Increasing breast and cervical cancer screening in low-income women

OBJECTIVE: To determine if women would have higher breast and cervical cancer screening rates if lay health advisers recommended screening and offered a convenient screening opportunity. DESIGN: Controlled trial. SETTING: Urban county teaching hospital. PARTICIPANTS: Women aged 40 years and over attending appointements in several non-primary-care outpatient clinics. INTERVENTIONS: Lay health advisers assessed the participants’ breast and cervical cancer screening status and offered women in the intervention group who were due for screening an appointment with a female nurse practitioner. MEASUREMENTS AND MAIN RESULTS: Screening rates at base-line and at follow-up 1 year after the intervention were determined. At follow-up, the mammography rate was 69% in the intervention group versus 63% in the usual care group (p=.009), and the Pap smear rate was 70% in the intervention group versus 63% in the usual care group (p=.02). In women who were due for screening at baseline, the mammography rate was 60% in the intervention group versus 50% in the usual care group (p=.006), and the Pap smear rate was 63% in the intervention group versus 50% in the usual care group (p=.002). The intervention was effective across age and insurance payer strata, and was particularly effective in Native American women. CONCLUSIONS: Breast and cervical cancer screening rates were improved in women attending non-primary-care outpatient clinics by using lay health advisers and a nurse practitioner to perform screening. The effect was strongest in women in greatest need of screening. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, D.C., May 2, 1996. This research was supported by a grant (R01-CA52994-02) from the National Cancer Institute, Dr. Margolis was supported by an American Cancer Society Clinical Oncology Career Development Award for Primary Care Physicians while this work was carried out.     

Cervical cancer screening in the urgent care setting

OBJECTIVE: To determine the feasibility of cervical cancer screening in an urgent care clinic. DESIGN: Prospective randomized trial. SETTING: Public teaching hospital. PATIENTS: Women presenting to the urgent care clinic whose evaluation necessitated a pelvic examination were eligible for participation. Women who had a hysterectomy, had a documented Pap test at our institution in the past year, did not speak English or Spanish, or had significant vaginal bleeding were excluded. Women presenting to the gynecology clinic for a scheduled Pap test were used as a comparison group for rates of follow-up, Pap smear adequacy, and Pap smear abnormalities. INTERVENTIONS: Women randomized to the intervention group had a Pap test performed as part of their pelvic examination, while women in the usual care group were encouraged to schedule an appointment in the gynecology clinic at a later date. The women in the two groups completed identical questionnaires regarding cervical cancer risk factors and demographic information. MEASUREMENTS AND MAIN RESULTS: Ninety-four (84.7%) of 111 women in the intervention group received a Pap test, as compared with 25 (29%) of 86 in the usual care group (P<.01). However, only 5 (24%) of 21 women with abnormal Pap smears in the intervention group received follow-up compared with 6 (60%) of 10 women seen during the same time period in the gynecology clinic for self-referred, routine annual examinations (P=.11). Pap smears obtained in the urgent care clinic were similar to those in the gynecology clinic with regard to abnormality rate (22.3% vs 20%; P=.75, respectively) and specimen adequacy (67% vs 72%; P=.54, respectively). CONCLUSIONS: Urgent care clinic visits can be used as opportunities to perform Pap test screening in women who are unlikely to adhere to cervical cancer screening recommendations. However, to accure the full potential benefit from this intervention, an improved process to ensure patient follow-up must be developed. Presented at the Society of General Internal Medicine annual meeting, San Francisco, Calif, May 1, 1999 Funding for this research was provided by the Division of General Internal Medicine, University of Colorado Health Sciences Center.     

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.     

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.     

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.     

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.     

Timely reminder interventions to improve annual Papanicolaou (Pap) smear rates among HIV-infected women in an outpatient center of southern Nevada: a short report

Current guidelines recommend annual Papanicolaou (Pap) smears for human immunodeficiency virus (HIV)-infected women for cervical cancer screening. Rates for such screening in Nevada are below the national rate. Our cohort includes 485 eligible HIV-infected adult women from an outpatient center in Southern Nevada of which only 12 women had obtained a Pap smear in the past year. An intervention was conducted from June 2015 to September 2015, in which reminders to schedule a Pap smear were sent to the remaining cohort of 473 women via sequential text messaging, followed by phone call attempts. Of all subjects, 94% contacted by text messages and 41% contacted by phone calls were successfully reached. There was an increase in the rate of completed Pap smears from 2.5% (12/485) at baseline to 11.8% (56/473) after interventions (p?相似文献   

Are patients of women physicians screened more aggressively?

