Preferences for Human Papillomavirus Testing with Routine Cervical Cancer Screening in Diverse Older Women

Background  Human papillomavirus (HPV) testing is increasingly being used to determine the optimal cervical cancer screening interval in older women. Little is known about women’s attitudes toward HPV testing or how these attitudes may influence medical discussions about cervical cancer screening. Methods  Preferences for HPV and concomitant Papanicolaou (Pap) testing were assessed through in-person interviews with diverse women aged 50 to 80 years recruited from community and university-based practices. Results  Eight hundred and sixty-five women (257 White, 87 African American, 149 Latina, and 372 Asian) were interviewed. Approximately 60% of participants wanted to be tested for HPV and another 15% would undergo testing if recommended by their physician. Among those wanting HPV testing, 94% would want more frequent than annual Pap tests if they had a positive HPV test and a normal Pap test. Two thirds of those under age 65 would be willing to switch to triennial Pap testing, and half of those aged 65 and older would be willing to discontinue Pap testing, if they had a negative HPV test and normal Pap test. Preferences for testing varied by ethnicity, age, place of birth, and cancer history. Conclusions  The majority of older women were willing to use HPV testing to make decisions about frequency and duration of cervical cancer screening, but up to one third would want at least annual, ongoing screening regardless of HPV test results. Efforts should be made to ensure that HPV testing is used to reinforce appropriate utilization of screening tests. This paper was presented at the national annual meeting of the Society for General Internal Medicine in Toronto, Canada, on April 25, 2007.     

Pap smear screening in women 65 and older

Pap smear screening in women 65 years of age and older is controversial. To assess the need to offer screening in this group, we examined Pap results of women 65 and older whose charts were reviewed as part of a cancer screening study in two San Francisco hospitals. Two hundred thirty women (41%) were 65 years of age or older (mean age, 73). Compared with younger women, they were less likely to have had a Pap smear during the past 3 years (61% versus 72%), less likely to have seen a gynecologist (24% versus 34%), and were more likely to have refused Pap screening (11% versus 5%). Of the 140 women who had Paps, five showed atypia (class II). None exhibited dysplasia or carcinoma in situ. Those with atypia were all nonwhite. One had had a hysterectomy; two had a history of previously abnormal Paps. Overall, women with a history of abnormal Paps were far more likely to be screened (91% versus 58%). Those who had had a hysterectomy were significantly less likely to be screened (51% versus 68%). These results showed a low rate of cervical dysplasia/carcinoma in older, low-income women. Although our sample was small, the low rate of abnormals may reflect the relatively high rate of prior screening in this population. Because older women are not likely to see gynecologists, primary care physicians should continue Pap screening in older women (including those with a history of hysterectomy) until a history of repeated, technically adequate, normal Pap smears is documented.     

Adherence to breast and cervical cancer screening in Spanish women with diabetes: associated factors and trend between 2006 and 2010

AimThis study aimed to assess the adherence to breast and cervical cancer screening of women with diabetes mellitus (DM), and the associated factors and trend of use over time of these preventative services between 2006 and 2010 in Spain.MethodsThe study used data from a population of women aged greater or equal to 18 years (n = 11,957) who participated in the European Health Interview Survey in Spain (EHISS, 2009). Diabetes status was self-reported and included those with type 2 DM. Adherence to screening for cancer prevention was assessed by asking women aged greater or equel to 40 years whether they had undergone mammography and a Papanicolaou (Pap) cervical smear (in those aged 18–69 years) within the previous 2 and 3 years, respectively. Independent variables included sociodemographic and health-related characteristics. Also, the age-standardized prevalences of mammography and Pap smear uptake were compared in women with diabetes between 2006 and 2010.ResultsAmong the diabetic women, 37.9% underwent mammography and 49.1% had a Pap smear vs 53.8% and 64%, respectively, in women without diabetes, with corresponding adjusted odds ratios of 0.81 (95% CI: 0.68–0.97) and 0.74 (95% CI: 0.60–0.91). Among diabetic women, attending more “physician visits” was a positive predictor of having both screening tests. Also, a higher monthly income level was associated with mammography uptake, and a higher educational level with Pap smear uptake. There was also a significant decrease in mammography screening uptake between 2006 and 2010 compared with a stable rate of uptake of cervical cancer screening.ConclusionSpanish women with diabetes consistently underuse breast and cervical cancer screening tests compared with non-diabetic women. The decline in mammography uptake rates needs to be carefully monitored and may even call for intervention.     

