COVID-19 impact on screening test volume through the National Breast and Cervical Cancer early detection program, January-June 2020, in the United States.

Women from racial and ethnic minority groups face a disproportionate burden of cervical and breast cancers in the United States. The Coronavirus Disease 2019 (COVID-19) pandemic might exacerbate these disparities as supply and demand for screening services are reduced. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides cancer screening services to women with low income and inadequate health insurance. We examined COVID-19's impact on NBCCEDP screening services during January-June 2020. We found the total number of NBCCEDP-funded breast and cervical cancer screening tests declined by 87% and 84%, respectively, during April 2020 compared with the previous 5-year averages for that month. The extent of declines varied by geography, race/ethnicity, and rurality. In April 2020, screening test volume declined most severely in Health and Human Services Region 2 - New York (96% for breast, 95% for cervical cancer screening) compared to the previous 5-year averages. The greatest declines were among American Indian/Alaskan Native women for breast cancer screening (98%) and Asian Pacific Islander women for cervical cancer screening (92%). Test volume began to recover in May and, by June 2020, NBCCEDP breast and cervical cancer screening test volume was 39% and 40% below the 5-year average for that month, respectively. However, breast cancer screening remained over 50% below the 5-year average among women in rural areas. NBCCEDP programs reported assisting health care providers resume screening.

Providers' practice, recommendations and beliefs about HPV vaccination and their adherence to guidelines about the use of HPV testing, 2007 to 2010.

Human papillomavirus (HPV) vaccines prevent cervical pre-cancer lesion and can potentially reduce abnormal Papanicolaou (Pap) results among vaccinated females. However, current U.S. cervical screening guidelines recommend no change in screening initiation and frequency based on vaccination status. We examined providers' practices and beliefs about HPV vaccination to evaluate their adherence to guidelines. We used 4-year data (2007-2010) from two nationally representative samples totaling 2119 primary-care providers from the Cervical Cancer Screening Supplement to the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Providers in each survey were stratified to obstetrician/gynecologist (OB/GYNs) and non-OB/GYNs. Descriptive statistics and chi-square tests were performed to assess differences between providers' types in each survey. Approximately 60% of providers believed that HPV vaccination will result in fewer abnormal Pap tests and fewer referrals to colposcopy and over 92% would not change their cervical cancer screening practices for fully vaccinated females. NAMCS OB/GYNs were more likely (p<0.05) than non-OB/GYNs to rarely/never use the number of sexual partners to determine who gets the HPV vaccine (68.4% vs. 59.1%), more likely to recommend the vaccine to females with history of abnormal Pap (79.6% vs. 68.4%) and to females with a history of HPV positive test result (75.3% vs. 62.8%). Consistent with guidelines, most providers would not change cervical cancer screening practices based on patients' vaccination history. However, some providers used inappropriate tests for making vaccination decisions. Improving HPV vaccine knowledge and recommendations for its use is warranted to implement a successful vaccine program.

The effectiveness of targeting never or rarely screened women in a national cervical cancer screening program for underserved women.

PURPOSE: To evaluate the effectiveness of a policy supporting early detection and prevention of cervical cancer among low-income and uninsured women by comparing women who reported never or rarely being screened (last screen >5 years) to those who reported screening in the past ≤5 years. METHODS: We analyzed data from 1,485,251 women who received their first Pap test in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) from July 2002 through June 2012. Of these, 461,893 women (31 %) reported being never or rarely screened and 1,023,358 (69 %) reported being screened in the past 5 years. Demographic (age, race/ethnicity, residence, and region) and clinic (cytologic and histologic results) characteristics were examined for the two groups. RESULTS: Women who were aged ≥50 years, Asian and Pacific Islander, American Indian or Alaska Native, multiracial, living in non-metro areas, or living in the South or a territory were more likely to report being never or rarely screened. The percentage of abnormal Pap tests and the rate of precancer and cancer (combined) was higher in the never or rarely screened group compared with the screened group (abnormal percentage: 2.9 vs 2.6 %, p value < 0.01; rate of precancer and cancer: 6.9 vs 3.7 per 1,000 women, p value < 0.01). CONCLUSIONS: The priority of reaching never or rarely screened women should continue since those women who entered the NBCCEDP not adequately screened had a greater prevalence of high-grade histological lesions and invasive cervical cancers at later stages than women screened more recently.

