Volume 24
Number 2/3
2003

[Table of Contents]

Effectiveness of letters to Cape Breton women who have not had a recent Pap smear 

Grace M Johnston, Christopher J Boyd, Margery A MacIsaac, Janice W Rhodes and Robert N Grimshaw 

Abstract

Nova Scotia, and especially Cape Breton, has high cervical cancer incidence and mortality rates. Letters were sent to 15,691 unscreened and 6,995 under-screened women from Cape Breton Island encouraging them to obtain a Pap test. Controls were 61,510 unscreened women and 32,996 under-screened women in mainland Nova Scotia who were not sent letters. For this cohort study, the provincial Health Card Number database and Provincial Cytology Registry were linked. Having a Pap smear was associated with having received a letter (OR = 1.64), having been previously under-screened rather than unscreened (OR = 1.85), with youth and with higher income (OR = 1.13). After receiving a letter, women in Aboriginal, Mixed Black, Acadian, and rural communities had smear rates similar to those of other women. Being previously unscreened, rather than under-screened, was associated with higher rates of abnormalities (OR = 1.62), indicating greater need for early detection and treatment to prevent invasive cancer. While one-time letters to women improved the Pap smear screening rates, multiple, continuous interventions are needed to make a more substantive improvement in these rates. 

Key words: cost; evaluation; letter intervention; Pap smear; screening 

Cape Breton Island has low rates of Pap smear screening and high rates of cervical cancer incidence and mortality compared with mainland Nova Scotia. Nova Scotia has had high cervical cancer rates compared with those of Canada (Figure 1).¹ Participation in regular, high-quality Pap smear screening by all eligible women has been recognized as the most effective means of decreasing incidence and mortality rates from invasive cervical cancer. In 1991, in response to recommendations in numerous Canadian reports,^2–4 Nova Scotia instituted an organized cervical screening program. 

In the mid 1990s, a case-control study was carried out of the Pap smear histories of Nova Scotia women with a diagnosis of invasive cervical cancer. From this screening failures study, it was seen that the majority of invasive cancer cases occurred among women who were unscreened or under-screened at the time of diagnosis.⁵ 

In 1997, the Nova Scotia Gynaecological Cancer Screening Program (GCSP) received funding from Health Canada's Population Health Fund, for a multifaceted Pap screening intervention in Cape Breton.⁶ As part of this three-year project, letters were sent to under-screened and unscreened women in Cape Breton asking them to go to their physician or to a clinic for a Pap smear. This paper reports the findings from the evaluation of the letter intervention. 

Letters of invitation to women have been successful to varying degrees.^7–14 Sometimes they have been accompanied by enhancements, such as questionnaires,⁷ appointments,¹⁰ media campaigns¹¹ and behavioural prompts.¹³ None of these studies has been population based, with personalized letters to unscreened and under-screened women only, i.e., excluding women who had had recent Pap smears. The strength of this Nova Scotia study is in the use of the long-standing, Provincial Cytology Registry (PCR), which is linked to the provincial Health Card Number (HCN) file to identify unscreened and under-screened women and send them personalized letters. Both the PCR and HCN databases use the same unique personal identifier. 

Maritime Medical Care (MMC) is a private, nonprofit company that administers the payment of physician billing claims and the HCN registration of everyone covered by the publicly funded, universal physician and hospital insurance for the province of Nova Scotia. The PCR, which is the responsibility of the GCSP, identifies all Pap smears performed in Nova Scotia since January 1988. 

Methods

Identifying the study subjects and their screening status

With approval from the Nova Scotia Department of Health, MMC identified 360,587 women who were 18 years and over, had a provincial HCN and resided in Nova Scotia between June 1998 and April 1999. The 61,929 women living on Cape Breton Island represent 17.2% of this population. The age range for the letter intervention and its evaluation is consistent with the provincial screening guidelines.¹⁵ 

The MMC database is believed to be an accurate source from which to identify women living in the province. MMC carries out a weekly death clearance of its HCN file using electronic Vital Statistics death registrations. Names are also removed if people do not renew their HCNs upon notification of expiry. The accuracy of the HCN database is supported by the fact that the 1996 Statistics Canada census shows a comparable number (360,450) of Nova Scotia women aged 18 years and over. 

