Cervical Cancer Early Detection Program Research Articles

Abstract A51: Understanding community-based primary care providers' attitudes toward caring for breast cancer survivors.

Abstract Background: Of the 13.7 million cancer survivors in the United States, 22% are breast cancer survivors. By 2050, this number is expected to double. The 2005 Institute of Medicine's Report “From Cancer Patient to Cancer Survivor: Lost in Transition,” identified 4 essential components of survivorship care. Central to this includes the coordination between specialists and primary care providers. Primary Care Providers (PCPs) often play a critical role in the follow-up care for patients with chronic diseases. Cancer survivorship can now be viewed as a chronic disease however PCPs have little access to training and education in survivorship care. By offering culturally appropriate and trusted care in a setting that is familiar and accessible to their patients, PCPs in the community setting are in a unique position to impact cancer follow-up care for their patients. Thus greater involvement by community PCPs is likely to impact cancer survivorship disparities. We sought to survey PCP attitudes regarding cancer survivorship care delivery. Methods: The Illinois Breast and Cervical Cancer Program (IBCCP) is part of the Center for Disease Control's National Breast and Cervical Cancer Early Detection Program. This program provides access to breast and cervical cancer screening services to underserved women. Illinois has 36 lead agencies. A 10-question survey based on the National Cancer Institute's Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS) was given to IBCCP providers. Providers were surveyed about their attitudes and self-efficacy as well as preferences for breast cancer care delivery. The SPARCCS surveyed over 1000 PCPs on their knowledge and attitudes on breast cancer survivorship care. 83% of SPARCCS PCPs work in either private practice or as part of a large healthcare system. Results: 110 PCPs completed the IBCCP survey. 54% (n=59) were physicians, 28% (n= 31) nurse practitioners, and 17% (n= 19) identified as other. 94.5% (n= 104) of the respondents reported having patients with a breast cancer history. Compared to PCPs in the original SPARCCS survey, 37% IBCCP providers' preferred oncologists take primary responsibility (SPARCCS 25%, p=0.0057) and 13% IBCCP providers' preferred survivorship care be delivered in specialized survivorship clinics led by a clinician other than a physician (SPARCCS 4%, p=0.0002). The other survivorship care model preference differences were not statistically significant. Overall, community-PCPs surveyed preferred follow-up care be delivered through specialized clinics and/or by cancer specialists. Conclusions: Limited information exists regarding the role of community PCPs in breast cancer survivorship follow-up care for the underserved. Most providers in our survey stated they preferred follow-up care be delivered by the cancer specialist or through specialized survivorship clinics. The role to which improving provider knowledge, attitudes, and self-efficacy can impact preferences for care delivery needs to be explored. Citation Format: Zakiya Moton, Danielle Weston, Rebecca McFarland, Tamara Hamlish, Daniel Johnson, Maureen Mencarni, Shannon Lightner, Jean Becker, Funmi Olopade, Susan Hong. Understanding community-based primary care providers' attitudes toward caring for breast cancer survivors. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A51.

Timeliness of Cervical Cancer Diagnosis and Initiation of Treatment in the National Breast and Cervical Cancer Early Detection Program

To examine time intervals from cervical cancer screening to diagnosis and treatment initiation among low-income and uninsured women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) during two consecutive time periods. We analyzed NBCCEDP data for women with abnormal Pap tests (n=100,167), from which 1,417 invasive cervical cancers were diagnosed. We examined two time intervals for this study: diagnostic interval (time from abnormal Pap test to the date of definitive diagnosis) and treatment initiation interval (time from definitive diagnosis to treatment initiation) for two time periods: 1996-2002 and 2003-2009. We compared median time intervals for diagnostic and treatment initiation using the Kruskal-Wallis test. Adjusted proportions (predicted marginals) were calculated using logistic regression to examine diagnosis and treatment within program benchmarks (≤60 days). Median diagnostic intervals decreased overall by 6 days (54 vs. 48 days, p<0.001). This decrease in the median diagnostic interval was noted for all variables examined. The median treatment initiation intervals remained stable over the two time periods. Women screened by the NBCCEDP receive diagnostic follow-up and initiate treatment within preestablished program guidelines.

