Trends in the use of cervical cancer screening tests in a large medical claims database, United States, 2013-2019.

OBJECTIVE: To examine trends in the use of cervical cancer screening tests during 2013-2019 among commercially insured women. METHODS: The study population included women of all ages with continuous enrollment each year in the IBM MarketScan commercial or Medicare supplemental databases and without known history of cervical cancer or precancer (range = 6.9-9.8 million women per year). Annual cervical cancer screening test use was examined by three modalities: cytology alone, cytology plus HPV testing (cotesting), and HPV testing alone. Trends were assessed using 2-sided Poisson regression. RESULTS: Use of cytology alone decreased from 34.2% in 2013 to 26.4% in 2019 among women aged 21-29 years (P < .0001). Among women aged 30-64 years, use of cytology alone decreased from 18.9% in 2013 to 8.6% in 2019 (P < .0001), whereas cotesting use increased from 14.9% in 2013 to 19.3% in 2019 (P < .0001). Annual test use for HPV testing alone was below 0.5% in all age groups throughout the study period. Annually, 8.7%-13.6% of women aged 18-20 years received cervical cancer screening. There were persistent differences in screening test use by metropolitan residence and census regions despite similar temporal trends. CONCLUSIONS: Temporal changes in the use of cervical cancer screening tests among commercially insured women track changes in clinical guidelines. Screening test use among individuals younger than 21 years shows that many young women are inappropriately screened for cervical cancer.

Trends in Uterine Cervical Cancer Screening at Physical Health Checkups for Company Employees in Japan.

The consultation rate for uterine cervical cancer screening in Japan is markedly low in comparison with other developed countries. The purpose of this study is to investigate the trends in uterine cervical cancer screening during regular company checkups and to identify potential problems. Questionnaires were sent to occupational health physicians through Sansuiken (Alumni Association of the University of Occupational and Environmental Health, Japan). Overall, 127 valid responses showed that Papanicolaou (Pap) tests are conducted in 100 companies (79%). The detailed information from 50 of the 100 responses was analyzed. Mandatory cervical cancer screenings are performed at just 6 companies (12%). Pap test are started at 30 years of age at 9 of 49 companies, and only 18 of 49 companies (37%) start Pap tests for employees at 20 years old. Of the 86,695 women, 31,294 (36%) received cervical cancer screening. Abnormal Pap test results were detected in 3.0%. Although cervical cancer screening rates have slightly increased compared to our previous studies (17% in 2004, 23% in 2008), it remains at a low level. Complete examinations with colposcopy and punch biopsy were carried out in 70% (61 of 87 women) of those with an abnormal Pap test. Twelve of 26 companies had no information about detailed examination results. It is important to note that cervical cancer incidence and mortality are increasing among young women in Japan. Occupational physicians and health nurses should manage female health education and care at the workplace, by including uterine cervical cancer screening in the growing female working population.

Pathway to the Papanicolaou smear: The development of cervical cytology in twentieth-century America and implications in the present day.

George Papanicolaou, a Greek immigrant and cytopathologist, was responsible for what is now colloquially known as the "Pap smear"-undoubtedly one of the greatest advances in medicine and public health of the last century. However, his landmark research on the development of cervical cytology for the detection of precancerous lesions of the cervix ("New Cancer Diagnosis," 1928) made a rather inauspicious debut in an unlikely venue: John Harvey Kellogg's Third Race Betterment Conference-a meeting devoted to the furtherance of the concept and implementation of eugenics. Herein, we discuss the stark juxtaposition of Papanicolaou's landmark discovery amid the pseudoscience of the third Race Betterment Conference. We discuss the latency of Papnicolaou's discovery-its potential implications unrealized-until co-publication with Herbert Traut, which catapulted Papanicolaou's research to the scientific foreground. This gave rise to public health initiatives aimed at establishing the Pap smear as a screening tool. We further delineate the progress made in recent decades with the identification of HPV as the etiological agent for cervical cancer, and the subsequent development of the HPV vaccine, and discuss ongoing research in the present day. In this way, we hope to provide a background and historical context for the development of the Pap smear.

Prevalence of cervical cancer and pre-cancerous lesions among unscreened Women in Kumasi, Ghana.

