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It is shocking to absolutely no one that there are large disparities in health care outcomes associated with socioeconomic status. As Morgan McSweeney recently wrote for OncoBites, melanoma patients on Medicaid or without access to health insurance wait longer for doctor’s visits and have poorer outcomes than patients on private insurance. And now, in the age of COVID-19, we are seeing the same trend play out; people with lower socioeconomic status are more highly exposed and face worse outcomes than those with private insurance and jobs that can be worked remotely.
Significant racial disparities exist in healthcare, even among individuals with higher socioeconomic status. In the US, Black Americans are more likely to die from many cancers than White Americans, even when diagnosed at similar rates. This is a trend we see over and over again–diseases treated like they are “equalizers” are far from it, as they strike everyone but primarily kill the less fortunate. And in the face of all this, there is a divide within healthcare fields between those who are pushing for more and more elaborate treatments regardless of cost, and those who are pushing to improve outcomes in patients who cannot afford cutting-edge therapies. To be clear, both approaches are vital to move the field forward, as costs associated with therapies tend to decrease over time. However, some of the most passionate cancer researchers I have ever seen speak are those who work tirelessly to expand access and improve outcomes in often overlooked communities by reaching them where they are. Some do this literally, by working to provide at-home cancer diagnostic tests to the people who need them most.
Testing for cancer at home often requires the collection of a sample, which may be blood, urine, stool, or cells from a particular site of the body, by the patient and the return of this sample to a doctor or other health professional for analysis. Some tests are being developed to deliver results at home in real-time, like a home pregnancy test, but at this time, to my knowledge, none are currently available in the US, so we will be focusing on samples collected by patients and then processed and analyzed in a lab for this article.
For brevity, we will be focusing on the work being done to apply at-home testing to cervical cancer screenings. Cervical cancer is one of the most easily preventable and treatable cancers, due the existence of a vaccine, Gardasil®, which can protect against the majority of HPV infections. Cervical cancer, unlike many other cancers, is almost entirely caused by HPV infections. However, the vaccine has only been available in the US since 2006, and is not mandatory, leaving many people unprotected. And while screening tools exist, the current standard is not sufficiently available to all people with cervixes.
A huge barrier to timely cancer therapy is diagnosis. Patient outcomes are astronomically higher when cancer is caught in early stages; for example, if cervical cancer is caught early, 92% of patients survive for at least five years after diagnosis. However, if cervical cancer is caught in later stages, once it has spread to organs outside of its immediate vicinity, only 17% of patients survive for five or more years. These numbers illustrate why regular cervical cancer screening is such a critical component of healthcare for people with uteruses. Current medical care guidelines in the US recommend a Papanicolaou test, commonly called a Pap smear or simply “Pap,” every three years for everyone with a cervix over the age of 21. In a Pap smear, a collection of cells is scraped off the cervix, tested for human papilloma virus (HPV), and spread onto a slide, which a pathologist analyzes for irregularities associated with cancer. Cervical cancer is a slow-growing cancer, and abnormalities found in Pap smears can often resolve on their own, so testing regularly, but not too frequently, is important to catch cervical cancer early while reducing unnecessary medical intervention. Because nearly all cervical cancer is caused by HPV, knowing if a patient has HPV or not is important to doctors as they decide what level of treatment is necessary if abnormalities are found.
As useful as Pap smears are for detecting cervical cancer, the fact remains that some people do not have access to them or choose not to get them regularly. Pap smears are often unpleasant, as they require the use of stirrups and a speculum for clinicians to scrape the cervix, leading many people to forgo regular checkups. Doctor’s visits can also be costly for underinsured/uninsured patients and/or may require unpaid time off work to make it to appointments. Many patients also lack transportation to doctor’s offices. There may also be a cultural distrust of doctors or discomfort of patients with the invasiveness of the exam. And, from my personal experience, guidelines for proper screening are not always made clear to the patient, and doctors in rural areas may disregard official guidelines for their own personal reasons, further leading to mistrust in the system. For these and many other reasons, disparities in cancer care have emerged world-wide, and at-home cancer tests may be a way of closing the gap.
Dr. Erin Kobetz, Associate Director of The Sylvester Comprehensive Cancer Center and Co-Vice Provost for Research at the University of Miami, Florida, has been leading research in Miami focused on bringing care to people instead of waiting for people to show up for care. Much of her work centers around improving cervical cancer screening in the Little Haiti, Hialeah, and South Dade areas of South Florida, in which many minority women lack access to or trust in the healthcare system, or both. Dr. Kobetz has run multiple clinical trials assessing the efficacy of direct outreach with community healthcare workers and mailed self-sampling tests in rates of cervical cancer testing. Over 70% of patients who had not received cervical cancer screening for three years completed the mailed self test when they also received in-person visits from community healthcare workers.
Dr. Jennifer Smith of the University of North Carolina at Chapel Hill works on cervical cancer screening worldwide. She is currently running a study of the cervical cancer self-tests in Mombasa, Kenya and the USA, but she has extensively researched at-home testing in China and South Africa as well. She is a strong proponent for increased HPV vaccination and early cancer screenings. She has found that in some groups of individuals who are primarily minority and low-income, trust in mailed testing was high (98%). While some self-testing methods are not quite as sensitive as physician-administered Pap smears, many are comparable. Additionally, self-administered, mailed-in tests are uniquely situated to reduce cervical cancer deaths each year by catching abnormalities early in people who may not get physician-administered tests. However, any self-administered testing should be accompanied by rigorous educational outreach so that patients understand the test they are taking, the next steps for treatment (if necessary), and other key information.
There are many other doctors working on reducing cervical cancer cases by improving access to preventative and diagnostic technology worldwide as part of a push to eliminate cervical cancer. At the same time, self-administered testing is being investigated for other forms of cancer, including colorectal cancer. We may one day live in a world in which people are empowered to take care of their health on their own terms and with fewer barriers to treatment.
Edited by: Manisit Das
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