Loss to Follow-Up and the Care Cascade for Cervical Cancer Care in Rural Guatemala: A Cross-Sectional Study

Abstract

PURPOSE More than 80% of cervical cancer cases and deaths occur in low- and middle-income countries. Here, we analyze a large geographically extensive cross-sectional data set from the Western rural highlands of Guatemala. Our objective is to better characterize weak points in care along the cervical cancer care continuum and investigate sociodemographic and clinical correlates of loss to follow-up. METHODS We conducted a retrospective review of electronic health records data from July 21, 2015, through December 10, 2020 for a cytology-based screening and cervical cancer treatment program. We used a care cascade analysis to characterize the progression of individuals through screening, confirmatory testing, and treatment. We examined demographic and clinical factors correlated with screening and loss to follow-up using multivariate logistic regression. RESULTS A total of 8,872 individuals were included in the analysis. Five thousand nine hundred thirteen cervical cancer screenings were conducted. 4.1% of all screening tests were abnormal, including 0.61% cervical intraepithelial neoplasia or overt cervical cancer. Care cascade analysis showed that 67% of eligible women accepted screening. Of those requiring confirmatory testing or treatment, 73% completed recommended follow-up. In adjusted multivariable analysis, prior history of sexual transmitted infection, prior experience with cervical cancer screening, older age, and current contraceptive use were associated with accepting screening. Age and contraceptive use were also associated with retention in care after a positive first screen. CONCLUSION In a large rural Guatemalan retrospective cohort, a care continuum analysis showed that both declining the opportunity to receive cervical cancer screening as well as declining confirmatory testing after a first positive screen were both important weak points along the care continuum. These data support the need for comprehensive and culturally appropriate initiatives to improve screening uptake and retention in care.

Cervical Cancer Screening via Visual Inspection With Acetic Acid and Lugol Iodine for Triage of HPV-Positive Women

“…An important advantage associated with triage with visual inspection in our study is the possibility of linking screening to immediate management. Reducing visit numbers is crucial in low-resource areas; for each additional visit, approximately one-fourth to one-third of screened women are lost to follow-up . Women in these settings often face economic disadvantages and social barriers and encounter limited access to health care services.…”

“…Reducing visit numbers is crucial in low-resource areas; for each additional visit, approximately one-fourth to one-third of screened women are lost to follow-up. 30 , 31 Women in these settings often face economic disadvantages and social barriers and encounter limited access to health care services. Failure to provide adequate care to these women may result in a worse prognosis for screening-detectable lesions.…”

Prevalence of diabetes among Indigenous women in Guatemala: A retrospective chart review study of 13 643 patients between 2015-2022

“…Program details previously have been described. 4,5 Upon enrollment in the program, patients were queried if they had a history of diabetes and, if not, were screened for diabetes using random or fasting glucose capillary measurements. For this analysis, we extracted electronic health record and administrative data between July 1, 2015, and December 31, 2022.…”

Understanding the key determinants of an HPV therapeutic vaccine: a modeling analysis

“…HPV DNA testing has transformed the ability to detect high-risk infection with a high degree of sensitivity and thermal ablation has enabled low-cost treatment of precancerous lesions (8)(9)(10)(11)(12). Screening and treatment programs remain expensive and challenging to scale-up in many LMIC geographies (13)(14)(15). The high cost of HPV DNA tests often lead to reliance on visual inspection with acetic acid (VIA), which is known to have both low sensitivity and variable performance, resulting in imprecise treatment decisions.…”