Table 4.

Illustrative case summaries of engaged women with cervical cancer

Failure to Screen
Case 1: Age mid-thirties  • Did not attend 16 scheduled Pap appointments in the HIV OB/GYN clinic in the 5 years prior to the abnormal Pap that led to cervical cancer diagnosis.  • Routinely seen in the HIV clinics during the study period.  • Poorly controlled HIV infection with increased viral load at multiple time points and self-reported non-adherence to medications.  • During HIV visits, providers stressed the importance of medication adherence so that she would be well enough to care for her family, as well as the importance of keeping gynecology appointments.  • Reported stress and competing demands, including caring for ill family members that involved travel.
Case 2: Age late fifties  • Post-menopausal with multiple comorbidities including tobacco use, hepatitis C, hypertension, dyslipidemia, multiple gastrointestinal conditions, and chronic abdominal pain.  • Nine emergency department visits in first 2 years of study for severe abdominal pain and GI symptoms. Seen frequently in GI-Liver Clinic and received multiple GI diagnostic evaluations. Seen at least annually in the same primary care clinic for 4 of 5 study years. Treatment through both primary care and specialty clinics focused on extreme hyperlipidemia and control of chronic GI symptoms.   • No Pap until seen for the first time at a women’s clinic at which time the patient was symptomatic (abnormal vaginal bleeding) and had a Pap performed indicative of cervical cancer.
Case 3: Age early sixties  • Post-menopausal with poorly controlled type II diabetes, hypertension, hyperlipidemia, congestive heart failure, and depression/anxiety.  • Seen regularly in primary care for 2.5 years before cancer diagnosis, with focus on control of diabetes and hypertension. Hospitalized for hypertensive crisis approximately 1 year prior to cervical cancer diagnosis; thereafter, attended cardiology clinic in addition to primary care clinic.  • CT angiography incidentally showed adnexal masses, confirmed by pelvic sonogram. The patient was seen in Gynecology Clinic 4 months later for further evaluation, which included her initial Pap within the system. Cervical cancer was subsequently diagnosed due to this Pap being abnormal.
Failure to Follow-Up Abnormal Test
Case 4: Age late thirties  • Reproductive-aged patient with history of diabetes mellitus and new diagnosis of advanced invasive breast cancer during the study period. Underwent mastectomy followed by neo-adjuvant chemotherapy for over 1 year.  • Screened for cervical cancer with co-tests one year apart in primary care clinic; both showed a negative Pap with positive high risk HPV testing. However, the patient was not referred for colposcopy as per management guidelines following the second such result.  • Thereafter, patient attended oncology follow-ups and infrequent primary care encounters that focused on her diabetes.  • Cholecystectomy performed after positive evaluation for gall bladder disease.  • Received a third Pap test approximately 2 years after the last co-test, with a negative result.  • Patient presented to gynecology clinic with symptoms of cervical cancer approximately 1 year after the 3rd negative Pap. A cervical mass was identified upon presentation to Gynecology Clinic.