cervical cancer screening, diagnosis and treatment ... · cervical cancer screening, diagnosis and...

Cervical Cancer Screening, Diagnosis and TreatmentInterventions for Racial and Ethnic Minorities: A Systematic Review

Susan B. Glick, MD1, Amanda R. Clarke, MPH2,3, Anita Blanchard, MD4, and Amy K. Whitaker, MD, MS4

1Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL, USA; 2Robert Wood Johnson FoundationFinding Answers: Disparities Research for Change National Program Office, Chicago, IL, USA; 3Center for Health and the Social Sciences,University of Chicago, Chicago, IL, USA; 4Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA.

OBJECTIVES: To systematically review the literature todetermine which interventions improve the screening,diagnosis or treatment of cervical cancer for racial and/or ethnic minorities.DATA SOURCES: Medline on OVID, Cochrane Registerof Controlled Trials, CINAHL, PsycINFO and CochraneSystematic Reviews.STUDY ELIGIBILITY CRITERIA, PARTICIPANTS ANDINTERVENTIONS: We searched the above databases fororiginal articles published in English with at least oneintervention designed to improve cervical cancer pre-vention, screening, diagnosis or treatment that linkedparticipants to the healthcare system; that focused onUS racial and/or ethnic minority populations; and thatmeasured health outcomes. Articles were reviewed todetermine the population, intervention(s), and out-comes. Articles published through August 2010 wereincluded.STUDY APPRAISAL AND SYNTHESIS METHODS: Oneauthor rated the methodological quality of each of theincluded articles. The strength of evidence was assessedusing the criteria developed by the GRADE WorkingGroup.45,46

RESULTS: Thirty-one studies were included. Thestrength of evidence is moderate that telephone supportwith navigation increases the rate of screening forcervical cancer in Spanish- and English-speaking pop-ulations; low that education delivered by lay healtheducators with navigation increases the rate of screen-ing for cervical cancer for Latinas, Chinese Americansand Vietnamese Americans; low that a single visit forscreening for cervical cancer and follow up of anabnormal result improves the diagnosis and treatmentof premalignant disease of the cervix for Latinas; andlow that telephone counseling increases the diagnosisand treatment of premalignant lesions of the cervix forAfrican Americans.LIMITATIONS: Studies that did not focus on racialand/or ethnic minority populations may have beenexcluded. In addition, this review excluded interven-tions that did not link racial and ethnic minorities tothe health care system. While inclusion of these studiesmay have altered our findings, they were outside thescope of our review.CONCLUSIONS AND IMPLICATIONS OF KEYFINDINGS: Patient navigation with telephone supportor education may be effective at improving screening,diagnosis, and treatment among racial and ethnic

minorities. Research is needed to determine the appli-cability of the findings beyond the populations studied.

KEY WORDS: cervical cancer; disparities; minority health; equity;

intervention.

J Gen Intern Med 27(8):1016–32

DOI: 10.1007/s11606-012-2052-2

© Society of General Internal Medicine 2012

INTRODUCTION

Though cervical cancer is a preventable illness, US womencontinue to develop this disease and to die from it. In 2011,12,710 US women were expected to be diagnosed with and4290 women to die from cervical cancer.1 The burden ofcervical cancer is not shared equally among women of allraces and ethnicities. While the age-adjusted incidence rateof cervical cancer for all US women is 8.1 per 100,000women per year,1 Latinas have a significantly higherincidence of cervical cancer (11.1 per 100,000 women), asdo African-American women (10.0 per 100,000).2 Theincidence is five times higher among Vietnamese Americanwomen than white women.3

In addition, the mortality from cervical cancer is higher forAfrican-American women (4.4 per 100,000 women), Latinas(3.1 per 100,000), and Native Americans/Native Alaskans(3.4 per 100,000), than it is for whites (2.2 per 100,000) andAsians/Pacific Islanders (2.1 per 100,000).1,4–6 Mortalityfrom cervical cancer shows geographic variation in the US,with higher mortality rates among African-Americans in theDeep South, Latinas on the Texas-Mexico border, whitewomen in Appalachia, rural New York State and northernNew England, Native Americans living in the NorthernPlains, and Native Alaskans.3 The mortality rate amongforeign-born women is increasing, especially in the South.3

Because premalignant cervical disease progresses slowlyto malignancy and is easily detected and treated, thecontinued existence of cervical cancer and the disparitiesin cervical cancer rates in the US are concerning. Humanpapillomavirus (HPV), a sexually transmitted infection, isimplicated as the cause of almost all cervical cancerworldwide, so interventions that promote safe sexual

1016

practices and HPV vaccination should theoretically elimi-nate the incidence of cervical cancer.7 In addition, becausethe Papanicolaou (Pap) smear is a safe, low cost andrelatively noninvasive screening test for cervical cancer,interventions targeted at increasing screening uptake andpromotion of follow-up after abnormal screening shoulddecrease the incidence of cervical cancer as well. Finally,because members of different racial and ethnic groups tendto achieve similar outcomes when they receive similartreatment, interventions that promote equal care andtreatment should decrease mortality from cervical cancer.8

Unfortunately, the continued existence of cervical cancer andthe disparities noted in its incidence and mortality suggest thatthese interventions have not been wholly successful. Amongthose newly diagnosed with cervical cancer, 30–60 % havenever had a screening test.47,48 Up to 15 % have hadinadequate follow up after an abnormal Pap smear.48 Sixty toeighty percent of women diagnosed with advanced cervicalcancer have not had a screening test within the past 5 years.49,50

Interventions that maximize the prevention, screening, diagno-sis or treatment of cervical cancer are critical to eradicate thisdisease. Currently, there exists no consolidated evaluation ofthe intervention research literature to determine which inter-

ventions improve cervical cancer prevention, screening, diag-nosis or treatment for racial or ethnic minorities in the US. Thepurpose of this systematic review is to fill that gap.

METHODS

Data Sources and Searches

We conducted a systematic review of the English languageliterature to assess studies that described and evaluatedinterventions with the potential to improve cervical cancerprevention, screening, diagnosis or treatment for racial and/or ethnic minorities in the United States. We conducted anelectronic search of the following five databases from theirinception through August 2010: MEDLINE on OVID, TheCochrane Register of Controlled Trials, CINAHL, Psy-cINFO, and Cochrane Systematic Reviews. We used anidentical search strategy for each database (see Text Box 1).In addition, we searched the reference sections of relevantreview articles as well as all included studies for additionalmanuscripts. This review does not have a publishedprotocol and therefore, was not registered.

Study Selection and Data Extraction

Titles and abstracts were reviewed by one author to determineeligibility for inclusion. Eligible studies had to meet all fiveinclusion criteria: 1) represent an original study; 2) include atleast one intervention designed to improve cervical cancerprevention, screening, diagnosis or treatment that linkedparticipants to the healthcare system; 3) present data for racialand/or ethnic minority populations in the US; 4) measuredirect outcomes such as HPV vaccination (cervical cancerprevention), Pap tests (cervical cancer screening), follow up

of abnormal Pap smears (cervical cancer diagnosis ortreatment of premalignant disease of the cervix) or treatmentof cervical cancer; and 5) report findings in English. We didnot include conference abstracts or unpublished studies.Articles not meeting inclusion criteria were reviewed by asecond author. When possible, disagreements were resolvedby discussion; when this was not possible, a third authorevaluated the title and abstract. Articles not recommended forexclusion were then reviewed in full. Following full textreview, those articles that did not meet all five inclusion

Text Box 1. Search Strategy

1017Glick et al.: Cervical Cancer Interventions for MinoritiesJGIM

criteria were excluded from further review using the processdescribed above for the title and abstract review. Figure 1summarizes the literature search and data selection process.