Ghana does not have a universal population-based cervical cancer screening program and there is very limited information about the distribution of cervical epithelial cell lesions. This study provides evidence that a moderately high prevalence of cervical cancer and precancerous lesions exists among unscreened women in Kumasi.The prevalence of cervical epithelial cell abnormalities among a cross-section of women attending cervical cancer screening for the first time in a suburb of Ghana from 2011 to 2014 was studied. Cervical smears were prepared and examined independently by 2 cytotechnologists and confirmed by a pathologist. Cervical lesions were classified according to the Bethesda System for cervical cytology 2001.Out of the 592 women for whom a Pap smear was available for evaluation, 555 (93.8%) were negative for intraepithelial lesion or malignancy. Eight women (1.4%) showed atypical squamous cells of undetermined significance (ASCUS), 9 (1.4%) low-grade squamous intraepithelial lesions, and 2 (0.3%) high-grade squamous intraepithelial lesions. A total of 15 (2.5%) smears were unsatisfactory for cervical cytology. Additionally, 3 women (0.5%) had squamous cell carcinoma, giving an overall rate of 3.7% for epithelial cell abnormalities.Cervical cancer and precursor epithelial cell abnormalities are common among women in Kumasi for a disease that can be prevented by early detection through routine screening and management. This study provides adequate background data to recommend the implementation of cervical cancer screening in all eligible women in Ghana.

Trends Over Time in Pap and Pap-HPV Cotesting for Cervical Cancer Screening.

BACKGROUND: In 2012, updated cervical cancer screening recommendations were released with consensus on Papanicolaou (Pap) testing every 3 years for women age 21-65 years or Pap-human papillomavirus (HPV) cotesting at 5-year intervals for women age 30-65 years. Primary study aims: Assess current use of Pap-HPV cotesting and describe local population trends over time in Pap and Pap-HPV cotesting. Secondary aim: Assess sociodemographic factors correlating with screening. METHODS: We assessed Rochester Epidemiology Project data for Pap and Pap-HPV cotesting among women age 16 years and older living in Olmsted County, Minnesota, yearly from 2005 (study population n = 47,203) through 2016 (study population n = 49,510). We calculated 3-year (Pap) and 5-year (Pap-HPV) moving prevalence rates of screening as proportion of eligible population. Multivariable logistic regression was used to assess factors potentially associated with screening. RESULTS: In 2016, 64.6% of 27,418 eligible 30- to 65-year-old women were up to date with cervical cancer screening; 60.8% had received Pap-HPV cotest screening. Significant declines in Pap completion rates over time were observed in all age groups, including an unexpected decline in 21- to 29-year-old women. Coincident with decreasing Pap screening rates, Pap-HPV cotesting significantly increased among women age 30-65 years, from 10.0% in 2007 to 60.8% in 2016. CONCLUSIONS: This suggests increasing adoption of 2012 screening recommendations in the 30- to 65-year-old population. However, decline in Pap screening among 21- to 29-year-old women is concerning. Disparities by race, ethnicity, smoking status, and comorbidity level were observed. Results suggest need for multilevel patient and clinician interventions to increase cervical cancer screening adherence.

Forecasting Participants in the All Women Count! Mammography Program.

INTRODUCTION: The All Women Count! (AWC!) program is a no-cost breast and cervical cancer screening program for qualifying women in South Dakota. Our study aimed to identify counties with similar socioeconomic characteristics and to estimate the number of women who will use the program for the next 5 years. METHODS: We used AWC! data and sociodemographic predictor variables (eg, poverty level [percentage of the population with an annual income at or below 200% of the Federal Poverty Level], median income) and a mixture of Gaussian regression time series models to perform clustering and forecasting simultaneously. Model selection was performed by using Bayesian information criterion (BIC). Forecasting of the predictor variables was done by using an autoregressive integrated moving average model. RESULTS: By using BIC, we identified 5 clusters showing the groups of South Dakota counties with similar characteristics in terms of predictor variables and the number of participants. The mixture model identified groups of counties with increasing or decreasing trends in participation and forecast averages per cluster. CONCLUSION: The mixture of regression time series model used in this study allowed for the identification of similar counties and provided a forecasting model for future years. Although several predictors contributed to program participation, we believe our forecasting analysis by county may provide useful information to improve the implementation of the AWC! program by informing program managers on the expected number of participants in the next 5 years. This, in turn, will help in data-driven resource allocation.

Updates in Cervical Cytology: The 90-Year-Long Journey from Battle Creek to Today.

