Journal of General Internal Medicine

Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic

Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016. To improve our clinic's CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions. A quality improvement project led by a multidisciplinary group of healthcare providers. Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population. Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period. Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population's CCS rate for all eligible clinic patients. After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P < 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P < 0.001). Our clinic's CCS rate improved from 70% to 75% after the 18-month intervention. The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS.

Patient Perspectives on Primary HPV Testing for Routine Cervical Cancer Screening

Rising Mortality Rate of Cervical Cancer in Younger Women in Urban China

Patient Navigation Increases Breast, Cervical, and Colorectal Cancer Screening Among Immigrants in the U.S.: A Systematic Review

The growing immigrant population in the United States faces disparities in cancer screening rates compared to U.S.-born individuals. Despite initially better health outcomes, foreign-born individuals experience declining health with prolonged residence in the U.S., typically exacerbated by lower utilization of preventive services such as cancer screenings. This systematic review examines the role of patient navigation (PN) programs in addressing disparities in colorectal, breast, and cervical cancer screenings among immigrant populations. A comprehensive search of PubMed, Web of Science, and Scopus was conducted. Eligibility criteria encompassed immigrant populations in the U.S. and their access to cancer screenings facilitated by PN programs. Risk of bias was accessed using tools developed by Cochrane for systematic reviews. Eighteen articles were included in the review. Data was extracted to highlight language spoken, country of origin, type of cancer screening, and specific details of navigation that were received. PN interventions, often delivered by bilingual community health workers or lay health educators, significantly increased screening rates for colorectal, breast, and cervical cancers compared to control groups in most studies. The most notable improvements were seen in colorectal cancer screening rates, where interventions raised screening completion from 10.8 to 89.7% in some populations. Key components of successful PN programs included education, appointment scheduling, and language support. The findings suggest that PN services are crucial in mitigating barriers such as language, cultural differences, and education which contribute to lower screening rates among immigrants. This review underscores the need for culturally and linguistically tailored PN programs to increase preventative cancer screenings in immigrant populations. Strengths of the review include capturing studies across different regions of the U.S. and numerous ethnicities. Limitations include lack of long-term follow-up. The review was registered to PROSPERO with the identification number CRD42023470973.

Strategies to Optimize Cervical Cancer Screening Rates Among Transgender and Gender-Diverse People Assigned Female at Birth

Self-sampling for primary HPV detection for cervical cancer screening is now FDA-approved. Many persons interested in cervical cancer screening are eager to opt out of the invasive speculum exam and opt into the self-sampling. There is no limitation on which persons can choose self-sampling. Transgender, nonbinary, and gender-diverse assigned female at birth (TGD AFAB) people experience barriers such as gender dysphoria and discomfort with sensitive exams. They may find more comfort with this equivalent method of screening. However, no clinical guidelines describe the best practices to increase screening among this underserved population. Much community work needs to occur to make the language of screening gender-affirming for all participants. Solutions to currently invasive follow-up exams after abnormal screens need to be communicated in language directed by the TGD AFAB community.

Association Between Clinician Confidence and Making Guideline-Recommended Decisions in the Management of Abnormal Cervical Cancer Screening Results

Guidelines for managing abnormal cervical cancer screening results are complex and adherence is challenging for clinicians. Previous studies have identified gaps in knowledge as a possible cause; few have explored the confidence clinicians have in their management decisions. Confidence in decision-making may influence management practices, particularly when guidelines are complex and evolving. Assess whether confidence in decision-making is associated with making guideline-concordant recommendations for abnormal cervical cancer screening results. A clinician survey used vignettes to ask clinicians to make a management recommendation for different abnormal results and rate their level of confidence in their response. Physicians and advanced practice providers (APPs) at three diverse health systems in Washington, Texas, and Massachusetts. Correct response to each vignette based on either the 2012 or 2019 American Colposcopy and Cervical Pathology (ASCCP) management guidelines. In total, 501 clinicians completed the survey between October and December 2020 (response rate 53.7%). Overall, most clinicians made guideline-recommended management decisions for two vignettes (73.2 and 73.7%), but fewer were confident in their selection (48.3% and 46.6%, respectively). Clinicians who reported high levels of confidence were more often correct than those who reported lower levels of confidence (85.8% vs. 62.2% and 87.5% vs. 60.7%, both p<0.001). After adjusting for clinician and practice characteristics, confidence remained significantly associated with selecting the correct answer. Clinician confidence in management decisions for abnormal cervical cancer screening results was significantly associated with knowing guideline-concordant recommendations. Given the complexity of cervical cancer management guidelines, solutions to improve clinician confidence in decision-making are needed.

