Mental illness is associated with advanced-stage cervical cancer in a vulnerable patient population

Abstract

<h3>Objectives:</h3> Most cases of cervical cancer occur in patients who were either under-screened or had poor follow-up of abnormal results. Mental illness has been associated with an increased risk of morbidity and mortality from other chronic illnesses as well as decreased rates of cancer screening. The objective of this study was to investigate the impact of mental illness on screening, diagnosis and compliance to care in patients diagnosed with cervical cancer. <h3>Methods:</h3> A retrospective cohort study of patients diagnosed with cervical cancer at University Hospital/Rutgers New Jersey Medical School in Newark, NJ was performed. According to the US Census Bureau, the estimated population of Newark is 282,090 of which 50% of people are African American, 36% are Latino and 28% live below the poverty line, making Newark a vulnerable population. According to the NJ Department of Health and hospital discharge data in 2016, the crude rate of women with mental illness was 70% in Essex County where we are located.Baseline clinical data was analyzed to calculate descriptive statistics. Patients with and without mental illness were identified and separated into two groups. Group specific rates of screening, stage at diagnosis, and compliance were determined using Chi-Square or Fisher's exact tests. In order to account for potential confounding factors (age, race, body mass index, insurance status, substance use, smoking status, homelessness, prior medical history, HIV status, family history of cancer, history of pap smear testing, and type of cervical cancer), multivariable logistic regression modeling was used to complete adjusted analyses. All tests were two-sided and p<0.05 was statistically significant. <h3>Results:</h3> From 2012-2019, 166 patients with cervical cancer were identified, of which 15% had a history of mental illness defined as depression, anxiety and/or psychotic disorder. There were no differences in age, race, or primary language spoken. HIV (25% vs 6%, p=0.01), smoking (29% vs 9%, p=0.01), substance abuse disorders (13% vs 5%, p=0.01) and homelessness (21% vs 1%, p=0.001) were more prevalent in those with mental illness. Only 54% of those with mental illness underwent HPV/cytologic testing compared to 76% in the group without mental illness; however, this was not statistically significant (p=0.14). After adjusting for potential confounders, mental illness significantly increased the odds of diagnosis with advanced stage cervical cancer (OR = 6.3, 95% CI:1.5, 30.0). There were no significant differences with treatment compliance (p=0.99) or time to treatment initiation (p=0.97). <h3>Conclusions:</h3> Patients with cervical cancer and mental illness are more likely to be diagnosed at an advanced stage. This may be due to a decreased rate of screening in patients with mental illness. Although rates of screening were not significantly different, we suspect was secondary to the high proportion of mentally ill patients with an unknown screening history compared to patients without mental illness (17% vs 5%). Prospective study designs with larger sample sizes are needed to understand the association between mental health and cervical cancer. Additionally, collaboration between psychiatry, community health workers, and gynecology can help address barriers to screening and decrease missed opportunities in this population that has many touchpoints with healthcare.