Ninety years ago, at the Battle Creek conference, Papanicolaou introduced cervical exfoliative cytology. Since then, the "Pap test" has come a long way. The discovery of a causal relationship between cervical carcinoma and HPV infection opened the door for molecular testing and immunomarkers for HPV. The Clinical Laboratory Improvement Amendments, 1988, established quality assurance and quality control programs to monitor performance of cytology laboratories. The Bethesda System for reporting cervical cytology laid the foundations for cervical cytology education, implementation of management guidelines, and further research on cervical carcinogenesis. HPV vaccine penetration in both genders remains 62% or less.

Routine colonoscopy, diabetic eye care, mammogram and pap smear screening in vascular surgery patients.

Objective An increasing emphasis on preventive medicine has been supported by the recent reforms in United States health care system. Majority of the patients seen in vascular surgery clinics are elderly with more extensive medical comorbidities compared to the general population. Thus, these patients would be expected at higher risk for common malignant pathologies such as colon, breast and cervical cancer, and nonmalignant diseases such as diabetic retinopathy. This study looked at the screening compliance of vascular patients compared to data provided by Centers for Disease Control on the national and state levels. Methods The office records of 851 consecutive patients seen in Brooklyn and Staten Island vascular clinics were examined. We queried patients regarding their last colonoscopy, diabetic eye exams, recent mammograms, and Pap smears. Our patient screening compliance was compared between the two clinics as well as to the national and New York state data provided by Centers for Disease Control. Compliance with regard to patient's age was also examined. Results Patients referred to the Staten Island office have a better colonoscopy compliance compared to the Brooklyn office ( P = .0001) and the national Centers for Disease Control average ( P = .026). Compliance for mammography and cervical cancer screening was higher in Staten Island office compared to the Brooklyn office ( P = .0001, P < .0001), respectively. Compliance was lower for Pap smear ( P = .0273) in Brooklyn when compared to the national average. Compliance for colonoscopy increased with age for both clinics ( P = .001, P < .001), while Pap smear decreased ( P < .001, P = .004). Conclusion Patients in vascular clinics in an urban setting had better adherence to screening protocol than the national and state average, with the exception of female patients for colonoscopy in our Brooklyn vascular office. There exists variability in both patient populations based on sub-specific locality and demographics including socioeconomic status. Overall, however patients in Staten Island had better compliance and adherence to the screening protocol than Brooklyn vascular clinic.

Trends in Pap test practices and results: An 11-year review of the annual ACHA Pap Test and STI Survey.

OBJECTIVE: To conduct a trend analysis of Pap test practices, Pap test results and related women's services and guidelines of college health centers. PARTICIPANTS: College health centers who participated in the annual ACHA Pap Test and STI (sexually transmitted infection) Survey years 2004-2014 (n ranged from 127 to 181 depending on year). METHODS: Descriptive analyses are presented with ANOVAs (Analysis of Variance) and chi-square tests calculated to examine trends over time. RESULTS: The number of Pap tests significantly decreased over time; however, the percentage of normal and HSIL (high-grade squamous intraepithelial lesion) results did not vary. Availability of conventional cytology slides and cryotherapy were significantly associated with year. Over time, college health centers' guidelines related to initiation of Pap testing evolved to consistently conform to national recommendations for cervical screening. CONCLUSIONS: The results indicate most college health centers are following the current national guidelines regarding Pap testing for young adult women.

Changing Trends and Practices in Cytopathology.

OBJECTIVE: To explore the current and anticipated changes in the practice of cytopathology. STUDY DESIGN: The present review is based on a review of recent literature and an evaluation of the authors' personal experiences. RESULTS AND CONCLUSION: In recent years the practice of cytopathology, nationwide and in our institute, has witnessed a major change affecting gynecologic and nongynecologic cytology. There has been a decline in the number of Papanicolaou tests which has affected the utilization of cytotechnologists and provoked a reorganization of their work flow. The "need to do more with less" in the era of targeted therapy/personalized medicine has resulted in an increasing preference for needle core biopsy when performing a rapid on-site evaluation. We feel that this change is unavoidable. It is pertinent that cytopathologists as a group recognize this change and prepare themselves and the trainees not only to become adapt but also to use this as an opportunity to discover the yet unexplored world of cytology.

Time to clinical investigation for Indigenous and non-Indigenous Queensland women after a high grade abnormal Pap smear, 2000-2009.

