Cervical cancer control program increases rate of follow-up

Nov 3 2005

Low-income women with abnormal Pap tests who participated in a program that combines screening and treatment in one visit had a higher rate of treatment and follow-up than women who did not participate, according to a study in the November 2 issue of JAMA: The Journal of the American Medical Association.

Cervical cancer incidence rates in the United States have progressively declined because of the widespread application of cervical cancer screening and treatment of precancerous lesions, according to background information in the article. The majority of cervical cancers diagnosed in this country are among women who have never received a Papanicolaou test or who are noncompliant with screening and follow-up. The incidence of cervical cancer is higher among low-income and minority women. The barriers to cervical cancer screening and management include poverty, lack of health insurance, limited transportation, language difficulties, lack of child care and lack of telephone access. The researchers believe that the usual approach to cervical cancer screening, diagnosis, and management accentuates some of these barriers because it is cumbersome and expensive, ordinarily involving multiple clinic or hospital visits and requiring a period of months to complete. Previous research has reported that between 20 percent and 50 percent of women with abnormal Papanicolaou test results do not have follow-up.

Wendy R. Brewster, M.D., Ph.D., of the University of California, Irvine, and colleagues developed a cancer control program to simplify cervical screening and management of high-grade cervical dysplasia among predominantly Latina women from underserved communities. They hypothesized that women who received results and explanations about the importance of follow-up for an abnormal Papanicolaou test result on the same day as the test would be more likely to follow up. The randomized trial included 3,521 women aged 18 or older recruited between January 1999 and April 2002 from U.S. community health centers, located in predominantly Latino underserved areas.

Women randomized to usual care (n=1,805) were discharged immediately after examination. Women randomized to the single-visit group (n=1,716) remained at the clinic until the results of their conventional Papanicolaou test were available. Large loop electrosurgical excision procedure was performed in single-visit patients with either a diagnosis of a high-grade squamous intraepithelial lesion (HGSIL)/atypical glandular cells of undetermined significance (AGUS) or suspicion of carcinoma. All other patients with abnormal Papanicolaou test results were referred to abnormal cytology clinics or elected to receive follow-up care outside the study's medical system.

Approximately 4 percent of all Papanicolaou test results in each of the 2 groups were abnormal, and 1 percent of results showed high-grade lesions. The researchers found that 53 percent of the women in the usual care group received definitive treatment within 6 months for their severe dysplasia compared with 88 percent of single-visit patients. Overall, 36 percent of women in each group presented for a follow-up Papanicolaou test 1 year later. Women in the single-visit group with high-grade lesions were significantly more likely to follow up for their Papanicolaou tests 12 months later than women with similar lesions in the usual care group (10 [63 percent] of 16 compared with 4 [21 percent] of 19. Examination of the other Papanicolaou test classifications did not demonstrate a difference in the follow-up rate 1 year later.

The average visit time for patients in the single-visit group, defined as the duration from when they came into the clinic until they left, was 2.8 hours. Slightly more than 1 hour (66 minutes) of this time was spent waiting for the transportation, processing, and reading of the Papanicolaou test. In comparison, the average visit time for the usual care group was 75 minutes. The acceptability of the visit duration was 76 percent in the single-visit group and 89 percent in the usual care group.

The researchers add that although the number of women at high risk of cervical cancer in this study was small, this program could prevent most cervical cancer if applied to all women with severely abnormal Papanicolaou test results. "In this era, when effective treatment of precancerous lesions is available, it is not acceptable for any woman to develop this disease."

"In summary, we have demonstrated that a single-visit cervical cancer screening and treatment program is feasible and the degree of acceptability is high. We believe that this strategy is best applied to practices of underserved groups with high rates of loss of follow-up. Single-visit programs provide an opportunity to ensure that severe cervical lesions are treated," the authors write.

http://jama.ama-assn.org/