Role of primary care enrolment in advanced cervical cancer diagnosis: a population-based case-control study.

INTRODUCTION: The elimination of cervical cancer will only be achievable through primary and secondary prevention. The aim of this study was to determine the effect of primary care enrolment on the prevention of advanced cervical cancer. METHODS: Using a population-based case-control study, all women (n=5548) above 18 years of age who were diagnosed with cervical cancer between January 2006 and December 2015 in Ontario, Canada were selected for the analysis. The controls were women (n=27 740) above 18 years of age and without a diagnosis of cervical cancer. Five controls were matched to each case by year of birth. Descriptive statistics were used to compare the patients and controls. Multiple imputations and logistic regression were used to estimate the correlation between enrolment with a primary care provider and diagnosis of cervical cancer. RESULTS: A total of 44% of advanced cervical cancer patients and 56% of controls had a screening test 10 years before the index date. The odds of having had a Pap test in the 3 and 10 years before were higher when patients were enrolled with a primary care provider (OR 3.5 and 5.1, p<0.001). The correlation between screening and advanced cervical cancer (stage II-IV) incidence was modified by primary care enrolment: if the patient was enrolled with a primary care provider and had at least one screen in the previous 10 years, the OR of developing advanced cervical cancer was 0.42 (95% CI 0.40 to 0.43); if the patient was not enrolled the OR was 0.78 (95% CI 0.72 to 0.84). DISCUSSION: Primary care enrolment is an effect modifier of cervical cancer screening on advanced cervical cancer incidence. Efforts should be made to increase the capacity of primary care providers to offer screening in order to eradicate cervical cancer.

Is Immigrant Status Associated With Cervical Cancer Screening Among Women in Canada? Results From a Cross-Sectional Study.

OBJECTIVE: Cervical cancer accounts for the highest mortality rate from cancer in women worldwide. Despite widespread availability of cervical cancer screening programs in Canada, immigrant women are largely underscreened. The most recently published Canadian-wide study evaluated screening uptake from 2001 to 2002. The objectives included identifying the prevalence of underscreened women in Canada, determining the risk of underscreening for cervical cancer among immigrant women, and providing an update on Canadian screening practices. METHODS: This study included women aged 20 to 69 who completed the Canadian Community Health Survey 2012. The prevalence of underscreening among Canadian-born and immigrant women was estimated. A log-binomial model was fit to estimate the relative risk (RR) of underscreening for immigrant women while controlling for age, income level, visible minority status, smoking status, and access to a regular physician. A secondary analysis compared immigrants residing in Canada for greater or less than 10 years to Canadian-born women. RESULTS: Of the 17 854 women eligible for this study, 18.6% of Canadian-born women and 28.9% of immigrant women were underscreened (P < 0.05). Immigrant women were at significantly higher risk of being underscreened compared with Canadian-born women (RR 1.32; 95% CI 1.20-1.45). The relative risk did not change when stratifying by length of time since immigration (RRrecent immigrant 1.32; 95% CI 1.16-1.50; and RRlong-term immigrant 1.32; 95% CI 1.19-1.47). CONCLUSION: Immigrant status continues to be associated with a significantly higher risk of underscreening, irrespective of time in Canada. Social and educational programs targeted towards immigrants are needed to mitigate the disparity in cervical cancer screening.

A National Survey of Canadian Adults on HPV: Knowledge, Attitudes, and Barriers to the HPV Vaccine.

