Comparative community outreach to increase cervical cancer screening in the Mississippi Delta
Introduction
More than half of all cervical cancer occurring in the U.S. is found in medically underserved populations (http://www.cdc.gov/cancer/cervical/). Cervical cancer occurs mainly in these populations as part of a complex of diseases linked to poverty and/or racial/ethnic disparities (Freeman & Wingrove, 2007). Although targeting the necessary cause of cervical cancer, human papillomavirus (HPV), by vaccination shows tremendous promise for prevention (The FUTURE II Study Group, 2007, Garland et al., 2007, Paavonen et al., 2009), HPV vaccination does not prevent 30% of the cervical cancer caused by the untargeted HPV types nor does it treat the pre-existing HPV infections and related precursor conditions in the population (The FUTURE II Study Group, 2007, Hildesheim et al., 2007). Given that only 1/4 of U.S. adolescent women have received all three doses of their immunization against HPV vaccination (Centers for Disease Control and Prevention (CDC), 2010), who will glean the greatest benefit from HPV vaccination, and current HPV vaccines provide only 70% protection against cervical cancer, it seems likely that cervical cancer screening will be needed for decades to come, especially in under-served populations.
African-American women are more likely to get cervical cancer and twice as likely to die from cervical cancer than their Caucasian counterparts (Freeman & Wingrove, 2007). The disparities in cervical cancer incidence and mortality (Fig. 1) are still greater in the Mississippi Delta region (Freeman & Wingrove, 2007) than in other African-American populations. In our previous work in the Mississippi Delta region (Scarinci et al., 2010), we found that door-to-door recruitment was a more effective means to engage and recruit under-screened women in participating in cervical cancer screening. In that study, we found that under-screened women were willing to come to the clinic to participate, take a kit home for self-collection of a cervicovaginal specimen (for HPV testing), and return it to the clinic (unpublished data). However, that study was clinic based and women were offered a financial incentive to participate.
In a follow-up feasibility study, we conducted a door-to-door recruitment without incentive to determine what type of free intervention under-screened women living in the Mississippi Delta might choose and, given that choice, complete: clinic-based, physician-collected cervical specimens for Pap testing vs. home-based, self-collected cervicovaginal specimen for HPV testing.
Section snippets
Methods
We conducted a door-to-door recruitment in 4 towns (Sunflower, Moorhead, Inverness, and Doddsville) in Sunflower County, a high-risk population living in rural northwest Mississippi (Fig. 1), to identify women aged 26–65 years who might be eligible for the study in 2009–10 (Fig. 2). Among the 543 women identified in this age group, 95.0% (n = 516) were available to participate. We then excluded 394 (76.4%) women for the following a priori reasons (not mutually exclusive): 345 (66.9%) had a Pap
Results
Of the 119 participants (Fig. 2), 77 (64.7%) chose self-collection with HPV testing and 42 (35.3%) women selected clinic-based Pap testing; three women who had originally chose to get Pap testing later chose self-collection while one woman chose to switch from self-collection to Pap testing. All but 2 participants (117 of 119, 98.3%) were African American. Women who chose Pap testing were significantly older than those chose self-collection with HPV testing (median ages: 49 years vs. 39 years,
Discussion
In this feasibility study, we showed that offering free cervical cancer screening through direct contact could increase participation of under-screened, primarily African-American women living in the high-risk region of the Mississippi Delta. Importantly, we found that when offered, self-collection (using a complex sampling device) was more acceptable and effective intervention than offering free Pap testing at the local clinic.
We also noted with interest that it was women in their 30s and
Conflict of interes statement
The authors have no conflict of interest to report.
Acknowledgments
This research was supported by the Intramural Research Program of the NIH, NCI and by the NCI Center for Reducing Cancer Health Disparities (CRCHD). The authors acknowledge former members of CRCHD, Dr. Harold Freeman and Ms. Jane Daye for their unwavering support of this effort.
References (19)
- et al.
Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study
Lancet Oncol.
(2008) - et al.
Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women
Lancet
(2009) - et al.
Prevalence of cervical cancer and feasibility of screening in rural China: a pilot study for the Shanxi Province Cervical Cancer Screening Study
Int. J. Gynecol. Cancer
(1999) - et al.
Shanxi Province cervical cancer screening study II: self-sampling for high-risk human papillomavirus compared to direct sampling for human papillomavirus and liquid based cervical cytology
Int. J. Gynecol. Cancer
(2003) - et al.
Detection of carcinogenic human papillomavirus in specimens collected with a novel self-sampling device
J. Clin. Microbiol.
(2006) - et al.
Mouthwash as a low-cost and safe specimen transport medium for human papillomavirus DNA testing of cervicovaginal specimens
Cancer Epidemiol. Biomarkers Prev.
(2007) - et al.
Five-year experience of human papillomavirus DNA and papanicolaou test cotesting
Obstet. Gynecol.
(2009) National, state, and local area vaccination coverage among adolescents aged 13–17 years—United States, 2009. MMWR Morb.
Mortal. Wkly. Rep.
(2009)Patient navigation: a community based strategy to reduce cancer disparities
J. Urban Health
(2006)
Cited by (80)
A Brief Summary of the Current Role of Human Papillomavirus Testing in Cervical Cancer Screening
2023, Clinical Microbiology NewsletterCervical Cancer Screening
2023, Medical Clinics of North AmericaRedefining precision cancer prevention to promote health equity
2022, Trends in CancerFeasibility of sending a direct send HPV self-sampling kit to long-term non-attenders in an organized cervical screening program
2022, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :Out of the 23 HPV-positive samples, 17% (4/23) were samples returned after the reminder had been sent out. Out of the 4 HPV-positive women, 2/4 (50%) attended colposcopy and 1/4 (25%) had a histopathologically confirmed HSIL lesion and underwent conization (Fig. 1) [1–17]. A meta-analysis published in 2018 by Arbyn et al stated that participation rates were highly variable among settings, and therefore pilots should be set up before roll-out of HPV self-sampling programs [10].