Assessment of factors impacting cervical cancer screening among low-income women living with HIV-AIDS

Very little is currently known about factors impacting the prevalence of cervical cancer screening among women living with HIV-AIDS (WLHA). To better understand this issue, we surveyed low-income, medically underserved women receiving subsidized gynecologic care through an integrated HIV clinic. A self-administered questionnaire was completed by 209 women who self-identified as HIV positive. A total of 179 subjects (85.7%) reported having had a Pap test in the last three years. The majority of WLHA (95%) knew that the Pap test screens for cervical cancer. However, overall knowledge of cervical cancer risk factors, such as multiple sexual partners or sex with a man with multiple partners, was low (43% and 35%, respectively). Unscreened women were younger and more likely to be single with multiple current sexual partners. In multivariable analyses, the only factors associated with Pap testing were a woman's perception that her partner wants her to receive regular screening (aOR 4.64; 95% CI: 1.15–23.76; p?=?.04), number of clinic visits during the past year (aOR 1.36, 95% CI: 1.05–1.94; p?=?.04) and knowledge that the need for a Pap test does not depend on whether or not a woman is experiencing vaginal bleeding (aOR 6.52, 95% CI: 1.04–49.71; p?=?.05). We conclude that support from male partners in addition to effective contact with the health system and knowledge of cervical cancer risk factors influence Pap utilization among low-income WLHA. Future measures to improve the care for this population should increase knowledge of cervical cancer risk factors and encourage social support for cervical cancer screening among WLHA.     

Health literacy as a predictor of follow-up after an abnormal pap smear

BACKGROUND: Low literacy influences cervical cancer screening knowledge, and is a possible contributor to racial disparities in cervical cancer. OBJECTIVE: To examine the hypothesis that literacy predicts patient adherence to follow-up recommendations after an abnormal Pap smear. DESIGN: A prospective, continuity clinic-based study. PARTICIPANTS: From a sample of 538 women undergoing literacy testing at the time of Pap smear screening, we studied 68 women with abnormal Pap smear diagnoses. MEASUREMENTS: Literacy was assessed using the Rapid Evaluation of Adult Literacy in Medicine (REALM). We also measured other proxies for literacy, including educational attainment and physician estimates of patients' literacy level. Outcome measures included on-time and 1-year follow-up and duration of time to follow-up after an abnormal Pap smear. RESULTS: Only one-third of the cohort adhered to follow-up recommendations. At 1 year, 25% of the women had not returned at all. Patients with inadequate literacy (as assessed by the REALM) were less likely to follow up within 1 year, although this result was not statistically significant (adjusted odds ratio [OR]=3.8, 95% confidence interval [CI]: 0.8 to 17.4). Patients subjectively assessed by their physician to have low literacy skills were significantly less likely to follow up within 1 year (adjusted OR=14, 95% CI: 3 to 65). Less than high school education (hazard ratio (HR)= 2.3; 95% CI: 1.2, 4.6) and low physician-estimated literacy level (HR=3.4, 95% CI: 1.4, 8.2), but not objective literacy level, were significant predictors of duration of time to follow-up, adjusting for recommended days to follow-up and other factors. CONCLUSIONS: Among women with an abnormal Pap smear, those perceived by their physician to have low literacy were significantly more likely to fail to present for follow-up.     

