The Journal of the American Board of Family Medicine

Kennedy v Braidwood Ruling Affects Women and Cervical Cancer Screening

The Affordable Care Act (ACA) requires private insurance plans to cover preventive services, receiving a Grade A or B rating by the United States Preventive Services Task Force (USPSTF) without cost sharing. Cervical cancer prevention is one such service. Family medicine provides more than half of all the cervical cancer screenings in the US. While the ACA has led to an increase in screening, half of the people assigned female at birth who develop cervical cancer have never been screened. In addition, 20 to 40% of screening-eligible people in the US do not participate in screening. Of those who do screen, and their screen is abnormal, only 34% attend their diagnostic colposcopy examination. Colposcopy with biopsy and endocervical curettage requires consequential copay for the examination and pathology, which increases financial toxicity. Beginning in 2027, policies similar to those in place for breast and colorectal cancer screening that require insurance plans to cover the entire diagnostic workup without cost sharing under the ACA preventive services provision, will be implemented for cervical cancer screening.

Electronically-Delivered Push Notifications Improve Patient Adherence to Preventive Care

Preventive care improves patient health and is cost-effective, yet many patients are not up to date on recommended screenings. Evaluate the effectiveness of an automated system for outreach to patients in need of annual preventive examinations, cervical cancer screening, and diabetes monitoring labs. As part of a quality improvement project, we created a population health algorithm and outreach system which was designed to send e-mail and smartphone notifications to patients overdue for preventive services. The study was a cohort study, with a matched control sample. We compared completion of preventive exams and screenings between the 2 groups, in the 4 weeks following the outreach. For annual preventive visits, the intervention group had 9.0% more visits (95%CI: 8.2 to 9.7) than the control group. For cervical cancer screening, the intervention group had 3.2% (95%CI: 2.0% - 4.4%) more visits. Lab action orders for diabetes showed the largest increases. The intervention group had 5.2% (2.5% - 7.9%) more patients get bloodwork and 20.8% (16.9% - 24.6%) get more urine microalbumin tests. A population health outreach system that used reminders for prevention resulted in patients completing appointments for necessary medical services. Such a system, when deployed more broadly could help close care gaps and improve health for people that are asymptomatic but are due for preventive screenings.

The Impact of COVID-19 on Cervical Cancer Screening in Primary Care

The COVID-19 pandemic has reduced the number of elective in-person visits to primary care practices. This study examined how the pandemic may have affected cervical cancer (CC) screening rates in primary care settings across the United States. We conducted a retrospective cross-sectional study using data from the PRIME Registry of the American Board of Family Medicine from March 15, 2017, to March 14, 2022. We included 2,207,355 women aged 21 to 65 years who had visited a clinician (n = 1,052) from any of 472 primary care practices. We compared CC screening rates among eligible women during in-person visits over the 3 prepandemic years with those during the 2 years of the pandemic. Screening rates (per 100 eligible patients with in-person visits) decreased from 1.85 to 1.12 in the first quarter of the first year and remained lower throughout both years of the pandemic compared with prepandemic year, had not returned to prepandemic levels by the end of the second year. Hispanic or Latino (odds ratio [OR] = 1.96) and Black or African American (OR = 1.37) women were more likely to be screened, whereas those receiving care from male clinicians (OR = 0.34) were less likely to be screened. CC screening rates remained below prepandemic levels throughout the 2 years of the pandemic. Policy makers and health care professionals should strategize approaches to enhance CC screening rates, including the exploration of alternative methods, such as home-based CC screening. New screening approaches are needed to ensure preparedness for future health crises.

The Effects of Testosterone on Cervicovaginal Cytology in Transgender and Gender-Diverse Individuals

The Papanicolaou (Papanicolaou) test is an effective and widely used cervical cancer screening procedure. Recommendations for cervical cancer screening do not incorporate patients' gender identities nor gender-affirming hormone statuses in determining screening surveillance intervals and interpreting test results. This study assessed the association between testosterone and rates of abnormal Papanicolaou specimens and specimen adequacy by comparing testosterone-associated Papanicolaou specimens and nontestosterone Papanicolaou specimens among transgender and gender-diverse (TGD) patients. Retrospective electronic health record chart review of 211 TGD patients with cervixes, contributing 298 unique Papanicolaou tests, with a visit to a primary care clinic between 2012 and 2019. Primary outcomes included specimen quality (transformation zone [TZ] present, TZ absent, atrophic specimen, scant cellularity), presence of inflammation (yes/no), and cytology results (normal, abnormal, inadequate specimen). χ A higher proportion of TAPS had missing TZ, showed atrophy, or had scant cellularity than NTPS (58.8% vs 33.5%; Findings confirmed an association between testosterone usage and cytology specimen adequacy and quality. No association was found between testosterone usage and rates of abnormal results within our TGD population. More research is needed to disentangle the effect of missing TZ on risk of future cervical dysplasia among this younger population.

BRCA-Related Cancer Genetic Counseling is Indicated in Many Women Seeking Primary Care

Guidelines updated by the United States Preventive Services Task Force (USPSTF) in 2019 recommend referral to genetic counseling for asymptomatic women that have a family history of cancers potentially associated with variants in the breast cancer type 1 and 2 susceptibility genes ( I performed a needs assessment for Out of 397 women, 97 women (24.4% ± 4.2%, 95% CI) met criteria for referral to genetic counseling. Among women with referral indications, 80 women (82.4% ± 7.6%) had no prior contact with genetic counseling and/or testing services (comprising 20.1% ± 3.9% of all women surveyed). The most common indication for The rate that undifferentiated women seeking primary care met 2019 USPSTF criteria for

Characterizing Cervical Cancer Screening in the US: Preparing for the Era of Self-Collection

Cervical cancer screening (CCS) is shifting from in-office to self-screening. The primary aim of this study is to define a baseline distribution of in-office CCS providers by specialty and the race/ethnicity and age of those screened. We extracted electronic health record data (Truveta-multiple health systems in 34 states) of individuals eligible for CCS aged 21 to 65, documented between January 1, 2017-December 31, 2022. Those with a hysterectomy before 2017, had any gynecological cancer at any time, or had evidence of CCS after the hysterectomy, except if there was a history of cervical intraepithelial neoplasia grade 2 or 3 (CIN 2/3) disease were excluded. We reported the total number of CCS and colposcopies per eligible patient and the specialty of the performing clinician (medical taxonomy). Among the 2,439,331 individuals included in the study, the average age was 42.9 (SD 11.7). There were 3,412,148 CCSs linked with 1 of 3 provider specialties: obstetrics & gynecology (OG), family medicine (FM), and general internal medicine (GIM). OG provided less than half of all CCS, dropping to 31.6% of those 50 to 65. While only 70.5% (1,718,914) of the population received at least 1 CCS during the study, the mean CCS per patient was 2.6 (SD 2.7). The rate of colposcopy after a CCS was 3.9%. Family and Internal Medicine clinicians provide the majority of CCS in the US (61.9%), particularly for people aged 50 to 65 (68.4%), when cervical cancer risk is the highest.