Screening rarely screened women: time-to-service and 24-month outcomes of tailored interventions

BACKGROUND: Managed care organizations and others reaching out to underscreened women seek strategies to encourage mammogram and Pap screening. METHODS: Female HMO members aged 50-69 years and overdue for a mammogram and a Pap test (n = 501) were followed for 24 months after interventions began. An Outreach intervention (tailored letters and motivational telephone interviews), an Inreach intervention (motivational interview delivered in clinics), and a Combined Inreach/Outreach intervention were compared to Usual Care at 24 months. Logistic regression and Cox hazard models examined predictors of obtaining screening services and time-to-service, respectively. RESULTS: Compared with Usual Care, the odds of Outreach women aged 50-64 obtaining a mammogram (OR = 2.06; 95% CI = 1.59-5.29), a Pap test (OR = 1.97; 95% CI = 1.12-3.53), or both (OR = 2.53; 95% CI = 1.40-4.63) remained significantly increased at 24 months. The average time-to-service for Outreach women was reduced by 4 months. Outreach effects persisted despite intensive, ongoing health plan efforts to improve screening of all women. CONCLUSIONS: This brief, tailored outreach intervention was an effective strategy for encouraging cervical and breast cancer screening among women overdue for both screening services. It also shortened time-to-service, an important benefit for early detection and treatment. Alternative strategies are needed for women who remain unscreened.     

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     

The effect of adding Pap smear information to a mammography reminder system in an HMO: results of randomized controlled trial

BACKGROUND: While reminders can promote cancer screening in primary care, little is known about the potential interaction between multiple reminders. METHODS: We conducted a randomized controlled trial to compare the effect of combined Pap smear plus mammogram reminders and mammogram-only reminders among 2471 women 40 years of age or older enrolled in a health maintenance organization serving a predominantly Medicaid-eligible population. Reminders included both a mailed letter for the woman and a medical record prompt. RESULTS: Intervention assignment was unassociated with differences in rates of visitation to family medicine or internal medicine or completion of mammography during the study year. Compared to women assigned to mammogram-only reminder treatment, those assigned to the combined Pap smear plus mammogram reminder intervention were more likely to visit a gynecologist (34% compared to 29%, adjusted odds ratio = 1.33, 95% confidence interval 1.08-1.63) and to complete a Pap smear (30% compared to 23%, adjusted odds ratio = 1.39, 95% confidence interval 1.07-1.89). CONCLUSIONS: In the study setting, the addition of Pap smear to mammography reminders has a procedure-specific effect, increasing gynecology visits and Pap smear use while neither increasing nor decreasing other primary care visits or mammography. We find no evidence of reinforcement or competition between these reminders.     

Pap smear use in a population of older Mexican-American women

BACKGROUND: Hispanic women and older women (age > or = 50 years) in general have been identified as populations of women who often underutilize Papanicolaou (Pap) smears. OBJECTIVE: To report the rates of cervical cancer screening in a group of older Mexican American women and to identify the correlates of having a Pap smear in the past three years. DATA SOURCE: The Mammography Use by Older Mexican-American Women Survey, a stratified area probability sample of 452 women ages 50-74 from three southeast Texas counties. Self-report data was collected with in-person interviews from 1997 to 1999. RESULTS: We found that 93.1% of the women reported at least one Pap smear in their lifetime and that 64.1% reported a Pap smear in the past three years. Odds of reporting a recent Pap smear was lower for older women (OR 0.51, 95% CI 0.32-0.82) and those below the poverty line (OR 0.52, 95% CI 0.33-0.82). The odds were higher for women who had a regular doctor for female care (OR 6.49, 95% CI 2.96-14.23) or a regular clinic or hospital source for female care (OR 5.50, 95% CI 2.55-11.89). Among these older Mexican-American women, cultural factors (language of interview, acculturation, fatalism) did not have a significant effect on screening use. CONCLUSION: Recent Pap smear use (64.1%) falls well below the year 2010 goal of 90%. Efforts need to be made to overcome barriers to Pap smear utilization for these women, such as providing access to female medical care.     

