Abnormal Cervical Cancer Screening Results Research Articles

Consequences of screening in cervical cancer: development and dimensionality of a questionnaire

BackgroundCervical cancer screening will inevitably lead to unintentional harmful effects e.g. detection of indolent pathological conditions defined as overdetection or overdiagnosis. Overdiagnosis often leads to overutilisation, overtreatment, labelling and thereby negative psychosocial consequences. There is a lack of adequate psychosocial measures when it comes to measurement of the harms of medical screening. However, the Consequences of Screening questionnaire (COS) has been found relevant and comprehensive with adequate psychometric properties in breast and lung cancer screening. Therefore, the aim of the present study was to extend the Consequences of Screening Questionnaire for use in cervical cancer screening by testing for content coverage, dimensionality, and reliability.MethodsIn interviews, the suitability, content coverage, and relevance of the COS were tested on participants in cervical screening. The results were thematically analysed to identify the key consequences of abnormal screening results. Item Response Theory and Classical Test Theory were used to analyse data. Dimensionality, invariance, and reliability were established by item analysis, examining the fit between item responses and Rasch models.ResultsAll COS items were found relevant by the interviewees and the ten COS constructs were confirmed each to be unidimensional in the Rasch models. Ten new themes specifically relevant for participants having abnormal cervical screening result were extracted from the interviews: ‘Uncertainty about the screening result’, ‘Uncertainty about future pregnancy’, ‘Change in body perception’, ‘Change in perception of own age’, ‘Guilt’, ‘Fear and powerlessness’, ‘Negative experiences from the pelvic examination’, ‘Negative experiences from the examination’, ‘Emotional reactions’ and ‘Sexuality’ Altogether, 50 new items were generated: 10 were single items. Most of the remaining 40 items were confirmed to fit Rasch models measuring ten different constructs. However, the two items in the scale ‘Change in perception of own age’ both possessed differential item functioning in relation to time, which can bias longitudinal repeated measurement.ConclusionsThe reliability and the dimensionality of a condition-specific measure with high content validity for women having an abnormal cervical cancer screening results have been demonstrated. This new questionnaire called Consequences Of Screening in Cervical Cancer (COS-CC) covers in two parts the psychosocial experience in cervical cancer screening.

Abstract B08: Acceptability of text messaging for communication of health information among Black and low-income women following abnormal cervical cancer screening

Abstract Background: An estimated one in eight cervical cancer cases is due to lack of follow-up care for abnormal Pap smear results. Low rates of completion of follow-up care particularly affect low-income and minority women and women from rural areas (SEER, 2014). The burden of cervical cancer could be significantly reduced through interventions that improve timely follow-up and treatment. Mobile communications via text messaging may present a low-cost opportunity to increase rates of clinic return among women referred to follow-up on abnormal primary cervical cancer screening results. Purpose: To determine the acceptability and feasibility of using text messaging as a means of increasing completion of follow-up care following an abnormal cervical cancer screening result. We also examined factors that may affect the acceptability and use of text messaging to increase communications between health care providers and low-income and minority women. Methods: Study participants were 15 African American and low-income women who had undergone a Pap smear within the preceding 12 months. Semistructured interviews, including open- and closed-ended questions from a validated questionnaire, were conducted by phone or in person, depending on participant preference. Data were analyzed using a mixed-methods approach. Responses to closed-ended survey items were tabulated and descriptive statistics generated using Excel. Responses to the open-ended questions were coded and analyzed using NVivo 11 qualitative analysis software. Results: Nearly all women in the study (93%) were comfortable receiving a text message from a health care provider stating that their Pap smear results were available (age <40 years:100%; age ≥40: 86%).Over half (53%) of all women were comfortable receiving a text message stating that their Pap smear results were abnormal, though many preferred to receive that information via a phone call (40%). The majority of participants (53%) indicated that text message was the best way to receive a reminder to come back to the clinic, though 40% preferred a call from a provider. Most participants (60%) believed receiving a text reminder would make them more likely to attend their appointment. The preferred method for receiving such a reminder appeared to vary by age. Analysis of open-ended questions suggested that text messaging to communicate with providers appeals to some women because of its wide use and convenience. However, several participants did report barriers to text messaging, including the lack of texting proficiency and difficulty in texting and a lack of confidence in their comprehension of the content of a text message. Most participants also reported some concerns over privacy and confidentiality of health information communicated by text. Conclusions: Most participants indicated a willingness to receive text messages from their health care providers on the results of their cervical cancer screening and believed that text messages were the best way to remind them of their appointment for follow-up care. Concerns about privacy of health information could be addressed by minimizing reference to the nature of an appointment in the message. While text messaging seems promising to improve adherence to timely follow-up, personal preferences should be considered in the use of this technology--possibly by allowing patients to opt out of text communications. Further research is needed to assess the feasibility and effectiveness of this approach to improve adherence to follow-up in high-risk populations. Citation Format: LaHoma Smith Romocki, Leslie Cofie, Andrea Des Marais, Theresa Curington, Chelsea Anderson, Jennifer S. Smith. Acceptability of text messaging for communication of health information among Black and low-income women following abnormal cervical cancer screening [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B08.