Association Between the Frequent Use of Perineal Talcum Powder Products and Ovarian Cancer: a Systematic Review and Meta-analysis

Abstract Background Risk of ovarian cancer in women with frequent perineal talcum powder product is not well understood. Prior systematic reviews focused on ever use. The purpose of this study is to estimate the association between frequent (at least 2 times per week) perineal talcum powder use and ovarian cancer. Methods A systematic review and meta-analysis was conducted according to meta-analysis of observational studies in epidemiology guidelines. Study protocol was prospectively registered at PROSPERO (registration number CRD42020172720). Searches were performed in PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials databases from their inception to August 2, 2021. Case-control and cohort studies were included if they reported frequent perineal talcum powder use and an adjusted odds ratio or hazard ratio for ovarian cancer. Review for inclusion, data extraction, and quality assessment (using the Newcastle-Ottawa Scale [NOS]) were performed independently by two reviewers. Pooled adjusted odds ratios with 95% confidence intervals were generated from the random effects model. Heterogeneity was quantified with I2 statistic. Funnel plot and Eger’s test were performed to assess publication bias. Subgroup and sensitivity analyses were performed for testing the robustness of the overall findings. Results Initial database searches returned 761 unique citations and after review, eleven studies describing 66,876 patients, and 6542 cancers were included (Cohen’s κ = 0.88). Publication quality was high (median NOS = 8, range: 4 to 9). Frequent talcum powder use was associated with an elevated risk of ovarian cancer (adjusted pooled summary odds ratio 1.47 (95% CI 1.31, 1.65, P&lt;0.0001). There was no evidence of bias and low heterogeneity (I2= 24%, P=0.22). There was no meaningful difference limiting analysis to publications with a NOS quality score of 8 or 9 or limiting studies based on study design. Conclusions This review suggests an increased risk of ovarian cancer associated with frequent perineal powder exposure of 31–65%.

Screening Beyond the Evidence: Patterns of Age and Comorbidity for Breast, Cervical, and Colorectal Cancer Screening

Little evidence exists to guide continuation of screening beyond the recommended ages of national guidelines for breast, cervical, and colorectal cancers, although increasing age and comorbidity burden is likely to reduce the screening benefit of lower mortality. Characterize screening after recommended stopping ages, by age and comorbidities in a large, diverse sample. Serial cross-sectional. All individuals in the PROSPR-I consortium cohorts from 75 to 89 years of age for breast cancer screening, 66-89 years of age for cervical cancer screening, and 76-89 years of age for colorectal cancer screening from 2011 to 2013. The lower age thresholds were based on the guidelines for each respective cancer type. Proportion of annual screening by cancer type in relation to age and Charlson comorbidity score and median years of screening past guideline age. We estimated the likelihood of screening past the guideline-based age as a function of age and comorbidity using logistic regression. The study cohorts included individuals screening for breast (n = 33,475); cervical (n = 459,318); and colorectal (n = 556,356) cancers. In the year following aging out, approximately 30% of the population was screened for breast cancer, 2% of the population was screened for cervical, and almost 5% for colorectal cancer. The median number of years screened past the guideline-based recommendation was 5, 3, and 4 for breast, cervical, and colorectal cancer, respectively. Of those screening  > 10 years past the guideline-based age,15%, 46%, and 25% had  ≥ 3 comorbidities respectively. Colorectal cancer screening had the smallest decline in the likelihood of screening beyond the age-based recommendation. The odds of screening past guideline-based age decreased with comorbidity burden for breast and cervical cancer screening but not for colorectal. These findings suggest the need to evaluate shared decision tools to help patients understand whether screening is appropriate and to generate more evidence in older populations.

Racial and Ethnic Disparities in Genetic Testing at a Hereditary Breast and Ovarian Cancer Center