Providers' beliefs about the effectiveness of the HPV vaccine in preventing cancer and their recommended age groups for vaccination: Findings from a provider survey, 2012.

BACKGROUND: The human papillomavirus (HPV) vaccine was recommended in 2007 by the Advisory Committee on Immunization Practices (ACIP) to preadolescent and adolescent girls. Vaccination initiation was recommended at age 11-12 years with the option to start at age 9. Catchup vaccination was recommended to females aged 13-26 previously not vaccinated. However, vaccination coverage remains low. Studies show that the HPV vaccine can prevent cervical, vulvar, vaginal, anal and some oropharyngeal cancers and that provider recommendation of vaccines can improve low vaccination rates. METHODS: Using data from 2012 DocStyles, an annual, web-based survey of U.S. healthcare professionals including physicians and nurse practitioners (n=1753), we examined providers' knowledge about the effectiveness of the HPV vaccine in preventing cancer and their vaccine recommendation to all age-eligible females (9-26 years). Descriptive statistics and Chi-square tests were used to assess differences across specialties. RESULTS: Knowledge about HPV vaccine effectiveness in preventing cervical cancer was highly prevalent (96.9%), but less so for anal, vaginal, vulvar and oropharyngeal cancers. Only 14.5% of providers recommended the vaccine to all age-eligible females and 20.2% recommended it to females aged 11-26 years. Knowledge assessment of cancers associated with HPV and vaccination recommendations varied significantly among providers (p<0.01). Providers more frequently recommended the vaccine to girls older than 11-12 years. CONCLUSIONS: Improving providers' knowledge about HPV-associated cancers and the age for vaccination initiation, communicating messages focusing on the vaccine safety and benefits in cancer prevention and on the importance of its delivery prior to sexual onset, may improve HPV vaccine coverage.

Evolution of cervical cancer screening and prevention in United States and Canada: implications for public health practitioners and clinicians.

OBJECTIVE: Declines in cervical cancer incidence and mortality in Canada and in the United States have been widely attributed to the introduction of the Papanicolaou (Pap) test. This article reviews changes in screening and introduction of HPV vaccination. METHOD: Sentinel events in cervical cancer screening and primary prevention through HPV vaccination in the US and Canada are described. RESULTS: Despite commonalities, cervical cancer screening and prevention differ between the two countries. Canada has a combination of opportunistic and organized programs at the provincial and territorial level, while the US has opportunistic screening and vaccination systems. In the US, the HPV test along with the Pap test (co-testing) is part of national recommendations for routine cervical cancer screening for women age 30 and older. Co-testing is not being considered anywhere in Canada, but primary HPV testing is currently recommended (but not implemented) in one province in Canada. CONCLUSION: Many prevention strategies are available for cervical cancer. Continued public health efforts should focus on increasing vaccine coverage in the target age groups and cervical cancer screening for women at appropriate intervals. Ongoing evaluation will be needed to ensure appropriate use of health resources, as vaccinated women become eligible for screening.

Primary care provider practices and beliefs related to cervical cancer screening with the HPV test in Federally Qualified Health Centers.