MMC linked the HCN and the PCR databases to identify the screening status of all women in Nova Scotia. Unscreened women were defined as those having had no Pap smear recorded in the PCR from January 1988 to their letter mailing date. Under-screened women had had one or more Pap smears recorded between January 1988 and December 1994 but none recorded from January 1995 to the letter mailing date. Screened women had had one or more Pap smears recorded between January 1995 and the letter mailing date. 

Letters were sent to Cape Breton women who were unscreened (15,691) and under-screened (6,995). Mainland Nova Scotia women who were unscreened (61,510) and under-screened (32,999) were the controls and were therefore not sent letters (Figure 2). The date on which a letter would have been sent if the woman had been in the letter intervention group was used to define the screening status of control group women. Age was used as a proxy to identify this date (Table 1). 

During data validation prior to data analysis, an additional control group was defined when 1,218 under-screened and unscreened Cape Breton women aged 34, 54, 55 and 64 were identified as never having had letters sent to them. This unanticipated natural experiment was used to validate the main study findings. 

All women were tracked in the PCR to determine whether they had a subsequent Pap smear, which was defined as the first Pap smear performed within six months after the letter mailing date, or the age-related date for the controls. 

Mailing the letters 

MMC sent the letters in six mailings based on the age group of the women. The sizes of the age groups were selected to stagger the additional workload created for physicians and laboratories as a result of the letter intervention. The first mailing, in June 1998, was sent to under-screened and unscreened women aged 25, 45, 65 and 85 years in Cape Breton to provide a measure of the response in terms of subsequent smear rates by age and to plan the mailing of the remaining letters. 

FIGURE 1
Cervical cancer incidence and mortality, Cape Breton Island,
mainland Nova Scotia and Canada, 1971–1999

The letters were addressed to individual women, asking them to make an appointment with their family physician or other appropriate service to have a Pap test. An information brochure about Pap smears was enclosed. A postage-paid envelope and tear-off reply were provided for the women to indicate why they did not think they needed a Pap smear, to ask questions or raise concerns. If a woman had questions about Pap tests or the letter, she was advised that she could also contact her physician or a public health nurse, or could call a toll-free number provided. The letter was signed by the medical director of the GCSP and the president of the provincial medical association. The letter was in English only; a needs assessment determined that having the letter in French or another language was not needed in Cape Breton. 

Information obtained from the first mailing, in June 1998, indicated that having had a hysterectomy was a common reason for not attending for a Pap smear. Therefore, in the remaining five mailings, from November 1998 to April 1999, letters were not sent to women who had had a complete hysterectomy, as identified by linkage to provincial physician billing claims from April 1988 to the letter mailing date, and to records of hysterectomy available before 1988. 

Validation steps 

After the first mailing, 197 women who had been sent a letter but did not have a Pap smear in the subsequent six months were contacted by telephone to verify that the letters had been received and understood. 

After all the letters had been mailed, MMC returned a file identifying all 360,587 women to the GCSP for data analysis. Mailing dates were verified by comparing cancellation stamp dates on letters returned to the GCSP to letter-sent dates in the MMC database. Letter tear-off replies that were received were tabulated. To verify that age was a good proxy for mailing date, a table of age group by mailing date was prepared. 

Since there is a lag time in the PCR receiving Pap smear results, in November 1999, before data analysis, the screening histories were re-checked in the PCR database. Women were re-coded as screened if they had had a Pap smear after January 1, 1995, and before their letter mailing date or proxy mailing date for controls. 

