"Access to these screenings have been a gift": A mixed methods assessment of a community navigation program for breast and cervical in the era of COVID-19

Background: The COVID-19 pandemic exacerbated health inequities among systematically marginalized populations. At the onset of the pandemic, routine cancer screenings were effectively halted;from March to May 2021, there was a deficit of 9.3 million screens. Early evidence suggests that non-White patients, compared to White, have experienced even greater declines in breast and cervical cancer screenings. Consequences of missed or late screenings include later stage diagnosis and poor outcomes. Community navigation programs have been used to promote engagement in cancer screenings in under-resourced communities, but these too were interrupted as restrictions were put in place to mitigate the spread of COVID-19. Objective(s): To use a mixed methods approach to describe the challenges, strengths, and lessons learned of implementing a community navigation program for breast and cervical cancer screening during the COVID-19 pandemic. Method(s): In 2019, The University of Illinois Cancer Screening, Access, Awareness, and Navigation (UI CAAN) intervention was established to address breast and cervical cancer disparities on Chicago's West side, an area with large Black and Latinx populations. The intervention included community navigators who worked in partnership with community-based safety net hospitals and organizations. Participants were recruited at community events and through clinical referrals and were eligible if they were overdue for a guideline concordant breast or cervical cancer screening. Quantitative navigation and screening data were collected by the navigators in a REDCap database. Qualitative data, four focus groups with participants and partners, were also collected to broaden our understanding of impact of COVID-19 on the community navigation intervention. For these analyses, we describe participants' navigation and screening outcomes and use content analysis methods for the focus groups. We then triangulate the findings to understand the challenges, strengths, and lessons learned of the UI CAAN. Result(s): From 2019-2022, a total of 366 individuals were navigated for breast and cervical cancer screenings. Of these, 68% (n = 248) received a breast and/or cervical cancer screening. Among those who were screened, 75% were Latinx and 23% were Black, 92% were uninsured, and 86% did not have a primary care provider. Concerning services received, 30% had a mammogram and a pap smear, 37% a pap smear only, and 33% a mammogram only. At the height of the pandemic, navigators coordinated with community and clinical partners to deliver 500 meals, held 9 PPE distribution events, distributed 3000 masks, and conducted 2 webinars about COVID-19. Conclusion(s): Despite the challenges of the COVID-19 pandemic, the UI CAAN community navigation program was able to shift its efforts at the height of the pandemic to assist its community and clinical partners. The continued collaboration allowed for a successful resumption of navigation and screening efforts once healthcare systems were able to re-engage patients in cancer screenings.

Women's Health Maintenance Efforts at a Student-Run Free Clinic in South Florida Exceeded National Trends During the COVID-19 Pandemic.

The COVID-19 pandemic posed a setback to health maintenance screenings worldwide. These delays have impacted minorities and those of low socioeconomic status in the same way that disparities in cancer screenings have historically trended. Here, we evaluated the performance of a student-run free clinic in maintaining women up-to-date with cancer screenings before, during, and after the pandemic in relation to national trends. We identified all women eligible for screening mammography and cervical cancer screenings between 2018 and 2022 at the clinic (N = 185). Adequate adherence to screening was defined according to the American Cancer Society (ACS) recommendations for breast mammography, and the United States Preventive Services Task Force (USPSTF) guidelines for cervical cancer screenings. For cervical cancer screening, 166 female patients seen between 2018 and 2022 were eligible, and up-to-date proportions were as follows: 81.3% in 2018; 90.9% in 2019; 83.3% in 2020; 93.3% in 2021; 93.8% in 2022. For breast surveillance, 143 women were eligible for screening mammography, and up-to-date proportions were as follows: 66.7% in 2018; 62.5% in 2019; 91.7% in 2020; 73.1% in 2021; 84.1% in 2022. These proportions were higher than or near national averages.In conclusion, adherence remained steady during the pandemic and was not subject to the declines seen nationally. Our clinic represents an effective model for promoting women's health maintenance and tempering the disparities seen among women of low socioeconomic status.