Recruitment for the National Breast and Cervical Cancer Early Detection Program

To reduce disparities in breast and cervical cancer in the U.S., it is essential that programs such as CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) use evidence-based strategies. Recommendations for interventions to increase breast and cervical cancer screening have been disseminated by national public health organizations. To increase screening, cancer control planners would benefit from use of evidence-based strategies for recruitment of participants in their communities. The purpose of the study was to inventory recruitment activities for cancer screening within NBCCEDP programs and assess if activities used to increase cancer screening are evidence-based. Interviews were conducted with 61 recruitment coordinators in 2008 to elicit their recruitment activities, use of evidence-based resources, and barriers to using evidence-based interventions (EBIs). Study data were analyzed in 2009. Of the 340 activities reported, many were categorized as educational materials, one-on-one education, mass media, group education, and special events. Two thirds of inventoried activities matched an EBI. Coordinators reported that colleagues and the CDC are their primary sources of information about EBIs and few coordinators had used evidence-based resources. Lack of money or funding, questionable applicability to priority populations, limited staffing or staff time, and insufficient evidence-based research were the most important barriers to EBI use. Although the majority of NBCCEDP recruitment activities were evidence-based, one third were not. Additional training and technical assistance are recommended to help public health agencies adopt the use of these strategies.

Cancer Screening Practices Among Physicians in the National Breast and Cervical Cancer Early Detection Program

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides low-income, uninsured women with screening and diagnostic services for breast and cervical cancer. Our study was conducted to describe the demographic and practice characteristics of participating and nonparticipating physicians, as well as their beliefs, adoption of new screening technologies, and recommendations for breast and cervical cancer screening. From a 2006-2007 nationally representative survey, we identified 1,111 practicing primary care physicians who provide breast and cervical cancer screenings and assessed their recommendations using clinical vignettes related to screening initiation, frequency, and cessation. Responses of physicians participating in the NBCCEDP were compared with those from nonparticipating physicians. Of the physicians surveyed, 15% reported participation in the NBCCEDP, 65% were not participants, and 20% were not sure or did not respond to this question. Program physicians were significantly more likely to practice in multispecialty settings, in a rural location, and in a hospital or clinic setting and had more patients who were female and insured by Medicaid or uninsured compared with nonprogram physicians. Beliefs about the effectiveness of screening tools or procedures in reducing breast or cervical cancer mortality were similar by program participation. Adoption of new technologies, including digital mammography and human papillomavirus (HPV) testing, and making guideline-consistent recommendations for screening initiation, frequency, and cessation did not differ significantly by program participation. Although there may be differences in physician characteristics and practice settings, the beliefs and screening practices for both breast and cervical cancer are similar between program and nonprogram providers.

WISEWOMAN: Addressing the Needs of Women at High Risk for Cardiovascular Disease

In the United States, the cardiovascular health of women is affected by the disparate impact of cardiovascular diseases (CVDs) on many minority ethnic and racial groups. Women with low income also endure a disproportionate impact of the burden of CVD. The Centers for Disease Control and Prevention's (CDC's) Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Program was authorized by Congress in 1993 to extend the preventive health services offered to participants of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). These are low-income, uninsured, and underinsured women. The intent was to expand services of an existing federal program to address cardiovascular health concerns in this vulnerable, high-risk population. CDC funds 19 state health departments and 2 tribal organizations (both in Alaska) to implement WISEWOMAN. In the first 2 years of the current 5-year funding cycle, which began in June 2008, the WISEWOMAN grantees succeeded in providing almost 78,000 screenings, of which 46% were to women of minority racial and ethnic groups. The individual successes are important, and the WISEWOMAN Program also has achieved success in the broader arenas of healthcare and the communities in which WISEWOMAN is implemented. WISEWOMAN impacts clinical systems of care, provider education, physician extenders, and the broader community and will continue to play an important role in connecting low-income, uninsured, and underinsured women with clinical systems of care and other community resources that will result in the prevention, treatment, and management of their CVD risk.