Data Synthesis and Analysis

We reviewed the included articles to determine the population,intervention(s) outcomes, study design and sample size. Wedid not contact authors about the possibility of unpublishedsubgroup analyses. One author rated the methodologicalquality of each of the included articles using a modifiedscoring algorithm based on criteria developed by Downs andBlack (DB).9 To describe the risk of methodological bias foreach study, we added one item from the Cochrane Collabo-ration tool10 to the DB tool, resulting in a maximum modifiedDB score of 29. Articles with a DB score >20 have been foundto be of very good quality, those with scores 15–19 are ofgood quality, 11–14 of fair quality and <10 of poor quality.43

A second author conducted a 23 % re-review of publications;the interrater Pearson’s correlation coefficient was .97.To determine the effect of each type of intervention, we

classified studies by intervention type. Because mostintervention strategies consisted of more than one interven-tion, we also grouped studies with similar interventioncomponents together to determine the effect of the combina-tion of interventions. We evaluated the strength of evidencefor individual interventions and for groups of similarinterventions using the criteria developed by the GRADEWorking Group.45,46 This system utilizes four domains (bias,

consistency, directness, and precision) to assess the strengthof evidence as high, moderate, low, or insufficient.

RESULTS

Search Results

After removal of duplicates, the electronic search of the fivedatabases yielded 2371 articles (Fig. 1). Following title andabstract review, we excluded 2192 articles for failure tomeet one of the inclusion criteria, leaving 179 articles forfull text review. Following full text review, 149 articles didnot meet one or more of the inclusion criteria and wereexcluded; 21 of these studies were excluded due to lack oflinkage to the health care setting. This left 30 interventionstudies for detailed review. Review of the reference lists ofrelevant review articles and of all included studies identifiedone additional article for inclusion.31 Therefore, 31 studieswere included in this systematic review.

Data Synthesis

Twenty-four studies described interventions to increasecervical cancer screening and six studies described inter-ventions to improve the diagnosis and treatment ofpremalignant lesions of the cervix. One study describedinterventions both to increase screening for cervical cancerand to improve the diagnosis and treatment of malignant or

Figure 1. Summary of literature search and selection process.

1018 Glick et al.: Cervical Cancer Interventions for Minorities JGIM

premalignant lesions of the cervix.42 No studies describedinterventions to improve HPV vaccination.

Quality Assessment

Of the studies of interventions to improve screening forcervical cancer in racial and ethnic minority popula-tions, one was of very good quality,14 ten were of goodquality,15,22,23,32–36,39,40 12 were of fair quality,12,13,16–21,25,37,38,41 and one was of poor quality.26 Of thestudies of interventions to improve the diagnosis andtreatment of premalignant disease of the cervix, three were ofgood quality27–29 and three were of fair quality.24,30,31 Thesingle study that included both types of interventions was offair quality.42 The average modified DB score of includedarticles was 15 (range 9–23). In comparison, for a recentgroup of systematic reviews of interventions to reducedisparities, the average DB score was 18 out of a maximumscore of 27 points.11

Types of Interventions Examined

Of the 25 studies evaluating interventions to improve the rateof screening for cervical cancer, eight included a singleintervention12,17,32–34,38,40,42 and 17 included multiple inter-ventions.13–16,18–23,25,26,35–37,39,41 The most common inter-ventions were educational materials and education programs.Nineteen interventions included educational materi-als12,13,15,16,18–23,25,26,32,33,36,37,39–41 and 15 included educa-tion programs.15,16,18,19,21–23,25,26,35–37,39,41 Seveninterventions included navigation (including assistance sched-uling appointments, finding low-cost sources of care and withtransportation),13–15,22,23,35,36 five included strategies to pro-vide low-cost screening,16,21,26,37,42 five included strategies toimprove access to screening,17,18,21,34,38,39 four includedreminders for healthcare providers,18–20,25,41 four includedadvertisements,22,25,26,39 four included office policies andprocedures (such as protocols or tracking systems),18,25,26,41

three included telephone counseling or support,13,14,20 twoincluded feedback for providers on screening rates,18,41 andone included upgraded equipment.18

Of the seven studies evaluating interventions to improve thediagnosis and treatment of premalignant disease of the cervixin minority populations, two involved telephone counsel-ing.27,28 One study created a streamlined process for cervicalcancer screening and follow up of abnormalities29; oneincluded intensive follow up and/or vouchers for reduced-cost care30; and one included a personalized letter andpamphlet and/or an audiovisual presentation and/or transpor-tation incentives.31 One study included written educationalmaterials, education programs, and messages in the media24;and one evaluated the Breast and Cervical Cancer Preventionand Treatment Act of 2000, which authorized Medicaidexpansion to cover treatment of patients screened under the

Breast and Cervical Cancer Mortality Prevention Act andfound to have an abnormal Pap smear.42

Impact of Interventions to Increase Screening

Of the eight studies that included a single intervention, fourevaluated the effect of educational materials alone toincrease the rate of screening for cervical cancer in minoritypopulations.12,32,33,40 For two of these studies, the educa-tional materials consisted of letters32,40; for the other twostudies, the intervention consisted of videos.12,33 Overall,Jibaja–Weiss found an increase in the rate of screening forcervical cancer for patients who received a form letter(43.9 % form letter vs. 39.9 % control), though not forpatients who received a tailored letter (23.7 % tailored lettervs. 39.9 % control).40 However, this difference was notstatistically significant. After examining the findings bypatient race and ethnicity, Jibaja–Weiss found a statisticallysignificant decrease in the rate of screening for cervicalcancer for African American, Mexican American and whitewomen who received a tailored letter.32 While white womenwho received a form letter experienced increased odds ofscreening (OR 2.13, 95 % CI 1.13–4.03); African Americanand Mexican American patients did not (for AfricanAmericans, OR 0.96, 95 % CI 0.63–1.46; for MexicanAmericans, OR 1.17, 95 % CI 0.78–1.76). Rivers found thatwhen the Pap smear was described as detection behavior, agroup of African American, Latino and white women weretwice as likely to obtain a Pap smear when the message wasloss-framed than when it was gain-framed (95 % CI 0.91–4.39).33 When the Pap smear was described as preventionbehavior, women were no more likely to obtain a Pap smearwhen the message was gain-framed than when it was loss-framed (OR 1.14, 95 % CI 0.55–2.36).33 Yancey showededucational videos to a sample of low income AfricanAmerican, Latina and white women in a clinic waitingroom. She found the proportion of women seen in the clinicreceiving screening was higher during intervention weeksthan during control weeks (clinic 1: 26.9 % intervention vs.19.4 % control, p=0.01; clinic 2 14.6 % interventionvs.10.3 % control, p=0.02).12 Because of the inconsistenteffect of the interventions, the strength of evidence thateducational materials improve screening for cervical cancerin minority populations is insufficient (Tables 1 and 2).Of the remaining four studies that addressed a single

intervention to improve screening for cervical cancer in racialor ethnic minority populations,17,34,38,42 each evaluated theimpact of a unique intervention. Margolis evaluated theimpact of using lay health advisers to offer women due forscreening an appointment with a female nurse practitioner.34

Because of the moderate risk of bias given this single studythat utilized a quasi-experimental design and the lack of astatistically significant impact for minority populations, thestrength of evidence is insufficient that offering women an


Tab

le1.