The Effectiveness of Pap and Visual Inspection With Acetic Acid (VIAA) Tests in Cervical Dysplasia Screenings During the COVID-19 Pandemic.

Objective This study was aimed at analyzing the validity and reliability of the Papanicolaou (Pap) test and visual inspection with acetic acid (VIAA) tests for cervical dysplasia screenings during the COVID-19 pandemic. Material and methods This was a retrospective study of patients 21 years or older seen at the Luis Negreiros Primary Care Center in Lima, Peru between 2020 and 2021, who underwent cervical dysplasia screening (Pap or VIAA). Relevant information regarding patient age, date of service, and Pap and VIAA results were collected. Parallel form reliability was analyzed with chi-square tests, and phi, contingency and Cramer's V coefficients. The validity of these tests was analyzed through the calculation of the sensitivity, specificity, and positive and negative predictive values with confidence intervals. A p-value less than 0.05 indicated statistical significance. Results From 4,503 records, the sensitivity, specificity, and positive and negative predictive values for Pap were 0.87 (0.81-0.92), 1.0 (1.0-1.0), 1.0 (1.0-1.0) and 0.99 (0.98-0.99), respectively, and those for VIAA were 0.22 (0.14-0.31), 0.10 (0.10-0.10), 0.53 (0.38-0.69) and 0.10 (0.10-0.10), respectively. Test validity varied slightly according to patient age and the year of testing. The correlation, although significant, was inverse; chi-square = 39.18, p <0.001, phi = -0.60, contingency = 0.51 and Cramer's V = -0.59. Conclusion The validity and reliability of Pap testing and VIAA for cervical dysplasia screening significantly decreased during the COVID-19 pandemic. The correlation between these tests, although significant, was inverse. More larger-scale studies are needed to confirm these findings and understand the reasons underlying the decreased effectiveness of these tests.

IMPLEMENTING AN IBD MEDICAL HOME IN A COMMUNITY PRACTICE SETTING

Introduction Inflammatory Bowel Disease (IBD) homes have been shown in academic settings to improve patient outcomes and decrease health care utilization, resulting in an overall improvement in healthcare quality. Scarce information is available demonstrating their utility in a community practice setting where economic drivers and available resources may differ significantly from academic institutions. The value of these integrated care model homes is often achieved by implementing basic health maintenance initiatives that are lacking with traditional care, which is largely focused on primary disease management. This study seeks to define the baseline compliance of required health maintenance screenings and vaccinations in patients enrolled in a community based IBD Home. Methods We conducted a retrospective analysis of IBD patients enrolling in the IBD Home program of a large community based practice from January 2021 to January 2022. The multidisciplinary team comprised of a gastroenterologist, physician's assistant, dietician, nurse and social worker. No specific education was provided regarding health maintenance requirements to collect baseline compliance. Data collection included patient compliance with bone density scans, dermatologic exams, annual pap smears and receipt of pneumonia, Hepatitis A, Hepatitis B, influenza, and COVID -19 vaccines. Results There were 51 IBD patients enrolled in the IBD Home program with 63% female. of the total cohort, 100% of patients lacked in one or more of the recommended health maintenance guidelines. Specifically, only 27% were current with bone density scans, 29% with routine dermatologic screening, and 16% with PAP smears (HPV vaccination status unknown). Regarding vaccinations, 78% had received influenza, 33% pneumonia, 27% hepatitis A, 43% hepatitis B and 60% for Covid 19 (two doses). Conclusions The analysis of these elements provided key insights into the factors contributing to the low levels of health maintenance compliance noted in these IBD patients. Many community-based gastroenterologists refer patients to their primary care physicians who are not aware of the specific IBD health maintenance guidelines. Further, many gastroenterologists educate patients about the guidelines but lack mechanisms to easily implement the recommendations and to closely monitor patient compliance. Enrolling patients into an integrated IBD medical home provides the resources needed to facilitate heath maintenance issues, although our study illustrates a need to intervene further to effectively impact compliance.