Prior studies suggest that referral to genetic counseling and completion of genetic testing vary by race/ethnicity; however, the data are limited. We sought to evaluate patterns of genetic testing and clinical outcomes across race/ethnicity at a hereditary breast and ovarian cancer center. The medical records for all patients undergoing genetic assessment at a hereditary breast and ovarian cancer center were reviewed and stratified by self-reported race/ethnicity (non-Hispanic White, Hispanic, non-Hispanic Black, and Asian). A total of 1666 patients met inclusion criteria (non-Hispanic Whites, 1367; Hispanics, 85, non-Hispanic Blacks, 101; Asians, 113). Demographics, patient characteristics, and referral patterns for patients who underwent genetic testing were analyzed using Kruskal-Wallis tests, chi-square test, or Fisher's exact tests, stratifying by self-reported race/ethnicity. Pathogenic mutations and variants of unknown significance (VUS) were reviewed. Outcomes of patients with genetic mutations and personal history of breast and/or gynecologic malignancies were compared. Non-Hispanic Whites were more likely to be referred due to family cancer history compared to all other ethnicities while Non-Hispanic Blacks, Hispanics, and Asians were more likely to be referred due to personal history of cancer (p < 0.001). Non-Hispanic Blacks and Hispanics were more likely to have advanced-stage cancer at the time of genetic testing (p < 0.02). Rates of mutations did not differ by race/ethnicity when Ashkenazi Jewish patients were excluded (p = 0.08). Among patients found to have a BRCA1/2 mutation, Non-Hispanic Whites were more likely to undergo cancer screening and risk-reducing surgery compared with all other ethnicities (p = 0.04). Minority patients were more likely to utilize genetic services following a cancer diagnosis and less likely due to family cancer history, suggesting a missed opportunity for mutation detection and cancer prevention in this population. Efforts to eradicate racial/ethnic disparities in early access to genetic testing and guided cancer prevention strategies are essential.

Patient Perceptions on the Follow-Up of Abnormal Cancer Screening Test Results

Timely follow-up after an abnormal cancer screening test result is needed to maximize the benefits of screening, but is frequently not achieved. Little is known about patient experiences with the process of following up abnormal screening results. Assess patient experiences and perceptions regarding the process of a diagnostic workup following abnormal breast, cervical, or colorectal cancer screening results. Survey of participating patients between April 2021 and June 2022 after reaching the primary outcome time point in a randomized controlled trial to improve follow-up of overdue abnormal screening results. Patients from 44 participating practices in three primary care practice networks. Self-reported ease of scheduling follow-up, perceived barriers or concerns, provider trust, and satisfaction with communication and care received for the follow-up of abnormal screening results. Overall, 241 (25.0%) patients completed the survey including 66 (32.8%) with breast, 79 (25.3%) with cervical, and 96 (21.3%) with colorectal screening test; median age 55 years, 79.7% women, 80.5% non-Hispanic white, and 51.0% did not complete recommended follow-up. Most patients were worried that the test would find cancer (63.1%), but fewer worried about discomfort or side effects (34.4%), and neither were associated with completing follow-up. However, 17% of patients did not think they needed follow-up tests or appointments and were less likely to complete follow-up (10.5% vs. 24.0%, respectively, p-value 0.009). Most patients were very satisfied with their overall care (71.0%), but only 50.2% strongly agreed that they trusted their provider to put their medical needs above all else when making recommendations. Patients with overdue abnormal breast, cervical, and colorectal cancer screening test results reported important deficiencies in the management of recommended follow-up. Addressing patient concerns about fear of cancer and effectively communicating the need for follow-up procedures may improve timely follow-up after an abnormal cancer screening result. ClinicalTrials.gov NCT03979495.

Barriers to the Equitable Implementation of Risk-Based Cervical Cancer Management Guidelines

The 2019 American Society for Colposcopy and Cervical Pathology provides risk-based management guidelines for abnormal cervical cancer screening test result management. It is not known whether populations facing inequities in primary care delivery have the prior screening history needed to take advantage of risk-based management of abnormal cervical cancer screening results. Determine the prevalence and associations of unknown screening history for people with an abnormal cervical cancer screening result. Retrospective multi-center population-based study of three large, structurally diverse healthcare systems in Washington state, Massachusetts, and Dallas County, Texas. Females ages 25-65 at index abnormal Pap cytology or positive Human Papillomavirus (HPV) result from 2010 to 2019 (n = 63,739). Unknown cervical cancer screening history, assessed as missing or insufficient documentation of cervical screening, diagnostic tests, and procedures extracted from administrative data and electronic health records of health systems. Over a third of patients had unknown cervical cancer screening history prior to the index abnormal test during the study period (38.3% overall, 27.6 to 52.3% across healthcare systems). Patients empaneled to a primary care provider at the time of their abnormal test had a lower prevalence of an unknown screening history than those who were not (prevalence ratio 0.74, 95% CL 0.72-0.75). Those who were uninsured or had multiple insurance transitions had a higher prevalence of unknown screening history than those who were commercially insured (PR 1.13, 95% CL 1.09-1.16). There were health system-specific associations with having an unknown screening history. In three large health systems, historical screening data needed to implement ASCCP risk-based guidelines were frequently missing. Our findings call for greater attention to potential management inequities for patients with missing data. Importantly, more attention is needed to address potential primary care access barriers to equitable delivery of risk-based cervical cancer surveillance and care.

