Acceptability of self-sample human papillomavirus testing among medically underserved women visiting the emergency department
Introduction
Since its introduction in the 1940s, Papanicolaou test-based screening has dramatically impacted cervical cancer morbidity and mortality in the U.S. and other countries with population-based screening programs. However, sociocultural and structural barriers that limit screening coverage continue to pose significant challenges to the effectiveness of these programs, with most invasive cancers occurring in never- and under-screened women [1], [2], [3]. In the U.S., lack of health insurance is one of the most significant structural barriers to regular cervical cancer screening [4], [5], [6]. Women without health insurance are less likely to attend for screening, with only 63.8% of uninsured women reporting a Pap test in the past three years compared to 88.7% among privately insured women [7]. Uninsured women are also more likely to be diagnosed at more advanced stages of disease that require more intensive treatments with a decreased chance of cure [8], [9]. In one study, 35% of uninsured women and 34% of those with Medicaid had advanced cancer at diagnosis, compared to 25% among privately insured patients [8].
For many adults without health insurance, local emergency departments (EDs) often serve as a primary point of care, providing otherwise inaccessible healthcare services [10]. Given that the ED visit may represent an uninsured patient's only encounter with the healthcare system, many emergency providers advocate that the ED go beyond providing urgent care for a patient's chief complaint and become a platform for the delivery of public health interventions [11]. Interventions in this model include those that aim to identify and intervene with high-risk patients. Women who do not attend for cervical cancer screening undoubtedly represent a high-risk, hard-to-reach population that may benefit from opportunistic screening encounters.
The causal relationship between persistent infection with oncogenic (i.e., high-risk) human papillomavirus (HPV) and cervical cancer [12] has stimulated the application of high-risk HPV testing as a cervical cancer screening strategy. The U.S. Food and Drug Administration (FDA) recently approved the HPV test as an alternative to Pap testing for primary cervical cancer screening among women 25 years and older [13] based on substantial evidence that the detection of HPV DNA alone is superior to cytology for detecting high-grade cervical intraepithelial neoplasia [14], [15], [16], [17], [18]. The test's high sensitivity makes it a viable option for opportunistic screening in resource-constrained settings and among hard-to-reach populations. Evidence from resource-constrained settings indicates that a single HR-HPV test among women aged 30–59 years may be associated with up to a 50% reduction in the detection of advanced cervical cancer and cervical cancer mortality [17].
The feasibility of opportunistic HR-HPV screening is augmented by the test's ability to be conducted with similar specificity and sensitivity on both clinician- and self-collected cervical samples [19], [20], [21]. Self-collection, which can be done in an unsupervised manner and involves a fairly simple procedure, offers the advantage of privacy and the adaptability to informal settings, such as restrooms. Furthermore, a preponderance of data indicates that self-sample HPV testing effectively increases screening participation in otherwise never- and under-screened women [22], [23].
Self-sample HPV testing in public EDs may be a viable strategy to opportunistically screen women who otherwise do not attend for regular cervical cancer screening (screening non-attendees). Public EDs in large urban centers, such as that of Harris County, Texas, see a large volume of patients, with over 170,000 encounters per year logged in Harris County's two public EDs [24]. With an average wait time of 6 h (Harris Health System, unpublished data), women waiting in the ED represent a captive population in which to implement a public health intervention. The purpose of the present study was to describe patterns of cervical cancer screening utilization and the acceptability of self-sample HPV testing among patients seeking healthcare at two high-volume, urban public EDs.
