Overdue Women Research Articles

Recovery strategies following COVID-19 disruption to cervical cancer screening and their impact on excess diagnoses

BackgroundThe COVID-19 pandemic has disrupted cervical cancer screening services. Assuming increases to screening capacity are unrealistic, we propose two recovery strategies: one extends the screening interval by 6 months for all and the other extends the interval by 36/60 months, but only for women who have already missed being screened.MethodsUsing routine statistics from England we estimate the number of women affected by delays to screening. We used published research to estimate the proportion of screening age women with high-grade cervical intraepithelial neoplasia and progression rates to cancer. Under two recovery scenarios, we estimate the impact of COVID-19 on cervical cancer over one screening cycle (3 years at ages 25–49 and 5 years at ages 50–64 years). The duration of disruption in both scenarios is 6 months. In the first scenario, 10.7 million women have their screening interval extended by 6 months. In the second, 1.5 million women (those due to be screened during the disruption) miss one screening cycle, but most women have no delay.ResultsBoth scenarios result in similar numbers of excess cervical cancers: 630 vs. 632 (both 4.3 per 100,000 women in the population). However, the scenario in which some women miss one screening cycle creates inequalities—they would have much higher rates of excess cancer: 41.5 per 100,000 delayed for screened women compared to those with a 6-month delay (5.9 per 100,000).ConclusionTo ensure equity for those affected by COVID-19 related screening delays additional screening capacity will need to be paired with prioritising the screening of overdue women.

381 Association between maternal birthplace and non catching-up among pregnant women overdue for cervical cancer screening

In France, the HAS recommends performing a pap test every 3 years for all sexually active women aged from 25 to 65 years old. Currently, screening access is inequitable, and pregnancy may be an ideal moment to catch-up with women who are overdue for cervical cancer screening. As in general population, several social factors associated with place of birth are also associated with less access to screening. Our objective was to study the association between maternal place of birth and non catching-up during pregnancy among the sample of women from the National Perinatal Survey (ENP 2016). The National Perinatal Survey 2016 has included 13,147 women who delivered after 22 weeks in mainland France. The factors associated with non-catching up (defined by the lack of pap test during pregnancy for overdue women) has been modelled by log-binomial regression. Multivariate analysis was adjusted on level of education, health insurance and the moment of initiation of prenatal care. Among all women included in the National Perinatal Survey and concerned by screening, 43% were overdue. Among them, 45% of women were not caught-up during pregnancy. After adjustment on covariates, women born in Northern Africa had higher risk of being not caught-up than women born in France (adjusted RR 1.14 95% CI [1.03,1.26]). A low level of education and the late initiation of prenatal care were also associated with non-catching up. 45% of overdue women are not caught-up during pregnancy. Being born in Northern Africa increases the risk of being not caught-up.

Improving the promise of embedded pragmatic trials: Surmountable barriers encountered in an evaluation of home-based HPV self-sampling to increase cervical cancer screening in overdue women

Despite increased attention on how to conduct pragmatic trials and their importance, there remains an under-appreciation for the reality of what they take to design, compete and secure funding and execute. Many barriers are surmountable through increased exposure to experiences from completed trials. This report summarizes our experience in designing, securing funding and implementing the Home-Based Options to Make screening Easier (HOME) pragmatic trial, which was designed to evaluate home human papillomavirus testing for cervical cancer screening in underscreened women (women who had not received a cervical cancer screening test in ≥3.5 years). This report highlights factors at the level of research teams, organizations seeking to conduct embedded research, reviewers and funding agencies that challenge pragmatic trial design and execution. There is an urgent need to train on peer-reviewers how to evaluate embedded trial grant proposals, for agencies to pursue more rapid and innovative funding strategies, and to consider strategies for reviewers and funders to evaluate stakeholder buy-in (beyond letters of support). These factors together are needed to realize the promise of pragmatic trials to more efficiently and effectively generate critical data that inform changes in health care delivery and benefit patients.

Signed family physician reminder letters to women overdue for screening mammography: A randomized clinical trial.

