Self-sampling for human papillomavirus in a community setting: feasibility in Hispanic women.

BACKGROUND: The aim of the study was (a) to assess sensitivity and specificity of self-sampling in a community setting for identifying high-risk human papillomavirus (HPV) infection and abnormal Papanicolaou (Pap) smears and (b) to assess satisfaction with this collection method among Hispanic women. METHODS: Lay health workers distributed self-collection kits to Hispanic women in the community. Participants collected an unsupervised vaginal sample at home or in the place and time of their preference. RESULTS: A total of 1,213 Hispanics were included and provided a self-sample for HPV testing and were invited for a Pap smear; 662 (55%) of them had a Pap smear and the first 386 of these also had a physician-collected sample for HPV retesting. Using physician collection as the gold standard, unsupervised self-collection had a sensitivity of 90% and specificity of 88% for identifying high-risk HPV. Compared with physician sampling, self-sampling in a community setting had comparable sensitivity for identifying a low-grade lesions or greater in the Pap smear (50% versus 55%; P = 0.45) but lower specificity (94% versus 79%). Overall experience with self-sampling was reported as excellent or very good by 64% and only 2.6% reported a poor or fair experience. CONCLUSIONS: Unsupervised self-collection of vaginal samples for HPV testing in a community setting has a high sensitivity for identifying high-risk HPV and a high satisfaction among Hispanics. This approach may benefit populations with limited access to health care or with cultural barriers to cervical cancer screening.

Addressing health care needs of the Latino community: one medical school's approach.

The Program in Medical Education for the Latino Community (PRIME-LC) at the University of California-Irvine (UCI) School of Medicine was designed to improve health care delivery, research, and policy in underserved Latino communities. Specialized training develops strongly committed physicians with linguistic skills and cultural understanding, enabling them to serve Latino patients. Presently, the health care system's shortage of providers with this expertise renders it unable to address the Latino community's needs adequately. The UCI School of Medicine realized they were proposing a radically different type of program at the onset of this project -- one designed to address the health care needs of a specific ethnic group. Developed with dual goals, PRIME-LC aspires to provide the Latino community with culturally sensitive, Spanish-speaking physicians who are well aware of medical and social conditions prevalent among Latinos, in addition to physicians with a broad understanding of community medicine who are well versed in advocacy and able to become leaders within and outside the Latino community. PRIME-LC must be placed within the context of predicted physician shortages in the United States attributable to the projected population increase in general and, more specifically, within the context of a growing Latino population nationwide. As medical schools prepare to increase their output, programs like PRIME-LC that address society's special needs deserve serious consideration.

A study of the physician workforce supply for the latino population in California.

PURPOSE: To determine the physician supply during two decades to the workforce available to California Latinos from two separate training tracks at the University of California, Irvine School of Medicine (UCI)--the Fifth Pathway Program (FPP) and the traditional medical school curriculum. METHOD: In 2002, the authors compared two groups of physicians practicing in California to ascertain the percentage of Latino patients in their practices. One group had completed the FPP (n = 229) during the period 1971-1991, and UCI graduates from the same period composed the second group (n = 960). The authors also examined Latino population statistics for California communities where physicians located their practices. RESULTS: Both groups practiced in California (71.5%) and in primary care (59.9%) at the same rates. Women were underrepresented among FPP physicians (12.2% versus 33.3%). FPP physicians self-reported seeing significantly more Latino patients (14.3% versus 9.2%; P < .001). However, the groups did not significantly differ in the rates at which they practiced in communities with 40% or more Latino residents (18.1% versus 12.9%). CONCLUSIONS: Reactivating the FPP may increase the raw number of physicians in California, but two decades of this program did not recruit physicians to practice in California's Latino community at a rate much above that for traditional medical school graduates, especially for communities having the highest Latino population densities.

Feasibility of management of high-grade cervical lesions in a single visit: a randomized controlled trial.