Reversals of Association for Pap, Colorectal, and Prostate Cancer Testing among Hispanic and Non-Hispanic Black Women and Men

Several studies have found that Hispanics and non-Hispanic blacks have statistically significantly higher adjusted OR for cancer screening tests compared to non-Hispanic whites, even though their crude percentages were lower than, or about equal to, those for the non-Hispanic whites. Most documentation is for mammography. This article investigates the prevalence of such unadjusted-to-adjusted "reversed associations" (RA) for Pap, colorectal, and prostate testing. We also investigate large percent changes (LPC) to the unadjusted ORs. Data were from the 2004/2006/2008 Behavioral Risk Factor Surveillance System (BRFSS) and the 2000/2003/2005/2008 National Health Interview Survey (NHIS). Analyses used a consistent set of covariates. RAs were more common for non-Hispanic blacks than Hispanics, but Hispanics had a greater number of LPCs. RAs and LPCs occurred more often for Pap testing than colorectal and prostate testing. However, results from the BRFSS and NHIS were often not consistent. Attention should be given to the National Breast and Cervical Cancer Early Detection Program, as well as public programs addressing other cancers, as possible contributors to RAs and LPCs. Hispanics may show more RAs in analyses of future data. Discrepancies between the BRFSS and the NHIS also must be recognized and explained. This research highlights the need for vigilance regarding the results of analyses to identify race/ethnicity as a correlate of cancer screening. Results also direct attention to aspects of the results of multivariable analysis other than ORs and confidence intervals.

Estimated Effects of the National Breast and Cervical Cancer Early Detection Program on Breast Cancer Mortality

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast cancer screening to medically underserved, low-income women aged 40-64 years. No study has evaluated NBCCEDP's effect on breast cancer mortality. This study estimates life-years saved by NBCCEDP breast cancer screening compared with screening in the absence of NBCCEDP and with no screening. A breast cancer simulation model based on existing Cancer Intervention and Surveillance Modeling Network models was constructed. The screening module from these models was modified to reflect screening frequency for NBCCEDP participants. Screening data for uninsured women represented what would have happened without the program. Separate simulations were performed for women who received NBCCEDP (Program) screening, women who potentially received screening without the program (No Program), and women who received no screening (No Screening). The impact of NBCCEDP was estimated as the difference in life-years between the Program and No Program, and the Program and No Screening scenarios. The analysis was performed in 2008-2009. Among 1.8 million women who were screened between 1991 and 2006, the Program saved 100,800 life-years compared with No Program and 369,000 life-years compared with No Screening. Per woman screened, the Program saved 0.056 life-years (95% CI=0.031, 0.081) compared with No Program and 0.206 life-years (95% CI=0.177, 0.234) compared with No Screening. Per woman with invasive breast cancer and screen-detected invasive cancer, the Program saved 0.41 and 0.71 life-years, respectively, compared with No Program. These estimates suggest that NBCCEDP breast cancer screening has reduced mortality among medically uninsured and underinsured low-income women.