Study outcome and covariate measures 

The major study outcome or dependent variable investigated was having a subsequent Pap smear after a letter. A secondary outcome was detection of a cervical cell abnormality on a subsequent Pap smear. An abnormality was defined as any Pap smear result with a PCR code other than negative or unsatisfactory. The goal of gynecological screening is the early detection of cell abnormalities to enable early treatment and prevent the development of invasive malignancy. Thus, both increasing the screening rates and taking into account any changes in the rates of detection of abnormalities are important in the evaluation of a screening intervention. The intervention cost was calculated in relation to each additional smear and abnormality detected. 

Predictors of the outcomes were investigated. As described already, previous screening status was defined as of the letter mailing date (Table 1). The women's ages were computed as of December 31, 1997, from birth dates provided by MMC. MMC postal codes were classified as urban or rural by Canada Post. Statistics Canada conversion tables were used to link postal codes to census enumeration areas (EAs). These EAs were then linked to the 1996 Statistics Canada census data to create community demographic measures for each woman. Using ecological proxies introduces a conservative bias to the analysis – actual covariate associations may be underestimated when aggregate data for EAs are used as a surrogate for data at the level of the individual woman.^16,17 

Since median household income for native reservations was unavailable in 1996 census reports, the mean income for females aged 15 years and older in an EA was used. Income cut points were chosen to give an approximately equal number of Nova Scotia women in three income groups (£ $12,500 per annum for low income, between $12,500 and $17,500 for middle income and ³ $17,500 for high income). 

Studies have shown low rates of cervical cancer screening among Black and Aboriginal women.^18,19 The Aboriginal people in Nova Scotia are heavily concentrated on a few reservations. At least two-thirds of the population of reservation EAs were Aboriginal, whereas no other EA had more than one-third. Hence, a woman in our study was considered to be from an Aboriginal community if she resided in a community with a majority Aboriginal population. Although there are more Black than Aboriginal residents of Nova Scotia, Black people are more dispersed. No Cape Breton EA had more than 15% of Black residents. A woman was coded as being from a Mixed community if her EA was at least 10% Black, and was considered to be from a Francophone community if at least 50% of the residents of her EA had French as their mother tongue. 

Two-dimensional cross-tabulations and chi-square statistics were used in the univariate analyses. Logistic regression was used to describe multivariate associations. Across the province, 4,025 women (1.1%) did not have a postal code in the MMC database. Using the provincial hospital separations database from April 1992 to March 1998, 8,663 Nova Scotia women were identified as having had a hysterectomy. Those who had had a hysterectomy and those with a missing postal code were excluded from the regression analyses reported. 

Results 

Validation steps 

From the telephone survey of the 197 randomly selected women conducted after the first mailing, there were no misunderstandings and few concerns regarding the intent of the letter. The women felt that the letter was a great idea for others, but they were too busy to obtain a Pap smear, did not like having a Pap smear or did not feel they needed one. 

To verify that age was a good proxy for the mailing date, a table of age groups by mailing date was prepared for the Cape Breton under-screened and unscreened women. A 99.8% match was found (Table 1). 

Cancellation stamp dates were used to verify the letter mailing dates provided by MMC. Letters were actually mailed up to nine days after the date provided by MMC. Therefore, a correction was made in the MMC mailing date before data analysis. 

Of the 22,686 letters mailed, 594 replies (2.6%) indicated that the woman had moved or the address was incorrect, and 38 (0.2%) reported that the woman was deceased. There was no upper age cut-off in the mailing, so many elderly women received letters. 

One hundred and twenty-five women were sent a letter by MMC but were coded in the final study data set as Cape Breton screened (37), or mainland screened (50), under-screened (13) or unscreened (25). In the analysis of subsequent smears, these 125 women were removed. Sending letters to 37 Cape Breton screened women probably resulted from a failure to receive all Pap smears in a timely manner before linkage and mailing. The mainland women probably moved from Cape Breton to the mainland between the time that MMC had them listed as a Cape Breton resident and the date that MMC released the study dataset for analysis. 