A prospective study of risk-based colposcopy demonstrates improved detection of cervical precancers

Sensitivity for detection of precancers at colposcopy and reassurance provided by a negative colposcopy are in need of systematic study and improvement. We sought to evaluate whether selecting the appropriate women for multiple targeted cervical biopsies based on screening cytology, human papillomavirus testing, and colposcopic impression could improve accuracy and efficiency of cervical precancer detection. In all, 690 women aged 18-67 years referred to colposcopy subsequent to abnormal cervical cancer screening results were included in the study (ClinicalTrials.gov: NCT00339989). Up to 4 cervical biopsies were taken during colposcopy to evaluate the incremental benefit of multiple biopsies. Cervical cytology, human papillomavirus genotyping, and colposcopy impression were used to establish up to 24 different risk strata. Outcomes for the primary analysis were cervical precancers, which included p16+ cervical intraepithelial neoplasia 2 and all cervical intraepithelial neoplasia 3 that were detected by colposcopy-guided biopsy during the colposcopy visit. Later outcomes in women without cervical intraepithelial neoplasia 2+ at baseline were abstracted from electronic medical records. The risk of detecting precancer ranged from 2-82% across 24 strata based on colposcopy impression, cytology, and human papillomavirus genotyping. The risk of precancer in the lowest stratum increased only marginally with multiple biopsies. Women in the highest-risk strata had risks of precancer consistent with immediate treatment. In other risk strata, multiple biopsies substantially improved detection of cervical precancer. Among 361 women with cervical intraepithelial neoplasia <2 at baseline, 195 (54%) had follow-up cytology or histology data with a median follow-up time of 508 days. Lack of detection of precancer at initial colposcopy that included multiple biopsies predicted low risk of precancer during follow-up. Risk assessment at the colposcopy visit makes identification of cervical precancers more effective and efficient. Not finding precancer after a multiple-biopsy protocol provides high reassurance and allows releasing women back to regular screening.

Providers' Views on a Community-Wide Patient Navigation Program: Implications for Dissemination and Future Implementation.

The DuPage Patient Navigation Collaborative (DPNC) adapted and scaled the Patient Navigation Research Program's intervention model to navigate uninsured suburban DuPage County women with an abnormal breast or cervical cancer screening result. Recent findings reveal the effectiveness of the DPNC in addressing patient risk factors for delayed follow-up, but gaps remain as patient measures may not adequately capture navigator impact. Using semistructured interviews with 19 DPNC providers (representing the county health department, clinics, advocacy organizations, and academic partners), this study explores the critical roles of the DPNC in strengthening community partnerships and enhancing clinical services. Findings from these provider interviews revealed that a wide range of resources existed within DuPage but were often underused. Providers indicated that the DPNC was instrumental in fostering community partnerships and that navigators enhanced the referral processes, communications, and service delivery among clinical teams. Providers also recommended expanding navigation to mental health, women's health, and for a variety of chronic conditions. Considering that many in the United States have recently gained access to the health care system, clinical teams might benefit by incorporating navigators who serve a dual working purpose embedded in the community and clinics to enhance the service delivery for vulnerable populations.

US Navy Women's Experience of an Abnormal Cervical Cancer Screening.