The association of ambulatory care with breast cancer stage at diagnosis among medicare beneficiaries

OBJECTIVE: Although nearly all elderly Americans are insured through Medicare, there is substantial variation in their use of services, which may influence detection of serious illnesses. We examined outpatient care in the 2 years before breast cancer diagnosis to identify women at high risk for limited care and assess the relationship of the physicians seen and number of visits with stage at diagnosis. DESIGN: Retrospective cohort study using cancer registry and Medicare claims data. PATIENTS: Population-based sample of 11,291 women aged > or =67 diagnosed with breast cancer during 1995 to 1996. MEASUREMENTS AND MAIN RESULTS: Ten percent of women had no visits or saw only physicians other than primary care physicians or medical specialists in the 2 years before diagnosis. Such women were more often unmarried, living in urban areas or areas with low median incomes (all P> or =.01). Overall, 11.2% were diagnosed with advanced (stage III/IV) cancer. The adjusted rate was highest among women with no visits (36.2%) or with visits to physicians other than primary care physicians or medical specialists (15.3%) compared to women with visits to either a primary care physician (8.6%) or medical specialist (9.4%) or both (7.8%) (P<.001). The rate of advanced cancer also decreased with increasing number of visits (P<.001). CONCLUSIONS: Even within this insured population, many elderly women had limited or no outpatient care in the 2 years before breast cancer diagnosis, and these women had a markedly increased risk of advanced-stage diagnosis. These women, many of whom were unmarried and living in poor and urban areas, may benefit from targeted outreach or coverage for preventive care visits.     

Determinants and evolution of squamous intraepithelial lesions in HIV-infected women, 1991-2004

This study presents a case-control nested analysis of cervical squamous intraepithelial lesions (SIL) in a cohort of 423 HIV-infected women with registered Pap smears between 1991 and 2004. Data on Pap smear results, CDC HIV classification, CD4 cell count and antiretroviral therapy were prospectively collected. Pap smears were classified using the Bethesda classification. Women had a median of three Pap smears registered in the database. The first Pap smear was registered 相似文献   

Cervical cancer screening in an urban emergency department.

STUDY OBJECTIVES: To determine the feasibility of Pap screening and follow-up of urban emergency department patients and the prevalence of cervical dysplasia and carcinoma in this group. DESIGN: During a four-month period, Pap smears were added to pelvic examinations performed in the ED. Follow-up, including repeat Pap smear or biopsy, was attempted on all abnormal smears. SETTING: Urban county hospital-based ED. INTERVENTIONS: Pap screening and follow-up. RESULTS: Dysplasia was present in 8% of screening Pap smears. Eighty-two percent of patients with dysplasia on screening Pap smear returned for follow-up. Four percent of screened patients received a confirmed diagnosis of CIN 1 or more following repeat Pap smear or biopsy. Two invasive cervical cancers were identified. CONCLUSIONS: There is a high prevalence of cervical dysplasia among women screened with Pap smears in an urban ED. Routine Pap screening in urban EDs can be an important component of cervical cancer control programs for high-risk women.     

Improving cervical cancer screening rates in an urban HIV clinic

Human immunodeficiency virus (HIV)-infected women are at increased risk of invasive cervical cancer; however, screening rates remain low. The objectives of this study were to analyze a quality improvement intervention to increase cervical cancer screening rates in an urban academic HIV clinic and to identify factors associated with inadequate screening. Barriers to screening were identified by a multidisciplinary quality improvement committee at the Washington University Infectious Diseases clinic. Several strategies were developed to address these barriers. The years pre- and post-implementation were analyzed to examine the clinical impact of the intervention. A total of 422 women were seen in both the pre-implementation and post-implementation periods. In the pre-implementation period, 222 women (53%) underwent cervical cancer screening in the form of Papanicolaou (Pap) testing. In the post-implementation period, 318 women (75.3%) underwent cervical cancer screening (p < 0.01). Factors associated with lack of screening included fewer visits attended (pre: 4.2 ± 1.5; post: 3.4 ± 1.4; p < 0.01). A multidisciplinary quality improvement intervention was successful in overcoming barriers and increasing cervical cancer screening rates in an urban academic HIV clinic.     

