Racial and Ethnic Disparities in Cervical Cancer Screening From Three U.S. Healthcare Settings

Spencer, Jennifer; Kim, Jane J.; Tiro, Jasmin A.; Feldman, Sarah; Kobrin, Sarah C.; Skinner, Celette Sugg; Wang, Lei; McCarthy, Anne Marie; Atlas, Steve J; Pruitt, Sandi L.; Silver, Michelle I.; Haas, Jennifer S.

doi:10.1016/j.amepre.2023.04.016

Cited by 20 publications

(12 citation statements)

References 47 publications

(58 reference statements)

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“…1,2,4,5 The trial's design allowed for evaluation of the effectiveness at the information technology system level and the individual clinician level (EHR reminders), and at the individual patient and the team outreach levels (the EHR reminders and outreach group; the EHR reminders, outreach, and navigation group), and reinforce prior research showing incomplete follow-up varying across cancer organ types and health care settings. 9,14,15,24,32,33 Even though active outreach by population health coordinators or patient navigators resulted in improved proportions of follow-up completion, many patients did not complete follow-up, which may in part reflect care disruptions resulting from the COVID-19 pandemic. However, studies conducted prior to the pandemic also show many patients do not complete recommended follow-up, 23 highlighting the need to understand factors associated with not completing follow-up that go beyond reminder efforts.…”

Section: Discussionmentioning

confidence: 99%

“…The race and ethnicity data recorded in the EHR were self-reported by the patient using openended questions and were included and assessed in this study due to the association previously reported between race and ethnicity and the likelihood of completing cancer screening. 15…”

Section: Study Design and Participantsmentioning

confidence: 99%

“…[9][10][11][12][13] Barriers to follow-up of abnormal cancer screening test results exist at multiple levels, including those involving the patient, primary care clinician, care team, specialist, and health system. 9,14,15 Most cancer screening is initiated in primary care settings. Apart from legislated requirements for radiologists to follow-up on abnormal mammograms, 16 the responsibility for managing abnormal test results is often less organized and variably falls to the performing or ordering clinician.…”

mentioning

confidence: 99%

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A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

Atlas,

Tosteson,

Wright

et al. 2023

JAMA

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ImportanceRealizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results.ObjectiveTo test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results.Design, Setting, and ParticipantsPragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021.InterventionAutomated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment.Main Outcomes and MeasuresThe primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk.ResultsAmong 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P &lt; .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result.Conclusions and RelevanceA multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer.Trial RegistrationClinicalTrials.gov Identifier: NCT03979495

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Section: Discussionmentioning

confidence: 99%

Section: Study Design and Participantsmentioning

confidence: 99%

mentioning

confidence: 99%

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A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

Atlas,

Tosteson,

Wright

et al. 2023

JAMA

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“…We feel we contribute to this essential and under-represented topic and population cohort in the research literature. While trends in incidence rates in CSCC of AA women have shown more decline than for Caucasian women, the absolute incidence and mortality remain significantly higher for AA women 40 . Despite the great concern among the health care community and overwhelming evidence of disparities outcomes, a few studies have focused on AA women to identify causes that led to those disparities.…”

Section: Discussionmentioning

confidence: 99%

Programmed Death Ligand-1 (PD-L1) Expression in Cervical Squamous Cell Carcinoma: Does it Correlate With Outcomes?

Monsrud

Avadhani

Mošunjac

et al. 2023

International Journal of Gynecological Pathology

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Cervical cancer is one of the most common gynecological malignancies. Upregulation of programmed death ligand-1 (PD-L1), an immunoregulatory protein, is associated with an adverse outcomes in several malignancies. Most studies evaluating PD-L1 expression in cervical squamous cell carcinoma (CSCC) lack data on outcomes. In this study, we correlate PD-L1 expression with clinicopathologic factors and clinical outcomes in invasive CSCC. Seventy-three cases of CSCC from 2010 to 2018 were immunostained for PD-L1. A combined positive score (CPS) of ≥1 and ≥10 was correlated with age, stage, and survival outcomes. Kaplan-Meier curves for progression-free survival and overall survival were plotted and compared using the log-rank test. Cox regression analysis was performed to identify significant prognostic factors (2-tailed P<0.05 was considered statistically significant). With CPS ≥1 or ≥10 as the cut-off, PD-L1 was positive in 52/73 (71.2%) and 23/73 (31.5%) of cases, respectively. PD-L1 positive patients present at a higher stage of disease, especially those with CPS ≥10. With CPS of ≥10 as the cut-off, the 5-yr progression-free survival and 5-yr overall survival were significantly lower (P = 0.034 and 0.012, respectively). Only stage was statistically significant for worse overall survival on multivariate analysis. PD-L1 positive patients present at a higher stage of disease, and stage is an independent prognostic indicator for adverse outcomes in CSCC. This study highlights the potential of PD-L1 targeted therapy in patients with CSCC.

