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Primary care providers play a crucial role in cancer control, including screening and follow-up. In particular, they are often responsible for performing the initial screening and, when necessary, discussing appropriate treatment options. However, cancer screening practices in primary care can vary significantly, leading to disparities in access to these services.
Arvizo and Mahdi discuss disparities in cervical cancer screening, noting that African American women have a higher risk of developing and dying of cervical cancer than white women, possibly because they are diagnosed at a later stage and have lower stage-specific survival rates. The authors state that equal access to healthcare may help mitigate these factors, and they also discuss how primary care providers can reduce these disparities.
Even in patients who have access to regular primary care, other barriers to cancer screening may exist. A 2014 study used self-reported data from the Behavioral Risk Factor Surveillance System survey to assess barriers to cervical cancer screening in older women (ages 40 to 65) who reported having health insurance and a personal healthcare provider. Those who were never or rarely screened for cervical cancer were more likely than those who were regularly screened to have a chronic condition, such as heart disease, chronic obstructive pulmonary disease, arthritis, depression kidney disease, or diabetes.
This finding suggests that cancer screening may be a low priority during an adult primary care visit in which multiple chronic diseases must be addressed. To reduce disparities in cancer screening, primary care systems need to be designed to optimize delivery of preventive care and disease management using a team approach.
Arvizo and Mahdi also discuss the follow-up of abnormal screening Papanicolaou (Pap) smears. While appropriate follow-up is a key factor in the management of cervical dysplasia, follow-up rates vary among African American women. System-level interventions such as the use of an electronic medical record-based tracking system in primary care settings with established protocols for follow-up may be effective.
But even with such systems in place, patients may face psychosocial barriers (e.g., lack of health literacy, distress after receiving an abnormal cervical cytology test result) that prevent them from seeking additional care. To improve follow-up rates, providers must be aware of these barriers and know how to address them through effective communication.
Finally, the association between human papilloma virus (HPV) infection and cervical cancer makes HPV vaccination a crucial step in cervical cancer prevention. Continued provider education regarding HPV vaccination can improve knowledge about the HPV vaccine, as well as improve vaccination rates. The recent approval of a two-dose vaccine schedule for younger girls may also help improve vaccine series completion rates.
Improving cervical cancer screening rates and follow-up will require providers and patients to be aware of cervical cancer risk factors. Further, system-level practice interventions will optimize primary care providers’ ability to engage patients in cancer screening conversations and ensure timely follow-up of screening tests.
Dr. Misra-Hebert is staff in the Department of Internal Medicine and a clinician investigator in the Center for Value Based Care Research at Cleveland Clinic.
This is an abridged excerpt from an editorial previously printed in Cleveland Clinic Journal of Medicine. For full article and reference list, click here.