Estimated Effects of the National Breast and Cervical Cancer Early Detection Program on Breast Cancer Mortality

Estimated Effects of the National Breast and Cervical Cancer Early Detection Program on Breast Cancer Mortality

Stage of breast cancer at diagnosis among low‐income women with access to mammography

This study assessed the relationship between area-level poverty and stage of breast cancer at diagnosis among low-income women when screening mammography was available at no cost. The authors identified women diagnosed with breast cancer from 1999 to 2005 through the Massachusetts Cancer Registry, and compared the odds of advanced stage disease for women with low incomes (n=546) for whom screening mammography and diagnostic services were available at no cost through the Massachusetts Breast and Cervical Cancer Early Detection Program, relative to a nonparticipating comparison group (n=1287) residing in the same neighborhoods with similar distribution of age, race, and ethnicity as Massachusetts Breast and Cervical Cancer Early Detection Program participants. Among Massachusetts Breast and Cervical Cancer Early Detection Program participants, the odds of advanced stage disease were estimated by mammography use. Although screening mammography was available at no cost, only 36% of program participants diagnosed with breast cancer used screening mammography. Stage of breast cancer at diagnosis was not associated with area-level poverty among Massachusetts Breast and Cervical Cancer Early Detection Program participants. For the comparison group, advanced stage disease was more likely for residents in high-poverty areas, relative to low-poverty areas (49% vs 37%, P<.01). The adjusted odds of advanced stage disease at diagnosis was greater for women aged 41 to 49 years, compared with those aged 50 to 64 years (P=.01). Programs that ensure breast cancer screening and diagnostic services are available at no cost to low-income women can mitigate the adverse effect of area-level poverty on stage of breast cancer. However, such programs require effective strategies to encourage use of screening mammography to promote diagnosis at an earlier stage.

Mexican Cervical Cancer Screening Study II: acceptability of human papillomavirus self-sampler.

Cervical cancer is the second most common cancer in women worldwide. In countries like Mexico, cervical cancer early detection programs have had a minimal impact on the incidence and death rates from cervical cancer. Self-sampling for the presence of high-risk human papillomavirus is potentially a more effective screening tool to reach women who have limited access to community healthcare resources. The objective of this phase 2 trial was to establish if the fourth generation Preventive Oncology International/National Institutes of Health self-sampler device is well accepted by women of all socioeconomic levels in Michoacán, Mexico. This is a prospective phase 2 trial. The patients used the self-sampler, and then the acceptability questionnaire (14 multiple choice questions) was completed with the assistance of nursing staff. Two thousand five hundred seventeen patients completed the questionnaire. The mean age of our patient population was 39 years. Eighty-six percent of patients reported being comfortable when using the self-test, and 76% preferred to do the test at the clinic. Ninety-one percent of patients said that if their only choice was to perform the test at home they would perform it rather than not perform the test. The major barriers for the use of self-sampler identified by the women in the study were fear (75%), woman might not perform the test because she does not feel ill (70%), women felt that husbands may stand in women's way of performing the test (66%), and lack of time (61%). Results differed by location but not by history of Papanicolaou test. Most patients reported being comfortable when using the Preventive Oncology International/National Institutes of Health fourth generation self-test. Most influential barriers identified by the acceptability questionnaire were fear, lack of signs or symptoms of illness, husbands' influence, cost, lack of time, being unable to read, and lack of trust in the medical community.

Get screened: a pragmatic randomized controlled trial to increase mammography and colorectal cancer screening in a large, safety net practice

BackgroundMost randomized controlled trials of interventions designed to promote cancer screening, particularly those targeting poor and minority patients, enroll selected patients. Relatively little is known about the benefits of these interventions among unselected patients.Methods/Design"Get Screened" is an American Cancer Society-sponsored randomized controlled trial designed to promote mammography and colorectal cancer screening in a primary care practice serving low-income patients. Eligible patients who are past due for mammography or colorectal cancer screening are entered into a tracking registry and randomly assigned to early or delayed intervention. This 6-month intervention is multimodal, involving patient prompts, clinician prompts, and outreach. At the time of the patient visit, eligible patients receive a low-literacy patient education tool. At the same time, clinicians receive a prompt to remind them to order the test and, when appropriate, a tool designed to simplify colorectal cancer screening decision-making. Patient outreach consists of personalized letters, automated telephone reminders, assistance with scheduling, and linkage of uninsured patients to the local National Breast and Cervical Cancer Early Detection program. Interventions are repeated for patients who fail to respond to early interventions. We will compare rates of screening between randomized groups, as well as planned secondary analyses of minority patients and uninsured patients. Data from the pilot phase show that this multimodal intervention triples rates of cancer screening (adjusted odds ratio 3.63; 95% CI 2.35 - 5.61).DiscussionThis study protocol is designed to assess a multimodal approach to promotion of breast and colorectal cancer screening among underserved patients. We hypothesize that a multimodal approach will significantly improve cancer screening rates.The trial was registered at Clinical Trials.gov NCT00818857

