Geographic Examination of COVID-19 Test Percent Positivity and Proportional Change in Cancer Screening Volume, National Breast and Cervical Cancer Early Detection Program.

INTRODUCTION: In 2020, the COVID-19 pandemic led to significant declines in cancer screening, including among women served by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This study examined the spatial association between state-based COVID-19 test percent positivity and proportional change in NBCCEDP screening volume. METHODS: Using the COVID-19 Diagnostic Laboratory Testing dataset, we calculated state-based monthly COVID-19 test percent positivity from July through December 2020 and categorized rates into low, medium, and high groups. We used data from 48 NBCCEDP state awardees to calculate the state-based monthly proportional change in screening volume and compared data for July-December 2020 with the previous 5-year average for those months. We categorized changes in screening volume into large decrease, medium decrease, and minimal change and created maps of the associations between variable subgroups by using bivariate mapping in QGIS. RESULTS: Bivariate relationships between COVID-19 test percent positivity and proportional change in cancer screening volume varied over time and geography. In 5 of 6 months, 4 states had high COVID-19 test percent positivity and minimal change in breast or cervical cancer screening volume; 2 states had high COVID-19 test percent positivity and minimal change in breast and cervical cancer screening volume. CONCLUSION: Some states maintained pre-COVID-19 screening volumes despite high COVID-19 test percent positivity. Follow-up research will be conducted to determine how these states differ from those with consistent decreases in screening volume and identify factors that may have contributed to differences. This information could be useful for planning to maximize NBCCEDP awardees' ability to maintain screening volume during future public health emergencies.

Variations in Screening Quality in a Federal Colorectal Cancer Screening Program for the Uninsured.

INTRODUCTION: Screening can decrease colorectal cancer incidence and mortality and is recommended in clinical practice guidelines. Poor quality of colorectal cancer screening can negate the benefit of screening. The objective of this study was to assess the quality of screening services provided by the Centers for Disease Control and Prevention's Colorectal Cancer Control Program from July 2009 through June 2015. METHODS: We collected data from the program's 29 grantees, funded to provide colorectal cancer screening and diagnostic services to asymptomatic, low-income, and underinsured or uninsured adults aged 50 to 64. We collected data on the dates and results of all screening and diagnostic tests and, for colonoscopies, on whether the cecum was reached, whether bowel preparation was adequate, and endoscopists' recommendations for the next test. RESULTS: Overall, 82.9% (range among grantees, 50.0%-97.2%) of positive FOBTs/FITs were followed up by colonoscopy; 95.2% of colonoscopies occurred within 180 days of the positive stool test. Cecal intubation rates ranged among grantees from 94.2% to 100%. Adenoma detection rates met recommended threshold levels for almost all grantees. Recommendations for rescreening and surveillance intervals deviated from guidelines in both directions. Of clients with normal colonoscopies, 85.3% (range, 37.7%-99.7%) were told to return in 10 years, as recommended in national guidelines. Of clients with advanced adenomas, 55.2% (range, 20.0%-84.6%) were told to return in 3 years as recommended, 25.4% (range, 3.8%-56.6%) in 5 or more years, and 18.6% (range, 0%-47.2%) in less than 3 years. CONCLUSION: Although overall screening quality was good, it varied considerably. Ongoing monitoring to identify performance problems is essential for all colorectal cancer screening activities, so that efforts designed to improve performance can be targeted to individual clinicians.

Clinical outcomes of mammography in the National Breast and Cervical Cancer Early Detection Program, 2009-2012.

PURPOSE: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) enrolls asymptomatic women for cancer screening and symptomatic women for diagnostic services. This study describes the results of mammograms provided by the NBCCEDP, by examination indication (screening or diagnostic), and by age group. METHODS: For the first NBCCEDP-funded mammogram received during 2009-2012, we calculated age-specific percentages of abnormal findings, rates of follow-up testing, and invasive and in situ breast cancer diagnoses per 1,000 mammograms. Logistic regression was used to estimate the odds for each of these outcomes by examination indication. RESULTS: The NBCCEDP provided 941,649 screening, 175,310 diagnostic, and 30,434 unknown indication mammograms to 1,147,393 women. The percentage with abnormal mammograms was higher for diagnostic mammograms (40.1 %) than for screening mammograms (15.5 %). Compared with women aged 40-49 years, fewer women aged 50-64 years had abnormal results for screening (13.7 vs. 19.7 %) and diagnostic mammograms (37.7 vs. 42.7 %). Follow-up rates per 1,000 mammograms were lower among women aged 50-64 compared to those aged 40-49 (screening: 143.9 vs. 207.5; diagnostic: 645.3 vs. 760.9); biopsy rates exhibited a similar pattern (screening: 24.1 vs. 32.9; diagnostic: 167.7 vs. 169.7). For screening mammograms, older women had more cancers detected than younger women (invasive: 3.6 vs. 2.2; in situ: 2.3 vs. 2.0). Similarly, for diagnostic mammograms, cancer detection was higher for older women (invasive: 67.8 vs. 36.6; in situ: 17.4 vs. 11.1). CONCLUSIONS: Abnormal mammograms and diagnostic follow-up procedures were less frequent in women aged 50-64 years compared to women aged 40-49 years, while breast cancer detection was higher, regardless of indication for the mammogram. Some of these differences between age groups were greater for screening mammograms than for diagnostic mammograms. Cancer detection rates were higher for diagnostic mammograms compared with screening mammograms. These findings support the NBCCEDP's priority of serving women aged 50-64 years and providing both screening and diagnostic mammograms.