Subsequent smears 

Table 2 gives subsequent smear rates by demographic characteristics. Women who received a letter were more likely to get a Pap smear (odds ratio [OR] = 1.64) than women who did not get a letter (Table 3). Previously unscreened women were less likely than previously under-screened women to get a Pap smear (OR=0.54). Subsequent smears were inversely associated with age. Residing in a community with a female income of over $17,500 was associated with an increased likelihood of getting a subsequent Pap smear (OR = 1.13). Language, ethnic group and urban/rural status had no statistically significant relation to the probability of getting a subsequent Pap smear. Sensitivity analysis showed that removal of the study subjects who had had a complete hysterectomy resulted in negligible impact on the multivariate odds ratios. 

Using the tear-off reply, women indicated the reasons why they did not get a Pap smear after receiving a letter. Six hundred and forty-eight women (2.9%) said that they had had a hysterectomy. Some of these indicated that they were uncertain whether they required a Pap smear or not; we were not able to determine whether they had had subtotal or total hysterectomies. One hundred and seventy-six (0.8%) stated that they had had a recent Pap smear; for 150 of these (85%), smears were found in the PCR. Other replies were from 47 who said that they were too old; 24 were too impaired, e.g., with Alzheimer's, multiple sclerosis, mental retardation, were in a nursing home or would require a general anesthetic; nine had never been sexually active; and three had no family physician. These women were not removed from the analysis since their equivalents in mainland NS could not be identified and their removal had little impact; the subsequent smear rate in Cape Breton among under-screened and unscreened women increased by 0.06% with their removal. 

Many women indicated that they planned to have a Pap smear. For some, a Pap smear was reported more than six months after receiving a letter. Of the 22,686 letters sent, only four replies expressed negative comments; thanks were expressed in 29 tear-off replies. 

Abnormal smear rate 

The purpose of screening is the early detection and treatment of abnormal cells to prevent the development of invasive malignancies. Along with increasing the screening rate, it is important, therefore, to consider differences in rates of detection of abnormal smears in a complete assessment of the impact of the letter intervention. Table 4 gives abnormal smear rates among the subsequent smears for previously unscreened, under-screened and screened women. Among Nova Scotia women, having an abnormal smear was significantly associated with having been screened (OR = 1.61) or with being unscreened (OR = 1.62) versus having been under-screened, being younger than 40 versus 40 to 59 years (OR = 1.74), having low income (OR = 1.80) and rural residence (OR = 1.48) (Table 5). Being from a predominantly French area decreased the risk of an abnormal smear (OR= 0.34). The letter intervention increased the abnormal smear rate (OR = 1.31), but this was not statistically significant (p = 0.26). 

Cost-benefit 

The overall subsequent Pap smear rate among previously unscreened and under-screened mainland women was 4.6%. The rate among women receiving letters in Cape Breton was 6.9%. This implies that there were 508 additional smears obtained from hard-to-reach Cape Breton women as a result of the letter intervention. This estimate is conservative, since historically Cape Breton rates were lower than mainland Pap smear rates. 

Each Pap smear was estimated to cost $27.91 for each normal smear and $31.68 for each abnormal smear; abnormal smears are reviewed by a pathologist, which increases the cost. The total letter intervention cost, including the database linkage, postage, stationery, receipt of the tear-off returns, as well as physician and laboratory time for the extra smears, was estimated to be $69,497 or $2.42 per letter. The cost per letter would be lower if all unscreened and under-screened women in the province were sent letters, and these mailings became an ongoing process. The costs of follow-up colposcopy and treatment were not determined. The letter intervention cost less than $140 per additional smear obtained, or $6,950 per abnormality detected early by screening, given that 1.94% of smears were abnormal. 

Discussion 

The gold standard design for evaluating an intervention is the randomized controlled trial. A double blind placebo letter intervention trial was not possible. Women would know whether or not they received a letter asking them to go for a Pap smear. An unblinded randomized trial was possible. However, it was not possible to ascertain any contamination effect of women in communities who received letters discussing their letters with other women who had not received a letter or with their physicians, who would be caring for both intervention and control women. Therefore, a geographically defined cohort design was used. 