The impact of a national program to provide free mammograms to low‐income, uninsured women on breast cancer mortality rates

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides free or low-cost breast and cervical cancer screening to low-income, uninsured or underinsured women. The authors analyzed the impact of the NBCCEDP on breast cancer mortality rates. The data consisted of observations for each state and year for the period from 1990 through 2004. The outcome variable was the breast cancer mortality rate for women ages 40 to 64 years. Independent variables included the proportion of women ages 40 to 64 years screened under NBCCEDP. The impact of screening intensity was estimated using least-squares regression with state and year fixed effects. In 2004, 1.2% of women ages 40 to 64 years were screened under NBCCEDP. The NBCCEDP screening rate was related significantly and negatively to breast cancer mortality in the same year. Results indicate that, for every 1000 women screened, there were 0.6 fewer deaths because of breast cancer among women ages 40 to 64 years. Changes in screening rates were unrelated to breast cancer mortality≥2 years in the future. In the current study, there was some evidence suggesting that the NBCCEDP led to a reduction in breast cancer mortality rates. However, the failure to detect an impact of screening on mortality rates in subsequent years suggests that caution is needed in interpreting these results as strong evidence in favor of the effectiveness of the NBCCEDP in reducing breast cancer mortality.

Meeting the cervical cancer screening needs of underserved women: The National Breast and Cervical Cancer Early Detection Program, 2004–2006

To examine the extent to which the only national organized screening program in the US, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), has helped to meet the cervical cancer screening needs of underserved women. Low-income, uninsured women 18-64 years of age are eligible for free cervical cancer screening services through NBCCEDP. We used data from the US Census Bureau to estimate the number of eligible women, based on insurance status and income. The estimates were adjusted for hysterectomy status using the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. We used administrative data from NBCCEDP to obtain the number of women receiving NBCCEDP-funded Papanicolaou (Pap) tests. We then calculated the percentage of NBCCEDP-eligible women who received free cervical cancer screening through NBCCEDP. We also used the NHIS to calculate the percentage of NBCCEDP-eligible women screened nationally and the percentage unscreened. In 2004-2006, nearly 9% (775,312 of 8.9 million) of NBCCEDP-eligible women, received NBCCEDP-funded Pap test. Rates varied substantially by age groups, race, and ethnicity. NBCCEDP-eligible women 40-64 years of age had a higher screening rate (22.6%) than eligible women 18-39 years of age (2.3%). Non-Hispanic women had a higher screening rate (9.3%) than Hispanic women (7.3%). Among non-Hispanics, the screening rate was highest among American Indian and Alaska Native (AIAN) women (36.1%) and lowest among women of different race combinations (4.6%), The percentage of eligible women screened in each state ranged from 2.0 to 38.4%. Although NBCCEDP provided cervical cancer screening services to 775,312 low-income, uninsured women, this number represented a small percentage of those eligible. In 2005, more than 34% of NBCCEDP-eligible women (3.1 million women) did not receive recommended Pap tests from either NBCCEDP or other sources.