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“…2 Systemic racism and discrimination in the health care system, poor CCS insurance coverage, inequitable health care access, and stigma against lesbian, gay, bisexual, transgender, queer, asexual, and intersex (LGBTQAI) individuals have caused CCS services to be underutilized by marginalized populations. 3,4 LGBTQAI populations face unique barriers to CCS; patients and practitioners often underestimate the risk of contracting high-risk human papillomavirus (HPV) and therefore may not screen as often as recommended. [5][6][7] Although sexually minoritized populations have poorer health care access in Chicago, 8 there is limited research on CCS disparities for LGBTQAI patients.…”

Section: Introductionmentioning

confidence: 99%

Sexual Orientation and Cervical Cancer Screening Among Cisgender Women

Baumann,

Matzke,

Peterson

et al. 2024

JAMA Netw Open

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ImportanceLesbian, gay, and bisexual populations face barriers accessing health care in Chicago, Illinois.ObjectiveTo describe the prevalence of up-to-date cervical cancer screening among lesbian, gay, and bisexual vs heterosexual cisgender women in Chicago.Design, Setting, and ParticipantsThis retrospective, cross-sectional, population-based study of cisgender women residing in Chicago was completed from 2020 to 2022 using data from the Healthy Chicago Survey, which is conducted annually by the Chicago Department of Public Health. Participants included cisgender women aged 25 to 64 years with no history of hysterectomy. Respondents who self-identified as lesbian, gay, or bisexual or other than straight, lesbian, or bisexual were coded as lesbian, gay, or bisexual (LGB). Respondents who self-identified as straight were coded as heterosexual. Those who reported having a Papanicolaou test within the past 3 years were considered up-to-date with cervical cancer screening. Data analysis was performed from June to October 2023.ExposuresThe primary exposure was sexual orientation. Covariates included age, income level, race, ethnicity, having a primary care practitioner (PCP), and insurance coverage.Main Outcomes and MeasuresPrevalence ratios (PRs), log-based regression models, and interaction analysis were used to describe the association of sexual orientation with up-to-date screening.ResultsThe sample included 5167 cisgender women (447 LGB and 4720 heterosexual), aged 25 to 64 years, with no history of hysterectomy. Among LGB cisgender women, 318 (71.14%) reported previous cervical cancer screening compared with 3632 (76.95%) heterosexual cisgender women. The prevalence of up-to-date screening was 10% lower in the LGB group compared with the heterosexual group (PR, 0.90; 95% CI, 0.82-1.00). In regression analysis, having a PCP (PR, 1.43; 95% CI, 1.29-1.59) was associated with up-to-date screening. In interaction analysis, LGB cisgender women with a PCP were 93% more likely to be up-to-date compared with those without a PCP (PR, 1.93; 95% CI, 1.37-2.72).Conclusions and RelevanceIn this cross-sectional study of cervical cancer screening rates between the heterosexual and LGB populations in Chicago, up-to-date cervical cancer screening was associated with having a PCP, regardless of sexual orientation, but this association was greater for LGB individuals. Although LGB populations were less likely to be screened, this disparity may be reduced with more consistent health care access and established care with PCPs.

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Racial and Ethnic Disparities in Cervical Cancer Screening From Three U.S. Healthcare Settings

Cited by 20 publications

References 47 publications

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

Programmed Death Ligand-1 (PD-L1) Expression in Cervical Squamous Cell Carcinoma: Does it Correlate With Outcomes?

Sexual Orientation and Cervical Cancer Screening Among Cisgender Women

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