Obstacles to Follow After Abnormal Cervical Cytology at an Urban Health Center in Worcester, MA
Department of Family Medicine and Community Health
Adler, R; Golding, J; Rafferty, E; Savageau, J.
Uterine Cervical Neoplasms; Vaginal Smears; Uterine Cervical Dysplasia; Patient Compliance; Follow-Up Studies
Community Health and Preventive Medicine | Health Services Research | Obstetrics and Gynecology | Oncology
Background: Despite the profound decrease in deaths from cervical cancer since the advent of the Papanicolaou smear, approximately 4,000 women still die of the disease annually in the US1. Women diagnosed with cervical cancer are likely to have never been screened, to not have been screened in the last 5 years, or to not have had appropriate follow-up2. More than 10% of cervical cancer cases in the US involve sub-optimal follow-up after abnormal screening3. Socio-economically disadvantaged women and minority women are at the greatest risk for default4. Numerous studies have investigated barriers to screening but few have examined the follow-up behaviors of women diagnosed with cervical dysplasia.
Methods:We identified 106 women who had recently been diagnosed with abnormal Papanicolaou smears. Charts were reviewed and sociodemographic and clinical information collected. Women were subsequently surveyed by mail or phone. The survey questions addressed numerous potential barriers to appointment attendance and compliance status as well as satisfaction with patient care and knowledge about HPV and cervical cancer.
Results:Medicaid insured patients were less likely to be compliant with recommended follow-up compared to privately insured patients (p=.005). Women who reported using their own cars as their primary transportation to appointments were more likely to be adherent to follow-up recommendations than patients who used another form (p=.013). Patients who lived within the city zip codes were less likely than those living outside the city to comply (p=.033). Patients who correctly described the follow-up plan as documented in their chart were also more likely to be adherent to follow-up recommendations (p=.039).
Additional variables bordered on significance when analyzed. Patients who subjectively reported that it was “not difficult” to get time off from work to attend appointments were more likely to comply with follow-up (p=.055). Patients who experienced colposcopy in the past were possibly more likely to adhere to recommended follow-up (p=.057).
Discussion:Adherence to recommended follow-up after abnormal pap smear results is correlated to identifiable factors in the population studied. Low economic status predicts default from follow-up. Physical barriers such as transportation challenges and difficulty getting time off from work should also be considered in assessing a patient’s risk of non-compliance. The practitioner-patient communication regarding the follow-up plan and the patient’s ability to retain this information also affects follow-up behavior. Patient knowledge about the disease process does not seem to influence whether patients return for recommended appointments.
1. Jamal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun M, Cancer Statistics, 2003. CA Cancer J Clin 2003; 53:5-26
2. US Preventive Services Task Force. Screening for cervical cancer: recommendations and rationale. AmFam Physician 2003;67:1759-66.
3. Janerich DT, Hajimichael O, Schwartz PE, Lowell DM, Meigs JW, Merino MJ et al. The screening histories of women with invasive cervical cancer, CT. Am J Public Health 1995;85:791-4.
4. Bernard VB, Lee NC, Piper M, Richardson L. Race-specific results of Papanicolaou testing and the rate of cervical neoplasia in the National Breast and Cervical Cancer Early Detection Program, 1991-1998 (United States). Cancer Causes Control 2001; 12:16-8.
Senior Scholars Program
Seymour, Patricia, "Obstacles to Follow After Abnormal Cervical Cytology at an Urban Health Center in Worcester, MA" (2007). University of Massachusetts Medical School. Senior Scholars Program. Paper 55.