Gaps in the screening process for women diagnosed with cervical cancer in four diverse US health care settings

Abstract

Background: Potential care gaps in the cervical cancer screening process among women diagnosed with cervical cancer in an era with increased human papillomavirus (HPV) testing have not been extensively evaluated.

Methods: Women diagnosed with cervical cancer between ages 21 and 65 at four study sites between 2010 and 2014 were included. Screening histories were ascertained from 0.5 to 4 years prior to cervical cancer diagnosis. We identified potential care gaps in the screening history for each woman and classified them into one of three mutually exclusive types: lack of a screening test, screening test failure, and diagnostic/treatment care gap. Distributions of care gaps were tabulated by stage, histology, and study site. Multivariable nominal logistic regression was used to examine the associations between demographic and cancer characteristics and type of care gap.

Results: Of 499 women evaluated, 46% lacked a screening test in the time window examined, 31% experienced a screening test failure, and 22% experienced a diagnostic/treatment care gap. More than half of the women with advanced cancer and squamous cell carcinoma lacked a screening test compared to 31% and 24% of women with localized cancer and adenocarcinoma, respectively. Women aged 21-29 at diagnosis were more likely to experience screening test failure and diagnostic/treatment care gap, while those aged 50-65 were more likely to lack a screening test, compared to women aged 30-39.

Conclusions: Our findings demonstrate a continuing need to develop interventions targeting unscreened and under-screened women and improve detection and diagnosis of adenocarcinoma in women undergoing cervical cancer screening and diagnostic follow-up.

Keywords: cancer screening; cervical cancer; cervical cancer prevention; cervical cancer screening; health service research.

FIGURE 1

Gaps in the cervical cancer screening process in the presumed chronology of events. Care gaps were hierarchically assigned moving from right to left such that the most recent gap took precedence.

FIGURE 2

Algorithm for assigning failure type in the cervical cancer screening process. * Abnormal screening results defined as atypical squamous cell of undetermined significance (ASC‐US)/HPV+ or more severe result. The 2012 national cervical cancer screening guidelines were used to determine this for those who had Pap test alone, co‐testing or HPV reflex. Determination depends on age as per clinical guidelines. **Abnormal results that should receive follow‐up testing on alternate time intervals and not immediate colposcopy [i.e., NILM / high‐risk (hr) HPV positive or ASC‐US/ hrHPV negative] as per management guidelines for cervical abnormalities.13,14 The latter two abnormal results were considered screening test failures because findings may not have warranted an immediate colposcopy referral. Although some of these results may have been the second or third abnormal findings under the co‐testing or HPV reflex algorithm, they were treated equally as the first co‐testing/HPV reflex result for the purpose of this analysis given uncertainty in follow‐up regimens (i.e., they do not always trigger immediate colposcopy referral depending on if it is the first or second/repeated test). Further, the design of the lookback period in this study precluded determining if a result was from a repeat test. †Six women had missing results for Pap test and were excluded as it was not possible to correctly assign their care gap.