Intervention

sto

Increase

ScreeningforCervicalCan

cerin

MinorityPop

ulation

s

Reference

DB

Quality

Score

Intervention

StudyDesign

Sam

ple

size,pop

ulation

Lengthof

Follow-up

Results

Con

tent

Typ

e*

DietrichAJ,et

al.

Ann

alsof

Internal

Medicine.

2006

.

23Telephonesupportcallsincluding

navigationprovided

byaprevention

caremanager.

E-T

RCT

N=1,41

3Wom

enattend

ing

amigrant

orcommun

ityhealth

center.Spanish

speakers:39

.2%;Eng

lish

speakers:49

.5%;Other:11.3

%

18mon

ths

Changeinproportionof

wom

enup

todateforcervicalcancer

screening0.07

(95%

CI0.03–

0.11).(Interventiongroup71

%baseline,78

%post-

ntervention;comparison

group

70%

baseline,70

%post-

intervention.)

PN

Jibaja–W

eiss,etal.

Patient

Education

andCounseling.

2003.

20Interventio

n1:

Tailoredletters

E-P

RCT

N=1,57

4African

American,

Hispanicandno

n-Hispanic

white

wom

enattend

ingan

urbanCHC.Mexican

American:42

%African

American:40

%White:18

%

12mon

ths

23.7%

inthetailoredlettergroup

received

screeningvs.43.9%

intheform

lettergroupvs.39.9%

control(notstatistically

significant).

Interventio

n2:

Form

letters

PR

Fernandez,etal.

American

Journal

ofPublicHealth.

2009.

19Edu

catio

nalmaterialsinclud

ing

writtenmaterialsandvideo.

Edu

catio

nby

layhealth

workers.

Navigation

E-P

Cluster

RCT

N=24

3Low

income,

low

literacyLatinafarm

workers

aged

50andolder.Latino:

100%

6mon

ths

Thoughahigher

percentage

ofwom

enin

theinterventio

ngroupcompleted

screening

comparedto

thecontrol

group(39.5%

vs.23.6%,

p<0.05),intentionto

treat

analysisrevealed

nostatistically

significant

difference

incervical

cancer

screeningbetweenthegroups

(24.2%

vs.18.9

%,p>0.05).

E-V

E-IP

LHW

PN

MockJ,et

al.

American

Journal

ofPu

blic

Health

.2007.

19Interventio

n:Edu

catio

nby

layhealth

workers.Writteneducational

materials.Navigation.

Adv

ertisem

entsin

print,television

andradio.

LHW

Quasi-Exp

erim

ental:

case

/con

trol

N=10

05Vietnam

eseAmerican

wom

en.Vietnam

ese

American:10

0%

3–4mon

ths

Rateof

Papsm

earinintervention

groupincreasedfrom

65.8%

to81.8%

(p<0.001);control

groupincreasedfrom

70.1

%to

75.5

%(p<0.001).Increase

incombinedintervention

groupsignificantly

greater

than

thatin

mediaonly

group

(Ztestp=0.001).

Con

trol:Adv

ertisem

entsin

print,

television

andradio.

Written

educationalmaterials.

E-P

E-IP

PN

AD

WangX,etal.

Journalof

Wom

en’s

Health.2010.

18Interventio

n:Edu

catio

nalmaterials

(writtenmaterials,videos).

Edu

catio

nby

layhealth

educators

andby

race

andlang

uage

concordant

physician.

Navigation.

E-P

Quasi-Exp

erim

ental:

case

/con

trol

N=13

4Chinese

American

wom

en,predom

inantly

low-

income,

uninsured,

recent

immigrants.Chinese:10

0%

12mon

ths

Screeningrate70

%intervention

vs.11.1%

control,p<0.001.

Contro

l:Generalhealth

educationby

layhealth

educators.Written

educationalmaterialsincluding

inform

ationaboutsitesthatprovided

free

screening.

Encouragementto

visitprovidersforscreening.

E-V

E-IP

LHW

PN

RELC


Table

1.(c

ontinue

d)

Reference

DB

Quality

Score

Intervention

StudyDesign

Sam

ple

size,pop

ulation

Lengthof

Follow-up

Results

Con

tent

Typ

e*

Jibaja–W

eiss

ML,

etal.Journalof

Health

Carefor

thePoo

rand

Und

erserved.20

05.

16Interventio

n1:

Tailo

redletters

E-P

second

aryanalysis

ofRCT

N=1,57

4Low

incomeAfrican

American,Mexican

American

andno

n-Hispanicwhitewom

enattend

ingacommun

ityhealth

center.Mexican

American:42

%.African

American:40

%.

White:18

%

12mon

ths

From

logisticregression

analysis:T

ailoredletterOR

0.52

(0.35–0.79)forAfrican

Americans;(0.34–0.82)for

Mexican

Americans;0.25

(0.11–0.54)forwhites.Form

letter0.96

(0.63–1.46)for

African

Americans;1.17

(0.78–

1.76)forMexican

Americans;

2.13

(1.13–4.03)forwhites

Interventio

n2:

Form

letters

PR

Jand

orfL,et

al.

Progressin

Com

mun

ityHealth

Partnerships:

Research,

Edu

catio

n,and

Action.

2008

.

17Edu

catio

nby

staffandlay

health

workers.Navigation.

E-IP

Cluster

RCT

N=48

7Latinas.Latino:

100%

2mon

ths

At2

monthfollowup,rateof

Pap

smearscreeningwas

51%

interventiongroupvs.30%

control(p0.0801).In

multivariateanalysisof

wom

ennonadherenttoscreening

guidelines

atenrollm

ent,the

interventionwas

associated

with

increasedodds

ofhaving

aPapsm

ear(OR3.9,95

%CI

1.1–14.1p=0.0437).

LHW

PN

Margo

lisKL.

Journalof

General

Internal

Medicine.

1998

.

16Lay

health

advisers

offered

wom

enwho

weredu

efor

screeningan

appo

intm

ent

with

afemalenu

rsepractitioner.

LHW

Quasi-exp

erim

ental:

controlledtrial

N=96

7(for

cervical

cancer

screening).Wom

enattend

inga

non-prim

arycare

outpatient

clinic

atacoun

tymedical

center.African

American

=15–1

8%.White=63–6

5%.

NativeAmerican

=12–1

5%.

Other=5–7%

12mon

ths

Atfollowup,the

screeningrate

increasedintheintervention

groupcomparedtousualcare

(70.3%

vs.62.9%,p

=0.02).

Whilethescreeningrate

increasedforAfrican

American

wom

enandfor

NativeAmerican

wom

en,this

increase

was

notstatistically

significant.