OBJECTIVE: Identifying human papillomavirus (HPV) vaccination motivators and barriers among adults could lead to new approaches to improve HPV vaccination rates in non-pediatric populations. This Canadian survey aimed to assess current knowledge of, attitudes towards, and barriers to the HPV vaccine among the general public. METHODS: An online panel was used to survey HPV unvaccinated women (n = 802) and vaccinated women (n = 250) 18 to 45 years old, as well as 18- to 26-year-old men (n = 200), in May and June 2016. A 16-item questionnaire collected data on sociodemographic factors, health-seeking behaviours, knowledge of HPV infection and its consequences, and the HPV vaccine. Data were stratified by sex and by vaccination status among women. RESULTS: The majority of individuals somewhat or strongly agreed that vaccination is an important aspect of disease prevention (vaccinated women, 93%; unvaccinated women, 85%; and men, 59%). However, a high proportion of patients were concerned about vaccine safety (vaccinated women, 26%; unvaccinated women, 40%; and men, 36%). Moreover, 58% to 61% of participants were generally cautious about taking any vaccine. The number one reported barrier to vaccination was not having a recommendation from a doctor (38%). Cost was seen as a barrier by only 18% to 20% of participants. CONCLUSION: Canadian participants show a broad diversity in HPV knowledge and regarding barriers to vaccination. The youngest populations (vaccinated women and men) showed higher levels of knowledge regarding HPV.

A National Survey of Canadian Physicians on HPV: Knowledge, Barriers, and Preventive Practices.

OBJECTIVE: Physicians are the sole prescribers of the human papillomavirus (HPV) vaccine for adults in Canada. This survey of Canadian physicians aimed to explore knowledge, barriers, and preventive practices regarding HPV vaccination. METHOD: A survey of general practitioners (GPs) (n = 337) and obstetrician/gynaecologists (OB/GYNs) (n = 81) was conducted in May and June 2016 using an online panel. Demographic data and information pertaining to HPV knowledge, attitudes, and vaccination practices were collected by using a 22-item questionnaire. RESULTS: A total of 83% of GPs recommended or administered HPV vaccine to adults. Among physicians, 99% to 100% strongly agreed that vaccination is an important aspect of disease prevention. Physicians were rarely concerned about vaccine safety (5%-11%). Cost was seen as the number one barrier by 92% to 95% of physicians. Physicians rated consumers' understanding of HPV to be low (11%-14%, very good; and 49%-56%, somewhat good knowledge). Among physicians, 60% to 66% of said they routinely discussed HPV vaccination with patients. Female physicians demonstrated greater knowledge of HPV than their male counterparts. CONCLUSION: GPs and obstetrician/gynaecologists routinely recommend and administer the HPV vaccine to patients. The majority of physicians showed high levels of knowledge regarding HPV vaccine and associated cancers; however, perceived barriers of cost may limit recommendations for vaccination, particularly among older women or men.

The optimum organization for the delivery of colposcopy service in Ontario: a systematic review.

OBJECTIVE: To determine the optimum organization for colposcopy service delivery in Ontario, Canada. METHODS: A multidisciplinary expert panel was convened to develop a systematic review to inform organizational guidelines. MEDLINE, EMBASE, CINAHL, HealthSTAR, and the Cochrane Library databases were searched from 1996 to February 2006 for articles that reported guidance or outcomes relating to improved outcomes in colposcopy training, qualifications, accreditation, maintenance of competency, the delivery of colposcopy, reducing default from colposcopy clinics, and/or strategies to improve patient satisfaction or comfort. In addition, an environmental scan identified unpublished documents related to the delivery of colposcopy services. RESULTS: Sixteen guidance documents related to the delivery of colposcopy services were identified; 5 from the published literature and 11 from the environmental scan. These documents were used by the panel to inform the systematic review and companion guidelines. CONCLUSIONS: Overall, the Ontario Colposcopy Guidelines Development Group believes that the benefits associated with the implementation of colposcopy recommendations in Ontario will result in greater organization of care and improved patient outcomes. In addition, the group anticipates that these recommendations will provide useful guidance to regional planning authorities, hospital administrators, and Cancer Care Ontario, as well as colposcopists and other practitioners, in the planning of integrated regional and provincial cancer screening services.

Development and field testing of a tool to elicit women's preferences among cervical cancer screening modalities.