OBJECTIVE: Cervical cancer screening using the human papillomavirus (HPV) test and Pap test together (co-testing) is an option for average-risk women ≥ 30 years of age. With normal co-test results, screening intervals can be extended. The study objective is to assess primary care provider practices, beliefs, facilitators and barriers to using the co-test and extending screening intervals among low-income women. METHOD: Data were collected from 98 providers in 15 Federally Qualified Health Center (FQHC) clinics in Illinois between August 2009 and March 2010 using a cross-sectional survey. RESULTS: 39% of providers reported using the co-test, and 25% would recommend a three-year screening interval for women with normal co-test results. Providers perceived greater encouragement for co-testing than for extending screening intervals with a normal co-test result. Barriers to extending screening intervals included concerns about patients not returning annually for other screening tests (77%), patient concerns about missing cancer (62%), and liability (52%). CONCLUSION: Among FQHC providers in Illinois, few administered the co-test for screening and recommended appropriate intervals, possibly due to concerns over loss to follow-up and liability. Education regarding harms of too-frequent screening and false positives may be necessary to balance barriers to extending screening intervals.

Worldwide burden of cervical cancer in 2008.

BACKGROUND: The knowledge that persistent human papillomavirus infection is the main cause of cervical cancer has resulted in the development of assays that detect nucleic acids of the virus and prophylactic vaccines. Up-to-date and reliable data are needed to assess impact of existing preventive measures and to define priorities for the future. MATERIALS AND METHODS: Best estimates on cervical cancer incidence and mortality are presented using recently compiled data from cancer and mortality registries for the year 2008. RESULTS: There were an estimated 530,000 cases of cervical cancer and 275,000 deaths from the disease in 2008. It is the third most common female cancer ranking after breast (1.38 million cases) and colorectal cancer (0.57 million cases). The incidence of cervical cancer varies widely among countries with world age-standardised rates ranging from <1 to >50 per 100,000. Cervical cancer is the leading cause of cancer-related death among women in Eastern, Western and Middle Africa; Central America; South-Central Asia and Melanesia. The highest incidence rate is observed in Guinea, with ∼6.5% of women developing cervical cancer before the age of 75 years. India is the country with the highest disease frequency with 134,000 cases and 73 000 deaths. Cervical cancer, more than the other major cancers, affects women <45 years. CONCLUSIONS: In spite of effective screening methods, cervical cancer continues to be a major public health problem. New methodologies of cervical cancer prevention should be made available and accessible for women of all countries through well-organised programmes.

Self-reported Papanicolaou smears and hysterectomies among women in the United States.

OBJECTIVE: To evaluate the potential overuse of Papanicolaou smears among women who have had a hysterectomy. METHODS: We analyzed two surveys of US women aged 18 years or older, the Behavioral Risk Factor Surveillance System (1992-1997) and the National Health Interview Survey (1993-1994), and one survey of US hospitals (National Hospital Discharge Survey, 1980-1997). We examined the number of women who have had a hysterectomy who had a recent (within 3 years) Papanicolaou smear. We also examined trends in the proportions and rates of hysterectomies by diagnoses and type of procedure that potentially could require a Papanicolaou smear. RESULTS: From the Behavioral Risk Factor Surveillance System, an estimated 21.2% of US women have had a hysterectomy. Among women who have had a hysterectomy, 78.3% had a recent Papanicolaou smear. Among those reporting no hysterectomy, 82.1% had a recent Papanicolaou smear. Estimates from the National Health Interview Survey were similar. From the National Hospital Discharge Survey, an estimated 6.7% to 15.4% of women with a history of hysterectomy would require a subsequent Papanicolaou smear because they had a diagnosis related to cervical neoplasia or because they had undergone a supracervical hysterectomy. For an estimated 10.6-11.6 million of the 12.5 million women who had a hysterectomy and a recent Papanicolaou smear, that test could be considered unnecessary. CONCLUSION: Continued Papanicolaou screening of women without an intact uteri may result in excessive use of resources in time and money with minimal impact on decreasing cervical cancer.

Spontaneous abortion-related deaths among women in the United States--1981-1991.