Community-Driven Approaches for Reducing Health Disparities in Cancer

SINCE 1990, OVERALL CANCER MORTALITY RATES HAVE declined at a rate of approximately 1% per year, with mortality from breast, colorectal, prostate, and lung cancer declining at about 2% per year. These declines have largely been attributed to favorable trends in some risk factors for cancer, increased use of methods to detect cancer earlier, and more effective means to treat the disease. However, cancer-related mortality rates for African Americans continue to be considerably higher than those for non-Hispanic whites in the United States. Although the mortality gap has decreased somewhat, mostly secondary to tobacco-related cancers and reflecting declining tobacco use by African Americans, the mortality gap has not diminished for cancers with rates affected by early detection or effective treatment. Differences in mortality and prevalence of risk factors are related to social class as defined by level of educational achievement. The decline in cancer mortality is greater for college graduates than for high school graduates, and no decline has occurred among those with less than a high school education. Other causes of cancer health disparities involve limited access to care, including prevention and early detection; unequal treatment when cancer is diagnosed; differences in behaviors that increase cancer risk, such as tobacco use, unhealthful diet, and lack of physical activity; differences in behaviors that decrease cancer risk, such as screening for breast, colorectal, and cervical cancer; and diverse cultural beliefs that influence the care-seeking behavior of patients. Advances in medical knowledge and technology also widen the disparity gap because technological innovations are differentially delivered to various groups and populations. Elimination of the screening gap between African American and white patients for breast, cervical, and colorectal cancer is perhaps the easiest way to influence cancer health disparity. Screening is at most an annual event, and at least for breast cancer and cervical cancer, most of the population has access to screening either through insurance, Medicare, or the Breast and Cervical Cancer Early Detection Program (colorectal screening is being added to the latter program incrementally). One approach to increase screening involves engaging low-income, low-education, mostly minority communities in a community-based participatory process that leads to “community efficacy,” a willingness on the part of community residents to help for the common good. This approach resulted in elimination of disparities in Medicare mammography screening rates between African American and white women in targeted counties in Alabama and Mississippi. Screening is in many ways the low-hanging fruit that allows programs to demonstrate success, and it also is an effective way to engage the community because the task is clear, achievable, and measurable in the short term. Other interventions, such as those aimed at tobacco cessation, healthful eating, and increased physical activity, require efforts that go beyond the individual behavioral change to a socioecological approach that engages all facets of the community—the individual, family, neighborhood, organizations, and policy makers. Because it is more complex, this approach is more difficult to implement. The first step is to engage the community. However, academic institutions, nongovernmental organizations, cancer volunteer organizations, and public health departments too often attempt health promotion from afar, working through the media, creating culturally relevant literature, and meeting with community members in conference rooms, without establishing an onsite presence in the community. Cancer control from a distance does not work in the geographic areas and demographic populations most at risk for disparities. Organizations and agencies must leave the comfort zone of the home base and begin engaging community members in the community, building mutual trust, offering guidance, sharing expertise, and empowering community volunteers to address the problem locally. Access to care will remain a major impediment to closing the disparity gap in cancer as long as substantial

Timely Care After an Abnormal Mammogram Among Low-Income Women in a Public Breast Cancer Screening Program

Since 1990, the National Breast and Cervical Cancer Early Detection Program (BCCEDP) has funded breast cancer screening and diagnostic services for low-income, underinsured women. Case management was implemented in 2001 to address barriers to follow-up after an abnormal mammogram, and free treatment was introduced in 2004. However, the effect of these policies on timeliness of care has not been empirically evaluated. Among 2252 BCCEDP participants in Massachusetts during 1998 through 2007, we conducted a time-to-event analysis with prepolicy-postpolicy comparisons to examine associations of case management and free treatment with diagnostic and treatment delays (>60 days and >90 days, respectively) after an abnormal mammogram. The proportion of women experiencing a diagnostic delay decreased from 33% to 23% after the introduction of case management (P < .001), with a significant reduction in the adjusted risk of diagnostic delay (relative risk [RR], 0.65; 95% confidence interval [CI], 0.53-0.79) that did not differ by race and ethnicity. However, case management was not associated with changes in treatment delay (RR, 0.93; 95% CI, 0.80-1.10). Free treatment was not associated with changes in the adjusted risk of diagnostic delay (RR, 0.61; 95% CI, 0.33-1.14) or treatment delay (RR, 0.77; 95% CI, 0.43-1.38) beyond improvements associated with case management. Case management to assist women in overcoming logistic and psychosocial barriers to care may improve time to diagnosis among low-income women who receive free breast cancer screening and diagnostic services. Programs that provide services to coordinate care, in addition to free screening and diagnostic tests, may improve population health.