CONTEXT: The incidence of cervical cancer is higher among low-income and minority women who have never undergone a conventional Papanicolaou test or who do not follow up after testing. Screening has been shown to reduce cervical cancer incidence rates. OBJECTIVES: To determine the feasibility and acceptability of immediately treating women with severely abnormal Papanicolaou test results by using a single-visit cervical cancer screening and treatment program and to compare treatment rates and 12-month follow-up rates with those of women who received usual care. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted among 3521 women aged 18 years or older recruited between January 1999 and April 2002 at US community health centers located in predominantly Latino underserved areas. INTERVENTIONS: Women randomized to usual care (n = 1805) were discharged immediately after examination. Women randomized to the single-visit group (n = 1716) remained at the clinic until the results of their conventional Papanicolaou test were available. Large loop electrosurgical excision procedure was performed in single-visit patients with either a diagnosis of a high-grade squamous intraepithelial lesion (HGSIL)/atypical glandular cells of undetermined significance (AGUS) or suspicion of carcinoma. All other patients with abnormal Papanicolaou test results were referred to abnormal cytology clinics or elected to receive follow-up care outside the study's medical system. MAIN OUTCOME MEASURES: Treatment rates for HGSIL/AGUS at 6 months, follow-up rates at 6 months for lower-grade lesions, and 1-year follow-up rates for all patients. RESULTS: The rate of abnormal Papanicolaou test results was 4.1%. One percent of results showed high-grade lesions. In the single-visit group, the mean visit time was 2.8 hours and the mean time for delivery and processing of the Papanicolaou tests was 66 minutes. Six months after randomization, 14 (88%) of 16 single-visit and 10 (53%) of 19 usual care patients with HGSIL/AGUS had completed treatment. Fifty percent in the single-visit program and 53% of usual care with less abnormal Papanicolaou tests completed treatment within 6 months. Overall, 36% in each group presented for a follow-up Papanicolaou test 1 year later. Women in the single-visit group with high-grade lesions (10/16; 63%) were significantly more likely to attend follow-up for Papanicolaou tests 12 months later than women with similar lesions in the usual care group (4/19; 21%). CONCLUSIONS: For cervical cancer screening, the single-visit program was feasible and the degree of acceptability was high in this underserved population. Single visit programs provide an opportunity to increase the rate of immediate treatment and follow-up of women with severely abnormal Papanicolaou test results. This strategy did not improve follow-up rates for women with less-abnormal results. Trial Registration http://ClinicalTrials.govIdentifier: NCT00237562.

Conservation of in vitro drug resistance patterns in epithelial ovarian carcinoma.

PURPOSE: To compare the in vitro drug resistance profiles of advanced stage primary and recurrent epithelial ovarian cancer specimens using the tritiated thymidine uptake assay. METHODS: Extreme drug resistance (EDR) to cisplatin, paclitaxel, 4-hydroxycyclophosphamide, and topotecan was determined for an unselected population of primary and metastatic malignant ovarian tissues, synchronous tumors (primary and metastatic tissues obtained from the same patient at diagnosis), and metachronous lesions (specimens from the same patient before and after chemotherapy). RESULTS: For the large unselected population of malignant tissues (total, N = 6990; primary ovarian, N = 2031; metastatic ovarian, N = 4959), no statistically significant differences were discovered between primary tissues and metastatic lesions when a comparison was made between the percentage of tumors from each group that exhibited extreme drug resistance to the agents assayed. From the library of 6990 specimens, 119 synchronous pairings were identified. These synchronous lesions did not differ significantly in the %EDR between primary and metastatic sites in the same patient; approximately 10% shifted between low drug resistance and EDR. A total of 334 metachronous pairings were identified and the percentage of tissues that exhibited EDR also failed to show a significant difference when primary tumors were compared with matched recurrences in the same patient. CONCLUSIONS: For the agents studied, acquired resistance was not a function of disease site. In vitro drug resistance observed at recurrence was not influenced significantly by intervening therapy. It is possible that assay results at diagnosis could be used to guide subsequent therapy at relapse, especially when recurrent tissue is not available for analysis.

Oral altretamine used as salvage therapy in recurrent ovarian cancer.

BACKGROUND: Altretamine has reported efficacy in the treatment of recurrent ovarian cancer following platinum-based therapy. This report presents the cases of two long-term survivors with recurrent ovarian cancer given oral altretamine. CASES: Two patients diagnosed with stage IIIC ovarian cancer underwent optimal cytoreductive surgery. Both women were subsequently treated with platinum-based chemotherapy. One had persistent cancer documented 2 months post therapy, while the other was disease-free for 22 months before recurring. Both received altretamine in a salvage setting. Each of these women achieved a prolonged response to third-line altretamine therapy, and one of whom was disease-free for 4 years and the other remains disease-free over 7 years following initiation of salvage therapy. CONCLUSION: Outpatient-administered oral altretamine can provide a prolonged disease-free interval with minimal toxicity.

Prevention of ureteral injuries in gynecologic surgery.

Pelvic surgery is the most common cause of iatrogenic ureteral injury. The majority of patients with ureteral injuries have no identifiable predisposing risk factors. A simple maneuver that has been taught successfully at our institution that facilitates the identification of the ureter is described. When injury is discovered during surgery, correction of the injury can be repaired with minimal risk of long-term sequelae. Postoperatively, patients with ureteral injury typically present with costovertebral angle tenderness, ileus, fever, and flank pain with a minimal rise in serum creatinine. To prevent ureteral injuries, the surgeon must have a thorough knowledge of the location of the ureter during various pelvic procedures and the specific regions where it is most susceptible to injury.

Prevention of femoral nerve injuries in gynecologic surgery.

Abdominopelvic operation is the most frequent cause of iatrogenic femoral nerve injury, particularly when self-retaining retractors are used. Transverse abdominal incisions and thin body habitus are significant risk factors. Patients typically have mild sensory and/or motor disturbances with diminished knee jerk reflexes. Most cases are self-limited, and symptoms resolve within several weeks. Most femoral nerve injuries that are associated with pelvic surgery can be prevented with a thorough understanding of the pelvic anatomy and proper placement of self-retaining retractors.