Cervical screening in general practice

Abstract: This study examined the effect of three interventions for encouraging women to have a Pap smear in a general practice: tagging the medical record to remind the doctor to offer a Pap smear, sending an invitation to make an appointment for a Pap smear, and sending an invitation with an appointment to attend for a Pap smear at a special screening clinic staffed by women. The study took place in a university general practice at Lockridge, near Perth. A computerised practice age-sex register provided 2139 women in the age range 36 to 69 inclusive. Of these, 757 were eligible for inclusion in the study and were allocated randomly to one of three intervention groups or a control group. In total, 177 women had a Pap smear during the study. Significantly more Pap smears were taken for the appointment-letter and letter-only groups than the control group (odds ratio (OR) 2.13, 95% confidence interval (CI) 1.34 to 3.57, and OR 1.67, CI 1.01 to 2.77 respectively), but there was no significant difference between the tagged-notes and the control groups. Women who attended the screening clinic rated the experience positively. Attendance, however, was inadequate for the clinic's viability in a private practice.     

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 cervical cancer screening in older women: the San Diego Medicare Preventive Health Project.

BACKGROUND. This study presents rates and correlates of cancer screening, including mammography, clinical breast exam, breast self-examination, and Pap tests, in older women. Age was the predictor of main interest. RESULTS. Among a sample of female Medicare beneficiaries ages 65 and older, who were members of a health maintenance organization, there was a significant, inverse relationship between age and mammography adherence, while controlling for health status, physician utilization, education, and income. The proportions of subjects ages 65-74 and 75+ never having had a mammogram were 17 and 32%, respectively, and the proportions having had annual mammograms were 40 and 28%, respectively. Pap test frequency showed a trend toward an inverse relationship with age, controlling for demographic and health-related variables. In the youngest age group (65-69), 52% had annual Pap tests, whereas in the oldest group (80+), only 36% had annual Pap tests. Age did not predict frequency of clinical breast exam, and the relationship of age to breast self-examination was inconclusive. The role of the physician in promoting cancer screening is discussed.     

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.     

Women's Behaviors Toward Mammogram and Pap Test: Opportunities to Increase Cervical Cancer Screening Participation Rates among Older Women

Objectives

Screening rates for cervical cancer remain moderate among women over 50 years of age. Because cervical and breast screening interventions can be linked, evaluating screening factors relating to both is important. This study evaluates factors associated with breast and cervical screening participation in women aged 52 to 69.

Cost-effectiveness of a tailored intervention designed to increase breast cancer screening among a non-adherent population: a randomized controlled trial

ABSTRACT: BACKGROUND: Although the percentage of women who initiate breast cancer screening is rising, the rate of continued adherence is poor. The purpose of this study was to examine the effectiveness and cost-effectiveness of a tailored print intervention compared with a non-tailored print intervention for increasing the breast cancer screening rate among a non-adherent population. METHODS: In total, 1859 participants aged 51--59 years (except those aged 55 years) were recruited from a Japanese urban community setting. Participants were randomly assigned to receive either a tailored print reminder (tailored intervention group) or non-tailored print reminder (non-tailored intervention group). The primary outcome was improvement in the breast cancer screening rate. The screening rates and cost-effectiveness were examined for each treatment group (tailored vs. non-tailored) and each intervention subgroup during a follow-up period of five months. All analyses followed the intention-to-treat principle. RESULTS: The number of women who underwent a screening mammogram following the reminder was 277 (19.9%) in the tailored reminder group and 27 (5.8%) in the non-tailored reminder group. A logistic regression model revealed that the odds of a woman who received a tailored print reminder undergoing mammography was 4.02 times those of a women who had received a non-tailored print reminder (95% confidence interval, 2.67--6.06). The cost of one mammography screening increase was 2,544 JPY or 30 USD in the tailored intervention group and 4,366 JPY or 52 USD in the non-tailored intervention group. CONCLUSIONS: Providing a tailored print reminder was an effective and cost-effective strategy for improving breast cancer screening rates among non-adherent women.     

Cervical cancer screening: who is not screened and why?