OBJECTIVES: To investigate time to follow-up (clinical investigation) for Indigenous and non-Indigenous women in Queensland after a high grade abnormality (HGA) being detected by Pap smear. DESIGN, SETTING, PARTICIPANTS: Population-based retrospective cohort analysis of linked data from the Queensland Pap Smear Register (PSR), the Queensland Hospital Admitted Patient Data Collection, and the Queensland Cancer Registry. 34 980 women aged 20-68 years (including 1592 Indigenous women) with their first HGA Pap smear result recorded on the PSR (index smear) during 2000-2009 were included and followed to the end of 2010. MAIN OUTCOME MEASURES: Time from the index smear to clinical investigation (histology test or cancer diagnosis date), censored at 12 months. RESULTS: The proportion of women who had a clinical investigation within 2 months of a HGA finding was lower for Indigenous (34.1%; 95% CI, 31.8-36.4%) than for non-Indigenous women (46.5%; 95% CI, 46.0-47.0%; unadjusted incidence rate ratio [IRR], 0.65; 95% CI, 0.60-0.71). This difference remained after adjusting for place of residence, area-level disadvantage, and age group (adjusted IRR, 0.74; 95% CI, 0.68-0.81). However, Indigenous women who had not been followed up within 2 months were subsequently more likely to have a clinical investigation than non-Indigenous women (adjusted IRR for 2-4 month interval, 1.21; 95% CI, 1.08-1.36); by 6 months, a similar proportion of Indigenous (62.2%; 95% CI, 59.8-64.6%) and non-Indigenous women (62.8%; 95% CI, 62.2-63.3%) had been followed up. CONCLUSIONS: Prompt follow-up after a HGA Pap smear finding needs to improve for Indigenous women. Nevertheless, slow follow-up is a smaller contributor to their higher cervical cancer incidence and mortality than their lower participation in cervical screening.

A Systematic Review of the Factors Influencing Ethnic Minority Women's Cervical Cancer Screening Behavior: From Intrapersonal to Policy Level.

BACKGROUND: Cervical cancer can be prevented by effective screening using Papanicolaou tests, but the utilization rate is lower among ethnic minorities than in the general population. Understanding the factors influencing minorities' use of such screening can aid the design of an appropriate intervention to increase their uptake rate. OBJECTIVE: The aims of this study were to examine the factors that influence ethnic minority women in using cervical cancer screening and the similarities and differences in associated factors across different groups and to explore the interrelationships between the factors identified. METHODS: A literature search was conducted using Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature Plus, Scopus, PsycINFO, and PubMed. Furthermore, 1390 articles were retrieved, of which 24 met the inclusion criteria. Critical appraisal was performed by means of a quality assessment tool. The findings were summarized in tabular and narrative forms. RESULTS: The findings showed that certain factors commonly affected ethnic minority women's screening behavior, including knowledge, attitude and perceptions, physician's recommendation, quality of care and service, language, and acculturation. Culture-related factors, religion, and acculturation exhibited close interrelationships with the attitude and perceptions factor, resulting in behavioral change. CONCLUSIONS: The review sheds light on how common or unique are the factors across ethnic minorities and how these factors interact to influence behavior. Further studies are warranted to develop and test empirically a comprehensive model leading to a better understanding of the interrelationships between multiple factors. IMPLICATIONS FOR PRACTICE: The model should be useful in informing policy makers about appropriate resource allocation and in guiding the development of culturally relevant programs to increase screening uptake.

Cervical cancer screening among homeless women in the Greater Paris Area (France): results of the ENFAMS survey.

Little is known about the prevalence of cervical cancer screening (CCS) and its correlates among homeless women in France. The objectives of this study were to determine the prevalence of women who had never been screened for cervical cancer and to identify the associated factors. This cross-sectional study was based on data collected in the ENFAMS survey, which was conducted in 2013 among 764 sheltered homeless mothers in the Greater Paris Area. Robust Poisson regression models were used to estimate the association between no lifetime CCS and certain sociodemographic and health-related factors (selected from the behavioral model of vulnerable populations). Analyses were carried out separately for women with and without a regular gynaecological follow-up (RGF). The proportion of never-screeners was 33% among the women with an RGF versus 64% among those without an RGF (P<0.001). Among the latter, never having been screened for CCS was associated mainly with socioeconomic conditions, the length of time lived in France, a history of delivery in France and the duration of homelessness. In those with an RGF, the factors were mainly poor health service utilization and language difficulties. This first quantitative study of CCS among homeless women in the Greater Paris Area points to the need for it to be proposed and performed more systematically in primary care. Every contact between this hard-to-reach population and health services should be an opportunity to check their screening status and to ensure that those in need actually undergo a Pap test.

Trends in cervical cancer incidence in younger US women from 2000 to 2013.