Who gets screened for cervical and breast cancer? Results from a new national survey

To evaluate the adequacy of cervical and breast cancer screening in the United States, data were analyzed from a 1986 nationwide telephone survey (n = 4659). Papanicolaou smears within the recommended three- to five-year interval were reported by 79% of women aged 20 years or older. Within the preceding year, 55% of women aged 40 years or older had breast examinations performed by physicians, and 20% of women aged 50 years or older had mammograms. Women who were uninsured or lower in socioeconomic status were less likely to have each of these three preventive measures, independent of the age, health status, and frequency of physician visits of the respondent. In addition, women aged 50 years or older were less likely to have had Papanicolaou smears (63% vs 89%) and breast examinations (52% vs 68%) than those women aged 20 to 49 years. These findings suggest that women who are older, uninsured, or lower in socioeconomic status are at an increased risk for not receiving preventive care, and that screening mammography, although more common than a decade ago, is still markedly underused.     

Cervical cancer screening in women aged 65 and over

Pap smear screening is an accepted method of detecting cervical dysplasia or malignancy, and use of this test has been shown to reduce the incidence of invasive squamous cervical cancer in young and middle aged women. Conflicting recommendations exist concerning the screening of women over the age of 65, and little information is available concerning the results of screening in this population. Elderly women are routinely omitted from screening, as it is generally believed that they usually refuse testing. This paper reports a study attempting to evaluate the feasibility of screening in women over the age of 64 attending a large urban outpatient geriatric clinic. It demonstrates that pap smear screening is acceptable to this population, particularly if performed by the usual primary care provider. It also confirms previous reports that women in this age group have had very little screening in the past, and that screening uncovers a large number of abnormalities. Of note is the high rate of false positive smears in this population.     

Cancer screening in patients with systemic lupus erythematosus

OBJECTIVE: To examine whether patients with systemic lupus erythematosus (SLE) undergo cancer screening according to established guidelines, to compare their reported screening practices with information from the general population, and to examine potential predictors of screening within our SLE sample. METHODS: We conducted a patient survey of cancer screening practices within the Montreal General Hospital lupus cohort. We compared self-reported frequency of cancer screening to guidelines suggested for the general population, and to figures for cancer screening reported in the general population. We also developed logistic regression models to establish potential predictors of screening for patients with SLE, with cervical cancer screening being the outcome of interest in our primary analyses. RESULTS: Of 48 women aged 50-69, 53% (95% confidence interval, CI: 38-68) had had a mammogram in the past 12 months, compared to 74% (95% CI: 73-75) for similarly aged Quebec women. Of 51 subjects aged 50 and older, only 18% (95% CI: 8-34) reported screening (fecal occult blood check with or without endoscopy) within the recommended time frame, compared to 48% (95% CI: 45-51) for colorectal screening for persons > 50 in the general population. Only 9 of 27 patients with SLE aged less than 30 had Pap tests in the past 12 months (33%, 95% CI: 19-52), compared with a general population rate of 56% (95% CI: 53-59) for similarly aged Quebec women. Our logistic regression model suggested that, among the SLE patients, non-whites, those with lower education, and those with higher disease damage scores were less likely to undergo cervical Pap testing. CONCLUSION: These data suggest that appropriate cancer screening may be overlooked in patients with SLE.     

The frequency of Pap smear screening in the United States

BACKGROUND: U.S. professional medical societies and the national health systems of all other industrialized nations recommend that most women need not undergo Papanicolaou (Pap) smear screening annually. There are no data, however, regarding the frequency at which women actually undergo screening. OBJECTIVE: To describe the frequency of cervical cancer screening in the United States. DESIGN: National Health Interview Survey, a cross-sectional population-based telephone survey conducted by the National Center for Health Statistics. PARTICIPANTS: Representative sample of U.S. women age 21 and older who denied a history of cancer (N = 16,467). MEASUREMENTS: Pap smear screening frequency, categorized as no regular screening or screening at 1 of 3 discrete screening intervals (every year, every 2 years, or every 3 years) based on each woman's reported number of Pap smears in the previous 6 years. RESULTS: The vast majority (93%) of American women report having had at least one Pap smear in their lifetime. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, 17% report a 2-year screening interval, 16% report being screened every 3 years, and 11% are not being screened regularly. Even the very elderly report frequent screening-38% of women age 75 to 84 and 20% of women age 85 and older reported annual Pap smears. Overall, 20% of women reported having had at least one abnormal Pap smear. Among these women, rates of frequent Pap smear screening are considerably higher-80% undergo annual screening, with only a modest decline in screening frequency with increasing age. CONCLUSIONS: The majority of American women report being screened for cervical cancer more frequently than recommended. Lengthening the screening interval would not only reduce the volume of specimens that cytotechnologists are required to read, but would also reduce the follow-up testing after abnormal smears.     