PN

RiversSE,et

al.

Journalof

Health

Psycholog

y.20

05.

16Videoswith

loss-or

gain-framed

messagesabou

tcervical

cancer

preventio

nor

detection.

E-V

Quasi-exp

erim

ental:

rand

omized

2x2

factorialdesign

N=44

1Peopleattend

inga

commun

ityhealth

clinic.

African

American:59

%.

Latino:

27%.White:11

%.

Other:3%

12mon

ths

WhenthePapwas

describ

edas

detectionbehavior,w

omen

were2.00

times

morelikelyto

obtainaPapwhenthe

message

was

loss-framed

than

whenitwas

gain-framed

(95

%CI0.91–4.39).W

henthe

Papwas

describ

edas

preventionbehavior,w

omen

were1.14

times

moreliketo

obtainaPapwhenthe

message

was

gain-ram

edthan

whenitwas

loss-framed

(95%

CI0.55–2.36).


Table

1.(c

ontinue

d)

Reference

DB

Quality

Score

Intervention

StudyDesign

Sam

ple

size,pop

ulation

Lengthof

Follow-up

Results

Con

tent

Typ

e*

Taylor

VM.Journal

oftheNational

CancerInstitute.

2002.

16Intervention1:Education

delivered

bybiculturaltrilingual

Chinese

femaleoutreach

worker.

Educationalm

aterials(written,

video).N

avigation.Intervention

E-IP

Randomized

controlled

trial

N=48

2Chinese

wom

enin

SeattleandVancouv

erwho

hadno

thadPap

testingin

the

last2yearsand/or

didno

tintend

tohave

aPap

inthe

next

twoyears.Chinese:10

0%

6mon

ths

ForparticipantsattheUSstudy

site,the

rateof

Paptestinginthe

intervalbetweenrandom

ization

andfollowup

was

37%

for

intervention1(p=0.07

vs.

control),22

%forintervention

2(p

0.98

vscontrol),and

22%

forthecontrol.The

rateof

Pap

testingin

theprior2yearswas

69%

forintervention1

(p<0.001vs.control,p=0.01

vs.intervention2),48

%for

intervention2(p=0.34

vs.

control),and39

%forthe

control.

2:Educationalmaterials(written,

video),includinginform

ation

aboutclinicswith

Chinese

language

interpreterservices

and

inform

ationaboutcoverage

ofcervicalcancer

screeningby

publicandprivateinsurers

E-P

E-V

PN

RELC

SuarezL,et

al.

American

Journal

ofPreventive

Medicine.

1997

.

15Educatio

ndeliv

ered

bytelevision,

newspapersandradio,as

wellasby

layhealth

workers.W

ritten

educationalm

aterialsincluding

inform

ationaboutclin

icsoffering

low-costexaminations.C

reationof

acancer

consortiu

m.

LHW

Quasi-exp

erim

ental:

before/after

design

N=92

3Low

-incom

eMexican

American

wom

enage40

and

older.Mexican

American:

100%

3years

Post-interventio

n,thepercent

ofwom

enreportingarecent

Papsm

earincreasedby

5.9%

intheinterventiongroup

(45.5%

to51.4%)andby

6.6%

inthecontrolg

roup

(50.1%

to56.7%).These

differenceswerenot

statistically

significant.

E-IP

AD

E-P

CL

Rim

erBK.Patient

Edu

catio

nand

Cou

nseling.

1999

.

14Interventio

n1:

Tailoredprom

ptsfor

prov

iders

Pr-R

Single-site

rand

omized

trial.

N=889Predom

inantly

low

incomewom

en.African

American:81

%.White:19

%

16mon

ths

Propo

rtionof

wom

enwho

received

cervical

cancer

screeningwas

high

erin

the

interventio

n3grou

p:64

%vs.52

%interventio

n2vs.

56%

interventio

n1,

p=0.05

.

Intervention2 :

Tailored

communications

topatients(letter,

newsletter).

E-P

Intervention3:

Tailored

communications

toprovider

(new

sletter)andpatients(letter,

telephonecounseling.

E-T

PaskettED,et

al.

Cancer

Epidemiology,

Biomarkers

and

Prevention.

1999

.

14Educationby

layhealtheducators.

Educationalinformation(written).

Advertisem

ents(busses,newspapers,

radio).E

ducationforhealthcare

providers.Visualpromptsin

exam

inationroom

s.Protocoland

tracking

system

forwom

enwith

abnorm

altestresults.P

ersonalized

lettersforwom

enwith

abnorm

altest

results.

LHW

Quasi-exp

erim

ental:

before/after

design

Baseline:

n=24

83years

Wom

enintheinterventioncity

weremorelikelytohave

received

cervicalcancer

screeninginthepast3years

comparedtothecontrolcity

(adjustedOR3.8,95

%CI1.6–9.2).

E-IP

Post-interventio

n:n=30

2.E-P

Predo

minantly

low

income

wom

enAD

African

American:66–9

2%

Pr-R

TS

PR

CME

PF

E-V

RP

CH

UE


Table

1.(c

ontinue

d)

Reference

DB

Quality

Score

Intervention

StudyDesign

Sam

ple

size,pop

ulation

Lengthof

Follow-up

Results

Con

tent

Typ

e*

Bastani

R,et

al.

Med

Care.

2002

.14

Contin

uing

medicaleducationfor

health

care

providers(w

orkshops,

meetin

gs).Referralforms,chart

reminderstam

ps,new

sletter,

feedback

onscreeningratesfor

providers.Educatio

nalm

aterials

forpatients(w

ritten,videos).Clin

iclevelchanges

(protocolsforfollo

wup

ofabnorm

alPap

smearsandfor

routinescreening,increasedclinic

hours,im

proved

staffing,upgraded

equipm

ent).

Quasi-experim

ental:

longitu

dinal

nonequivalentcontrol

groupdesign,w

ithindependentrandom

samples

before

andafter

interventio

n

N=18

,642

Predo

minantly

low

incomewom

en.Latino:

57%;African

American:

15%;White:14

%;Other:

14%

2.5years

The

rateof

screeningforcervical

cancerincreasedforthe

interventionsitesvs.contro

lsitesatboththehospital

(adjustedOR3.06,95%

CI

2.07–4.54)

andthecommunity

healthcenterlevels(adjusted

OR2.34,95%

CI1.05–5.23).

Noeffectwas

seen

inthepublic

healthcenters(adjustedOR

1.00,95%

CI0.63–1.56).

OrnsteinSM.

Journalof

Fam

ilyPractice.

1991

.

14Writtenphysicianreminders,

patient

remindersor

both.

Educatio

nsessions

forphysicians,

ahealth

maintenance

flow

sheet,

andchartaudits

inboth

interventio

nandcontrolsites.

Pr-R

Quasi-exp

erim

ental:

before/after

design

Patients:baseline:n=7397;

African

American:61

%;

White:38

%;Other:2%;

Physicians:N=49;race/

ethnicity

datanotcollected

12mon

ths

Allsitesshow

edadecrease

inpercentage

ofpatients

compliantwith

screeningfor

cervicalcancer:physician

reminders-2.1%,p

=0.12;

patient

reminders-4.5

%,p=

0.001,

both

reminders-0.8

%,

p=0.60;control-0.9

%,

p=0.54).