OBJECTIVE: To determine the effects of physician gender on rates of Pap testing, mammography, and cholesterol testing when identifying and adjusting for demographic, psycho-social, and other patient variables known to influence screening rates. DESIGN: A prospective design with baseline and six-month follow-up assessments of patients’ screening status. SETTING: Twelve community-based group family practice medicine offices in North Carolina. PARTICIPANTS: 1,850 adult patients, aged 18–75 years (six-month response rate, 83%), each of whom identified one of 37 physicians as being his or her regular care provider. MAIN RESULTS: Where screening was indicated at baseline, the patients of the women physicians were 47% more likely to get a Pap test [odds ratio (OR)=1.47, 95% confidence interval (CI)=1.05, 2.04] and 56% more likely to get a cholesterol test (OR=1.56, 95% CI=1.08, 2.24) during the study period than were the patients of the men physicians. For mammography, the younger patients (aged 35–39 years) of the women physicians were screened at a much higher rate than were the younger patients of the men physicians (OR=2.69, 95% CI=0.98, 7.34); however, at older ages, the patients of the women and the men physicians had similar rates of screening. CONCLUSIONS: In general, the patients of the women physicians were screened at a higher rate than were the patients of the men physicians, even after adjusting for important patient variables. These findings were not limited to gender-specific screening activities (e.g.. Pap testing), as in some previous studies. However, the patients of the women physicians were aggressively screened for breast cancer at the youngest ages, where there is little evidence of benefit from mammography. Larger studies are needed to determine whether this pattern of effects reflects a broader phenomenon in primary care.     

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.     

Chronic disease as a barrier to breast and cervical cancer screening

OBJECTIVE: To assess whether chronic disease is a barrier to screening for breast and cervical cancer. DESIGN: Structured medical record review of a retrospectively defined cohort. SETTING: Two primary care clinics of one academic medical center. PATIENTS: All eligible women at least 43 years of age seen during a 6-month period in each of the two study clinics (n=1,764). MEASUREMENTS AND MAIN RESULTS: Study outcomes were whether women had been screened: for mammogram, every 2 years for ages 50–74; for clinical breast examinations (CBEs), every year for all ages; and for Pap smears, every 3 years for ages under 65. An index of comorbidity, adapted from Charlson (0 for no disease, maximum index of 8 among our patients), and specific chronic diseases were the main independent variables. Demographics, clinic use, insurance, and clinical data were covariates. In the appropriate age groups for each test, 58% of women had a mammogram, 43% had a CBE, and 66% had a Pap smear. As comorbidity increased, screening rates decreased (p<.05 for linear trend). After adjustment, each unit increase in the comorbidity index corresponded to a 17% decrease in the likelihood of mammography (p=.005), 13% decrease in CBE (p=.006), and 20% decrease in Pap smears (p=.002). The rate of mammography in women with stable angina was only two fifths of that in women without. CONCLUSIONS: Among women who sought outpatient care, screening rates decreased as comorbidity increased. Whether clinicians and patients are making appropriate decisions about screening is not known. This work was supported in part through a Cooperative Agreement (U48/CCU409679) between the Centers for Disease Control and Prevention and the University of Alabama at Birmingham Center for Health Promotion, and through a cooperative agreement with the Agency for Health Care Policy and Research (HS09446).     

Influence of financial productivity incentives on the use of preventive care

PURPOSE: We examined whether physician factors, particularly financial productivity incentives, affect the provision of preventive care. SUBJECTS AND METHODS: We surveyed and reviewed the charts of 4,473 patients who saw 1 of 169 internists from 11 academically affiliated primary care practices in Boston. We abstracted cancer risk factors, comorbid conditions, and the dates of the last Papanicolaou (Pap) smear, mammogram, cholesterol screening, and influenza vaccination. We obtained physician information including the method of financial compensation through a mailed physician survey. We used multivariable logistic regression to examine the association between physician factors and four outcomes based on Health Plan Employer Data and Information Set (HEDIS) measures: (1) Pap smear within the prior 3 years among women 20 to 75 years old; (2) mammogram in the prior 2 years among women 52 to 69 years old; (3) cholesterol screening within the prior 5 years among patients 40 to 64 years old; and (4) influenza vaccination among patients 65 years old and older. All analyses accounted for clus-tering by provider and site and were converted into adjusted rates. RESULTS: After adjustment for practice site, clinical, and physician factors, patients cared for by physicians with financial productivity incentives were significantly less likely than those cared for by physicians without this incentive to receive Pap smears (rate difference, 12%; 95% confidence interval [CI]: 5% to 18%) and cholesterol screening (rate difference, 4%; 95% CI: 0% to 8%). Financial incentives were not significantly associated with rates of mammography (rate difference, -3%; 95% CI: -15% to 10%) or influenza vaccination (rate difference, -13%; 95% CI: -28% to 2%). CONCLUSIONS: Our findings suggest that some financial productivity incentives may discourage the performance of certain forms of preventive care, specifically Pap smears and cholesterol screening. More studies are needed to examine the effects of financial incentives on the quality of care, and to examine whether quality improvement interventions or incentives based on quality improve the performance of preventive care.     