Section snippets
Participant recruitment
Women 21 years of age and older were recruited from the ED waiting areas of two public hospitals in Houston (Lyndon B. Johnson and Ben Taub Hospitals). A two-stage cluster sampling design modeled after the World Health Organization's Expanded Programme on Immunizations (EPI) method [25] was used to systematically sample individuals. EPI cluster sampling affords the benefit of a probability-based sample when a simple random sample is not feasible due to time and cost constraints and/or the lack
Results
Of the 306 women approached, 224 (73.2%) agreed to participate. Of these, 216 (70.5%) were eligible and 210 (68.6%) completed the interview. Demographic and healthcare characteristics of the sample are summarized in Table 1. The mean age of study participants was 38.1 years. Hispanic women represented the largest racial/ethnic group (56.7%), followed by African Americans (24.8%) and Non-Hispanic Whites (17.1%). Most participants were born in the U.S. (59.3%), had a high school education or less
Discussion
Despite steady reductions in its incidence over the past 50 years, cervical cancer remains an important public health problem in the U.S. and elsewhere. In nations where population-based screening strategies have been implemented, the majority of women diagnosed with cervical cancer are never- and under-screened women [1], [2], [3]. The purpose of this study was to determine whether self-sample HPV testing is acceptable to women seeking care at two large EDs serving a medically underserved,
Conflict of interest statement
None of the authors have any conflicts of interest to declare.
Acknowledgements
We thank the leadership for the Departments of Emergency Medicine at Ben Taub and Lyndon B. Johnson hospitals for their support. The development of the instructional materials used in this project was made possible through a pilot grant from the Dan L. Duncan Cancer Center at Baylor College of Medicine. JRM is supported by a grant from the National Institutes of Health (P01CA082710, PI: M Follen).
References (40)
- et al.
Advanced cervical cancer treatment in Harris County: pilot evaluation of factors that prevent optimal therapy
Gynecol. Oncol.
(2006) - et al.
Efficacy of human papillomavirus testing for the detection of invasive cervical cancers and cervical intraepithelial neoplasia: a randomised controlled trial
Lancet Oncol.
(2010) - et al.
Are self-collected samples comparable to physician-collected cervical specimens for human papillomavirus DNA testing? A systematic review and meta-analysis
Gynecol. Oncol.
(2007) - et al.
Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis
Lancet Oncol.
(2014) - et al.
Self-sampling experiences among non-attendees to cervical screening
Gynecol. Oncol.
(2014) - et al.
Frequency and outcome of cervical cancer prevention failures in the United States
Am. J. Clin. Pathol.
(2007) - et al.
Uptake in cancer screening programmes: a priority in cancer control
Br. J. Cancer
(2009) - et al.
The screening histories of women with invasive cervical cancer, Connecticut
Am. J. Public Health
(1995) - et al.
Receipt of preventive care among adults: insurance status and usual source of care
Am. J. Public Health
(2003) - et al.
Use of health care services by lower-income and higher-income uninsured adults
JAMA
(2006)
Association of insurance with cancer care utilization and outcomes
CA Cancer J. Clin.
Cancer screening — United States, 2010
MMWR Morb. Mortal. Wkly Rep.
Ethnic disparities in cervical cancer survival among Medicare eligible women in a multiethnic population
Int. J. Gynecol. Cancer
Emergency Room Use Among Adults Aged 18–64: Early Release of Estimates From the National Health Interview Survey, January–June 2011
Public health in the emergency department: overcoming barriers to implementation and dissemination
Acad. Emerg. Med.
Human papillomavirus is a necessary cause of invasive cervical cancer worldwide
J. Pathol.
FDA news release: FDA approves first human papillomavirus test for primary cervical cancer screening
Human papillomavirus DNA versus Papanicolaou screening tests for cervical cancer
N. Engl. J. Med.
Rate of cervical cancer, severe intraepithelial neoplasia, and adenocarcinoma in situ in primary HPV DNA screening with cytology triage: randomised study within organised screening programme
BMJ
Age-specific evaluation of primary human papillomavirus screening vs conventional cytology in a randomized setting
J. Natl. Cancer Inst.
Cited by (20)
Self-Sampling for Human Papillomavirus Testing: Acceptability in a U.S. Safety Net Health System
2024, American Journal of Preventive Medicine
- 1
Drs. Scheurer and Ramondetta contributed equally to this work.