Cancers of the breast, uterus, ovary and cervix among Alaska Native women, 1974–2003

Objectives. Alaska Native (AN) women have exhibited some of the highest incidence rates of cancer overall, and different patterns of site-specific incidence compared to other U.S. populations. This study compares incidence rates between AN and U.S. white women (USW) for cancers of the breast, uterus, ovary and cervix, and examines effects of time period and birth cohort as determinants of incidence trends among AN women.Study design. Observational, population-based study.Methods. Cancer incidence data from the Alaska Native Tumor Registry and SEERStat, 1974– 2003. Age-adjusted World Standard Population rates were calculated for a current 5-year period and over time (30 years), and compared to other populations using rate ratios with 95% confidence intervals. Log-linear regression models used to assess impact on trend of age, time period and birth cohort.Results. Compared to U.S. white women, current cancer rates among AN women are not significantly different for cancer of the breast and cervix, and significantly lower for cancers of the ovary and uterus. Trends over time over a 30-year time period also differ for these cancer sites. There were significant increases in breast and uterine cancer, and in contrast, a marked decline in cervical cancer. There was no significant change for cancer of the ovary. Changes appear to be due largely to period, not birth cohort effects.Conclusions. Increases in breast cancer may be due to a combination of modifiable behaviours; increased BMI and a shift to a non-traditional diet. Increases in uterine cancer could be associated with increased BMI and diabetes. Cervical cancer rates have declined to USW levels. The marked decline is likely due to enhanced screening and control efforts within the Alaska Native Tribal Health System (formerly Alaska Area USPHS, Indian Health Service utilizing resources available from the Centers for Disease Control tribal and state Breast and Cervical Cancer Early Detection Programs).

Evaluation of colposcopy vs cytology as secondary test to triage women found positive on visual inspection test

Colposcopic evaluation and guided biopsy is an important diagnostic step and standard of management for abnormal cytology smears in developed countries. The present study evaluates the performance of colposcopy vs conventional cytology in estimating the presence and grade of cervical disease against the reference standard of histopathology as a secondary test modality to triage women found positive on primary screening by visual inspection with 5% acetic acid (VIA). Colposcopy and directed biopsy were performed after primary screening for cervical cancer in an urban hospital cancer screening clinic between January 2000 and June 2005, in Mumbai, India. Healthy women (8863) in the age group of 35-65 years participated in the cervical cancer early detection program in the hospital and community cancer screening clinics in Mumbai. Women found positive on the primary screening test by VIA underwent diagnostic evaluation by Pap smear cytology and colposcopy evaluation with directed biopsies. Accuracy parameters and their 95% confidence intervals were calculated using 2 X 2 tables and standard formulae. The test range of sensitivity of colposcopy for the detection of histologically confirmed cervical intraepithelial neoplasia grade 1+ (CIN1+) or CIN2+ was 58.0-74.7% and that of specificity was 57.5-92.9%. The sensitivity and specificity of cytology to detect CIN2+ was 57.4% and 99.4%, respectively. Colposcopy is a good sensitive test for the detection of CIN and can be considered as a secondary testing tool to triage women found positive on VIA.