To determine whether signed family physician reminder letters to women overdue for screening mammography prompts rescreening. A randomized double-blind trial conducted in 2013 among women aged 51-73 and overdue for screening by 6-24 months. The study was carried out by the publicly funded British Columbia Cancer Agency Screening Mammography Program, which routinely sends standard reminder postcards to women who are due for mammography. Participating family physicians signed letters for the overdue women in their practices. The overdue women were mailed either the signed reminder letter and the standard reminder postcard, or the standard reminder postcard alone. The primary endpoint was the proportion of overdue women that attended a screening mammogram appointment within six months of mailing the study letters. The analysis was by intention to treat. In total, 822 family physicians participated and 5638 women were randomized. Mammography attendance by six months after mailing the reminders was 34.4% (947/2749) for women in the signed family physician letter arm, compared with 24.0% (660/2749) for women in the control arm (p < 0.0001). Adjusting for age, number of previous screening mammograms, and months overdue, women in the signed letter arm were significantly more likely to return for screening than women in the control arm (RR 1.41; 95% confidence interval: 1.30-1.54). A signed family physician reminder letter improved mammography attendance for women who were overdue for screening mammography.

Breast cancer screening outreach effectiveness: Mammogram-specific reminders vs. comprehensive preventive services birthday letters.

We compared the effectiveness of two outreach strategies on timely mammography adherence: a mammogram-specific reminder letter (sent just before a woman was due) to a birthday letter (addresses multiple preventive services and not timed around due dates). We evaluated screening mammography adherence following 79,848 mammogram-specific and 151,626 birthday letters mailed between 2002 and 2012 to women aged 40-74years enrolled in Kaiser Permanente Washington. Screening mammogram adherence was specifically tied to due date and was evaluated separately by age group and up-to-date or overdue status at the time of mailing. We used generalized estimating equations to account for correlation between repeated observations, to model the odds of screening mammography adherence by letter type. Among women up-to-date, adherence following birthday letters was 22-76% lower compared to the mammogram-specific reminders, with the greatest decreases in adherence in women aged 70-74. Birthday letters were more effective at activating screening uptake among some subgroups of overdue women aged 50-69 and most overdue women aged 70-74, but universally low adherence rates were observed in overdue women. Increasing number of recommended services for women aged 50-74 who were up-to-date resulted in 12-17% lower mammography adherence, but had no effect in women aged 40-49 or in overdue women. Birthday letters are less effective than mammogram-specific reminder letters at prompting women to undergo timely breast cancer screening, particularly among women up-to-date with screening. Birthday letters may be effective at increasing overall preventive care; however, supplemental outreach may be needed around the due date to increase timely preventive services receipt.

Comparative effectiveness of two outreach strategies for cervical cancer screening

ObjectiveTest-specific reminder letters can improve cancer screening adherence. Little is known about the effectiveness of a reminder system that targets the whole person by including multiple screening recommendations per letter. MethodsWe compared the effectiveness of a Pap-specific reminder letter sent 27months after a woman's last Pap, to a reminder letter that included up to seven preventive service recommendations sent before a woman's birthday (“birthday letter”) on Pap smear adherence from a natural experiment occurring in routine clinical care. Participants included 82,016 women from Washington State who received 72,615 Pap-specific letters between 2003 and 2007 and 100,218 birthday letters between 2009 and 2012. We defined adherence as having a Pap test within a six month window around the Pap test due date. Using logistic regression, we calculated adjusted odds ratios (OR) for adherence with 95% confidence intervals (CI) following the birthday letter with 1–2 recommendations, 3–5 recommendations, and 6–7 recommendations compared to the Pap-specific letter. All analyses were stratified by whether a woman was up-to-date or overdue for screening at the time she received a letter. ResultsAdjusted ORs showed reduced adherence following the birthday letter compared with the Pap-specific letter for up-to-date women whether the letter had 1–2 recommendations (OR=0.37, 95%CI=0.36–0.39), 3–5 recommendations (OR=0.44, 95%CI=0.42–0.45), or 6–7 recommendations (OR=0.36, 95%CI=0.32–0.40). We noted no difference in Pap-test adherence between letter types for overdue women. ConclusionsIn conclusion, for women regularly adherent to screening, an annual birthday letter containing reminders for multiple preventive services was less effective at promoting cervical cancer screening compared with a Pap-specific letter.