P-R

E-IP

TS

Yancey.

Preventive

Medicine.

1995

.14

Six

videos

abou

tcervical

and

breastcancer

preventio

nwere

show

ncontinuo

usly

inthe

waitin

groom

sof

twoclinics.

E-V

Quasi-exp

erim

ental:

one-week-on

-1-w

eek-

offstud

ydesign

N=1,74

4Predo

minantly

low

incomewom

en.

6mon

ths

The

proportionof

wom

enseen

intheclinicreceivingscreening

was

significantly

higherduring

interventionweeks

than

during

controlw

eeks

(clinic1:26.9%

interventionvs.19.4%

control,

p=0.01;clinic214.6

%interventionvs.10.3%

control,

p=0.02).

Latino:

65%

African

American:21

%White:10

%Other:4%

Ngu

yenBH,et

al.

Journalof

Cancer

Edu

catio

n.20

00.

13Ph

ysicianremindersystem

,health

educationmaterialsforphysicians

togive

patients(w

ritten,videos),

continuing

medicaleducationfor

physicians

includingwritten

materialswith

inform

ationabout

low-costo

ptions

forcare,

newslettersforphysicians,and

access

toinform

ationaboutcancer

treatm

entand

research

for

physicians.

Pr-R

Rando

mized

controlled

trialof

physicians.

Physician

s:n=20

;Vietnam

ese:

100%

3year

intervention

period;post

intervention

followup

notreported

Inmultiv

ariableanalysis,

physicians

intheinterventio

ngrouphadahigher

performance

rateof

cervical

cancer

screeningthan

controls

(p=.004).

E-P

E-V

CME


Table

1.(c

ontinue

d)

Reference

DB

Quality

Score

Intervention

StudyDesign

Sam

ple

size,pop

ulation

Lengthof

Follow-up

Results

Con

tent

Typ

e*

Sox

CH,et

al.

Journalof

Com

mun

ityHealth

.19

99.

13Com

munity

health

aidestrainedto

perform

cervicalcancer

screening.

CHW

Quasi-exp

erim

ental:

before/after

design

N=8villageswith

1098

wom

en;NativeAlaskan:

100%

12mon

ths

The

proportionof

wom

enreceivingaPaptestduring

the

baselineandfollowup

periods

increasedintheintervention

group(0.44+/-0.04

to0.48

+/-

0.05),butnotinthecontrol

group(0.42+/-0.04

to0.39

+/-

0.02).The

change

inproportionbetween

interventionandcontrolgroups

was

notstatisticallysignificant

(p=0.37).

Beach,et

al.

Cancer

Epidemiology,

Biomarkers

and

Prevention.

2007

13Langu

age-concordant

teleph

one

supp

ortforwom

enno

tup

-to-date

onscreening,

includ

ingnavigatio

n.Writteneducationalmaterialswere

mailedto

patients.

RELC

Quasi-exp

erim

ental:

second

aryanalysisof

data

from

arand

omized

controlledtrial

N=1,34

6Predo

minantly

low

incomewom

en18

mon

thsor

until

fully

up-to-date

with

screening

(whichever

camefirst)

For

allwom

en,increased

up-to-date

status

forcervical

cancer

screeningin

interventio

ngrou

pvs.con

trol

grou

p(adjustedOR1.73

,95

%CI1.31

–2.27).Greater

benefitforSpanish-speaking

wom

en(adjustedOR2.18

,95

%CI1.52–3

.13).

E-T

Spanish

speakers:63

%PN

Eng

lishspeakers:37

%E-P

Gotay

CC,et

al.

Preventive

Medicine.

2000

.

13Edu

catio

nby

layhealth

educators.

Edu

catio

nalmaterials(w

ritten,

audiov

isual).Vou

chersforfree

screening.

Accessto

awom

en’s

clinic

with

alayhealth

educator

inattend

ance.

LHW

E-IP

Quasi-exp

erim

ental:

prospectivecoho

rtstud

y,usingpo

pulatio

n-based

teleph

onesurveysto

assess

screeningbefore

andafterinterventio

n

N=67

8;NativeHaw

aiians:

100%

3years

The

prop

ortio

nof

wom

encompliant

with

screening

increasedsign

ificantly

(59%

to67

%,p<0.05

)in

the

interventio

ncommun

itybu

tno

tin

thecontrolcommun

ity(63to

64%,p>0.05

).

E-P

E-V

PN

V

Lantz

PM,et

al.

Wom

en’sHealth

Issues.20

09.

12Medicaidexpansionto

cover

treatm

entforpatientsthroug

hthe

BreastandCervicalCancer

PreventionandTreatmentAct

of20

00.

PQuasi-exp

erim

ental:fixed

effects,retrospective

long

itudinaltim

eseries

design

.

N=45

,321

;White:61

.1%

5yearsprior

tothe

interventio

nand5years

afterthe

interventio

n

Propo

rtionof

peop

lescreened

who

hadan

abno

rmal

Pap

test

decreasedforblackwom

enfrom

1995

–00to

2001

–05

(11.9%

to10

.6%,p<0.05

;andincreasedforHispanic

wom

en(22.4%

to22

.7%,p<0.05

).


Table

1.(c

ontinue

d)

Reference

DB

Quality

Score

Intervention

StudyDesign

Sam

ple

size,pop

ulation

Lengthof

Follow-up

Results

Con

tent

Typ

e*

Latino:

22.6

%11–15

mon

ths

Rateof

screeningincreasedin

both

theinterventio

nclinic

(17.8%

to56.9%,p

<0.01)

andthecontrolclinic

(11.8to

18.2,p>0.05),though

the

increase

inthecontrolclinic

was

notstatistically

significant.

African

American:11.1

%Asian:2.0%

American

Indian:1.2%

Other:2.1%

MandelblattJ.

Journalof

General

Internal

Med.19

93.

12Sam

e-daycervical

cancer

screening

byanu

rsepractitionerdu

ring

routineprim

arycare

clinic

visits.

ISQuasi-exp

erim

ental:

Before/afterdesign

.Baseline:

n=35

4Post:n=31

9Elderly

wom

enInterventio

n:African

American:93

.0%

White:0.5%

Other/Unk

nown:

6.5%;

Con

trol:

African

American:81

.9%

White:14

.8%

Other/Unk

nown:

3.2%

Tho

mpson

B,et

al.

CancerCauses

andCon

trol.

2006

.

12Com

mun

itylevelinterventio

ns:

health

fairs,blockparties,

festivals,funruns.Edu

catio

nal

presentatio

ns.Edu

catio

nal

materialsdistribu

ted.

E-P

Cluster

rand

omized

controlledtrial

N=17

95;Latino:

46.8

%30

mon

ths

Betweentheinterventionand

controlgroups,therewas

nosignificantdifference

inthe

percentofHispanicwom

eneverscreened

forcervical

cancer(91%

vs.89%,p

=0.44)andthepercent

compliant

with

screening(94.2

%vs.93.7

%,p=0.83).The

percentof

non-Hispanicwhite

wom

enever

screened

increasedin

theintervention

groupcomparedto

thecontrol

group(99.6%

vs96.3

%,p=

0.04)as

didthepercentof

wom

encomplaint

with

screening(80.4%

vs88.2

%,

p=0.02).