Delays in Follow-up Care for Abnormal Mammograms in Mobile Mammography Versus Fixed-Clinic Patients

Mobile mammographic services (MM) have been shown to increase breast cancer screening in medically underserved women. However, little is known about MM patients' adherence to follow-up of abnormal mammograms and how this compares with patients from traditional, fixed clinics. To assess delays in follow-up of abnormal mammograms in women screened using MM versus fixed clinics. Electronic medical record review of abnormal screening mammograms. Women screened on a MM van or at a fixed clinic with an abnormal radiographic result in 2019 (N = 1,337). Our outcome was delay in follow-up of an abnormal mammogram of 60 days or greater. Guided by Andersen's Behavioral Model of Health Services Utilization, we assessed the following: predisposing (age, ethnicity, marital status, preferred language), enabling (insurance, provider referral, clinic site), and need (personal breast cancer history, family history of breast/ovarian cancer) factors. Only 45% of MM patients had obtained recommended follow-up within 60 days of an abnormal screening compared to 72% of fixed-site patients (p < .001). After adjusting for predisposing, enabling, and need factors, MM patients were 2.1 times more likely to experience follow-up delays than fixed-site patients (CI: 1.5-3.1; p < .001). African American (OR: 1.5; CI: 1.0-2.1; p < .05) and self-referred (OR: 1.8; CI: 1.2-2.8; p < .01) women were significantly more likely to experience delays compared to Non-Hispanic White women or women with a provider referral, respectively. Women who were married (OR: 0.63; CI: 0.5-0.9; p < .01), had breast cancer previously (OR: 0.37; CI: 0.2-0.8; p < .05), or had a family history of breast/ovarian cancer (OR: 0.76; CI: 0.6-0.9; p < .05) were less likely to experience delayed care compared to unmarried women, women with no breast cancer history, or women without a family history of breast/ovarian cancer, respectively. A substantial proportion of women screened using MM had follow-up delays. Women who are African American, self-referred, or unmarried are particularly at risk of experiencing delays in care for an abnormal mammogram.

Awareness of HPV Testing and Acceptability of Self-sampling for Cervical Cancer Screening Among Women in Minnesota

Cervical Cancer Mortality in Younger Women

Gonorrhea and Chlamydia Testing and Case Rates Among Women Veterans in the Veterans Health Administration

Abstract Background United States (US) rates of sexually transmitted infection (STI) in women, especially gonorrhea and chlamydia, have increased over the past decade. Women Veterans may be at increased risk for STIs due to high rates of sexual trauma. Despite the availability of effective diagnostic tests and evidence-based guidelines for annual screening among sexually active women under age 25, screening rates for gonorrhea and chlamydia remain low in the US and among Veterans. Objective To examine patient characteristics and health system factors associated with gonorrhea and chlamydia testing and case rates among women Veterans in the Veterans Health Administration (VHA) in 2019. Design We performed a retrospective cohort study of all women Veterans in VHA care between January 1, 2018, and December 31, 2019. Participants Women Veteran patients were identified as receiving VHA care if they had at least one inpatient admission or outpatient visit in 2019 or the preceding calendar year. Key Results Among women under age 25, 21.3% were tested for gonorrhea or chlamydia in 2019. After adjusting for demographic and other health factors, correlates of testing in women under age 25 included Black race (aOR: 2.11, CI: 1.89, 2.36), rural residence (aOR: 0.84, CI: 0.74, 0.95), and cervical cancer screening (aOR: 5.05, CI: 4.59, 5.56). Women under age 25 had the highest infection rates, with an incidence of chlamydia and gonorrhea of 1,950 and 267 cases/100,000, respectively. Incidence of gonorrhea and chlamydia was higher for women with a history of military sexual trauma (MST) (chlamydia case rate: 265, gonorrhea case rate: 97/100,000) and those with mental health diagnoses (chlamydia case rate: 263, gonorrhea case rate: 72/100,000.) Conclusions Gonorrhea and chlamydia testing remains underutilized among women in VHA care, and infection rates are high among younger women. Patient-centered, system-level interventions are urgently needed to address low testing rates.