Screening for cervical and breast cancer: is obesity an unrecognized barrier to preventive care?

BACKGROUND: Compared with thinner women, obese women have higher mortality rates for breast and cervical cancer. In addition, obesity leads to adverse social and psychological consequences. Whether obesity limits access to screening for breast and cervical cancer is unclear. OBJECTIVE: To examine the relation between obesity and screening with Papanicolaou (Pap) smears and mammography. DESIGN: Population-based survey. SETTING: United States. PARTICIPANTS: 11 435 women who responded to the "Year 2000 Supplement" of the 1994 National Health Interview Survey. MEASUREMENTS: Screening with Pap smears and mammography was assessed by questionnaire. RESULTS: In women 18 to 75 years of age who had not previously undergone hysterectomy (n = 8394), fewer overweight women (78%) and obese women (78%) than normal-weight women (84%) had had Pap smears in the previous 3 years (P < 0.001). After adjustment for sociodemographic information, insurance and access to care, illness burden, and provider specialty, rate differences for screening with Pap smears were still seen among overweight (-3.5% [95% CI, -5.9% to -1.1%]) and obese women (-5.3% [CI, -8.0% to -2.6%]). In women 50 to 75 years of age (n = 3502), fewer overweight women (64%) and obese women (62%) than normal-weight women (68%) had had mammography in the previous 2 years (P < 0.002). After adjustment, rate differences were -2.8% (CI, -6.7% to 0.9%) for overweight women and -5.4% (CI, -10.8% to -0.1%) for obese women. CONCLUSIONS: Overweight and obese women were less likely to be screened for cervical and breast cancer with Pap smears and mammography, even after adjustment for other known barriers to care. Because overweight and obese women have higher mortality rates for cervical and breast cancer, they should be targeted for increased screening.     

Cancer Screening and Early Detection Among Ageing Women: Should Practice or Policy Change?

Australian health authorities recommend cessation of Pap smear screening at the age of 70 years for women who have had two normal Pap smears within the last five years. Pap smear screening should be initiated for women over 70 years of age who never have been screened. Mammographic screening is recommended for women 50–70 years. All adults over 40 years of age are advised to check for rectal blood after every bowel motion. This study was conducted to determine current compliance with these guidelines in an ageing female population, using a self-administered questionnaire. A 94% response rate resulted in 414 completed questionnaires from women aged 60 to 99 years (median 81). Of women over 70 years with intact uteri, 40% never had had a Pap smear. Twelve percent of women over 70 had had a recent screening mammogram. In total, 21% of respondents checked the toilet bowl every time they passed a bowel motion and 27% checked the toilet paper every time. These results demonstrate that cancer screening and early detection practices among ageing women are varied. In contrast to current policies, cervical cancer screening is not always initiated for women over 70 years who never have been screened. Further, mammographic screening continues beyond 70 years of age although there is no evidence of benefit for these older women. Too few studies have been conducted to ascertain the benefits, acceptability and unintended negative sequelae of cancer screening activities in ageing women. Research is required to inform and, if necessary, revise screening policies and clarify the preventive messages promulgated to the elderly and their health care providers.     

Does Patient Health and Hysterectomy Status Influence Cervical Cancer Screening in Older Women?