Organizationallevelinterventions:

Staffandvolunteersspread

messagesaboutcancerprevention.

Free

orreducedcostscreening.

E-IP

White:47

.8%

Smallgrou

plevel:Edu

catio

nal

presentatio

ns.

HF

Individu

allevel:Edu

catio

nby

layhealth

educators.

LHW

FS


Table

1.(c

ontinue

d)

Reference

DB

Quality

Score

Intervention

StudyDesign

Sam

ple

size,pop

ulation

Lengthof

Follow-up

Results

Con

tent

Typ

e*

Whitm

anS,et

al.

Fam

ilyand

Com

mun

ityHealth

.19

94.

11Edu

catio

nby

nurses

andou

treach

workers.Writteneducational

materials.Invitatio

nto

receive

free

screening.

E-P

Quasi-exp

erim

ental:

controlledtrial

N=22

99;African

American:

100%

18mon

ths

The

percentofpatientsscreened

forcervicalcancerincreasedin

theinterventiongroup(12%

atbaselinevs.26%

post-

intervention,p<0.001),but

decreasedin

thecontrolgroup

(39%

vs.17

%,p<0.001).

E-IP

PR

FosterJ,et

al.

Journalof

Cancer

Edu

catio

n.19

88

9Free

cervicalcancerscreening.

Advertisem

entsandmediacoverage

toprom

otescreening.Standardized

procedureforscreeningof

outpatients.Com

munity

cancer

educationprogram.D

issemination

ofinform

ationaboutearlydetection.

FS

Quasi-exp

erim

ental:

before/after

design

N=44

8;African

American:

81%;White:19

%12–1

8mon

ths

Com

paredtothepre-

interventionperiod

(1970–76),

theratio

ofinsitutoinvasive

carcinom

asincreasedforblack

wom

eninallage

groups

exceptage70–79(in

sufficient

samplesize)andage10–19

(p=0.01).In

addition,

therate

ofcervicalcancer

decreased

forblackwom

enin

allage

groups

(p>0.05

age10–19,

p=0.05

age20–29,

p=0.01

for

allotheragegroups).

AD

RP

E-IP

E-P


appointment with a female nurse practitioner increasesscreening for cervical cancer in minority populations (seeTables 1 and 2). The fair or poor quality of the three otherstudies that addressed a single intervention to improvescreening for cervical cancer in minority populations confersa high risk of bias. Therefore, the strength of evidence forthese interventions is also insufficient (see Tables 1 and 2).Of the studies that evaluated the impact of multiple

interventions, five included education delivered by layhealth workers plus navigation in combination with otherinterventions (educational materials and/or messages in themedia), on the rate of screening for cervical cancer.15,22,23,35,36

Compared to control, all found an increase in the rate ofscreening for cervical cancer with the intervention. Wangfound a 70 % rate of screening for cervical cancer with theintervention for Chinese American women compared to11.1 % for the control condition (p<0.001).23 Mock foundincreases in the rate of screening for cervical cancer forVietnamese women in both intervention and control groups(intervention 65.8 % to 81.8 %, p<0.001; control 70.1 % to75.5 %, p<0.001).22 The increase in the intervention groupwas significantly greater than that in the control (Z test p=0.001).22 Fernandez found that 39.5 % of Latinas in theintervention group completed screening compared to 23.6 %in the control group (p<0.05).36 However, intention to treatanalysis showed no significant difference in the rate ofscreening.36 Taylor found an increase in Pap testing forChinese women in the interval between randomization andthe follow up survey (37 % vs. 22 %); however, this findingwas not statistically significant.15 Jandorf also found anincrease in the rate of Pap smear screening following theintervention for Latinas that was not statistically significant(51 % vs. 30 %, p=0.0801).35 However, multivariate analysisrevealed a statistically significant adjusted odds ratio of 3.9

for the effect of the intervention on adherence to screening(95 % CI 1.1–14.1).35 Because of the low risk of bias due tothe presence of multiple good quality studies, the consistencyof study findings, and the imprecise estimates of effect, thestrength of evidence is low that education delivered by layhealth educators together with navigation increases the rate ofscreening for cervical cancer for minority populations(Tables 1 and 2).Two of the studies that evaluated the impact of multiple

interventions on screening for cervical cancer examined theeffect of navigation and telephone support.13,14 One of thesestudies also included written educational materials13; theother did not. Following the intervention, Dietrich found a7 % increase in the proportion of women up to date forcervical cancer screening (95 % CI 0.03–0.11).14 Similarly,Beach found an increase in the up-to-date status for cervicalcancer screening in the intervention group compared to thecontrol group (adjusted odds ratio 1.73, 95 % CI 1.31–2.27).13

The benefit was greater for Spanish-speaking women than forEnglish-speaking women (adjusted OR for Spanish-speakingwomen 2.18, 95 % CI 1.52–3.13; adjusted OR for English-speaking women 1.25, 95 % CI 0.81–1.91).13 Because of thelow risk of bias due to one randomized controlled trial of verygood quality, the consistency of study findings, and theprecise estimate of effect, the strength of evidence is moderatethat telephone support together with navigation increases therate of screening for cervical cancer for minority populations(Tables 1 and 2).The remaining studies that evaluated the impact of

multiple interventions on screening for cervical cancerexamined the effect of unique combinations of interven-tions.18–21,25,26,39,41 Due to the high risk of bias conferredby a single quasi-experimental study of good quality39 or asingle study of fair or poor quality,16,18–21,25,26,37,41 the

Table 2. Strength of Evidence for the Intervention on the Rate of Screening for Cervical Cancer

Intervention Strategy No. of Studies Risk of Bias Consistency Directness Precision Grade

Educational Materials 1 RCT and 3 Quasi-experimental Moderate Inconsistent Direct Imprecise InsufficientLay health advisers offered anappointment to women duefor screening

1 Quasi-experimental High Unknown Direct Imprecise Insufficient

Community health aides trainedto perform cervical cancerscreening


Medicaid expansion to covertreatment for patients throughthe Breast and CervicalCancer Prevention andTreatment Act of 2000


Same-day cervical cancerscreening by a nursepractitioner during routineprimary care clinic visits


Lay health workers plusnavigation

1 RCT, 2 Cluster RCT,2 Quasi-Experimental

Low Consistent Direct Imprecise Low

Telephone support plusnavigation

1 RCT, 1 Quasi-experimental Low Consistent Direct Precise Moderate


Tab

le3.

Intervention

sto

Improve

Follow

Upof

anAbnormal

Pap

SmearforMinorityPop

ulation

s

Reference

DB

Quality

Score

Intervention

StudyDesign

Sam

ple

size,

pop

ulation

Lengthof

Follow-up

Results

Con

tent

Typ

e

Brewster

WR,etal.

Journalof

the

American

medical

Association.

2005.

19Singlevisitfor

Papsm

earandfollo

wup

ofan

abnorm

alresult(H

GSIL,

AGUSor

carcinom

a).

