Effect of Patient Characteristics on Uptake of Screening Using a Mailed Human Papillomavirus Self-sampling Kit

Abstract

ImportanceMailing human papillomavirus (HPV) self-sampling kits increases cervical cancer screening participation, but effects may differ across subpopulations. Subpopulation data can inform US health care system implementation.ObjectiveTo identify patient characteristics that modify effectiveness of a mailed kit intervention at increasing screening.Design, Setting, and ParticipantsThis was a secondary analysis of data from the Home-Based Options to Make Cervical Cancer Screening Easy (HOME) randomized clinical trial conducted from 2014 to 2018 at Kaiser Permanente Washington. Data analysis was performed from March 2018 to May 2022. Individuals aged 30 to 64 years with female sex, health plan enrollment longer than 3 years and 5 months, a current primary care clinician, and no Papanicolaou test within the prior 3 years and 5 months were identified through electronic medical records and randomized (1:1) to the control or intervention group.InterventionsThe control group received usual care Papanicolaou screening reminders and outreach. The intervention group received usual care plus an unsolicited mailed HPV self-sampling kit.Main Outcomes and MeasuresScreening uptake was captured within 6 months after randomization. Baseline patient characteristics (age, race, ethnicity, travel time to clinic, income, body mass index, tobacco use, health plan enrollment duration, time since last Papanicolaou test, mammography, comorbidities, and colorectal cancer screening adherence) were extracted from the electronic medical record.ResultsOf 19 734 individuals (mean [SD] age, 50.1 [9.5] years; 14 129 [71.6%] White), 9843 were randomized to the intervention group, and 9891 were randomized to the control group. Screening uptake was 26.3% (2592 of 9843 individuals) in the intervention group vs 17.4% (1719 of 9891 individuals) in the control group (relative risk [RR], 1.51; 95% CI, 1.43-1.60). Although absolute differences in uptake by group varied little by screening history, relative effects were greater with longer vs shorter time since last Papanicolaou test (no prior Papanicolaou test: RRs, 1.85-3.25; ≥10 years: RR, 2.78; 5-10 years: RRs, 1.69-1.86; <5 years: RRs 1.29-1.37). Relative effects were greater in participants overdue (RR, 2.03; 95% CI, 1.73-2.38) vs up-to-date with mammography (RR, 1.53; 95% CI, 1.41-1.67), although absolute difference was greater in the up-to-date group. Differences by age were not significant, with RRs of 1.33 to 1.48 across 5-year age groups in participants 30 to 54, vs 1.60 (95% CI, 1.40-1.82) in participants 55 to 59 and 1.77 (95% CI, 1.56-2.01) in participants 60 to 64 years. Among those mailed kits, there were differences in kit use vs in-clinic screening by age, race, plan enrollment duration, underscreening duration, and colorectal cancer screening adherence.Conclusions and RelevanceIn this secondary analysis of a randomized clinical trial, clinically important improvements in screening uptake were observed for all subgroups. Differences in magnitude of intervention effect and kit use highlighted opportunities to optimize HPV self-sampling for priority groups.Trial RegistrationClinicalTrials.gov Identifier: NCT02005510

Economic Evaluation of Mailed Home-Based Human Papillomavirus Self-sampling Kits for Cervical Cancer Screening

“…Race and ethnicity at randomization were derived from self-reported EMR data; categories included American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, White, other race and/or ethnicity (those selecting the other category were able to enter a free-text description; IRB approval did not allow reporting of individual-level data for all participants, so to maintain consistency across all participants in categorization of race and ethnicity, free-text entries were not reviewed or coded), and unknown race and/or ethnicity. 23 …”

Sociodemographic characteristics associated with cervical cancer screening participation by send‐to‐all and opt‐in HPV self‐sampling: Who benefits? Results from a randomized controlled trial among long‐term non‐attending women in Norway

“…In addition to differences in design and sociodemographic data, a major difference between the studies from the United States and Denmark and the present study is that the United States and Denmark studies include women only marginally overdue (e.g., 1 year overdue) for screening, while we restricted the trial to only include long-term non-attending women who had not attended screening for at least 10 years (i.e., who were at least 7 years overdue, indicating ignoration of at least four reminder letters for inclinic screening attendance). Winer et al 26 and Tranberg et al 25 thus report a higher participation rate among controls, a smaller total increase in participation for the women offered self-sampling relative to controls, and a higher proportion of in-clinic screening among T A B L E 4 (Continued) women offered self-sampling, compared to the present RCT. This limits the comparability to our study, especially for absolute effects because the baseline participation rates differ.…”

“…RCTs from Denmark and the United States, that also include women marginally overdue for screening, indicate little or no difference in sociodemographic inequalities between screening modalities. 25,26 To our knowledge, no RCT has addressed this issue among long-term non-attenders to cervical screening. Assessing interventions to improve screening compliance in this group is important because women who are long overdue for screening have relatively high cervical cancer incidence and mortality.…”

Strategies to Increase Cervical Cancer Screening With Mailed Human Papillomavirus Self-Sampling Kits

“…Our 2014-2017 HOME trial, 17 which was embedded in a US health care system, found that mailing HPV self-sampling kits to underscreened individuals increased screening by 9% over usual care (26% vs 17%), similar to international trials. 18,19 However, most individuals remained unscreened with low follow-up of HPV-positive results and patient understanding of testing. [18][19][20][21] As US health care systems introduce primary HPV screening with possible self-sampling, they need data to inform implementation.…”

“…18,19 However, most individuals remained unscreened with low follow-up of HPV-positive results and patient understanding of testing. [18][19][20][21] As US health care systems introduce primary HPV screening with possible self-sampling, they need data to inform implementation. HPV self-sampling trials 22 have not specifically evaluated kit uptake among populations that are screeningadherent or have unknown screening history (where potential overscreening is a concern).…”