The impact of the COVID-19 on the screening of breast and cervical cancer in Korea

Background: The COVID-19 pandemic has affected use of healthcare services, especially disrupting individual participation in cancer screening programs. The National Cancer Screening Program (NCSP) of Korea provides screening services for six common cancers - stomach, liver, colorectum, breast, cervix, and lung. As complete national lockdown measures were not implemented, the NCSP continued operation during the three major COVID-19 waves in Korea, which allowed us to assess the changes in health-seeking behavior. We examined the cancer screening rates for breast and cervical cancers among NCSP participants in different geographic regions and by age group, in association with the COVID-19 pandemic. Methods: From the National Health Insurance Service database, we obtained information on the number of eligible population and NCSP participants from January 2019 to December 2020. The target group for biennial mammography screening is women aged 40 years and over, and that for biennial pap smear is women aged 20 years and over. We compared monthly screening rates for breast and cervical cancer between 2020 vs 2019 and described them as a percentage change. Results: The overall cancer screening rate has decreased in both cancers in 2020 compared with that of 2019: breast (55.8% vs 63.8%), cervical (52.2% vs 57.8%). Screening rates for both cancers declined in all age groups in March and December of 2020, which corresponds to the first and third COVID-19 wave. The month of March 2020 had the sharpest drop in screening rates, by 57.9% for breast cancer and 43.7% for cervical cancer compared with March 2019. In June 2020, screening rates for both cancers rebounded compared with 2019 (breast, +29.2%;cervical, +26.3%), which remained higher compared with the same months in 2019 until November 2020. By December 2020, screening rates for both cancers have dropped, compared with December 2019 (breast, -19.5%;cervical, -21.0%). For breast cancer, the screening rate decreased in all age groups, and the largest decline was observed in women aged 80 years and over. Although the cervical cancer screening rate has been steadily increasing since 2010, it decreased in all age groups in 2020 compared with that of 2019, with the exception of the 20-29 age group. Considering social distancing measures that were implemented nationwide during each COVID-19 wave, we observed a similar pattern of cancer screening rates in major cities. Conclusions: It was observed that after the two major COVID-19 waves, mammography and pap smear rates declined compared with that of 2019. The largest decline in cancer screening rates was seen in elderly women. The pattern of screening rate changes was comparable according to geographic region. In contrast to reports showing a deficit in cancer screening in other countries, our results suggest a substantial recovery in cancer screening in Korea. Additional analyses are needed to assess the effect of the 6-month extension of NCSP.

The Effects of Theory-Based Educational Intervention and WhatsApp Follow-up on Papanicolaou Smear Uptake Among Postnatal Women in Malaysia: Randomized Controlled Trial.