BACKGROUND: The decline in death rates from cervical cancer in the United States has been widely attributed to the use of Papanicolaou (Pap) smears for early detection of cervical cancer. METHODS: Pap smear screening rates, beliefs about appropriate screening intervals and factors affecting screening were examined using 1987 National Health Interview Survey data. RESULTS: Results indicate that through age 69, Blacks are screened at similar or higher rates than Whites. Hispanics, particularly those speaking only or mostly Spanish, are least likely to have received a Pap smear within the last three years. Of women who had never heard of or never had a Pap smear, nearly 80 percent reported contact with a medical practitioner in the past two years, while more than 90 percent reported a contact in the past five years. Overall, the most frequently reported reason for not having a recent Pap smear was procrastinating or not believing it was necessary. CONCLUSIONS: Thus, in developing screening programs, Hispanics, particularly Spanish speakers, must be targeted. In addition, educational programs should target unscreened women who forego the test due to underestimating its importance, procrastination, or because their medical care provider did not suggest the procedure. Women must be intensively educated that Pap smears should be scheduled routinely to detect asymptomatic cervical cancer.     

Survey of El Paso physicians' breast and cervical cancer screening attitudes and practices

One hundred and ninety-eight primary care physicians in El Paso, Texas, were surveyed for their practices and attitudes concerning breast and cervical cancer screening. The response rate was 83%. For women 40–49 years old, 77% of respondents stated that they ordered a screening mammogram at least every two years. For women 50–74 years old, 73% said they ordered an annual screening mammogram. For women 75 years and older, 61% stated they ordered an annual screening mammogram. For women 40 years or older, 89% of respondents said they performed annual or more frequent clinical breast examinations. Eighty-four percent of respondents stated they ordered a Pap smear every 1–3 years, both for pre- and post-menopausal women. The most common reasons given for not ordering or doing a breast or cervical screening exam were patient refusal, knowledge that other doctor performs exam, high price, inadequate insurance, patient not under regular care, do not see patient for gynecologic care, and patient being seen for different reason. Seventy percent of respondents do vaginal smears on women who have had a total hysterectomy for a benign condition, and 38% use a cytobrush for endocervical sampling. Respondents were generally more comfortable with their ability to do Pap smears (72% comfortable, 1% uncomfortable) than they were in performing clinical breast examinations (52% comfortable, 4% uncomfortable). Obstetricians and gynecologists were more likely than other physicians to do vaginal smears, use a cytobrush, and feel comfortable with their Pap smear technique.This research was funded through grant 5 RO1 CA52977-03 from the National Cancer Institute. The Luces de Salud office at the El Paso City-County Health Department assisted with data collection.     

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.     

Accuracy of Self-Report of Mammography and Pap Smear in a Low-Income Urban Population

Background:Cancer screening history can often be obtained only by self-report, particularly for disadvantaged populations. We examined the accuracy of self-report of mammography and Pap smear for an urban, low-income population.Methods:Women attending non-primary care clinics (mostly surgery and orthopedics) at a large public teaching hospital in Minneapolis between July 1992 and May 1993 were queried about their screening history (n = 477). The women were interviewed by a trained peer-recruiter and asked whether they had ever heard of a Pap smear or mammogram, whether they had ever had one, where it was done, and when the last one was. We verified self-report by checking medical records where the test was performed.Results:The positive and negative predictive value of recall of mammography in the previous year was 72.4% and 90.6%, respectively. The figures for Pap smear recall were somewhat lower, 65.5% and 85.9%, respectively. We found a record of a mammogram in 88% of women able to recall the year. Of these, slightly over two-thirds recalled their mammogram in the same year as their record indicated. Inaccurate recalls were more commonly of the “telescoping” type, i.e., tests were recalled as having occurred more recently than was the case. Recall was substantially better for recent tests. Results for Pap smear recalls were broadly similar.Conclusions:The accuracy of self-report of mammography and Pap smear is relatively poor for medical practice but is acceptable in population surveys with appropriate correction for overreporting.     

