design was used for this retrospective study. Eligible women included those over 50 years of age who had no history of breast cancer or mastectomy and who had made at least one visit to a family practice residency program during the 2-year study period. Cases were randomly selected from women who had mammograms performed. For each case, one control subject who did not have a mammogram was matched by age and number of visits. A chart audit was performed to collect data on the characteristics of these women and whether they completed their screening tests. RESULTS. The adjusted odds ratio (controlling for the patient's age and number of physician visits) for mammogram completion among women who had a Pap smear compared with those who did not was 6.67. This effect persisted after controlling for other confounding factors using logistic regression. CONCLUSIONS. Performing a Pap smear appears to serve as a prompt for the physician to order a screening mammogram. That physicians appear to provide screening tests, particularly Pap smears and mammograms, as a package of services should be considered when future efforts to improve implementation are made.     

Validation of recall of breast and cervical cancer screening by women in an ethnically diverse population

BACKGROUND: Screening mammogram and Pap smear rates are lower for women in underserved racial and ethnic groups, yet may be overestimated due to reliance on patients' self-reports. The purpose of this study was to determine accuracy of self-reports of mammograms and Pap smears in a multiethnic, multilingual population of African American, Latina, Chinese, Filipina, and White women residing in low-income census tracts of Alameda County, California. METHODS: Following a baseline telephone survey of 1,464 women regarding receipt of mammograms and Pap smears, we examined computerized and written medical records to validate the dates and locations of tests reported by women. RESULTS: Of 1,464 subjects, 94.9% reported having had a Pap smear, and 87% reported having had a mammogram. For Pap smears, in a subsample of 448 cases, we validated only 69.4% of the women's self-reports, and for mammography, in a subsample of 846 women, we validated only 75.4% of the self-reports. Validation rates differed significantly by ethnicity and site of care for both Pap smears and mammograms. CONCLUSIONS: Population estimates of breast and cervical cancer screening rates based upon patient self-reports need to be adjusted downward, by as much as one-quarter to one-third, for low-income, ethnic women.     

Knowledge, Attitudes, and Patterns of Cancer Screening: A Self-report Among Foreign Born Hispanic Women Utilizing Rural Migrant Health Clinics

Hispanics are the fastest growing minority in the United States and are currently Washington state's largest minority, with the highest growth rates found in the rural agricultural areas of eastern Washington state. Because breast and cervical cancer mortality rates are higher in Hispanics than other U.S. women, subgroups of Hispanic women with the lowest cancer screening utilization rates need to be identified and targeted for cancer control intervention to most effectively reduce late-stage cancer diagnoses and mortality. A study was conducted at six migrant health clinics located throughout eastern Washington state to discern age-specific proportions for utilization of mammography, breast self-examination, and Pap smears among Hispanic migrants to the United States. Knowledge and attitudes regarding these procedures also were assessed and face-to-face interviews were completed with 512 women. Among women 20 years or older, 15 percent had never heard of a Pap smear, only 78 percent had ever received a Pap smear, and only 44 percent had received a Pap smear within the prior year. In all, 73 percent of the women had been taught breast self-examination, 62 percent performed breast self-examination, and 41 percent had performed a breast self-examination in the prior month. Among women 40 years or older, only 38 percent had never heard of a mammogram, 38 percent had ever received a mammogram, and only 30 percent had received a mammogram in the prior two years. Cost was reported as a major barrier for screening in this population. Additionally, a substantial proportion of the women perceived Pap smears and mammography as unnecessary or diagnostic procedures, rather than preventive health measures.     

Use of mammography and Pap smear in Estonia,a country without organized cancer screening

Summary Objectives: To analyze mammography and Pap smear status in Estonia where no organized population-based cancer screening is available. Methods: 5000 individuals (aged 16–64) were randomly chosen from the national population register; among them, 1755 women filled out postal questionnaires. Results: 50% of respondents aged 45–64 reported having taken a mammogram, 51% of women aged 25–64 had the Pap smear at least once in their lifetime. Corresponding figures for the past two years were 37% and 30%. Irrespective of age, women taking fewer tests over the past two years were rural workers, unemployed, and health behavior recommendations ignorers. In most cases, initiative for mammogram came from women, and from the physician in the case of Pap smear. Moderate increase in mammography use occurred after a project for early detection of breast cancer was launched. Conclusion: Women must continuously be informed that early detection of breast and cervical cancer is possible. Young women should be encouraged to ask for Pap testing. Knowledge of family physicians should be improved. Submitted: 13 February 2006; Revised: 4 October 2006; Accepted: 8 November 2006     

Mammography and pap smear use by older rural women.