Recent policy revisions allow greater inclusion of military women in operational and/or deployable positions (ie, shipboard, overseas, and war zone duty assignments), but these positions can create unique health care challenges. Military members are often transient due to deployments and change of duty stations, impacting timely follow-up care for treatable health conditions. There has been minimal research on challenges or strategies in preventive health screening and follow-up for US military women. The purpose of this qualitative research study was to describe US Navy women's experiences with abnormal cervical cancer screenings requiring colposcopic follow-up care. Ship- and shored-based women receiving care at a military colposcopy clinic completed interviews about their experience. Two forms of narrative analysis, Labov's sociolinguistic structural analysis and Braun and Clarke's thematic analysis, were employed to gain a more robust understanding of the women's experiences. The sample was comprised of 26 women (16 ship-based, 10 shore-based). Five themes were identified: 1) It's like this bombshell (initial abnormal results notification); 2) I didn't understand (self-discovery process); 3) Freaked (emotional toll); 4) It's kind of like this back and forth (scheduling and navigating care); and 5) It really opened my eyes (lessons learned). The women's stories highlighted some issues unique to military health care, such as operational demands and follow-up care; other issues are likely common for most women learning about an abnormal cervical cancer screening result. Areas important for practice and future research include improving notification practices, providing information, understanding women's fear, and continuity of care. Research exploring educational initiatives and self-management practices are critical within military populations.

Multiple biopsies and detection of cervical cancer precursors at colposcopy.

Women with abnormal cervical cancer screening results are referred to colposcopy and biopsy for diagnosis of cervical cancer precursors (high-grade squamous intraepithelial lesions [HSILs]). Colposcopy with a single biopsy can miss identification of HSILs. No systematic study has quantified the improved detection of HSIL by taking multiple lesion-directed biopsies. The Biopsy Study was an observational study of 690 women referred to colposcopy after abnormal cervical cancer screening results. Up to four directed biopsies were taken from distinct acetowhite lesions and ranked by colposcopic impression. A nondirected biopsy of a normal-appearing area was added if fewer than four directed biopsies were taken. HSIL identified by any biopsy was the reference standard of disease used to evaluate the incremental yield and sensitivity of multiple biopsies. In the overall population, sensitivities for detecting HSIL increased from 60.6% (95% CI, 54.8% to 66.6%) from a single biopsy to 85.6% (95% CI, 80.3% to 90.2%) after two biopsies and to 95.6% (95% CI, 91.3% to 99.2%) after three biopsies. A significant increase in sensitivity of multiple biopsies was observed in all subgroups. The highest increase in yield of HSIL was observed for women with a high-grade colposcopic impression, HSIL cytology, and human papillomavirus (HPV) type 16 positivity. Only 2% of all HSILs diagnosed in the participants were detected by biopsies of normal-appearing transformation zone. Collection of additional lesion-directed biopsies during colposcopy increased detection of histologic HSIL, regardless of patient characteristics. Taking additional biopsies when multiple lesions are present should become the standard practice of colposcopic biopsy.

What Women Want: Patient Recommendations for Improving Access to Breast and Cervical Cancer Screening and Follow-up

BackgroundThe patient voice remains underrepresented in clinical and public health interventions. To inform interventions that strive to improve access to breast and cervical cancer screening and follow-up among low-income populations, we explored recommendations from low-income women pursuing health care in the safety net. MethodsSemi-structured interviews were conducted among women receiving follow-up care for an abnormal breast or cervical cancer screening result or a positive cancer diagnosis in federally qualified health centers, free clinics, or an academic cancer center in the Chicago metropolitan area. FindingsOf the 138 women interviewed in the parent study, 52 women provided recommendations for improving access to screening and follow-up care. Most were between 41 and 65 years old (62%) and African American (60%) or White (25%). Recommendations included strengthening community-based health education with more urgent messaging, strategic partnerships, and active learning experiences to increase patient engagement, which women regarded as a key driver of access. Women also suggested increasing access by way of changes to health care delivery systems and policy, including more direct patient–provider and patient–clinic communications, addressing delays caused by high patient volume, combining preventive services, expanding insurance coverage, and adjusting screening guidelines. ConclusionsThis exploratory study demonstrates important insights from the patient lens that may help to increase the acceptability and efficacy of community and clinical interventions aimed at improving access to breast and cervical cancer screening and follow-up. Further research is needed to identify appropriate integration of patient input into interventions, practice, and policy change.