Background  Decisions to screen older patients for cancer are complicated by the fact that aging populations are heterogeneous with respect to life expectancy. Objective  To examine national trends in the association between cervical cancer screening and age, health and hysterectomy status. Design and participants  Cross-sectional data from the 1993, 1998, 2000, and 2005 National Health Interview Surveys (NHIS) were used to examine trends in screening for women age 35–64 and 65+ years of age. We investigated whether health is associated with Pap testing among older women using the 2005 NHIS (N = 3,073). We excluded women with a history of cervical cancer or who had their last Pap because of a problem. Measurements  The dependent variable was having a Pap test within the past 3 years. Independent variables included three measures of respondent health (the Charlson comorbidity index (CCI), general health status and having a chronic disability), hysterectomy status and sociodemographic factors. Main results  NHIS data showed a consistent pattern of lower Pap use among older women (65+) compared to younger women regardless of hysterectomy status. Screening also was lower among older women who reported being in fair/poor health, having a chronic disability, or a higher CCI score (4+). Multivariate models showed that over 50% of older women reporting poor health status or a chronic disability and 47% with a hysterectomy still had a recent Pap. Conclusions  Though age, health and hysterectomy status appear to influence Pap test use, current national data suggest that there still may be overutilization and inappropriate screening of older women.     

Delayed diagnosis of gynecologic tumors in elderly women: relation to national medical practice patterns

PURPOSE: To evaluate the hypothesis that less aggressive cancer screening practices might result in later diagnosis of cancer in the elderly, we analyzed the stage of diagnosis of tumors by age in the Connecticut Tumor Registry. PATIENTS AND METHODS: Using Registry data from 1960 to 1975 and 1976 to 1983, we compared the proportion of tumors that were diagnosed at a localized stage among white women of various age groups. Thirteen specific tumor sites were analyzed, accounting for 55,688 tumors between 1960 and 1975 and 38,715 tumors between 1976 and 1983. RESULTS: Only gynecologic cancers demonstrated a significant inverse relationship between the relative proportion of tumors that were diagnosed at a localized stage and advancing patient age during both time periods. Specifically, when the youngest women (aged 25 to 34) were compared with the oldest women (aged 85 and over), between 1960 and 1975, the relative proportion of localized cervical, uterine, and ovarian cancer dropped from 98 percent to 59 percent, 92 percent to 77 percent, and 59 percent to 27 percent, respectively. Similar declines were also seen between the intermediate-age groups, and data from 1976 to 1983 demonstrated identical age-related trends. CONCLUSION: Our study reveals that the probability of diagnosing cancer of the cervix, uterus and ovaries at a localized and potentially curable stage decreases with advancing age. Published national health practice patterns demonstrated a similar age-related decline in gynecologic examinations and Pap smears even after adjustment for the exclusion of women who would have undergone previous hysterectomy. This decreasing use of gynecologic examinations may in part explain the age-related decline in localized gynecologic cancers.     

Prevalence, referral patterns, testing, and surgery in aortic valve disease: leaving women and elderly patients behind?

BACKGROUND AND AIM OF THE STUDY: The prevalence of aortic valve disease is not well defined, and it is not known to what degree gender and age affect testing and surgery for this condition. The study aim was to describe the prevalence of aortic valve disease in the United States population by extrapolating from administrative claims databases; and to investigate differences associated with gender and age in referral, diagnostic testing, and aortic valve replacement (AVR). METHODS: A claims database of approximately five million privately insured beneficiaries and a 5% sample of Medicare beneficiaries were queried for patients with aortic valve disease. Prevalence was calculated by age group and gender, and extrapolated to the 2005 US population. The proportion of patients with a cardiologist or cardiovascular surgeon visit, performance of echocardiography or stress testing, and AVR within a year of diagnosis was determined. RESULTS: The extrapolated prevalence of aortic valve disease in the US in 2005 was 1.8% (approximately 5.2 million people); in persons aged > or =65 years, prevalence was 10.7%. Women were seen by a specialist, underwent diagnostic tests and underwent AVR at rates significantly lower than men, as did patients aged > or =80 years compared to those aged 65-79 years. AVR was performed at approximately half the rate in women (1.4%) compared to men (2.7%, p <0.001), and in patients aged > or =80 years (1.1%) compared to those aged 65-79 years (2.5%, p <0.001). CONCLUSION: In 2005, approximately 5.2 million adults in the US were estimated to have a diagnosis of aortic valve disease. Advanced age and female gender were associated with lower rates of specialist visits, diagnostic testing, and AVR.