OBJECTIVE. To compare the characteristics of older women who did and did not have screening mammograms and Pap smears during the first two years both services were a Medicare Part B benefit. METHODS. A prospective study was conducted in five rural Pennsylvania counties of 2205 female community-dwelling Medicare Part B beneficiaries who volunteered to participate in a Medicare prevention demonstration project. The baseline health risk appraisal included information on demographics, insurance status, disease history, symptomatology, and functional and cognitive status. These variables were tested for their association with the use of mammography and Pap smear using Medicare utilization claims data from 1991 to 1992. RESULTS. Of 2175 women still alive after three years, 44.6% had had a mammogram and 14.6% had had a Pap smear in either 1991 or 1992. Multivariate logistic regression revealed that women were more likely to have a mammogram if they were younger, were more educated, had supplemental insurance, did not need assistance with activities of daily living, and did not have diabetes or arthritis. Younger, college educated, and non-widowed women were more likely to have Pap smears than women in other categories. CONCLUSIONS. With cost less of a barrier, more aggressive efforts to persuade older women to have mammograms and Pap smears must be developed.     

Pap smear and mammogram screening in Mexican-American women: the effects of acculturation.

OBJECTIVES. For Mexican Americans, acculturation is a multidimensional process of adopting attitudes, values, and behavior from the non-Hispanic White culture. This study examines the effects of different dimensions of acculturation on the cancer screening behavior of Mexican-American women. METHODS. Subjects were 450 randomly selected Mexican-American women age 40 years and older living in El Paso, Texas. Personal interviews solicited information on age, income, education, health insurance, Pap smear and mammogram use, and acculturation. Acculturation was measured with five scales that assessed English proficiency, English use, value placed on culture, traditional family attitudes, and social interaction. RESULTS. The 2-year prevalence of Pap smear and mammogram screening increased with each gain in acculturation on English proficiency and use. These associations disappeared when adjusted for age, income, insurance, and education. After adjusting for sociodemographic factors and other acculturation dimensions, a strong traditional Mexican attitude toward family was positively related to mammography use. CONCLUSIONS. Taking advantage of the positive influence of Hispanic familism on cancer screening behavior may increase the effectiveness of cancer control interventions in Mexican Americans.     

Cancer screening in women: a study of house staff behavior

To explore physician, patient, and provider factors associated with house staff performance of cancer screening in women, we reviewed 565 randomly selected charts of 58 medical residents in two San Francisco teaching hospitals, H1 and H2. We assessed performance of Pap smear, breast exam, mammography, rectal exam, and stool occult blood testing, and administered questionnaires to all residents to ascertain screening beliefs and attitudes and individual screening criteria. The main finding was a significant difference in screening between the two hospitals. Four of five tests (Pap smear, breast exam, mammography, rectal exam) were performed more frequently at H2. Neither provider nor patient factors could explain this. Organizational differences between the sites included more frequent flow sheet recommendations for mammography and rectal exams at H2. Increased gynecological referral at H2 was also associated with more frequent Pap smears, breast exams, and rectal exams. White women did receive more frequent rectal exams, and mammography was increased among those who agreed with American Cancer Society screening recommendations, but no other provider or patient characteristics were associated with difference in screening. Results of further study of the effect of the learning environment and referral strategies on cancer screening, including assessment of patient acceptability and cost, can be used to improve cancer screening behaviors of medical house staff.     

Receipt of preventive health care services by lesbians

BACKGROUND: We measured receipt of age-appropriate preventive health services by lesbians and assessed whether provider and individual characteristics, including disclosure of sexual orientation, are independently associated with receipt of these services. METHODS: A questionnaire was printed in a national biweekly gay, lesbian, and bisexual news magazine, and self-identified lesbians living in all U. S. states (N =6935) responded to the survey. Main outcome variables were receipt of a Pap smear within the preceding 1 and 2 years and, for women aged > or= 50, receipt of a mammogram within the past 1 and 2 years. RESULTS: Fifty-four percent had Pap smears within 1 year and 71% within 2 years, with increasing rates among older and more educated respondents. Seventy percent of respondents aged > or = 50 had a mammogram in the past year, and 83% within 2 years; rates did not vary significantly controlling for education. Sixty percent had disclosed their sexual orientation to their regular health care provider. Controlling for patient and provider characteristics, disclosure was independently associated with receipt of Pap smears, but not mammograms. CONCLUSIONS: It is important for providers to identify their lesbian patients' unmet needs for preventive health care. Additionally, it is important for providers to provide complete and appropriate preventive health care for their lesbian patients. Further research is needed to determine why lesbians are not receiving Pap smears at the recommended rate and whether this disparity is reflective of aspects of cervical cancer screening or indicates a more general problem with access to health care including receipt of preventive services.     