Chromosomal gains measured in cytology samples from women with abnormal cervical cancer screening results

ObjectiveChromosomal gains at 3q26, 5p15 and 20q13 have been described in cervical precancer and cancer. We evaluated a novel fluorescence in situ hybridization (FISH) assay that detects gains at these three loci simultaneously as a possible biomarker for detecting cervical precancer. MethodsChromosomal copy numbers at 3q26, 5p15, 20q13 and the centromere of chromosome7 (cen7) in liquid-based cytology specimens from 168 women enrolled in the Biopsy Study were determined by FISH. The number of cells with ≥3 or ≥4 signals for a genomic locus was enumerated and diagnostic test performance measures were calculated using receiver operating characteristic (ROC) analyses. Sensitivity and specificity values were determined for the detection of CIN2+ and/or HSIL. ResultsThe median number of cells with ≥3 signals increased with the severity of cervical lesion for each genomic locus (p-trend<0.02 for each locus). ROC analysis for the number of cells with ≥3 signals resulted in area under the curve values of 0.70 (95% CI: 0.54–0.86), 0.67 (0.52–0.83), 0.67 (0.51–0.83) and 0.78 (0.64–0.92) for 3q26, 5p15, 20q13 and cen7, respectively, for the detection of CIN2+ and/or HSIL. Positivity for gains at multiple loci resulted in only slightly better test performance measures than those for the individual probes for four distinct combinations of probes. ConclusionsChromosomal gains at 3q26, 5p15, 20q13 and cen7 are associated with severity of cervical lesions. Further studies are required to quantify risk stratification of FISH assays for cervical cancer screening.

New Guidance for Management of Women with Abnormal Cervical Cancer Screening Results

In 2012, the American Cancer Society, American Society for Clinical Pathology, and American Society for Colposcopy and Cervical Pathology (ASCCP)

Molecular mapping of high‐grade cervical intraepithelial neoplasia shows etiological dominance of HPV16

Women with high-grade cervical intraepithelial neoplasia (HGCIN) frequently present with multiple cervical lesions and multiple concomitant Human papillomavirus (HPV) genotype infections. To elucidate HPV genotype attribution in different regions on the cervix, we performed molecular mapping of cervical disease in women with HGCIN. Thirteen subjects referred to colposcopy for abnormal cervical cancer screening results were included. A cervical smear and biopsies from 4 different areas on the cervix were collected. HPV genotyping using Linear Array (for cytology) or SPF(10) LiPA(25) (for histology) were performed in 13 smears, 52 whole sections from biopsies and 138 tissue regions isolated with laser capture microdissection (LCM). Twelve subjects had a diagnosis of CIN3 and one subject had a diagnosis of CIN2 based on the worst histology found in 4 biopsies. Eight of the 13 smears (62%) showed multiple genotype infections. Four of 13 women (31%) had multiple HPV infections in their biopsies. After performing LCM-PCR, only one woman (8%) had two different carcinogenic HPV types in morphologically distinct, but colliding HGCIN lesions. HPV16 was identified as the causal type in all women with HPV16 in cytology. A large proportion of other HPV types found in cervical smears were not detected at the tissue level. Using tissue-based genotyping and LCM-PCR analysis, we were able to attribute an individual HPV type to each area of CIN lesions. We demonstrate that HPV16 is even more etiologically dominant than previously thought, based on various genotype attribution models.

Clinical and Pathological Heterogeneity of Cervical Intraepithelial Neoplasia Grade 3

