Analyzing Physician and Patient factors in optimizing Cervical Cancer Screening in Alberta: Progress, Barriers, and Enablers
Creators: name: Sayed, Sayeeda Amber
Publisher: name: Graduate Studies
Year: 2023
Subjects: subject: Cervical cancer
subject: Screening
subject: Primary Care
subject: Family Physicians
subject: Sociodemographic characterisitcs
subject: Alberta
subject: Epidemiology
subject: Public Health
subject: Biostatistics

description: Cervical cancer screening (CCS) program effectiveness is well-accepted; however, inappropriate CCS results in either a woman being tested too often or not being tested at the recommended intervals. Widespread disparities in CCS uptake also exist, even when screening is offered without cost through a publicly funded and organized CCS in Alberta. This thesis has three main objectives: Study 1.To describe temporal trends in screening and outcomes for women, after changes in guidelines in Alberta, Canada, that raised the starting age for screening to 21, then to 25 years of age, and reduced frequency to 3-yearly Study 2. To identify family physicians’ (FP) characteristics that are associated with over- and under-screening for 25-69-year-old women in Calgary, Alberta. Study 3. To study spatial and temporal associations of CCS and sociodemographic variables in Calgary, Canada using Census Canada datasets (2006, 2011, 2016). Methods Study 1: Calgary Laboratory Information System data were used to examine CCS, follow-up procedures, and cancer among women 10 to 29 years from 2007 to 2016 in the whole population of Calgary. Interrupted time-series analyses were used to assess changes in screening and subsequent diagnostic procedures over the ten-year period. Study 2: A population-based retrospective observational study was performed by linking the College of Physicians and Surgeons Alberta physicians’ database of FPs practicing in Calgary with the Calgary Laboratory Services database. We matched physicians’ sex, country and year of medical school graduation, years since medical school graduation, city quadrant of practice, and their estimated patient panel size. Logistic regression models were applied to analyze the over-screening and under-screening patterns. Study 3: CCS rates were obtained from a population-wide laboratory administrative database for Calgary, Alberta for the years 2006, 2011, and 2016 for women 25-69 years of age. These years coincide with Census Canada years, allowing comparison with sociodemographic factors Ordinary Least Square regression (OLS) and geographically weighted regression models (GWR) were used to examine sociodemographic variables associated with CCS rates. Results Study 1: Annual Screening rates dropped by around 10% for all ages over 15 after the 2009 Alberta cervical cancer screening guidelines, followed by a steady decrease. The rates of abnormal test results and biopsies did not increase with decreased screening. Likewise, no increases in Cervical intra-epithelial neoplasias (CIN I, CIN II/III), or invasive cervical cancer rates were observed after reduced testing. Study 2: Among 807 physicians included in the over-screening analysis, 43% of physicians had over-screened their screen-eligible patients. Among the 317 physicians included in the underscreening analysis, 42% had under-screened during the three-year study period. Physician characteristics significantly associated with over-screening included more years of practice and having more female patients in the practice. Female physicians were less likely to under-screen their eligible female patients. Physicians practicing in the Northeast quadrant of the city also had lower odds of screening. Study 3: We analyzed approximately 200,000 cervical cancer screening tests for each year and noted a considerable decrease in screening rates between 2006 and 2011, consistent with changes in screening guidelines. The OLS results showed that a high median household income and university education were strongly associated with higher screening rates in all three census years. 2006 and 2011 OLS models showed negative associations with screening of Aboriginals, Blacks, and recent immigrant women. Conclusions Study 1: The largest decrease in screening and follow-up procedures occurred in the period immediately following the implementation of 2009 Alberta screening guidelines. The number of consequent procedures also decreased in proportion to decreased screening, but there was no increase in cancer rates. Starting screening at age 25 and reducing intervals appears to be safe. Study 2: Screening patterns of family physicians indicate both overuse and underuse, which indicates inconsistencies in adherence to screening guideline recommendations. Identifying strategies and addressing disparities to improve guideline adherence among different physician demographic groups is critical for the success of screening programs. More education and guideline publicity are required to encourage compliance with screening guidelines. Study 3: There were significant sociodemographic differences associated with cervical cancer screening in Calgary. Understanding these sociodemographic associations could form the basis of future education or outreach screening programs, targeting underserved populations, such as women with low income and education.