BACKGROUND: Despite the availability and accessibility of free Papanicolaou (Pap) smear as a screening tool for cervical cancer, the uptake of Pap smear in Malaysia has not changed in the last 15 years. Previous studies have shown that the high uptake of Pap smear reduces the mortality rate of patients with cervical cancer. The low uptake of Pap smear is multifactorial, and the problem could be minimized through the use of mobile technologies. Nevertheless, most intervention studies focused on individual factors, while other important aspects such as mobile technologies, especially WhatsApp, have not been investigated yet. OBJECTIVE: This study aims to determine the effects of a theory-based educational intervention and WhatsApp follow-up (Pap smear uptake [PSU] intervention) in improving PSU among postnatal women in Seremban, Negeri Sembilan, Malaysia. METHODS: A 2-arm, parallel single-blind cluster randomized controlled trial was conducted among postpartum women from the Seremban district. Twelve health clinics were randomly assigned to the intervention and control groups. At baseline, both groups received a self-administered questionnaire. The intervention group received standard care and PSU intervention delivered by a researcher. This 2-stage intervention module was developed based on Social Cognitive Theory, where the first stage was conducted face-to-face and the second stage included a WhatsApp follow-up. The control group received standard care. Participants were observed immediately and at 4, 8, and 12 weeks after the intervention. The primary endpoint was PSU, whereas the secondary endpoints were knowledge, attitude, and self-efficacy scores for Pap smear screening self-assessed using a Google Forms questionnaire. A generalized mixed model was used to determine the effectiveness of the intervention. All data were analyzed using IBM SPSS (version 25), and P value of .05 was considered statistically significant. RESULTS: We analyzed 401 women, of whom 76 (response rate: 325/401, 81%) had withdrawn because of the COVID-19 pandemic, with a total of 162 respondents in the intervention group and 163 respondents in the control group. The proportion of Pap smears at the 12-week follow-up was 67.9% (110/162) in the intervention group versus 39.8% (65/163) in the control group (P<.001). Significant differences between the intervention and control groups were found for Pap smear use (F4,1178; P<.001), knowledge scores (F4,1172=14.946; P<.001), attitude scores (F4,1172=24.417; P<.001), and self-efficacy scores (F1,1172=10.432; P<.001). CONCLUSIONS: This study demonstrated that the PSU intervention is effective in increasing the uptake of Pap smear among postnatal women in Seremban district, Malaysia. This intervention module can be tested in other populations of women. TRIAL REGISTRATION: Thai Clinical Trials Registry TCTR20200205001; https://www.thaiclinicaltrials.org/show/TCTR20200205001.

A deadly cold.

This narrative describes how non-execution of screening at an urgent care visit may have delayed the diagnosis of cervical cancer in a young woman.

POS-153 COLLAPSING GLOMERULOPATHY IN A FILIPINO FEMALE PRESENTING WITH NEPHROTIC SYNDROME POST-PARTUM

Introduction: Collapsing Glomerulopathy (CG) is a rare entity presenting as nephrotic syndrome and rapidly progressive renal deterioration. It has been first identified among African-American patients with nephrotic syndrome. Subsequently, it has been called HIV-associated nephropathy (HIVAN) after a number of patients with HIV were found to have CG. It has re-emerged recently among patients with COVID-19 dubbing it as the new HIVAN. In the Philippines, Focal Segmental Glomerulosclerosis (FSGS) is the second most common glomerular disease but with no available data on the subtypes.To our knowledge, this is the first case of collapsing glomerulopathy in the country to be published. Methods: This is a case report of primary Collapsing Glomerulopathy seen in our institution. Results: The case is a 36 year-old Filipino female admitted due to edema which started 2 weeks post-partum. She is gravida 3 para 3 (1203), with no complications in all the pregnancies. She had no known comorbidities. Social history was negative for intravenous or illicit drug use. She initially sought consult with her obstetrician where work up showed hypoalbuminemia and diffuse hepatic disease on ultrasound. She was referred to a gastroenterologist where albumin infusion and paracentesis was done but with no improvement. She developed anasarca and was admitted in our institution. Paracentesis was attempted but only minimal ascitic fluid was obtained. Serum ascites albumin gradient was low and baseline laboratories showed high creatinine at 146 mmol/L, hypoalbuminemia at 16 g/L and +3 albumin on urinalysis. Further testing showed a 24-hour urine protein of 11 grams. ANA and anti-DsDNA were negative and c3 and c4 levels were normal. Hepatitis profile was negative for infection. Abdominal CT scan revealed a hypoenhancing pancreatic tail lesion, breast cyst and nodule. Tumor markers showed high CA-125, CA 19-9 and CA 15-3. Breast ultrasound showed simple breast cyst. Gyneocology consult was called where pap smear done was negative for malignancy. Surgery service recommended observation and monitoring for the pancreatic and breast lesions. Kidney biopsy was delayed due to new onset bacterial pneumonia. COVID-19 RT-PCR test was negative. Kidney biopsy was done after lysis of fever. Pending pathologic diagnosis, patient was discharged clinically improved with no edema. She was sent home on prednisone, ARB, statin, fenofibrate and anti-platelet. On follow up at the outpatient clinic, the kidney biopsy result came out to be collapsing glomerulopathy, acute tubular injury, mild interstitial fibrosis and atrophy. HIV test was done and came out negative. Bipedal edema has recurred and albumin/creatinine ration was 731mg/g. She was then started on tacrolimus. She has been on regular follow up and currently has no edema and has ACR of 79mg/g and normal creatinine level. Conclusions: This is an interesting case as the primary glomerular disease has been masked by the initial laboratory findings. The ultrasound showed parenchymal liver disease. Further work-up revealed multiple lesions in the pancreas, breasts and lymph nodes with high tumor-markers which led us to think of paraneoplastic nephrotic syndrome. The renal biopsy revealed a rare diagnosis with no previous local data. This serves as an index case for primary collapsing glomerulopathy in a Filipino patient on remission after being treated with tacrolimus. No conflict of interest