OBJECTIVE: To examine trends in spontaneous abortion-related mortality and risk factors for these deaths from 1981 through 1991. METHODS: We used national data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to identify deaths due to spontaneous abortion (less than 20 weeks' gestation). Case-fatality rates were defined as the number of spontaneous abortion-related deaths per 100,000 spontaneous abortions. We calculated annual case-fatality rates as well as risk ratios by maternal age, race, and gestational age. RESULTS: During 1981-1991, a total of 62 spontaneous abortion-related deaths were reported to the Pregnancy Mortality Surveillance System. The overall case fatality rate was 0.7 per 100,000 spontaneous abortions. Maternal age 35 years and older (risk ratio [RR] 1.7, 95% confidence interval [CI] 0.9-3.0), maternal race other than white (RR 3.8, 95% CI 2.2-5.9), and gestational age over 12 weeks (RR 8.0, 95% CI 4.2-11.9) were risk factors for death due to spontaneous abortion. Of the 62 deaths, 59% were caused by infection, 18% by hemorrhage, 13% by embolism, 5% from complications of anesthesia, and 5% by other causes. Disseminated intravascular coagulation (DIC) was an associated condition among half of those deaths for which it was not the primary cause of death. CONCLUSION: Women 35 years of age and older, of races other than white, and in the second trimester of pregnancy age are at increased risk of death from spontaneous abortion. In addition, DIC complicates many spontaneous abortion cases that end in death. Because spontaneous abortion is a common outcome of pregnancy, continued monitoring of spontaneous abortion-related deaths is recommended.

Personal and clinical skin cancer prevention practices of US women physicians.

OBJECTIVE: To document physician clinical and personal skin cancer prevention practices and associated characteristics. DESIGN: A cross-sectional questionnaire survey of a representative sample of US women physicians. SETTING: Mail survey. SUBJECTS: Three thousand thirty-two nondermatologists and 95 dermatologists. MAIN OUTCOME MEASURE: Personal and clinical practices. RESULTS: Twenty-seven percent of nondermatologists counseled or screened their typical patients on skin cancer or sunscreen use at least once a year, while 49% did so less frequently, and 24% never counseled or screened at all. Of the 95 dermatologists, two thirds reported counseling or screening their typical patients at every visit. In bivariate analysis of nondermatologists, the distribution of counseling or screening was significantly (P<.05) associated with the following personal and professional characteristics: frequent sunscreen use, recent (within 2 years) skin examination, good health status, a primary care specialty, self-confidence in counseling or screening, extensive training in counseling or screening, high perceived relevance to the practice of the counseling or screening, nonurban practice site, and nonhospital-based or non-medical school-based practice. We found that 48% of all physicians always or nearly always used sunscreen, and 25% had received a clinical skin examination in the previous 2 years. CONCLUSIONS: Although many primary care physicians report ever counseling or screening their typical patients about skin cancer and sunscreen use, increased professional education for primary care physicians could improve patient counseling about skin cancer prevention.

Prevalence and correlates of sunscreen use among US high school students.

Sun exposure during childhood and adolescence increases the risk of skin cancer later in life. To determine the prevalence and correlates of sunscreen use among US high school students, researchers assessed data on sunscreen use, demographic characteristics, and health behaviors obtained from the 1999 Youth Risk Behavior Survey (YRBS). This survey used a three-stage cluster sample design to produce a nationally representative sample of students in grades 9-12 (N = 15,349). Overall, 13.3% (95% confidence interval, +/- 1.3) of students used sunscreen always or most of the time (i.e., frequent use). Frequent sunscreen use was lower among males (8.6%, +/- 1.2) than females (18.1%, +/- 1.9) and among Blacks (4.8%, +/- 1.7) and Hispanics (10.8%, +/- 2.8) than Whites (16.5%, +/- 1.9). Frequent sunscreen use decreased with age. Infrequent use of sunscreen was associated with other risky health behaviors, such as driving after drinking or riding in a car with a drinking driver, smoking cigarettes, being sexually active, and being physically inactive. Results indicate a need for health education interventions addressing sunscreen use that target high school students.

First metatarsal fractures.

