Increasing breast and cervical cancer screening in low-income women

Abstract

OBJECTIVE:To determine if women would have higher breast and cervical cancer screening rates if lay health advisers recommended screening and offered a convenient screening opportunity. DESIGN: Controlled trial. SETTING: Urban county teaching hospital.PARTICIPANTS: Women aged 40 years and over attending appointments in several non-primary-care outpatient clinics. INTERVENTIONS:Lay health advisers assessed the participants' breast and cervical cancer screening status and offered women in the intervention group who were due for screening an appointment with a female nurse practitioner. MEASUREMENTS AND MAIN RESULTS:Screening rates at baseline and at follow-up 1 year after the intervention were determined. At follow-up, the mammography rate was 69% in the intervention group versus 63% in the usual care group ( p ‫؍‬ .009), and the Pap smear rate was 70% in the intervention group versus 63% in the usual care group ( p ‫؍‬ .02). In women who were due for screening at baseline, the mammography rate was 60% in the intervention group versus 50% in the usual care group ( p ‫؍‬ .006), and the Pap smear rate was 63% in the intervention group versus 50% in the usual care group ( p ‫؍‬ .002). The intervention was effective across age and insurance payer strata, and was particularly effective in Native American women. CONCLUSIONS:Breast and cervical cancer screening rates were improved in women attending non-primary-care outpatient clinics by using lay health advisers and a nurse practitioner to perform screening. The effect was strongest in women in greatest need of screening.KEY WORDS: mass screening; vaginal smears; mammography; nurse practitioners; community health aides. J GEN INTERN MED 1998;13:515-521.S creening mammography and Pap smears have been shown convincingly to decrease breast and cervical cancer mortality. 1,2 Recent population-based surveys suggest progress toward the year 2000 goals in the general population for both breast and cervical cancer screening. 3,4 However, nonwhite women, older women, and those with lower incomes and less education generally have lower screening rates. [4][5][6] Strategies to improve screening rates in these groups are needed.Hennepin County Medical Center, the urban county teaching hospital in Minneapolis, serves many women from groups that are less likely to receive breast and cervical cancer screening. Preliminary reviews of the charts of women attending appointments in the general medicine clinic, medical subspecialty clinics, and surgical clinics, showed the lowest screening rates in women attending surgical clinics (K.L. Margolis, unpublished data). Primary care physicians have been urged to "put prevention into practice" with each patient contact, 7 but few specialists are prepared to utilize each patient contact this way. Physicianoriented interventions such as education, 8 feedback of screening rates, 9 checklists, 10,11 nurse-generated reminders, 12 and computer-generated reminders 9,13 have been modestly successful in increasing cancer screening in primary care setting...

Interventions targeted at women to encourage the uptake of cervical screening

“…Fifteen were quasi randomised (Baele 1998;Chumworathayi 2007;Hicks 1997;Hou 2002;Hou 2005;Lantz 1995;Lantz 1996;Levine 2003;Marcus 1992;Margolis 1998;Maxwell 2003;Park 2005;Paskett 1990;Ward 1999;Yancey 1995), three studies included participants who may have been screened before receiving the intervention (Dignan 1996;Dignan 1998;Gotay 2000), ten studies used an intervention aimed at either the physician or both the physician and patient (Boissel 1995;Bonevski 1999;Campbell 1997;Cecchini 1989;Hillman 1998;Litzelman 1993;Manfredi 1998;Nguyen 2000;Roetzheim 2004;Roetzheim 2005), seven studies used an intervention or an outcome that was not strictly concerned with increasing uptake (Brewster 2002;Del Mar 1995;Holloway 2003;Katz 2007;Paul 2003;Philips 2006;Sankaranarayanan 2003;), nine studies concerned intervention aimed at improving follow-up of an abnormal smear results rather than initial Pap screening uptake (Engelstad 2005;Lauver 1990;Marcus 1998;Miller 1999;Paske...…”

Cervical Cancer Screening, Diagnosis and Treatment Interventions for Racial and Ethnic Minorities: A Systematic Review

“…Of the studies of interventions to improve screening for cervical cancer in racial and ethnic minority populations, one was of very good quality, 14 ten were of good quality, 15,22,23,[32][33][34][35][36]39,40 12 were of fair quality, 12,13,[16][17][18][19][20][21]25,37,38,41 and one was of poor quality. 26 Of the studies of interventions to improve the diagnosis and treatment of premalignant disease of the cervix, three were of good quality [27][28][29] and three were of fair quality.…”

“…Of the 25 studies evaluating interventions to improve the rate of screening for cervical cancer, eight included a single intervention 12,17,[32][33][34]38,40,42 and 17 included multiple interventions. [13][14][15][16][18][19][20][21][22][23]25,26,[35][36][37]39,41 The most common interventions were educational materials and education programs.…”

“…Nineteen interventions included educational materials 12,13,15,16,[18][19][20][21][22][23]25,26,32,33,36,37,[39][40][41] and 15 included education programs. 15,16,18,19,[21][22][23]25,26,[35][36][37]39,41 Seven interventions included navigation (including assistance scheduling appointments, finding low-cost sources of care and with transportation), [13][14][15]22,23,35,36 five included strategies to provide low-cost screening, 16,21,26,37,42 five included strategies to improve access to screening, 17,18,21,34,…”

“…Of the remaining four studies that addressed a single intervention to improve screening for cervical cancer in racial or ethnic minority populations, 17,34,38,42 each evaluated the impact of a unique intervention. Margolis evaluated the impact of using lay health advisers to offer women due for screening an appointment with a female nurse practitioner.…”