The role of health insurance on Pap smear and mammography utilization by immigrants living in the United States

BACKGROUND: Nearly half of recent immigrants to the United States lack health insurance. Access to cancer screening services for this group is problematic. We examine the role of health insurance and having a usual source of care (USC) on Pap smear and mammography utilization by immigrant women using a nationally representative sample. METHODS: We used a telephone survey that oversampled racial and ethnic minorities. We analyzed data on 3,622 women age 18-70. We classified the 822 foreign-born women as recent immigrants if they had resided in the United States for under 10 years; LT immigrants were those with a longer tenure. RESULTS: Among recent immigrants, 73% and 78% (SE 4%) reported a Pap smear or mammogram, respectively, in the previous 2 years versus 89% and 89% of U.S.-born women (P < 0.05 for both comparisons). Among those with insurance or a USC, differences in screening between recent immigrants and U.S.-born women were four percentage points or less and not statistically significant. However, uninsured recent immigrants were less likely than uninsured U.S.-born women to have Pap smears [60% (SE 7%) versus 71%, P < 0.05]. Adjusting for differences in sociodemographics, health attitudes or beliefs, patient or provider communication, and the medical care environment, insurance remained the strongest predictor of screening. CONCLUSION: Disparities in screening were greatly attenuated among the insured population. Increasing awareness of available safety net sources of care may also improve cancer screening among uninsured recent immigrants.     

Screening HMO women overdue for both mammograms and pap tests.

BACKGROUND: Regular screening has the potential to reduce breast and cervical cancer mortality, but despite health plan programs to encourage screening, many women remain unscreened. Tailored communications have been identified as a promising approach to promote mammography and Pap test screening. METHODS: The study used a four-group randomized design to compare with Usual Care the separate and combined effects of two tailored, motivational interventions to increase screening-a clinical office In-reach intervention and a sequential letter/telephone Outreach intervention. Subjects were 510 female HMO members ages 52-69 who had had no mammogram in the past 2 years and no Pap smear in the past 3 years. Primary outcomes were the percentage of women in each condition who received a mammogram, a Pap smear, or both screening tests during the 14-month study period. RESULTS: Thirty-two percent of the Combined group, 39% of the Outreach group, and 26% of the In-reach group obtained both services versus 19% of Usual Care participants. Overall, compared with Usual Care, both Outreach (P = 0.006) and Combined (P = 0.05) screened significantly more women. For subjects ages 65-69, Outreach rates were lower than those of Usual Care. CONCLUSION: A tailored letter-telephone Outreach appears to be more effective at screening women ages 52-64 than a tailored office-based intervention, in large part because most In-reach women did not have clinic visits at which to receive the intervention.     

Cancer screening in women: body mass index and adherence to physician recommendations

BACKGROUND: The reasons that obese women are less likely to obtain mammograms and Papanicolaou tests (Pap smears) are poorly understood. This study evaluated associations between body mass index (BMI) and receipt of and adherence to physician recommendations for mammography and Pap smear. METHODS: Data from the 2000 National Health Interview Survey (8289 women aged 40 to 74 years) were analyzed in 2006 using logistic regression. Women with previous hysterectomy were excluded from Pap smear analyses (n=5521). Outcome measures were being up-to-date with screening, receipt of physician recommendations, and women's adherence to physician recommendations for mammography and Pap smear. RESULTS: After adjusting for sociodemographic variables, healthcare access, health behaviors, and comorbidity, severely obese women (BMI > 40 kg/m(2)) were less likely to have had mammography within 2 years (odds ratio [OR]=0.50, 95% confidence interval [CI]=0.37-0.68) and a Pap smear within 3 years (OR=0.43, 95% CI=0.27-0.70). Obese women were as likely as normal-weight women to receive physician recommendations for mammography and Pap smear. Severely obese women were less likely to adhere to physician recommendations for mammography (OR=0.49, 95% CI=0.32-0.76). Women in all obese categories (BMI > 30 kg/m(2)) were less likely to adhere to physician recommendations for Pap smear (ORs ranged from 0.17 to 0.28, p<0.001). CONCLUSIONS: Obese women are less likely to adhere to physician recommendations for breast and cervical cancer screening. Interventions focusing solely on increasing physician recommendations for mammography and Pap smears will probably be insufficient for obese women. Additional strategies are needed to make cancer screening more acceptable for this high-risk group.     