First metatarsal fractures are rare because of their thick size and shape. They are to be treated aggressively because of the prolonged disability associated with such fractures. Any injury to the first ray may drastically alter the pattern of normal gait and weight-bearing. Most of the literature regarding such fractures is anecdotal, and there is little in the way of scientific articles that investigate their management. The general consensus for treatment of closed, nondisplaced first metatarsal fractures is to use some form of plaster immobilization. Nevertheless, there is much variation in the literature concerning the length of time patients should be casted. Rigid internal fixation using AO techniques is preferred if open reduction is to be instituted. Long-term complications with first metatarsal fractures are attributed mostly to malunion in the sagittal plane, resulting in a nonplantigrade foot.

Sun exposure and risk of melanoma.

BACKGROUND: As skin cancer education programmes directed to children and adolescents continue to expand, an epidemiological basis for these programmes is necessary to target efforts and plan for further evaluation. AIMS: To summarise the epidemiological evidence on sun exposure during childhood and adolescence and melanoma risk. METHODS: A literature review was conducted using Medline (1966 to December 2004) to identify articles relating to sun exposure and melanoma. The review was restricted to studies that included sun exposure information on subjects 18 years of age or younger. RESULTS: Migrant studies generally indicate an increased melanoma risk in individuals who spent childhood in sunny geographical locations, and decreasing melanoma risk with older age at arrival. Individuals who resided in geographical locations close to the equator or close to the coast during childhood and/or adolescence have an increased melanoma risk compared to those who lived at higher latitudes or never lived near the coast. The intermittent exposure hypothesis remains controversial; some studies indicate that children and adolescents who received intermittent sun exposure during vacation, recreation, or occupation are at increased melanoma risk as adults, but more recent studies suggest intermittent exposure to have a protective effect. The majority of sunburn studies suggest a positive association between early age sunburn and subsequent risk of melanoma. CONCLUSION: Future research efforts should focus on: (1) clarifying the relation between sun exposure and melanoma; (2) conducting prospective studies; (3) assessing sun exposure during different time periods of life using a reliable and quantitative method; (4) obtaining information on protective measures; and (5) examining the interrelations between ability to tan, propensity to burn, skin type, history of sunburns, timing and pattern of sun exposure, number of nevi, and other host factors in the child and adolescent populations.

Use of a comprehensive state birth data system to assess mother's satisfaction with length of stay.

OBJECTIVE: To assess length of stay, home visits, and mothers' feelings after full implementation of a law requiring a 48-hour minimum stay for women with normal vaginal deliveries. METHODS: The New Jersey Electronic Birth Certificate System (EBC) was used to capture demographic characteristics, and length of stay (LOS), and to select a sample of women with low risk uncomplicated vaginal deliveries. A follow-up mail survey (with a nonresponder phone component) enhanced the information available on the EBC. RESULTS: The response rate for women included in the sample was 82.1% (1276/1555). The mean length of stay was 1.9 days. Sixty-two percent (787) of women thought their LOS after delivery was just right. Women who thought their stays were too short tended to be older, married, working outside the home, or have an LOS of less than 48 hours. The most common reasons for thinking the LOS was too short was a need for rest and concern about the baby. DISCUSSION: The combination of an augmented electronic birth certificate system and a follow-up survey proved to be a rapid, reliable, and inexpensive method of assessment. The mothers' desires for rest, education on the care of her newborn, and reassurance that any medical complications could be handled, are paramount concerns that need to be taken into account by payers and practitioners wanting to decrease LOS.

Trends and predictors of infant sleep positions in Georgia, 1990 to 1995.