Improving screening mammography return rates in overdue women: A randomized study of signed reminder letters from family physicians.

1 Background: For asymptomatic women aged 50 to 74 with an average risk for developing breast cancer, screening mammography (SM) is recommended every 2 years in British Columbia (BC). The Screening Mammography Program of BC (SMP) uses a schedule of multiple postcard reminders, which achieves an on-time (within 30 months) participation rate of 54% among those aged 50 to 69. The purpose of this study was to determine whether the SM return rate of overdue women could be improved by a reminder letter signed by their family physicians. Methods: Eligible women met the following criteria: prior normal SM, age 52 to 74, overdue by 30 to 48 months from their last SM and had agreed to being contacted for research by the SMP. All family physicians in BC were invited to participate. Consenting physicians signed the study letters, which encouraged SM, for all of the overdue women in their practice. Women were randomized to receive a postcard reminder or a postcard reminder and the signed family physician reminder letter. Six months after the mailing, the SMP database was queried to determine the SM return rate. Results: In BC, 822 physicians participated in the study and 5,385 women with signed letters were randomized. SMP sent a postcard to 2,689 women and a postcard and letter to 2,696 women. The age, number of prior SMs and time overdue were not statistically different between the arms. Within 6 months, 600 women (22.3%) in the postcard arm returned, while 894 women (33.2%) in the postcard and letter arm returned (odds ratio 1.7, p &lt; 0.0001). The maximum difference between the SM return rates was observed at 4 months. On multivariable analysis, women who had &gt;1 previous SM were more likely to return compared to those who only had 1 previous SM (odds ratio 2.2, p &lt; 0.0001). Women who were 30 to 36 months overdue were more likely to return compared to those who were 42 to 48 months overdue (odds ratio 2.4, p &lt; 0.0001). Conclusions: A signed family physician reminder letter is a simple and effective intervention to improve screening mammography return rates in overdue women.

Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial

Health Plans are uniquely positioned to deliver outreach to members. We explored whether telephone outreach, delivered by Medicaid managed care organization (MMCO) staff, could increase colorectal cancer (CRC) screening among publicly insured urban women, potentially reducing disparities. We conducted an 18-month randomized clinical trial in 3 MMCOs in New York City in 2008-2010, randomizing 2,240 MMCO-insured women, aged 50 to 63 years, who received care at a participating practice and were overdue for CRC screening. MMCO outreach staff provided cancer screening telephone support, educating patients and helping overcome barriers. The primary outcome was the number of women screened for CRC during the 18-month intervention, assessed using claims. MMCO staff reached 60% of women in the intervention arm by telephone. Although significantly more women in the intervention (36.7%) than in the usual care (30.6%) arm received CRC screening (odds ratio [OR] = 1.32; 95% CI, 1.08-1.62), increases varied from 1.1% to 13.7% across the participating MMCOs, and the overall increase was driven by increases at 1 MMCO. In an as-treated comparison, 41.8% of women in the intervention arm who were reached by telephone received CRC screening compared with 26.8% of women in the usual care arm who were not contacted during the study (OR = 1.84; 95% CI, 1.38, 2.44); 7 women needed to be reached by telephone for 1 to become screened. The telephone outreach intervention delivered by MMCO staff increased CRC screening by 6% more than usual care among randomized women, and by 15.1% more than usual care among previously overdue women reached by the intervention. Our research-based intervention was successfully translated to the health plan arena, with variable effects in the participating MMCOs.