Factors associated with Pap smear taking in general practice: focusing public health initiatives

Abstract: This study ascertained the relationships of patient, practitioner and consultation factors with: 1. taking a Pap smear or referral to a specialist in the consultation; and 2. an unsuccessful offer to take a Pap smear or making an appointment for a smear. In a cross-sectional study of 3478 women presenting to 230 randomly selected general practitioners in Brisbane and Toowoomba, information about most recent Pap smear, screening in the consultation, and independent variables were collected from patients and doctors. Relationships between three levels of outcome variable (no action, Pap smear taken or referral, appointment or refusal), and independent variables (practitioner variables, consultation variables, patient variables) were modelled using polytomous logistic regression. Presenting for a routine checkup and breast cancer screening were associated with all types of action. Younger age, longer consultations and consultations with a female practitioner were associated with Pap smear taking and referrals, and not appointments or refusals. Being due for a Pap smear, having blood pressure measured, consulting a younger general practitioner and one who ascribed to current guidelines on screening were associated with an appointment or a refusal, when compared with no action. Results identify different profiles of those who get a Pap smear and those who do not, the former indicating a more proactive patient group, while the latter suggest more active general practitioners who attempted opportunistic screening of passive patients, or women who do not specifically seek Pap smears. We have identified factors that have significance for developing public health programs focused on consumers and providers.     

Agreement between patient self-reports and medical records for Pap smear histories.

As part of a larger cervical cancer study, we tried to verify the Pap smear histories for 125 black women with cervical cancer. For 105 of the patients, we identified all possible providers for the five-year period before the calendar year of diagnosis. Agreement between the medical records and the patient reports was poor to fair (kappa = 0.34) for whether the patient had a Pap smear in the three-year period before diagnosis. Patients tended to report far more Pap smears than medical records confirmed. Important determinants of agreement were the number of Pap smears reported during the five-year period and the age of the patient. The older the patient and the more Pap smears reported, the larger the discrepancy between the medical record and her self-report. The medical records did not contain enough data for us to complete an investigation of the possible reasons for this disagreement. Our results suggest these implications: (1) clinicians should strongly consider performing Pap smears if they doubt a patient's screening history, and (2) Pap smear registries are required for reliable and efficient evaluations of cervical cancer control programs because neither the patient report nor medical records are adequate.     

Breast self-examination and cervical cancer testing among Norwegian female physicians. A nation-wide comparative study

Practice of breast self-examination (BSE) and cervical cancer testing (Pap smear tests) was studied in a nation-wide Norwegian representative sample of 284 female physicians aged 24-67. BSE was performed at least once a month in 30.6% of the cases, and 54.6% had a Pap smear test once every third year at least. BSE was never practised among 19.2% of the physicians, the main reasons being that they forgot it, or that they stated that they were in a low risk group or had no symptoms of disease. 16.2% had never had routine Pap smears, and these physicians claimed that they were in a low risk group or had no symptoms of disease, that they had a problem in finding a physician to attend, or that they forgot to take the test. A subgroup of 135 physicians aged 35-49 years was compared with 738 women with higher university education included from a nation-wide representative sample of the general population of Norway. A significantly higher percentage of physicians practised BSE monthly or more often compared with other university educated women. However, a significantly lower percentage of the physicians had Pap smear tests every third year or more frequently. The positive association between being a physician and practising BSE, and the negative association between being a physician and having Pap smear tests, remained after controlling for potential confounders in multivariate analyses.     

Impact of a new cervical pap smear screening guideline on member perceptions and comfort levels.

BACKGROUND: An evaluation was conducted to assess patient perceptions and comfort levels with a new triennial Pap smear screening guideline. METHODS: A random sample of women ages 20-69 (N = 673) was selected among members of three provider groups within a large health maintenance organization and mailed a survey. Questions pertained to Pap smear history and perceptions of the new guideline. RESULTS: The overall response rate was 63%. Over one-half of respondents had no recollection of being informed about the change in recommendation. Fourteen percent of subjects responded positively to the change, 16% were neutral, 20% were skeptical, and 50% made negative comments. Women significantly more likely to be negative or skeptical about the new guide line were those who reported more frequent prior Pap smears (P < 0.0001), those reporting a history of abnormal Pap smear (P < 0.01), and more educated women (P < 0.05). No statistical differences were found for those reporting a recent abnormal result, or based on provider group, age, or recollection of being informed. CONCLUSIONS: Regardless of patient knowledge and intellectual understanding of screening intervals, this new guideline raises patient concern about preventive care. More must be done to educate women regarding the change in recommended screening frequency and the reasons for it.     