The intervention and control cohorts were selected so that the study findings would be a conservative estimate of any actual difference. Historically, the women in Cape Breton, where the intervention occurred, were less likely to go for screening than mainland women. Thus any difference observed between the responses of Cape Breton women receiving a letter asking them to get a Pap smear in comparison to mainland women who did not get a letter was likely to underestimate the actual impact of the letter intervention. 

The study findings were validated by an unanticipated "natural experiment". Unscreened and under-screened Cape Breton women aged 34, 54, 55 and 64 were not sent letters, as planned in the design. When the subsequent smear rates for these women were compared with those of the Cape Breton women receiving a letter, the findings were essentially the same as those found in the primary comparison of mainland women not sent letters (Table 3). 

The study findings were compared with the findings reported for other geographic areas. The magnitude of increased screening among under-screened and unscreened Cape Breton women who received letters was similar to the increase reported by others.^7,11,13,14 As in other studies, the Nova Scotia study demonstrates that obtaining a subsequent smear varies inversely with age, is greater for under-screened than unscreened women and increases with income. Further comparison is not straightforward for many reasons, such as differences in age groups;^7,9–11 inclusion of women who have had hysterectomies ^7,9,11,13 or not;^10,12,14 and method of determining Pap smear histories, e.g., central registries,^7,14 HMO databases,⁹ physician practice registers,¹⁰ self-report¹² and health insurance claims.¹³ Definitions of unscreened and under-screened vary.^7,10,13 Studies may include invitations to women regardless of screening status.¹¹ There is also variation in follow-up time for the intervention.^7,10–14 

Unique contributions of our research are the inclusion of an analysis of community ethnicity and language as well as identification of factors associated with abnormal smear rates. Lower screening rates have been reported in North America among women from Black and Aboriginal communities and among women whose first language differed from the main language used in screening programming and promotion. However, the question remained regarding how these subgroups of women respond to a formalized, personal letter asking them to get a Pap smear. Our results show that their subsequent smear rates are similar to those of other women of the same age, income and prior screening history. 

Abnormal smears were detected more frequently among women who had received a letter (OR = 1.31), although this was not statistically significant. Prior screening history (screened or unscreened versus under-screened), being younger, having a lower income and living in a rural community were all associated with an increased risk of detection of an abnormal smear. The association between being screened and a higher rate of abnormal smears is explained by the fact that all Pap smears are included in this analysis: diagnostic, follow-up, symptomatic and asymptomatic screening. When other factors were controlled for, women in Aboriginal and Mixed communities did not have significantly higher rates of abnormal smears. The significantly lower rate of abnormalities detected among women from Francophone communities was not anticipated. We may have something to learn from these Acadian communities regarding cervical cancer prevention. 

While it is easier to prompt under-screened than unscreened women to attend for a Pap smear using a letter of invitation, the yield in terms of greater detection and opportunity for early treatment to reduce the rate of invasive disease may well be greater among the unscreened than under-screened women. The two groups require different strategies. Unscreened women need to get a first screen. For women who lapse in their screening practices, the most cost-effective interval between Pap smears must be determined. 

The one-time Nova Scotia letter intervention had some impact. However, letters signed by patients' physicians have been shown to be more effective than "anonymous" letters.¹² Other studies have also demonstrated additional benefits with the use of enhancements.^9–11 

Other interventions (peer educators, physician practice profiles, nurses trained to do Pap testing) were developed and piloted in Cape Breton after the letter intervention and so did not influence the letter intervention findings reported here, but they have the potential to further improve screening rates. An exception was peer education outreach in the Aboriginal communities, which occurred concurrently with the letter intervention. However, the number of women reached during the time of the study reported here was limited. Publicity surrounding the three-year Health Canada project may have had some impact, but this was not likely substantial since previously screened women in Cape Breton had a subsequent Pap smear rate (24.3%) that remained lower than in the mainland (26.7%). 

