Lisa P. Spees

Variation in Cervical Cancer Screening Preferences among Medically Underserved Individuals in the United States: A Systematic Review

AbstractUnderutilization of effective screening is one driver of disparities in cervical cancer incidence and mortality. Consideration of patient preferences could help to improve screening rates in populations facing substantial barriers to preventive care. We conducted a systematic review of the literature on cervical cancer screening preferences among medically underserved patients in the United States. We searched six electronic databases (PubMed, Web of Science, EMBASE, Scopus, CINAHL, and PsycINFO) for articles published through February 2019 (Prospero ID: CRD42019125431). Among the 43 articles included, 23 reported screening modality preferences, 11 reported preferences related to provider demographics and attributes, six reported screening scheduling and results delivery preferences, and nine reported preferences related to health education and communication. This review demonstrates the wide variety of medically underserved patient preferences related to cervical cancer screening. It also draws attention to two key preference trends that emerged despite heterogeneity in study design, populations, and preference assessment. Consistent preferences for human papillomavirus self-testing over traditional Pap testing highlight a key potential mechanism for increasing cervical cancer screening uptake among medically underserved populations. In addition, preferences for gender- and language-concordant providers underscore the need for continued efforts toward expanding diversity among medical professionals.

Cost-effectiveness of Human Papillomavirus Self-collection Intervention on Cervical Cancer Screening Uptake among Underscreened U.S. Persons with a Cervix

Abstract Background: We evaluate the cost-effectiveness of human papillomavirus (HPV) self-collection (followed by scheduling assistance for those who were HPV+ or inconclusive) compared with scheduling assistance only and usual care among underscreened persons with a cervix (PWAC). Methods: A decision tree analysis was used to estimate the incremental cost-effectiveness ratios (ICER), or the cost per additional PWAC screened, from the Medicaid/state and clinic perspectives. A hypothetical cohort represented 90,807 low-income, underscreened individuals. Costs and health outcomes were derived from the MyBodyMyTest-3 randomized trial except the usual care health outcomes were derived from literature. We performed probabilistic sensitivity analyses (PSA) to evaluate model uncertainty. Results: Screening uptake was highest in the self-collection alternative (n = 65,721), followed by the scheduling assistance alternative (n = 34,003) and usual care (n = 18,161). The self-collection alternative costs less and was more effective than the scheduling assistance alternative from the Medicaid/state perspective. Comparing the self-collection alternative with usual care, the ICERs were $284 per additional PWAC screened from the Medicaid/state perspective and $298 per additional PWAC screened from the clinic perspective. PSAs demonstrated that the self-collection alternative was cost-effective compared with usual care at a willingness-to-pay threshold of $300 per additional PWAC screened in 66% of simulations from the Medicaid/state perspective and 58% of simulations from the clinic perspective. Conclusions: Compared with usual care and scheduling assistance, mailing HPV self-collection kits to underscreened individuals appears to be cost-effective in increasing screening uptake. Impact: This is the first analysis to demonstrate the cost-effectiveness of mailed self-collection in the United States.

“It really takes a village”: perspectives on multi-level barriers to endometrial cancer care for rural patients

While it is established that rural cancer patients face multi-level barriers to high-quality treatment, the interconnections between these barriers and how they drive rural cancer disparities is not well-understood. Therefore, our objective was to better understand the interconnections between barriers to high-quality treatment faced by rural endometrial cancer (EC) patients. We conducted semi-structured interviews with 32 clinicians and healthcare personnel from three large, geographically diverse, rural-serving, integrated healthcare systems in North Carolina. A semi-structured interview guide was developed to examine barriers to high-quality treatment for rural EC patients. Initial codes were derived from a multi-level conceptual framework of rural cancer control, and transcribed interviews were analyzed using thematic analysis. We identified three domains of interconnected barriers. First, travel distance, the most frequently noted barrier, amplified financial barriers and caregiver burden. While gynecologic oncologists could reduce travel burden by referring patients to nearby treatment facilities, provider participants expressed mixed opinions regarding the quality of care received at local facilities. Second, limited health literacy among rural patients often led to challenges in patient-provider communication, including challenges with care-related decision making and comprehension of diagnosis and treatment goals. Finally, supportive care and financial resources were often concentrated at large, urban facilities and not accessible to rural patients. However, even these large facilities lack established systems or standardized processes for supporting the most vulnerable patients. To achieve equitable access to care and outcomes among EC patients, those living in rural areas may require more targeted, intensive outreach, support, and resources.