OBJECTIVE: This study aimed to assess the temporal trends in invasive cervical cancer (ICC) incidence rates among 21-25year-olds. US guidelines no longer recommend screening prior to age 21, and concerns have been raised that delayed screening initiation may increase ICC incidence among young women. METHODS: This study utilized ICC incidence data from 18 US population-based cancer registries in SEER from 2000 to 2013 and Pap test prevalence data from the Behavioral Risk Factor Surveillance System from 1996 to 2012. Trends were evaluated with annual percent changes (APCs) using Joinpoint regression. RESULTS: The prevalence of never having a Pap test before age 21 increased from 22.0% in 1996-2004 to 38.3% in 2006-2012 (APC=+5.48, 95%CI=+4.20, +7.50). Despite this decline in screening, ICC incidence among 21-23year olds significantly declined between 2000 and 13 (APC=-5.36, 95%CI=-7.83,-2.82), particularly from 2006 to 2013 (APC=-9.70, 95%CI=-15.79, -3.17). ICC incidence remained constant among 24-25year olds (APC=+0.45, 95%CI=-2.00, 2.97). Compared to women born in 1978-1985, women born in 1986-1991 had a higher prevalence of never receiving a Pap test prior to 21 (35.4% vs. 22.1%, p<0.001), but a lower ICC incidence at 21-23 (0.98 vs. 1.55 per 100,000, p<0.001). CONCLUSION: While US females born in 1986-1991 were less likely to receive a Pap test before age 21, diagnoses of ICC in the early 20s were rare and lower than for those born in earlier years. This provides reassurance that the updated guidelines to delay screening until 21 has not resulted in a population-level increase in ICC rates among young women.

Citología Papanicolaou 100 años. Un éxito compartido / A hundred years of Papanicolaou cytology: a success shared

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Federal Support for Family Planning Clinics Associated with Dramatic Gains in Cervical Cancer Screening.

BACKGROUND: Since the 1990s, policymakers have successfully increased cervical cancer screening through federal and state public policies. However, the most dramatic gains in Pap smear use occurred in the 1960's and 70's, during the establishment of federal support for family planning clinics through the War on Poverty and Title X. This study estimated the effect of this support on cervical cancer screening, and quantified its role in dramatic increases in Pap smear use. METHODS: Using a natural experiment in the timing and receipt of federal family planning grants, the screening behavior of women who did and did not have access to a federally funded family planning clinic were analyzed. Cross-sectional probability models of annual and lifetime Pap smear use using the 1970 National Fertility Survey were estimated and linked to administrative data on grant timing and receipt between 1964 and 1973. FINDINGS: Federal support for family planning clinics was associated with a 7-percentage point increase in annual use (p < .01), and a 5-percentage point decrease in never use of the Pap smear (p < .001). Scaled by the fraction of women who used funded clinics, federal support for family planning was associated with a roughly 70% increase in Pap smear use. Estimates suggest that the establishment of federal support could explain as much as 15% of the national increase in Pap smear use between 1966 and 1973. CONCLUSIONS: Federal support for family planning played an important--and previously unacknowledged--role in promoting cervical cancer screening and investments in future health.

Pap Test Reporting Rates for Conventional Smear and Liquid-Based Cervical Cytology from the Largest Academic Women's Hospital in China: Analysis of 1,248,785 Pap Test Reports.

OBJECTIVE: The Obstetrics and Gynecology Hospital of Fudan University (OGHFU) in Shanghai is the largest academic women's hospital in China. Between 2009 and 2014, the use of liquid-based cytology (LBC) significantly increased while gradually adopting the Bethesda System (TBS), and in 2012 local regulations mandated that pathologists replace technicians to sign out Pap tests. DESIGN: A retrospective OGHFU database search documented all Pap test reports between 2009 and 2014 by specimen type, either LBC or conventional Pap smears (CPS), and final reporting category. A total of 1,224,785 Pap reports were analyzed to document variations in Pap test reporting during a period of major change in cervical screening in China. RESULTS: LBC gradually replaced CPS, which declined from over 65% of Pap tests in 2010 to 6.4% in 2014. Of 514,811 Pap reports using the traditional class system, class I (negative) reports accounted for 98.3% of results. With the introduction of TBS reporting, pathologist reviews and substantial replacement of CPS by LBC, the laboratory abnormal Pap test rate increased significantly to almost 5%. CONCLUSIONS: Changes in cervical cytology reporting between 2009 and 2014 in China's largest academic women's hospital reflected both increased use of LBC and the introduction of pathologist TBS reporting. Abnormality rates increased significantly and fell within CAP benchmark ranges.