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.     

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.     

Variations in Practice Guideline Adherence for Abnormal Cervical Cytology in a County Healthcare System

Background Reduction in cervical cancer incidence and mortality is not only dependant on promoting cervical cancer screening but also on providing appropriate follow-up and treatment of abnormal cervical cytology. Objectives The objective of this study was to determine variations in guideline adherence for women requiring abnormal cervical cytology follow-up. Subjects Subjects of the study are women 18 years or older with an abnormal Pap test in 2000 within a large county healthcare system (n = 8,571). Measurements Guideline adherence was determined by the presence or absence of the appropriate follow-up procedure within an acceptable time interval for each degree of cytological abnormality. Patients with no follow-up studies were deemed to be lost to follow-up. Results Of study subjects, 18.5% were lost to follow-up care. Of the remaining 6,987 women, 60.3% received optimal care, 9.4% received suboptimal care, and 30.3% received poor care. Follow-up rates were higher for patients with higher degree of cytological abnormality (OR, 1.29, 95% CI, 1.17–1.42), older patients (OR, 1.03, 95% CI, 1.02–1.030) and those receiving the index Pap test at a larger healthcare facility (OR, 1.13; 95% CI, 1.01–1.27). Receiving optimal care was positively correlated with higher degree of cytological abnormality (p < .0001) and larger facility size (p = .002). Regional variations in care demonstrated the largest cluster having the lowest lost to follow-up rate and the most optimal care. Conclusions A significant number of women with abnormal cervical cytology are receiving less than optimal care. Further studies are required to determine the specific healthcare delivery practices that need to be targeted to improve guideline adherence for follow-up of abnormal cytology. This work was presented as a research abstract in a poster session at the Academy Health’s annual meeting, June 2004, San Diego, CA and at the 33rd annual meeting of the Western Association of Gynecologic Oncologists, May 2004, Monterey, CA.     

Predictors of failure to attend scheduled mammography appointments at a Public Teaching Hospital

Objective: To identify patient, institutional, and physician characteristics that predict failure to attend scheduled mammography appointments. Design: Retrospective chart review. Setting: Medicine clinic at an urban public teaching hospital. Patients: All 907 women aged 40 years and more scheduled for mammography from March 1990 to June 1991. Measurements and main results: The main outcome measure was whether a woman kept her scheduled mammography appointment. Potential predictor variables included patient age, race, marital status, and insurance status; waiting interval to obtain a mammography appointment; and physician gender, level of training, country of training, and native language. The rate of failed mammography appointments was 23%. Univariate analysis showed that appointment failure was associated with age (p=0.03), with the lowest failure rates (19%) among women aged 60 years and more. Appointment keeping varied significantly by race (p=0.01), largely because of the higher failure rate among Native American women (36%). Insured women had a failure rate of 22% vs 33% for uninsured women (p=0.01). The rate of failed appointments varied significantly by waiting interval (p=0.05), with a peak failure rate of 27% for appointments scheduled 14–27 days in advance. None of the physician variables was associated with appointment failure. Multivariate analysis confirmed these results. Conclusions: Interventions to improve completion of breast cancer screening should include additional efforts targeted at groups with high rates of appointment failure, such as women under the age of 60, the uninsured, and Native Americans. Long waiting intervals to obtain mammography appointments may decrease compliance. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 30, 1992. Supported by research grant CA 52994 from the National Cancer Institute, Bethesda, Maryland. Dr. Margolis was supported by an American Cancer Society Cancer Control Career Development Award for Primary Care Physicians. Dr. Lurie is a Henry J. Kaiser Family Foundation Scholar in General Internal Medicine.     

Perceptions of barriers and facilitators to cervical cancer screening among low-income,HIV-infected women from an integrated HIV clinic

Significantly elevated rates of cervical cancer and low rates of Papanicolaou (Pap) smear screening have been documented among HIV-infected women. However, little is known about women's perceptions of cervical cancer screening utilization. Hence, this study describes barriers and facilitators related to cervical cancer screening in a sample of HIV-infected women seeking care at an integrated HIV clinic in Houston, Texas. Using an inductive qualitative methodological approach, data were obtained from five focus group discussions with a total of 33, HIV-infected women. The majority of the study sample consisted of women who self-identified as Black (69.7%), and reported heterosexual contact as the mode of HIV acquisition (75.8%). Barriers to cervical cancer screening were described as pain and discomfort associated with receiving Pap smears and subsequent procedures; lack of awareness of cervical cancer as a preventable disease; limited transportation access; and systemic issues as it relates to scheduling gynecological appointments. Facilitators were described as awareness of HIV-infected women's increased risk of cervical cancer and strong provider–patient relationships. To address disparities in cervical cancer screening among low-income HIV-infected women, programs should capitalize on the identified facilitators and alleviate modifiable barriers using multilevel strategies.     