OBJECTIVE: The objective of the present study is to describe the development and field testing of a preference-elicitation tool for cervical cancer screening, meeting International Patient Decision Aids Standards (IPDAS) quality criteria. METHODS: We developed a tool designed to elicit women's preferences among cervical cancer screening modalities. The Ottawa Decision Support Framework and IPDAS systematic development process guided the design, and we followed IPDAS criteria for conducting a field test in a real-world setting. Using social media recruitment strategies, we identified a convenience sample of Ontario women who were currently eligible for cervical screening to test the tool. We evaluated the feasibility, acceptability, balance of information, and ability to elicit women's informed, values-based preferences using an online survey embedded in the tool. RESULTS: Twenty-five women participated in the field test. Participants were aged 20 to 63 years , and identified as predominantly white (88%), living in Northern Ontario (68%), and most had university education (75%). Most participants (72%) considered the length of the website as "just right," and 100% indicated that they would find the tool useful for decision-making. Over two-thirds (68%) of participants perceived the information in the tool as "balanced." Almost all (92%) participants scored at least 4 out of 7 on the knowledge quiz, and most participants (84%) selected their preference in an informed, values-based way. CONCLUSION: The results from our field test of this tool provide preliminary evidence of the tool's feasibility, acceptability, balance, and ability to elicit women's informed, values-based preferences among available cervical screening modalities. Further research should elicit the distribution of preferences of cervical screening modalities in other regions, using a sample who represents the screening population and a rigorous study design. It will be important for researchers and screening programmes to evaluate the tool's ability to elicit women's informed, values-based preferences compared with educational materials.

"They Should Be Asking Us": A Qualitative Decisional Needs Assessment for Women Considering Cervical Cancer Screening.

In this study, we examine from multiple perspectives, women's shared decision-making needs when considering cervical screening options: Pap testing, in-clinic human papillomavirus (HPV) testing, self-collected HPV testing, or no screening. The Ottawa Decision Support Framework guided the development of the interview schedule. We conducted semi-structured interviews with seven screen-eligible women and five health care professionals (three health care providers and two health system managers). Women did not perceive that cervical screening involves a "decision," which limited their knowledge of options, risks, and benefits. Women and health professionals emphasized how a trusted primary care provider can support women making a choice among cervical screening modalities. Having all cervical screening options recommended and funded was perceived as an important step to facilitate shared decision making. Supporting women in making preference-based decisions in cervical cancer screening may increase screening among those who do not undergo screening regularly and decrease uptake in women who are over-screened.

Eliciting women's cervical screening preferences: a mixed methods systematic review protocol.

BACKGROUND: With the accumulation of evidence regarding potential harms of cancer screening in recent years, researchers, policy-makers, and the public are becoming more critical of population-based cancer screening. Consequently, a high-quality cancer screening program should consider individuals' values and preferences when determining recommendations. In cervical cancer screening, offering women autonomy is considered a "person-centered" approach to health care services; however, it may impact the effectiveness of the program should women choose to not participate. As part of a larger project to investigate women's cervical screening preferences and correlates of these preferences, this systematic review will capture quantitative and qualitative investigations of women's cervical screening preferences and the methods used to elicit them. DESIGN AND METHODS: This mixed methods synthesis will use a thematic analysis approach to synthesize qualitative, quantitative, and mixed methods evidence. This protocol describes the methods that will be used in this investigation. A search strategy has been developed with a health librarian and peer reviewed using PRESS. Based on this strategy, five databases and the gray literature will be searched for studies that meet the inclusion criteria. The quality of the included individual studies will be examined using the Mixed Methods Appraisal Tool. Three reviewers will extract data from the primary studies on the tools or instruments used to elicit women's preferences regarding cervical cancer screening, theoretical frameworks used, outcomes measured, the outstanding themes from quantitative and qualitative evidence, and the identified preferences for cervical cancer screening. We will describe the relationships between study results and the study population, "intervention" (e.g., tool or instrument), and context. We will follow the PRISMA reporting guideline. We will compare findings across studies and between study methods (e.g., qualitative versus quantitative study designs). The strength of the synthesized findings will be assessed using the validated GRADE and CERQual tool. DISCUSSION: This review will inform the development of a tool to elicit women's cervical screening preferences. Understanding the methods used to elicit women's preferences and what is known about women's cervical screening preferences will be useful for guideline developers who wish to incorporate a woman-centered approach specifically for cervical screening guidelines. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016035737.