Timeliness of Breast Cancer Diagnosis and Initiation of Treatment in the National Breast and Cervical Cancer Early Detection Program, 1996–2005

To determine the effects of program policy changes, we examined service delivery benchmarks for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). We analyzed NBCCEDP data for women with abnormal mammogram or clinical breast examination (n=382 416) from which 23 701 cancers were diagnosed. We examined time to diagnosis and treatment for 2 time periods: 1996 to 2000 and 2001 to 2005. We compared median time for diagnostic, treatment initiation, and total intervals with the Kruskal-Wallis test. We calculated adjusted proportions (predicted marginals) with logistic regression to examine diagnosis and treatment within program benchmarks (<or=60 days) and time from screening to treatment (<or=120 days). Median diagnostic intervals decreased by 2 days (25 vs 23; P<.001). Median treatment initiation intervals increased by 2 days (12 vs 14; P<.001). Total intervals decreased by 3 days (43 vs 40; P<.001). Women meeting the 60-day benchmark for diagnosis improved the most for women with normal mammograms and abnormal clinical breast examinations from 77% to 82%. Women screened by the NBCCEDP received diagnostic follow-up and initiated treatment within preestablished program guidelines.

Repeat Pap Testing and Colposcopic Biopsies in the Underserved

To quantify repeat Pap testing and colposcopic biopsies among women in the National Breast and Cervical Cancer Early Detection Program between 2003 and 2006 (N=955,494). Rates of repeat Pap testing (two tests within 9 months) and colposcopic biopsies were estimated along with 95% confidence intervals (CIs). Odds ratios and 95% CIs for receipt of colposcopic biopsy compared with repeat Pap testing were estimated from multivariable logistic regression models. Finally, we estimated positive predictive values and 95% CIs of cervical intraepithelial neoplasia (CIN) 2 or worse (CIN 3, carcinoma in situ, invasive cancer) for two strategies: 1) repeat Pap testing followed by colposcopic biopsy and 2) colposcopic biopsy alone. There were 39,583 and 53,880 women with repeat Pap testing and colposcopic biopsy, respectively, from 2003 to 2006. Overall, age-standardized rates of repeat Pap testing and colposcopic biopsies were 37.2 per 1,000 women and 39.3 per 1,000 women, respectively. Younger women, Hispanic women, and African-American women were more likely to receive colposcopic biopsies compared with repeat Pap tests. Positive predictive values of colposcopic biopsy were highest after abnormal Pap test results (27% after a result of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion, 70% after a result of high-grade squamous intraepithelial lesion/squamous cell cancer). Colposcopic biopsies are common among young women after being screened for cervical cancer and, except among those with the most severe Pap test results, may not be efficient in detecting serious disease. These results conflict with current recommendations for less aggressive follow-up for most young women. II.

Developing and Testing a Cost-Assessment Tool for Cancer Screening Programs

Cancer screening programs require substantial resources, and economic assessments have become increasingly important in identifying the most cost-effective means of conducting these programs. Such economic assessments require detailed program cost data, but there is no standardized instrument for obtaining these data. This study was designed to develop a standardized instrument to collect cost data from cancer screening programs. A cost-assessment tool (CAT) was developed to collect annual cost data based on the findings from case studies at four sites funded by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The data elements collected in the CAT were specifically tailored to collect cost and resource-use information from cancer screening programs. The tool was pilot-tested at nine NBCCEDP sites, and activity-based costs were generated by assigning all cost and resource-use data to specific program activities. Data were collected from November 2004 to February 2005, and the analysis was performed from March to July 2005. Overall, a majority of the sites (eight of nine) met the acceptable threshold of <5% of total cost remaining unallocated. On average, the largest cost components of the nine programs were screening and diagnostic services (44.4%); recruitment (11.4%); database management (10.9%); and patient support/case management (9.3%). Findings from the CAT pilot-testing showed that NBCCEDP cancer screening programs were able to report detailed activity-based cost data. The comparability of these cost data across programs should facilitate pooled analyses that, in turn, may lead to a better understanding of the impact and cost effectiveness of the screening program.