S-T

RCT

N=3521;Latina:79.5

%singlevisit

6–12

mon

ths

Forw

omen

whosePapsm

earrevealedHGSIL/

AGUS,

88%

inthesinglevisitprogram

vs.

53%

intheusualcaregroupweretreated

within6monthsof

diagnosis(p=0.04);in

addition,63

%inthesinglevisitprogram

vs.

21%

intheusualcare

groupreturned

one

year

laterforrecommendedfollow

upPap

testing(p=0.02).

79.1%

usualcare;

White:

16.6%

singlevisit

16.4%

usualcare;

Other:

3.9%

sing

levisit

4.6%

usualcare

Lerman

C,etal.

Journalof

Clinical

Oncology.1992.

16Telephonecounselingtoincrease

adherencetofollowup

andtreatment

amongwom

ennoncom

pliantwith

theirfirstcolposcopy

appointment.

E-T

RCT

N=90;African

American:84.4

%Not

repo

rted

67%

intheinterventiongroupwereadherent

tocolposcopy

comparedto43

%inthe

controlgroup

(p<0.05).The

odds

ofadherenceto

colposcopy

were2.6tim

eshigher

fortheinterventiongroupthan

the

controlgroup(p<0.003).

Latino:

8.9%

White:6.7%

Miller.Journalof

the

NationalCancer

Institute.1997.

16Brieftelephonecounselingfollowing

anabnorm

alPapsm

earwith

orwithouta

boostercallpriorto

colposcopy.

E-T

Quasi-exp

erim

ental:

controlledtrial

N=82

8;African

American:86

%6mon

ths

Com

paredtotelephoneappointment

confirmation,telephonecounselingresulted

inincreasedadherencetotheinitial

colposcopy

appointment(76

%vs.68%,O

R1.50,95%

CI1.04–2.17),and

forattendance

atthe6-monthcolposcopy

appointment(61

%vs.36%,O

R2.70,95%

CI1.15–6.51).

Com

paredtotelephoneappointment

confirm

ation,standard

careresultedin

decreasedadherencetotheinitialcolposcopy

appointment(50

%vs.68%,O

R=0.47,95%

CI0.32–0.73)

anddidnotimpactadherence

torepeat(6

month)colposcopy.

Latino:

6%

White:6%

Other:2%

MarcusAC,et

al.

Medical

Care.

1992

.

14Personalized

follow-upletterand

pamphletoran

audiovisualprogram

onpapsm

earsor

transportation

incentives

(bus

passes/parking

perm

its).

PR

Quasi-exp

erim

ental:

2x2x

2factorial

N=20

44Predom

inantly

low

incomewom

en.

Hispanic41.4%

4mon

ths

Forthetransportationincentiveintervention,

theodds

ratio

ofreturningforfollowup

was

1.48

(95%

CI1.06–2.06).F

orthe

combinationpersonalized

form

letterand

audiovisualintervention,theodds

ratio


was

2.30

(95%

CI

1.21–4.34).

E-P

Black

27.7

%

E-V

White

26.7

%

V

Asian

2.7%

Other

1.6%


Table

3.(c

ontinue

d)

Reference

DB

Quality

Score

Intervention

StudyDesign

Sam

ple

size,

pop

ulation

Lengthof

Follow-up

Results

Con

tent

Typ

e

LantzPM

,etal.

Wom

en’sHealth

Issues.2009.

12Medicaidexpansiontocover

treatmentfor

patientsthroughthe

Breastand

CervicalC

ancer

PreventionandTreatmentA

ctof

2000.

PQuasi-exp

erim

ental:

fixedeffects,

retrospective

long

itudinaltim

eseries

design

N=45

,321

;White:

61.1

%5yearspriorto

the

interventio

nand5

yearsafterthe

interventio

n.

The

numberof

days

todefinitivediagnosis

decreasedby

12.8%

forwhitewom

en.T

heaveragetim

ebetweenadiagnosisof

cervical

dysplasiaor

cancerandinitiationof

treatm

ent

increasedsignificantly

forBlack

and

Hispanicwom

en.T

heprobabilitythatBlack

wom

enwouldinitiatetreatmentw

ithin60

days

ofacervicalcancerdiagnosisdecreased

9%

(-0.094,95

%CI-0.178

to-0.01).

Latino:

22.6

%African

American:

11.1

%Asian:2.0%

American

Indian:

1.2%

Other:2.1%

MarcusAC,et

al.

11Intensivefollo

wup

,vo

uchers

orbo

th.

PR

Quasi-exp

erim

ental:

2×2factorial

N=14

53Predo

minantly

low

incomewom

en

4–6mon

ths

Com

paredtothecontrolcondition,theodds


wereapproximately

50%

higherintheintensivefollowup

(OR

1.56,95%

CI1

.12–2.17,p

<0.01)andin

the

voucherconditions(OR1.50,95

%CI

1.09–2.05,

p<.01).The

combined

interventionwas

notsignificantly

relatedto

follow

upcare

aftertaking

into

accountthe

maineffectsof

both

interventions.

MedicalCare.1998.

V

Latino:

84%

African

American:

7.6%

White:5.8%

Other

2.6%

MichielutteR,etal.

Health

Education

Research.

1994.

11Messagesin

themedia.E

ducatio

nal

materials(w

ritten).E

ducatio

nfor

patientsandthecommunity.

Educatio

nforproviders

(presentations,w

rittenmaterials).

AD

Quasi-experim

ental:

singlegroup,

modifiedtrend

analysis.

N=87

8;African

12–1

8mon

ths

The

%of

blackwom

encompliantwith

follow

upandtreatmentofabnorm

alPaptests

increasedfrom

64%

pre-interventionto79

%post-intervention(p<0.001).

E-P

American:53

.1%

E-IP

White:46

.9%

*E-T=Educatio

ndelivered

bytelephone;PN=Patientnavigatio

n;E-P=Educatio

ndelivered

onprintm

aterials;P

R=Patientreminder;Pr-R=ProviderRem

inder;E-V=Educatio

ndelivered

inavideo;

E-IP=

Educatio

ndelivered

inperson;L

HW=Involvem

entofa

layhealthworker;AD=Public

advertisem

entsdelivered

inprint,television,orradio;RELC

=Patient-providerracial/ethnic/language

concordance;CL=

Learning

colla

borativeor

consortiu

m;TS

=Tracking

system

;CME=Contin

uing

medical

education;

PF=Perform

ance

feedback;RP=Revised

protocols;

CH=Changes

toclinic

hours;

UE=Upgraded

equipm

ent;CHW=Com

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Health

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strength of evidence is insufficient that these combinationsof interventions improve the rate of screening for cervicalcancer in minority populations (Tables 1 and 2).