Impact of COVID-19 public policies on utilization on cervical cancer screening in Puerto Rico during March 15, 2020 to July 31, 2020

Introduction: Among jurisdictions of the United States, Puerto Rico (PR) has the highest incidence of cervical cancer, and cervical cancer screening (CCS) is below 80%. Public health emergencies have an impact on people's access to health care services. We examined the impact of the public policy implemented by the government of Puerto Rico during the first 5 months of the COVID-19 pandemic in the utilization of CCS for participants of the Government's Public Health Plan. Methodology: This was a retrospective cohort study. A total of 40 government executive orders (issued between March 15 to July 31, 2020) were analyzed according to the level of restrictions they imposed on the population. Three periods with the greatest restrictions were identified: two of them in the government's initial response phase (March 15-30th & March 31st -April 12th ) and one in the re-opening phase (July 17-July 31st ). We examined the utilization of all modalities of CCS (pap test only and pap + HPV contesting). Rate ratios (RRs) were estimated to compare to CCS rates during periods of 2020 and compared to 2018-2019. Results: In comparison to 2019, CCS decreased during the most restricted period (March 31st-April 12th) of the response phase (RR= 0.19, 95% CI=0.15-0.24 for women 21-29 years;RR= 0.04 95% CI= 0.03-0.05 for women 30-65 years). During the re-opening phase, screening services started to rebound. However, an increase in COVID-19 cases led to another restriction (July 17-July31st), which led to a second phase of decrease in utilization of CCS (RR=0.17 95% CI=0.13-0.21 for women 21-29 years (RR= 0.09, 95% CI=0.08-0.10 for women 30-65 years). Conclusion: Our results evidence how the public policy implemented as a result of the COVID-19 pandemic in Puerto Rico had a direct impact on the utilization of CCS services in this Hispanic population. Future studies should examine screening patterns and social barriers of service utilization after July 2020 in Puerto Rico.

Overcoming challenges through an academic-community health center collaborative to conduct cancer screening, prevention, & control among Asian Americans and sustainability initatives