Clinical outcomes from the CDC's Colorectal Cancer Screening Demonstration Program.

BACKGROUND: Colorectal cancer remains the second leading cause of cancer-related deaths among US men and women. Screening rates have been slow to increase, and disparities in screening remain. METHODS: To address the disparity in screening for this high burden but largely preventable disease, the Centers for Disease Control and Prevention (CDC) designed and established a 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) in 2005 for low-income, under-insured or uninsured men and women aged 50 to 64 years in 5 participating US program sites. In this report, the authors describe the design of the CRCSDP and the overall clinical findings and screening test performance characteristics, including the positive fecal occult blood testing (FOBT) rate; the rates of polyp, adenoma, and cancer detection with FOBTs and colonoscopies; and the positive predicative value for polyps, adenomas, and cancers. RESULTS: In total, 5233 individuals at average risk and increased risk were screened for colorectal cancer across all 5 sites, including 44% who underwent screening FOBT and 56% who underwent screening colonoscopy. Overall, 77% of all individuals screened were women. The FOBT positivity rate was 10%. Results from all screening or diagnostic colonoscopies indicated that 75% had negative results and required a repeat screening colonoscopy in 10 years, 16% had low-risk adenomas and required surveillance colonoscopy in 5 to 10 years, 8% had high-risk adenomas and required surveillance colonoscopy in 3 years, and 0.6% had invasive cancers. CONCLUSIONS: This report documents the successes and challenges in implementing the CDC's CRCSDP and describes the clinical outcomes of this 4-year initiative, the patterns in program uptake and test choice, and the comparative test performance characteristics of FOBT versus colonoscopy. Patterns in final outcomes from the follow-up of positive screening tests were consistent with national registry data.

Timeliness of breast cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program, 1996-2005.

OBJECTIVES: 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). METHODS: 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 (

Assessment of follow-up for low-grade cytological abnormalities in the National Breast and Cervical Cancer Early Detection Program, 2000-2005.

OBJECTIVE: To assess the management of women in the National Breast and Cervical Cancer Early Detection Program with low-grade squamous intraepithelial lesions (LSIL) before and after the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines for management of abnormal cytology were published in 2002. MATERIALS AND METHODS: We examined the follow-up for 22,342 women with LSIL during 2 periods: 2000-2002 and 2003-2005. RESULTS: The percentage of providers who followed the recommended guidelines with colposcopy for an LSIL Pap test result increased by 9% from the pre-ASCCP to the post-ASCCP period. An increase was seen in every age and racial/ethnic group. Younger women (<30 years) and white women were more likely than comparison groups to be followed by colposcopy rather than a repeat Pap test. CONCLUSIONS: The increase in percentage of women having colposcopy in 2003, 1 year after the new guidelines were published, suggests a change in provider practices consistent with those guidelines.

A combined approach to women's health is associated with a greater likelihood of repeat mammography in a population of financially disadvantaged women.

INTRODUCTION: Integrating one or more public health programs may improve the ability of programs to achieve common goals. Expanding knowledge on how program integration occurs, how it benefits each individual program, and how it contributes to the achievement of common goals is an important area of inquiry in public health. METHODS: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program combined data from 10 of their overlapping state or tribal programs to calculate prevalence estimates of repeat mammography at 18 months. The data were stratified by whether women attended the combined program or only the NBCCEDP. Logistic regression analyses were conducted to identify factors that were thought to independently contribute to a greater likelihood of a woman receiving a repeat mammogram. RESULTS: Women who participated in both programs were 1.5 to 5.1 times as likely to be rescreened, depending on program location, as women who participated only in the NBCCEDP. WISEWOMAN participants who received a follow-up WISEWOMAN screening for chronic disease risk factors within a year of their initial WISEWOMAN screening were 5 times more likely to return for a follow-up mammogram through the NBCCEDP than were WISEWOMAN participants who did not. DISCUSSION: Participation in both the NBCCEDP and the WISEWOMAN program is associated with a greater likelihood of a woman returning for a follow-up mammogram within 18 months of her initial examination. Collecting more in-depth information on motivational factors and on the association between receipt of multiple services and a woman's engagement in a health program should be the subject of future research.

Adherence to guidelines for follow-up of low-grade cytologic abnormalities among medically underserved women.