Interventions to Improve Diagnosisor Treatment

Of the seven studies that evaluated the impact of interventionsto improve the diagnosis or treatment of premalignant diseaseof the cervix, four evaluated the impact of a singleintervention27–29,42 and three evaluated the impact of acombination of interventions.24,30,31 In a randomized con-trolled trial, Brewster evaluated a single visit for bothscreening for cervical cancer and follow up of an abnormalresult (High-Grade Squamous Intraepithelial Lesion (HGSIL),Atypical Glandular Cells of Uncertain Significance (AGUS)or carcinoma).29 She found that for women whose Pap smearrevealed HGSIL/AGUS, 88 % in the intervention group weretreated within six months of diagnosis compared to 53 % inthe usual care group (p=0.04).29 Because of the low risk ofbias given the study design and quality for this single study,the direct measurement of outcomes, and the precision of theestimate, the strength of evidence is low that a single visit forscreening for cervical cancer and follow up of an abnormalresult results in improvement in the diagnosis and treatmentof premalignant disease of the cervix in minority populations(Tables 3 and 4).Two studies assessed the impact of telephone counseling

on the diagnosis and treatment of premalignant disease ofthe cervix.27,28 Compared to the control group, Lermanfound the odds of adherence to colposcopy were 2.6 timeshigher for the intervention group (p<0.003).27 Miller foundthat compared to telephone appointment confirmation,telephone counseling resulted in increased adherence tothe initial colposcopy appointment (76 % vs. 68 %, OR1.50, 95 % CI 1.04–2.17), and for attendance at the six-month colposcopy appointment (61 % vs. 36 %, OR 2.70,95 % CI 1.15–6.51).28 Given the moderate risk of bias dueto one randomized controlled trial and one quasi-experi-mental study of good quality, the consistency of thefindings, and the precision of the estimate, the strength ofevidence is low that telephone counseling increases thediagnosis and treatment of premalignant lesions of thecervix for minority women (Tables 3 and 4).

One study evaluated the impact of Medicaid expansion tocover treatment for patients diagnosed with malignant orpremalignant disease of the cervix through the NationalBreast and Cervical Cancer Early Detection Program.42 Dueto the high risk of bias conferred by a single quasi-experimental study of fair quality and the lack of precisionaround the estimates, the strength of evidence is insufficientthat this intervention improves the diagnosis or treatment ofpremalignant disease of the cervix in minority populations(Tables 3 and 4).The three studies that evaluated the impact of multiple

interventions on screening for cervical cancer examined theeffect of unique combinations of interventions.24,30,31 Dueto the high risk of bias conferred by a single quasi-experimental study of fair quality, the strength of evidenceis insufficient that these combinations of interventionsimprove the diagnosis or treatment of premalignant diseaseof the cervix in minority populations.

DISCUSSION

Summary of Results

This systematic review found a moderate strength ofevidence that telephone support with navigation increasesthe rate of screening for cervical cancer in minoritypopulations. The strength of evidence is low that educationdelivered by lay health educators with navigation increasesthe rate of screening for cervical cancer in minoritypopulations. For all of the other interventions andcombinations of interventions studied, the strength ofevidence is insufficient that these interventions improvethe rate of screening for cervical cancer in minoritypopulations.This systematic review also found a low strength of

evidence that a single visit for screening for cervical cancerand follow up of an abnormal result improves the diagnosisand treatment of premalignant disease of the cervix inminority populations. In addition, the strength of evidenceis low that telephone counseling increases the diagnosis andtreatment of premalignant lesions of the cervix for minoritywomen. For all of the other interventions and combinationsof interventions studied, the strength of evidence isinsufficient that these interventions improve the diagnosis

Table 4. Strength of Evidence for the Intervention on the Diagnosis and Treatment of Premalignant Disease of the Cervix

Intervention strategy No. of studies Risk of bias Consistency Directness Precision Grade

Single visit for screening andfollow up

1 RCT Low Unknown Direct Precise Low

Telephone counseling 1 RCT, 1 Quasi-experimental Moderate Consistent Direct Precise LowMedicaid expansion to covertreatment for patients throughthe Breast and Cervical CancerPrevention and TreatmentAct of 2000



and treatment of premalignant lesions of the cervix forminority women.

Implications

For clinicians, administrators, policy makers and othersstriving to improve the rate of screening for cervical cancerin minority populations, telephone support with navigationand education programs by lay health educators withnavigation may be of benefit. Telephone support withnavigation has been shown to be effective for bothSpanish-speaking and English-speaking populations.13,14

Education programs led by lay health educators togetherwith navigation have been shown to be effective for Latina,Chinese and Vietnamese populations.22,23,36

A single visit for screening for cervical cancer and followup of an abnormal result may improve the diagnosis andtreatment of premalignant disease of the cervix for minoritypopulations, as may telephone counseling. A single visit forscreening and follow up was evaluated in a population thatwas predominantly Latina; therefore, its findings are mostapplicable to this group. Telephone counseling was evaluatedin a population that was predominantly African American;therefore, its conclusions are directly applicable to this group.

Limitations of the Systematic Review Process

Our search strategy may have overlooked studies that reporteddata on racial and ethnic minorities, but did not focus on thesepopulation groups. However, we feel this is unlikely becauseour search identified studies that focused on populations otherthan racial or ethnic minorities, such as women attending acommunity health clinic or low-income women.Because our aim was to evaluate the effectiveness of

interventions that linked participants to the health caresystem, we deliberately excluded 21 studies that failed to doso. While it is possible that inclusion of these studies wouldhave altered our findings, these studies were outside thescope of our systematic review.44

Though the original DB score has been validated and theuse of DB to categorize studies qualitatively has beendescribed,43 the use of this strategy to classify studies asvery good, good, fair or poor has not yet been validated.Therefore, it is possible that we have misclassified somestudies, especially those near the cut point for a qualitativescore. However, because we were conservative in ourestimate of risk of bias when determining the strength ofevidence, if misclassification were to have affected ourresults, it would have biased our findings toward the null.We neither searched for unpublished studies nor contacted

authors about potential unpublished subgroup analyses. Thus,the results of our review may be influenced by publicationbias and might bias our findings away from the null.

Recommendations for Future Research

While navigation seems a core element of the interventionsthat improve screening for cervical cancer in minoritypopulations, there is insufficient evidence to determinewhether navigation alone improves this outcome. Because asingle intervention may be more easily implemented and lesscostly than one that includes multiple elements, it isimportant to determine whether navigation alone improvesscreening for cervical cancer, as well as the added costs andbenefits of adding lay health education or telephone support.In addition, because the combination of navigation andeducation programs conducted by lay health educators havebeen inadequately studied in African Americans or NativeAmericans, future research should fill this gap. As navigationin conjunction with telephone support has been inadequatelystudied in populations that speak languages other thanEnglish or Spanish, further studies should confirm that thiscombination of interventions is effective in these populations.Interventions with the potential to improve the diagnosis

and treatment of premalignant lesions of the cervix areunderstudied. Future research should seek to extend thefindings of the Brewster study29 to additional populations,especially African Americans, Asian Americans and NativeAmericans. In addition, future research should confirm theeffect of telephone counseling in additional populations,notably Latinas, Asian Americans and Native Americans.

Funding Source: Support was provided by a grant from the RobertWood Johnson Foundation’s Finding Answers: Disparities Researchfor Change Program. The content is solely the responsibility of theauthors and does not necessarily represent the official views of theRobert Wood Johnson Foundation or of Finding Answers: DisparitiesResearch for Change Program.

Conflict of Interest: The authors declare that they do not have aconflict of interest.

Corresponding Author: Susan B. Glick, MD; Department ofMedicine, Section of General Internal Medicine, University ofChicago, Chicago, IL 60637, USA (e-mail: [email protected]).

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