The letters were accepted and valued by Cape Breton women, as has been found elsewhere.²⁰ Ronco et al.²¹ defined an organized program as one in which personal invitations are routinely sent. In Finland, reminder letters are sent every five years to eligible women aged 30 to 60 years.²² The findings reported here provide information to enable further development of letters of invitation processes in combination with other interventions to improve Pap smear screening in Canada and other countries. 

The goal of a good Pap smear screening program is to find and effectively treat pre-invasive (i.e., abnormal) cases.²³ Knowing both screening and abnormal smear rates helps target screening interventions and, conversely, may justify extending the screening interval for women at lower risk of abnormal smears. Cervical cancer is preventable if detected early, but one in three women will die of the disease if it is not detected and treated at the pre-invasive stage. The authors believe that the mailing of letters to unscreened and under-screened women, ideally signed by the woman's own physician, is worth the cost incurred to save the lives of women. We also conclude that multiple, continuous interventions, including letters to women, physician practice profiles, nurse service providers and community educators, are needed to further improve the Pap smear rates of hard to reach women in Nova Scotia. 

Acknowledgements 

The authors acknowledge the contribution of Ralph Jackson for computer systems support, Elaine Rankin for the telephone survey, Ethel Langille for the cost analysis and Maritime Medical Care staff who linked the cytology database to the provincial Health Card Number database, sent the letters to unscreened women in Cape Breton and provided a database to the authors for analysis. The Nova Scotia Department of Health provided the hysterectomy database for hysterectomy clearance across all study subjects for 1992–98. Health Canada's Population Health Fund provided funding for the project. 

References 

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8. Hyndman JCG, Straton JAY, Pritchard DA et al. Cost-effectiveness of interventions to promote cervical screening in general practice. Aust N Z J Public Health 1996;20: 272–77. 

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15. Screening for cancer of the cervix: An office manual for health professionals. (3^rd Ed) Halifax: Nova Scotia Gynaecological Cancer Screening Programme, 1998. 

16. Mustard CA, Derksen S, Berthelot JM et al. Assessing ecologic proxies for household income: a comparison of household and neighbourhood level income measures in the study of population health status. Health Place 1999;5:157–71. 

17. Anderson RT, Sorlie P, Backlund E et al. Mortality effects of community socioeconomic status. Epidemiology 1997;8:42–7. 

18. Sung JF, Blumenthal DS, Coates RJ et al. Knowledge, beliefs, attitudes, and cancer screening among inner-city African-American women. J Natl Med Assoc 1997; 89:405–11. 

19. Coughlin SS, Uhler RJ, Blackman DK. Breast and cervical cancer screening practices among American Indian and Alaska Native women in the United States, 1992– 1997. Prev Med 1999;29:287–95. 

20. Haines CS, Butschler M, Schacherl M. Development of instrument and results of pilot testing of a survey of public opinion regarding active cytology registries. Chron Dis Can 1993;14:105–09. 

21. Ronco G, Iossa A, Naldoni C et al. A first survey of organized cervical cancer screening programs in Italy. Tumori 1998;84: 624–30. 

22. Anittila A, Pukkala E, Soderman B et al. Effect of organised screening on cervical cancer incidence and mortality in Finland, 1963–1995: recent increase in cervical cancer incidence. Int J Cancer 1999;83:59–65. 

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Author References 

Grace Johnston, School of Health Services Administration, Dalhousie University and Surveillance and Epidemiology Unit, Cancer Care Nova Scotia, Halifax, Nova Scotia, Canada 

Christopher Boyd, formerly with Nova Scotia Cancer Registry, now the Surveillance and Epidemiology Unit, Cancer Care Nova Scotia, Halifax, Nova Scotia, Canada 

Margery MacIsaac, Janice Rhodes, Robert Grimshaw, Gynaecological Cancer Screening Program, Cancer Care Nova Scotia, Halifax, Nova Scotia, Canada 

Correspondence: Dr. Grace Johnston, School of Health Services Administration, Dalhousie University, 5599 Fenwick Street, Halifax, Nova Scotia, Canada B3H 1R2, Fax: (902) 494-6849, E-mail: Grace.Johnston@cdha.nshealth.ca 

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