OBJECTIVE: To determine whether women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) who had findings on a Papanicolaou (Pap) test of atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL) were followed up in accordance with the interim guidelines for management of abnormal cervical cytology. METHODS: For this study period, the guidelines for a Pap result of ASC-US or LSIL specified follow-up by Pap tests repeated every 4 to 6 months for 2 years. If a second report of ASC-US or LSIL was made, the patient was to have colposcopy. We analyzed data from 10,004 women who had a result of ASC-US or LSIL followed by a second ASC-US or LSIL from 1991-2000. RESULTS: As judged by the guidelines, 44% of women who had 2 low-grade abnormalities were followed up appropriately with colposcopy. Among women with 2 ASC-US results, those aged less than 30 years were more likely to receive colposcopy than the other age groups, while women who were aged 60 years and older were more likely to be followed up with a third Pap test. For each of the 4 result groups, American Indian or Alaska Native women had the highest percentages of a third Pap test, whereas Black or African-American women had a higher percentage of no follow-up. CONCLUSION: More than one half of the women studied were not followed up in accordance with the established guidelines for managing abnormal cervical cytology. Factors such as age and race or ethnicity influence whether women with cytologic abnormalities receive appropriate follow-up.

Serum carotenoids and alpha-tocopherol and risk of nonmelanoma skin cancer.

BACKGROUND: Carotenoids and tocopherols have been hypothesized to protect against cancer. METHODS: We prospectively evaluated associations of several carotenoids and alpha-tocopherol with risk of nonmelanoma skin cancer using serum collected at baseline from 302 subjects in the Isotretinoin-Basal Cell Carcinoma Prevention Trial. All subjects had at least two BCCs in the 5 years prior to randomization. During 5 years of follow-up, 70 subjects did not develop a nonmelanoma skin cancer, 221 developed a BCC, and 85 developed a squamous cell carcinoma (SCC). Cox proportional hazards models were used to estimate risk ratios. Models were stratified by clinical center and gender and adjusted for age, solar damage, skin type, number of prior BCCs and/or SCCs, treatment group, body mass index, and serum low-density lipoprotein-cholesterol and high-density lipoprotein-cholesterol. RESULTS: Risk of developing a subsequent BCC was not related to serum levels of any of the carotenoids measured or to alpha-tocopherol. Serum levels of alpha-carotene, beta-carotene, lycopene, and alpha-tocopherol also were not independently related to risk of a subsequent SCC. However, serum lutein, zeaxanthin, and beta-cryptoxanthin were positively related to SCC risk; risk ratios for subjects in the highest versus lowest tertiles of these micronutrients were 1.63 [95% confidence interval (95% CI) 0.88-3.01; P for trend = 0.01], 2.40 (95% CI 1.30-4.42; P for trend = 0.01), and 2.15 (95% CI 1.21-3.83; P for trend = 0.09), respectively. CONCLUSION: Additional research is needed on the relationship of carotenoids to SCC risk in the general population and in subsets of the population who are at increased risk.

Cervical screening in the National Breast and Cervical Cancer Early Detection Program, 1995-2001.

OBJECTIVE: To describe results of cervical cytology screening among low-income and uninsured women in the National Breast and Cervical Cancer Early Detection Program. METHODS: We analyzed data from 750,591 women who received their first Papanicolaou (Pap) test in the program between July 1995 and March 2001. RESULTS: Nearly 85% of the women were aged 40 years or older. Almost half were members of racial or ethnic minority groups. Overall, the percentage of abnormal Pap test results decreased with increasing age. The rates of cervical intraepithelial neoplasia (CIN) were highest in the younger age groups but the rate of invasive cancer increased with age. White women had the highest age-adjusted percentage of abnormal Pap test results and the highest rate of biopsy-confirmed CIN 2 or worse. CONCLUSIONS: In this nationwide screening program, only 7% of all biopsy-confirmed high-grade cervical lesions (CIN 2 or worse) were invasive cancer. This underscores the success of Pap screening in identifying preinvasive disease and preventing cancer. LEVEL OF EVIDENCE: II-3

Timeliness of cervical cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program.

OBJECTIVES: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: Women screened by the NBCCEDP receive diagnostic follow-up and initiate treatment within preestablished program guidelines.

Breast cancer screening among low-income or uninsured women: results from the National Breast and Cervical Cancer Early Detection Program, July 1995 to March 2002 (United States).

OBJECTIVE: To describe the results of breast cancer screening among low-income and uninsured women in the only national organized screening program in the US, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: We analyzed mammography and diagnostic follow-up data for 789,647 women who received their first mammogram in the NBCCEDP and 454,754 subsequent mammograms among these women. We calculated the rate of mammograms with abnormal findings, diagnostic follow-up, biopsy, and cancers detected per 1000 mammograms by age and racial or ethnic groups. Positive Predictive Values (PPVs) were estimated for abnormal mammograms and biopsy. RESULTS: Nearly 64% of the women screened in the program were from 50 to 64 years of age and about 46% were members of racial or ethnic minority groups. Women aged 40 to 49 years had the highest rates of abnormal mammograms and of diagnostic follow-up. However, cancer detection rates were highest in women aged 60 to 64 years. In addition, the PPVs for both abnormal mammograms and biopsy were highest in the oldest age group. CONCLUSIONS: Cancer detection rates and PPVs for both abnormal mammograms and biopsy were highest in women aged 50 years or more. These results support the programs focus on screening women aged 50 and older for breast cancer.