Breast and cervix cancer screening among multiethnic women: role of age, health, and source of care

OBJECTIVE: The aim of this study was to evaluate the relationships between age, health status, access to care, and breast and cervical cancer screening among multiethnic elderly and nonelderly women. METHODS: A structured telephone survey of a quota sample of 1,420 New York City women from four Hispanic groups (Columbian, Dominican, Puerto Rican, Ecuadorian) and three black groups (U.S., Caribbean, and Haitian) was performed. Outcome measures included "ever" and "recent" self-reported use of mammography, clinical breast examination (CBE), and Pap smears. Logistic regression models assessed the predictors of screening use. RESULTS: Having a regular source of care significantly predicted all screening use for both elderly and nonelderly, controlling for ethnicity, sociodemographics, health status, access to care, proportion of life in the United States, and cancer attitudes. Elderly women (>/=65 years) were significantly less likely to have ever had (OR = 0.79, 95% CI 0.65-0. 96) and to have recently had (OR = 0.67, 95% CI 0.57-0.79) Pap smears than younger women, controlling for the other variables; being elderly also tended to be an independent predictor of ever and recent mammography and CBE use. Interestingly, there was a trend for health status to act differently in predicting Pap smear use for the two age groups. For younger women, being in poor health increased the odds of Pap smear screening, while for elderly women, being in good health increased the odds of screening. CONCLUSIONS: Elderly women reported being screened less than younger women; interactions between health status and age need further exploration.     

Cancer screening behaviors among U.S. women: breast cancer, 1987-1989, and cervical cancer, 1988-1989.

Data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to examine trends in breast and cervical cancer screening behaviors among U.S. women in selected states. Data reported are from the 1987, 1988, and 1989 BRFSS for breast cancer screening (mammography) and from the 1988 and 1989 BRFSS for cervical cancer screening (Papanicolaou [Pap] smear). Results are presented as either state-specific or state-aggregate data for the years noted above. State-specific analyses indicated that self-reported mammography utilization increased between 1987 and 1989. Although whites and blacks reported similar mammography utilization rates both for screening and for a current or previous breast problem, disparities were evident among women of different ages and incomes. The proportion of women who reported ever having had a Pap smear and having heard of a Pap smear were extremely high and remained fairly consistent across the 2 survey years. State-aggregate analyses, however, showed that the percentage of women who had had a Pap smear within the previous year was negatively associated with age and positively associated with income. A higher proportion of blacks than whites obtained Pap smears. These results indicate that certain segments of the population are not taking full advantage of available breast and cervical cancer screening technologies. Public health strategies, such as those outlined in the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101-354), should enhance screening opportunities for these women.     

Breast and cervical cancer screening: Knowledge, attitudes and behaviour among schoolteachers in Italy

The study explores knowledge, attitudes and behavior regarding screening for breast and cervical cancers. All female teachers in primary and secondary schools in Crotone and in Cassino (Italy) received a questionnaire on demographic and socioeconomic characteristics, clinical history, knowledge, behavior and attitudes about breast and cervical cancer and related screening procedures. A response rate of 65% was achieved. Knowledge on effectiveness of mammography and pap test in finding related cancers was widely spread in the sample. Only about 30% and 50% had respectively undergone their last mammogram and pap test according to the recommended time interval. Having been examined by a physician in the previous year and having had a screening CBE or a screening pap smear in the past three years were significantly more likely in women who underwent mammography for screening purposes in the past two years. Pap smear in the previous three years was significantly more likely in women in their forties, with a higher family income and in those who had been examined by a physician in the previous year. The results strongly recommend continued emphasis of physicians on education of women regarding mammography and pap smear.     

Comparison of cytobrush with Cervex-Brush for endocervical cytologic sampling.

This study was designed to compare the quality of the Papanicolaou (Pap) smear and side effects associated with the Ayres spatula/cytobrush combination and the Cervex-Brush. We evaluated 165 Pap smears, of which 84 (51%) were cytobrush/spatula specimens, and 81 (49%) were from Cervex-Brush specimens. The cytobrush/Ayres spatula combination and the Cervex-Brush alone were equally successful in detecting squamous cells, however, the cytobrush/Ayres spatula combination was significantly better in picking up endocervical cells than the Cervex-Brush (p less than 0.01). There were no significant differences between the two techniques in degree of bleeding and pain in adolescents. The combination of the cytobrush and spatula appears to be superior to the Cervex-Brush alone in producing adequate Pap smears.