ObjectiveCervical intraepithelial neoplasia grade 3 (CIN3), the immediate cervical cancer precursor, is a target of cervical cancer prevention. However, less than half of CIN3s will progress to cancer. Routine treatment of all CIN3s and the majority of CIN2s may lead to overtreatment of many lesions that would not progress. To improve our understanding of CIN3 natural history, we performed a detailed characterization of CIN3 heterogeneity in a large referral population in the US.MethodsWe examined 309 CIN3 cases in the SUCCEED, a large population-based study of women with abnormal cervical cancer screening results. Histology information for 12 individual loop electrosurgical excision procedure (LEEP) segments was evaluated for each woman. We performed case-case comparisons of CIN3s to analyze determinants of heterogeneity and screening test performance.ResultsCIN3 cases varied substantially by size (1–10 LEEP segments) and by presentation with concomitant CIN2 and CIN1. All grades of CINs were equally distributed over the cervical surface. In half of the women, CIN3 lesions were found as multiple distinct lesions on the cervix. Women with large and solitary CIN3 lesions were more likely to be older, have longer sexual activity span, and have fewer multiple high risk HPV infections. Screening frequency, but not HPV16 positivity, was an important predictor of CIN3 size. Large CIN3 lesions were also characterized by high-grade clinical test results.ConclusionsWe demonstrate substantial heterogeneity in clinical and pathological presentation of CIN3 in a US population. Time since sexual debut and participation in screening were predictors of CIN3 size. We did not observe a preferential site of CIN3 on the cervical surface that could serve as a target for cervical biopsy. Cervical cancer screening procedures were more likely to detect larger CIN3s, suggesting that CIN3s detected by multiple independent diagnostic tests may represent cases with increased risk of invasion.

Triage of women with atypical squamous cells of undetermined significance cytology result

Repeat cervical cytologic testing,human papillomavirus(HPV)testing and immediate colposcopy are currently the most general managements in women with atypical squamous cells of undetermined significance(ASCUS)result.However,the efficacy of these three methods is hampered by strong subjectivity,high false negative and positive rates.With the development of the aetiology of cervical cancer,there is good evidence that biomarkers for persistent HPV infection,HPV integration,instability of host genes and malignancy triage ASCUS more objectively and efficiently.The three-dimensional multiparameter biomarker-based detection may be the predominant method for the triage of women with abnormal cervical cancer screening result. Key words: Uterine cervical dysplasia; Cytology; Papillomatirus infections; Biological markers

Preliminary findings from a patient navigator program with Hispanic women from community clinics in South Texas.

Abstract Abstract #5097 A patient navigator program that uses a trained community health worker to assist Hispanic women in utilizing cancer care services has been successfully implemented in South Texas for the past two years. The objectives of this program are to 1) reduce the rate of noncompliance after reception of abnormal breast and cervical cancer screening results, which will in turn reduce the time between screening and the commencement of treatment, and 2) improve patient satisfaction with the health care system experience. Participants include low-income Hispanic women who receive abnormal breast and/or cervical cancer screening results from two community clinics, a Treatment and a Comparison clinic. Participants from both clinics are administered a pre-(baseline) and a post-survey. The pre-survey is administered upon recruitment into the study, and the post-survey is administered six months after the baseline survey. Clinical data about participants' abnormal screening results are also extracted from their medical records. In addition, a patient navigator facilitates scheduling clinic visits, resolving medical problems and avoiding non-medical delays in evaluation for patients participating in the Treatment Arm. This session will present preliminary results, lessons learned, common patient barriers and strategies to address the barriers. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5097.

Women's uncertainties, coping, and moods regarding abnormal papanicolaou results.

The overall purpose of this study was to understand the process of coping with the news of abnormal cervical cancer screening results. The specific aims were (1) to compare women's uncertainty about the implications of abnormal Papanicolaou (Pap) tests and women's psychological distress over time and (2) to describe relationships among uncertainty, perceived coping ability, coping strategies that were used and helpful, and psychological distress. Seventy-five women were interviewed using standardized measures after hearing the news of their abnormal Paps tests; 40 completed similar questionnaires before follow-up colposcopy, and 35 of these also completed questionnaires after colposcopy. Women's uncertainty about abnormal Pap test results decreased over time. Negative mood scores, reflecting psychological distress, did not change over time. Uncertainty about Pap tests, ambiguity about cancer, and perceived inability to deal with Pap test results were related positively. Uncertainty was related positively to the coping strategy of catharsis as well as to negative mood scores both after receiving the news and precolposcopy. Catharsis was associated with higher negative mood scores, but acceptance was associated with lower negative mood scores. The helpfulness of relaxation and diversion was associated with lower negative mood scores. Clinical interventions can address women's uncertainty and promote coping strategies to reduce psychological distress among women with abnormal cervical cancer screening results.