Comparative effectiveness of mailed reminder letters on mammography screening compliance

ObjectiveReminder letters are effective at prompting women to schedule mammograms. Less well studied are reminders addressing multiple preventive service recommendations. We compared the effectiveness of a mammogram-specific reminder sent when a woman was due for a mammogram to a reminder letter addressing multiple preventive services and sent on a woman's birthday on mammography receipt. MethodsThe study included 48,583 women 52–74years enrolled in Group Health Cooperative, a health plan in Washington State. From 2005 to 2009, women were mailed 88,605 mammogram-specific or birthday letters. In this one group pretest–posttest study, we modeled the odds of obtaining a screening mammogram after receiving a letter by reminder type using logistic regression, controlling for demographic and healthcare use characteristics and stratifying by whether women were overdue or up-to-date with mammography at the mailing. ResultsAmong women up-to-date with screening, birthday letters were negatively associated with mammography receipt compared to mammogram-specific letters (birthday letters with 1–2 recommendations: OR=0.73; 95% CI:0.68–0.79; 3 recommendations: OR=0.74; 95% CI:0.69–0.78; 4–8 recommendations: OR=0.62 95% CI:0.55–0.68) after. Among overdue women, birthday letters with 4–8 recommendations were negatively associated with mammography receipt. ConclusionsTransitioning from mammogram-specific reminder letters to multiple preventive service birthday letters was associated with decreased mammography receipt.

Barriers to Colorectal Cancer Screening Among Publicly Insured Urban Women: No Knowledge of Tests and No Clinician Recommendation

To assess barriers to colorectal cancer screening among urban publicly insured women and to evaluate how barriers among underscreened urban women have changed between 2001 and 2007-2008. Eligible women were selected using Medicaid Managed Care Organization (MMCO) administrative data. MMCO outreach staff interviewed women by phone between October 2007 and February 2008, and assessed their barriers to colorectal cancer screening. We compared the results of these interviews with interviews conducted in 2001 with women in community health center waiting rooms. Thirty percent of overdue women had never heard of either colonoscopy or sigmoidoscopy, and 55% had never heard of home fecal occult blood testing (FOBT). Among overdue women who had heard of colonoscopy or sigmoidoscopy, 33% reported misconceptions and 28% reported worry as a barrier. No clinician recommendation was the most commonly reported barrier to home FOBT (44%) and was also reported as a barrier to endoscopy by 22% of women. Between 2001 and 2007-2008, the proportion of women reporting that they had not received a clinician's recommendation for endoscopy or home FOBT increased significantly. A lack of information, no clinician recommendation, misconceptions, and worry persist as barriers to colon cancer screening among this underscreened urban population. An increased focus on clinician recommendation and patient education about stool-based as well as endoscopic screening methods could lead to greater screening compliance.

Moving Mammogram-Reluctant Women to Screening: A Pilot Study

Effective interventions are needed for women long overdue for screening mammography. The purpose of this study is to pilot test an intervention for motivating overdue women to receive a mammogram. Subjects aged 45-79 without a mammogram in > or =27 months and enrolled in study practices were identified from claims data. The intervention included a mailed, educational booklet, computer-assisted barrier-specific tailored counseling and motivational interviewing, and facilitated, short-interval mammography scheduling. Of 127 eligible women, 45 (35.4%) agreed to counseling and data collection. Most were > or =3 years overdue. Twenty-six (57.8%) of the counseled women got a mammogram within 12 months. Thirty-one (72.1%) of 43 counseled women moved > or =1 stage closer to screening, based on a modified Precaution Adoption Process Model. It is feasible to reach and counsel women who are long overdue for a mammogram and to advance their stage of adoption. The intervention should be formally evaluated in a prospective trial comparing it to control or to proven interventions.

Staging mammography nonadherent women: A qualitative study

Few studies have related stages of mammography screening nonadherence with the rationale used by overdue women. We used a grounded theory approach to obtain and analyze data from focus groups, telephone interviews, and surveys. Emergent specific themes were compared with emerging decision levels of nonadherence. Each decision level was then compared with the Precaution Adoption Process Model and the Transtheoretical Model. A total of 6 key themes influencing mammogram nonadherence emerged as did 6 decision levels. Variability within themes was associated with specific decision levels. The decision levels were not adequately classified by either stage model. Stage-based educational strategies may benefit by tailoring interventions to these 6 decision levels.