The purpose of this presentation is to report accomplishments of a 3-year [5/1/2018-4/30/2021] Bristol-Meyers Squibb Foundation-funded collaboration between UC Davis and the Health and Life Organization (HALO), a Federally Qualified Health Center Look-Alike in increasing cancer screenings and cancer prevention/control behaviors among Asian Americans. HALO was selected for this study becuase it is the largest health system serving Asian Americans in Sacramento Co., CA. About one-third of their patients (9000) are Asian [primarily Hmong and other SE Asains). The hypothesis we tested was based on UC Davis's prior completed research that bilingual/bicultural Hmong lay health workers significantly increased screenings for HBV and colorectal cancer screening in randomized controlled community trials among Asians who largely had limited English proficiency. Our premise was to apply this concept to a clinical setting through HALO's bilingual/bicultural medical assistants (MAs). By comparing baseline (prior to the initiation of our funding) to 3 years of collaboration, we observed an overall 13.3% increase (surpassing our 10% goal) in cancer screenings & prevention/control behaviors. The largest percentage increases were in mammography (20.3%), colorectal cancer screening (11.6%), and Pap tests (7.9%).vaccination (2.8%). Since this was our first collaboration, much was shared through our monthly UCD-HALO leadership meetings where adjustments were made. A major adjustment was to learn that the electronic health systems used by community health centers such as HALO were not intended for reseearch purposes. While primary care provider time was less flexible, we found that MAs who reflect the HALO patient population were very receptive to training. We provided training through 10 Saturday academies, in-person and later delivered virtually during the COVID-19 pandemic. All of the topics related to the above metrics as well as other topics such as cultural competence, resources for patients, and optimizing patient workflows. Effectiveness of these academies were documented through gains in average scores from pre-tests [58%] to post-tests [84%] and qualitative feedback. Fifity-eight participants attended. More rigorous evaluation approaches to link our efforts to the impact of our work would have been preferred, but would have needed to be more resource-intensive. However, we anticipate that the equipping of MAs in new competencies and tools we provided for patients in various languages as infographics will be the bases for sustained effectiveness. Another measure of success was that this collaborative contributed to the receipt of a major Federal grant to eliminate perinatal HBV transmission through HALO. A UC Davis You-Tube style interactive modules as refresher materials and for new MAs will be another means of sustaining impact.

Increasing breast and cervical cancer knowledge during COVID-19 pandemic in collaboration with Cooperative Extension Program

Introduction: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) of the Centers for Disease Control and Prevention (CDC) reported that in April 2020, screening tests for breast cancer decreased by 87% and 84% for cervical cancer, compared to the averages of the previous 5-year for the same month. In response to this finding, the Puerto Rico Breast and Cervical Cancer Prevention and Early Detection Program (PR-BCCPEDP), in collaboration with the Cooperative Extension Program (CEP), implemented an educational intervention of breast and cervical cancer in the northeast region of the island. The intervention aimed to reinforce knowledge in the early detection of breast and cervical cancer, increase screening tests, and reach out to women without health insurance who may qualify for the Program. Methodology: Since 2017, the PR-BCCPEDP agreed with the CEP to implement educational interventions for breast and cervical cancer in 4 of CEP's regions throughout the island. From February to May 2021, seven CEP Family and Consumer Educators (EFC) carried out 8 educational activities with 182 participants in the island's northeast region. We collected age, town of residence, level of education, health insurance, breast and cervical cancer screening history, and the reasons for not having performed screening tests according to the recommended guidelines. The educational activities were performed virtually through an educational PowerPoint and face-to-face using flip charts. The topics included breast and cervical cancer statistics, risk factors, symptoms, early detection guidelines, myths and facts, and barriers to not having screening tests. Participants that didn't have the screening tests according to the recommended guidelines had follow-up calls. Results: A total of 182 women participated in the intervention, with an average age of 47 years;most participants had a high school degree (42%), and 59% had the government's health plan. Regarding screening tests, 35.1% reported that they had not had a mammogram in the last two years, 73.4% authorized to be contacted after the intervention. Similarly, Pap tests, 30.7% reported that they had not had a Pap test in the last three years, of which 87.5% authorized to be contacted. Of the participants who had not had a mammogram (35.1%) or Pap test (30.7%), the main reason was the COVID-19 Pandemic (22.9% and 21.8%, respectively). Regarding the participants referred to the PR-BCCPEDP, 3.6% of the women without health insurance were referred to the Program and of these, 50% were recruited. Conclusion: Despite security, restrictions from the Pandemic, collaborations with community-based programs helped to reach a greater number of women to provide education and awareness about breast and cervical cancer. In terms of breast and cervical cancer screening, more than a third of the participants had not had their mammogram or Pap done due to the Pandemic. Women were recruited for the Program;however, additional efforts are necessary in order to reach a higher number of uninsured women.