BACKGROUND: In recent years, the prone sleeping position has emerged as the strongest modifiable risk factor for sudden infant death syndrome, the leading cause of infant mortality between 1 month and 1 year of age in the United States. Since April 1992, sudden infant death syndrome risk-reduction strategies have included the promotion of the back or side sleeping position (nonprone) for healthy infants younger than 1 year of age. Most recently, the back position has been advocated as the best sleeping position and the side position as an alternative. METHODS: To evaluate trends in prevalence of the prone position from 1990 to 1995, we used data available from the Georgia Women's Health Survey, a random digit-dialed telephone survey of 3130 women 15 to 44 years of age. We examined the position in which women put their infant to sleep in the first 2 months of life for their most recent live birth (N = 868) and determined independent predictors of prone sleep position among women who consistently used the prone or the back/side position (n = 636) using multiple logistic regression. RESULTS: The prevalence of mothers who put their infant to sleep in the prone position significantly decreased, from 49% in 1990 to 15% in 1995. This decrease is primarily attributable to a major shift to the side position rather than to the back. Using multiple logistic regression, we found the prone sleeping position to be significantly higher among women who entered prenatal care after the first trimester (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.4-9.2), were black (OR, 2.1; 95% CI, 1.4-3.1), had less than a high school education (OR, 2.2; 95% CI, 1.4-3.4), and were living in rural Georgia (OR, 1.9; 95% CI, 1.3-2.7). For the period after April 1992, women who had previous children were 2.6 (OR, 95% CI, 1.7-4.1) times more likely to use the prone sleep position than were first-time mothers. CONCLUSIONS: The prevalence of the use of the prone sleep position for infants decreased significantly over the study period. This decrease coincided with national efforts to promote the back or side sleeping position. Increased efforts should target groups who are more likely to use the prone position to attain the national goal of

Estimates of the annual number of clinically recognized pregnancies in the United States, 1981-1991.

The authors estimated the number of clinically recognized pregnancies that occurred annually from 1981 to 1991 in the United States by type of outcome and by race. Estimates of the numbers of livebirths, induced abortions, ectopic pregnancies, and fetal deaths were obtained by using data from the Centers for Disease Control and Prevention in Atlanta, Georgia. The number of spontaneous abortions was estimated by using previously published, age-specific rates. More than 67 million pregnancies occurred during the study period. Overall, 62.5% of these pregnancies resulted in livebirths, 21.9% in legal induced abortions, 13.8% in spontaneous abortions, 1.3% in ectopic pregnancies, and 0.5% in fetal deaths. These data can be used to provide denominators for the calculation of a variety of pregnancy outcome-specific rates.

Cigarette smoking as a risk factor for ectopic pregnancy.

OBJECTIVE: Our purpose was to assess the risk of ectopic pregnancy among women who smoke cigarettes. STUDY DESIGN: We used data from a case-control study of ectopic pregnancy conducted from October 1988 to August 1990 at an inner-city hospital in Georgia. Cases were 196 non-Hispanic black women with a surgically confirmed ectopic pregnancy. Controls were non-Hispanic black women who had delivered either a live or a stillborn infant weighing at least 500 gm (n = 882) or who were pregnant and seeking an induced abortion (n = 237). RESULTS: After we adjusted for parity, douching history, history of infertility, and age, the odds ratio for ectopic pregnancy was 1.9 (95% confidence interval 1.4 to 2.7) for women who smoked during the periconception period compared with women who did not smoke at that time. After stratification by the amount of daily smoking during the periconception period, the odds ratio rose from 1.6 (95% confidence interval 0.9 to 2.9) for women who smoked 1 to 5 cigarettes to 1.7 (95% confidence interval 1.1 to 2.8) for women who smoked 6 to 10 cigarettes to 2.3 (95% confidence interval 1.3 to 4.0) for women who smoked 11 to 20 cigarettes, and to 3.5 (95% confidence interval 1.4 to 8.6) for women who smoked >20 cigarettes per day. CONCLUSION: In this inner-city population, cigarette smoking was an independent, dose-related risk factor for ectopic pregnancy among black women. The public health and medical care communities should inform the public of this additional risk associated with cigarette smoking and intensify intervention strategies to reduce cigarette smoking among women of reproductive age.