Cost-effectiveness of a tailored intervention to increase screening in HMO women overdue for Pap test and mammography services

BACKGROUND: Research has established the societal cost-effectiveness of providing breast and cervical cancer screening to women. Less is known about the cost of motivating women significantly overdue for services to receive screening. METHODS: In this intent-to-treat study, a total of 254 women, aged 52-69, who were overdue for both Pap test and mammography, were randomized to two groups, a tailored, motivational outreach or usual care. For effectiveness, we calculated the percent of women who received both services within 14 months of randomization. We used a comprehensive cost model to estimate total cost, per-participant cost, and the incremental cost-effectiveness of delivering the outreach intervention from the health plan perspective. We also conducted sensitivity analyses around two key parameters, target population size and level of effectiveness. RESULTS: Compared with usual care, outreach (P = 0.006) screened significantly more women. The intervention cost US dollars 167.62 (2000 U.S. dollars) for each woman randomized to outreach, and incremental cost-effectiveness of outreach over usual care was US dollars 818 per additional woman screened. Sensitivity analyses estimated incremental cost-effectiveness between Us dollars 19 and US dollars 90 per additional woman screened. CONCLUSIONS: Larger health plans can likely increase Pap test and mammography services in this population for a relatively low cost using this outreach intervention.     

Cervical cancer screening for hospital inpatients: report of an intervention study

A pilot study of a cervical cancer screening service was carried out at a major teaching hospital in Perth. The service, for women inpatients aged 20 to 69 years, was staffed by a women's health nurse. The effect of providing the service (service) was compared with giving a leaflet on Pap smears to eligible women (education) and with no intervention (control). Of 517 women in the service group, 184 (36 per cent) needed a Pap smear and were well enough to be offered screening; only 29 of 184 (16 per cent) refused and 132 of 184 (72 per cent) were screened. Of those screened, 29 per cent had never had a Pap smear. Information on women in the education and control groups was obtained by mailed questionnaire. Of the eligible women in the service group, 72 per cent accepted screening in hospital, but only 24 per cent of eligible women in the education group and 20 per cent in the control group reported having a Pap smear in the four months since leaving hospital. The service group showed a very large effect relative to the control group (odds ratio (OR) 17.71, 95 per cent confidence interval (CI) 10.05 to 31.22), but there was no significant difference between the education and control groups. Other significant variables in the logistic regression model were age, marital status, and sex of the woman's general practitioner. The effect of offering the service was greater for women over 50 (OR 51.51, CI 19.01 to 139.60) A hospital-based cervical screening service provides an important opportunity for screening women who are not being reached by other services. (Aust J Public Health 1995; 19: 288–93)     

Prevalence and associated factors of cancer screening: why are so many older Mexican American women never screened?

OBJECTIVES: The aim of this study was to identify patterns of mammogram and Papanicolaou (Pap) screenings among Mexican American women ages 67 and over. METHODS: Data on 1,403 Mexican American women from the Hispanic Established Population for the Epidemiological Study of the Elderly, a cohort study of community-dwelling Mexican Americans ages 65 years or over from the southwestern United States, were analyzed. RESULTS: Mexican American women age 75 or older were less likely to ever have had breast or cervical screening than women ages 67 to 74, even controlling for sociodemographic, cultural, and selected health factors. Overall, fewer medical conditions and never having had a hysterectomy were found to be associated with a decreased chance of ever having had a mammogram or a Pap test. Women who lacked insurance coverage and had fewer doctor visits were less likely to ever have had a mammogram, whereas women with low education, low acculturation, and lower cognitive status scores were less likely to ever have had a Pap test. CONCLUSIONS: If these results withstand more detailed studies (e.g., with the addition of important variables such as awareness), better communication with health professional doctors and improvement of access to heath care services should increase rates of both mammogram and Pap screenings.     

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.     

Increasing women's compliance with opportunistic cervical cancer screening: a randomized trial.

Our objective was to evaluate the efficacy and acceptability of two interventions designed to increase opportunistic cervical cancer screening. We designed a randomized trial of two interventions additional to usual care. We recruited 17 male general practitioners selected at random from the inner metropolitan region of Sydney, Australia. The patients were 202 women, between 20 and 65 years of age, eligible for a Pap smear. We allocated minimal and maximal interactional interventions to obtain consent for a Pap smear. Our main outcome measure was women's having a Pap smear during the consultation or within one month. We also measured acceptability of interventions to practitioners and women. These were our results: minimal: 55% of women had a Pap smear; maximal: 67% of women had a Pap smear; total when both approaches are combined: 61%. We conclude that brief advice is as effective as maximal persuasion in increasing women's compliance with opportunistic screening in routine consultations. Both interventions were acceptable to women. Practitioners preferred the minimal intervention. We demonstrate opportunistic screening is an effective and acceptable way to encourage women at risk to have a Pap smear.