Community-Based Screening Initiatives in Women's Health


The panel highlights initiatives to aid women in early cervical cancer diagnosis and intervention.

Derek van Amerongen, MD, MS: As we’ve seen cervical cancer rates decrease over the last 20 years, they do seem to have plateaued. So the question is understanding the issues around racial disparities and the challenges that you’ve all mentioned, how do we get that curve to keep going down?

Sharon Deans, MD, MPH, MBA: I think continued screening. The education around continued screening is extremely important. When I was practicing Pap smear, ASCUS [atypical squamous cells of undetermined significance] Pap smear was my favorite area because you could cure it. We were doing a lot of over-treatment, say 15, 20 years ago, based on the technology we had available. When we got to the point where we can test for HPV [human papillomavirus] and the presence of HPV, that gave us additional guidance and being able to be a little bit less invasive in treating women and not too aggressive in treating women. I think there is an opportunity but there’s still a small segment that doesn’t get screened, for whatever reason. And unfortunately, when we see them with cervical cancer, it’s usually advanced disease. The first patient that I ever diagnosed, I had to pronounce death, was a patient that died from cervical cancer, and it was a black woman, and I was like this can’t be happening. But it is. I’ve done mission work in Haiti. [There is an] unbelievable rate of cervical cancer there. I spent 3 years doing Pap smear screening, trying to do a telehealth Pap smear screening there to help abate that. So there’s still a population that’s not being screened, getting screened too late, not understanding their risk factors, is extremely important. Earlier we were talking about how you have a safe pregnancy and it’s the selections or the decisions that you make prior to that that can help you with that. I think we do have more opportunities to decrease the rate. But we have our work cut out for us in that aspect and education is extremely important.

Roxie Cannon Wells, MD: If I may add to that, after the ACA [Affordable Care Act] came about and more women ages 19 to 25, according to the American Cancer Society, got vaccinated for HPV after the ACA banned the same cohort before. But here’s another caveat, right now we have 40 states who have expanded Medicaid for individuals who make too much money to be regular Medicaid but don’t make enough money to have private insurance. So 40 states, and North Carolina finally is one, and I’m really proud about that. But there is a population of millions of people who now have health insurance who, in that 19 to 25 age group, may be able to get HPV vaccinated because they now have insurance. That may help us from a plateau standpoint to see additional people get vaccinated for HPV.

Derek van Amerongen, MD, MS: In your organizations and practice, Dr Hawkins, are you undertaking specific initiatives or strategies to focus primarily on cervical cancer?

Soyini Hawkins, MD, MPH, FACOG: Yeah. We have ongoing campaigns for cervical cancer screening, breast cancer screening, trying to meet them where they are as much as we can, bringing things into the community. In some instances, we can’t do cervical cancer screening in the school-based health setting, but we can do STD [sexually transmitted disease] testing in the school-based health setting. So using those settings to try to get services to members is important as well. But this is a constant conversation. We’ve seen an increase in syphilis in pregnancy, and an increased rate of NICU [neonatal intensive care unit] admissions because of syphilis. We now have a campaign on how are we testing these women and there’s a disparity. When I was in private practice, you’d test a private patient for syphilis, they’re appalled. But to me, anybody who’s having sex is at risk. But then it was OK to test Medicaid women multiple times. So how do you close those disparities and still get the screening that you need? There’s a lot of opportunity but there’s a constant campaign. This is ongoing. Using vans for mammograms, and texting campaigns to get women in for their Pap smears. And the other difficulty with cervical screening is it used to be every year and now it’s every 3 years. They’re not getting it as soon as they should. They get it as soon as they become sexually active, not necessarily when they turn 18. That period of time and that transition with Pap smear screening was very difficult in a managed care space because we had this cadence around it and now it’s shifted very significantly. And one of the challenges is knowing when that prior Pap smear occurred, and you don’t always know that in a managed care setting because oftentimes members are not with you that long. So you have a 3-year setting for you to be able to go back and look. And then trying to convince them to at least get it done or if they have the result, to bring the result so that we can see that it’s been done.

Soyini Hawkins, MD, MPH, FACOG: And that’s why we have to tailor care for patients. Because we have patients that will come and be new to our practice and we don’t know their Pap history. And this year the HPV is positive, [HPV-] 16 [and] [HPV-] 18 high risk. What do we do if we don’t know what it looked like last year? And I want to say that we can always trust the patient’s memory, but we can’t. And sometimes it’s simply because they don’t understand what an ASCUS Pap means. And if we’re not able to trace back, then we don’t necessarily have the perfect guidance as to what to do next for these women. A lot of our cervical cancer recommendations change quite frequently, as they should, as we advance in the research and understanding of outcomes and what we should not be doing, how to not over treat, especially younger patients where we may have been overzealous in the past and done LEEPs [loop electrosurgical excision procedures] and cones and decreased some of their pregnancy risks or influenced some of their pregnancy outcomes because of that. We now know this research will guide us, but it does become blurry sometimes and we have to individualize our care to what is going on with this patient right in front of me and what information do I have? Do I have a baseline to start with? But then what ends up happening is we just re-Pap them.

Sharon Deans, MD, MPH, MBA: I’m going to use your point to make a plug for HIE, for Health Information Exchange.

Soyini Hawkins, MD, MPH, FACOG: Absolutely.

Sharon Deans, MD, MPH, MBA: Every state has one. They’re suboptimally used.

Soyini Hawkins, MD, MPH, FACOG: Yeah.

Sharon Deans, MD, MPH, MBA: Not every facility, every lab will contribute to that information. Do you know how much waste that would take out of the system?

Soyini Hawkins, MD, MPH, FACOG: Oh, my goodness. So much waste.

Sharon Deans, MD, MPH, MBA: If we had access, if the states mandated that facilities had to share this information. They get to share selectively and so we miss a lot of data, and we do a lot of repeat testing, and it puts a lot of waste into the system. Even as we talk about forming doulas. It’s just taking waste out of the system, forming doula programs. There are community-based organizations that have doulas, so we partner with those community-based organizations to set up those doula programs rather than hiring doulas and putting them out into the community. But just a big plug for HIE, Health Information Exchange, and being able to bring that information so that it’s readily available. We have the information from the EMR [electronic medical record] chart at the facilities, from the laboratories, and so on.

Transcript edited for clarity.

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