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.     

Comparison of endoscopic procedures for colorectal cancer screening in women with mammography and Pap smear

BACKGROUND: This study compared the experiences of women who underwent endoscopic screening for colorectal cancer vs. their experiences with breast and cervical cancer screening by mammography and Pap smear, respectively. METHODS: Women who had either flexible sigmoidoscopy or colonoscopy as a screening procedure for colorectal cancer were asked to return a questionnaire by mail. In the questionnaire, they were asked about the procedure they had just undergone and to compare it with recent mammograms and Pap smears. Flexible sigmoidoscopy was performed without sedating the patient; colonoscopy was performed with the patient under deep sedation (midazolam, fentanyl, and propofol administered by an anesthesiologist). RESULTS: Responses were obtained from 258 women (88%). Of these, 152 had colonoscopy and 106 had flexible sigmoidoscopy. A total of 72% of respondents found colonoscopy to be a comfortable test. Only 26% found flexible sigmoidoscopy uncomfortable, which was similar to mammography and Pap smear, at 22%. In terms of the test considered to be the most embarrassing, the highest response rate (38%) was for the Pap smear. Most women had no preference as to the gender of the endoscopist, but 46% preferred a woman doctor for a Pap smear (p < 0.001). Preparation was regarded as the worst part of the colonoscopy procedure; for flexible sigmoidoscopy, the procedure itself and the preparation were equivalent. CONCLUSIONS: Women found flexible sigmoidoscopy or colonoscopy comfortable and less embarrassing than a Pap smear or a mammography. There was no preference with respect to the gender of the physician who performed the colorectal screening procedures, unlike the Pap smear. Most respondents would have the procedure again and would recommend it to others.     

Why Do Patients of Female Physicians Have Higher Rates of Breast and Cervical Cancer Screening?

OBJECTIVE: Women are more likely to receive breast and cervical cancer screening if they see female physicians. We studied whether this is due to differences between male and female physicians, or to differences in their patients. SETTING: Large midwestern, independent practice association style of health plan. DESIGN: We surveyed male and female primary care physicians matched for age and specialty and a stratified random sample of three of each physician's women patients. Physicians reported on their practice setting, their attitudes and practices regarding prevention, and their comfort and skill with various examinations. Patients reported on their sociodemographic characteristics, their attitudes and practices regarding prevention, and their preferences for physician gender. Claims data were used to calculate mammography and Pap smear screening rates for the physicians PARTICIPANTS: We studied 154 female and 190 male internists and family physicians and 794 of their patients. MEASUREMENTS AND MAIN RESULTS: We compared the responses of male and female physicians and their patients and used multivariable analysis to identify the patient and physician factors that accounted for the differences in screening rates between male and female physicians. Female physicians were more likely to ask new patients about components of prevention, to believe in the effectiveness of mammography, to feel more personal responsibility for ensuring that their patients received screening, and to report more comfort in performing Pap smears and breast examinations. Patients of female physicians were more educated and less likely to be married, but did not differ in other sociodemographic characteristics. They had similar attitudes and practices regarding prevention, except that patients of male physicians were more likely to smoke. Significantly more patients of female physicians preferred a female for some component of care. In multivariable analyses, practice organization, patient preference for a female physician, and prevention orientation of female physicians accounted for up to 40% of screening rate differences between female and male physicians for Pap smears, and 33% for mammography. CONCLUSIONS: Differences in beliefs of male and female physicians and patient preference for a female provider contribute independently to the higher rate of breast and cervical cancer screening by female physicians.     

The relationship of Papanicolaou testing and contacts with the medical care system to stage at diagnosis of cervical cancer

The relationship of Papanicolaou (Pap) testing and physician visits to stage at diagnosis of cervical cancer was assessed by interviews with 149 women with invasive cervical cancer and 214 women with in situ cervical cancer. A significantly smaller percent of study subjects with invasive disease than in situ disease had at least one Pap test in the 3 years prior to diagnosis (age- and race-adjusted odds ratio: 3.38). The two groups did not differ in visits to a physician for other reasons during this period. Pap testing decreased with increasing age for both groups, but not physician visits. While 65% percent of the subjects with invasive disease aged between 65 and 79 years had never had a Pap test until diagnosis, 88% had seen a physician in the preceding 3 years. Women with regional or distant invasive disease were least likely to have had Pap tests, and, within this group, those aged between 35 and 64 years were also least likely to have seen a physician. Strategies for early detection must reflect missed opportunities and the need to bring those not receiving care into the system.