More than half of cervical cancer cases in the United States occur in women who have not had timely Pap smears and/or HPV tests — screenings that allow for detection of precancerous or cancerous cells on the cervix. Encouraging low-income women in particular to participate in such screenings likely would improve cancer detection and save lives, but health-care professionals have been uncertain of how best to improve patient adherence to screenings and follow-ups involving abnormal results.
Women with low incomes sometimes skip Pap smears and other cancer prevention screenings because they are focused on more pressing needs such as housing, food and other necessary expenses. So, researchers at Washington University in St. Louis evaluated efforts to help such women obtain cervical cancer screenings.
The scientists studied a group of female callers in Missouri seeking assistance from a free and confidential phone service that helps people find basic resources. The researchers determined that many female callers were due for cervical cancer screenings but most did not schedule one, even with the support of a health navigator, an individual trained to help people access medical care. Their findings indicate a new, more involved approach is needed to achieve such screenings and, ultimately, lower the number of women treated for advanced cancer.
“Reasons for inadequate screening are many and often deeply rooted to social and structural determinants of health that drive health inequities,” said first author Lindsay Kuroki, MD, assistant professor of obstetrics and gynecology at the School of Medicine. “We wanted to determine the need for cervical cancer screening among women seeking assistance with unmet basic needs and to assess different methods of encouraging callers to seek Pap screening. Connecting underserved women to cervical cancer-screening services and assisting them with barriers to access medical care can improve health equity and reduce cancer disparities.”
The findings are published in April in the American Journal of Obstetrics & Gynecology.
Participants were recruited from June 2010 through June 2012 from among callers to United Way 2-1-1 Missouri, a telephone helpline for local health and social service resources. Most callers seek help with basic needs such as food, utility bills, shelter and unexpected expenses.
Of 932 callers, 211 were referred for cervical cancer screenings. Callers were randomized to one of three conditions: phone call only; phone call and a print reminder; or a phone call and a personal navigator. The researchers looked at how many women contacted a clinic to schedule a Pap test one month after receiving a referral.
Patients in need of Pap screening had multiple cervical cancer risk factors. These women had a mean age of 48.2 years, were predominantly non-white, poor and unemployed, not married, and actively smoking. Nearly all (94.7%) female callers, regardless of their need for Pap testing, had at least one unmet basic need, with callers reporting an average of two unmet needs.
Women in the group that was assigned health navigators reported higher rates of contacting Pap services (29.6%) than those given phone calls only (15.1%), or phone calls and tailored print reminders (13.4%). Health navigators tripled the likelihood that women made contact with Pap services, and this remained true even among women with multiple unmet needs. Nevertheless, only 41 of 211 (19.4%) women who were overdue for Pap testing and received a referral contacted the referred clinic to schedule cervical cancer screenings.
The scientists said future research is necessary to understand how unmet basic needs pose barriers to cervical screening and how effective interventions to meet basic needs may lead to improved access to cancer prevention services. Some of these interventions might include immediate help such as assisting women with transportation and child care. Other interventions might focus on redesigning health systems and influencing social policy to provide women at risk for cervical cancer with secure homes free of hunger and tobacco.
“Women contacting 2-1-1 are likely to have health needs that greatly exceed those of the general population, in addition to lacking financial resources and social support required to seek cervical cancer screening,” said senior author Matthew Kreuter, PhD, the Kahn Family Professor of Public Health at the Brown School. “Continuing this line of research is critical to improving outcomes for low-income, medically underserved populations. No woman should die from a preventable cancer.”
Kuroki LM, Massad LS, Woolfolk C, et al. Cervical cancer risk and screening among women seeking assistance with basic needs. American Journal of Obstetrics & Gynecology, published online Dec. 11, 2020.
This work was supported by the National Cancer Institute, grant number P50-CA095815.
Washington University School of Medicine’s 1,500 faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is a leader in medical research, teaching and patient care, consistently ranking among the top medical schools in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.