See, Test & Treat: A 5-Year Experience of Pathologists Driving Cervical and Breast Cancer Screening to Underserved and Underinsured Populations

On the surface, offering a See, Test & Treat program appears deceptively easy. Papanicolaou (Pap) tests obtained during a pelvic exam, followed by mammograms, as needed (determined from an initial history and physical exam), would be processed and interpreted the same day of the event, with results going directly to the patients. However, assembling a team to address all the aspects of the program is required for successful implementation. Extensive planning is required, initially perhaps as long as 9–10 months during the first offering of the program; for subsequent programs, at least several months of planning is sufficient once the team has experience. Various departments in the hospital environment have a role in the successful execution of the program. Because the See, Test & Treat program was the vision of the CAP, and subsequently, the CAP Foundation, a pathologist takes the lead and drives the program forward. Establishing working relationships with other clinicians in the hospital is already part of the pathologist's skill set because pathologists provide interpretive results for most aspects of medicine and surgery. These relationships already exist, with 2 or more key departments needed to participate in the program: gynecologists or primary care physicians who obtain Pap tests as part of their routine care, and radiologists who provide and interpret mammograms. Initial skepticism may be encountered if either group expresses surprise that a pathologist would lead such a patient-centered enterprise, or asks the “what's in it for me?” (my department) question. Health care today is notably a team effort, and in most hospital settings, tumor boards are an example of multiple physicians with different subspecialties coming together to discuss treatment and prognosis (as well as diagnosis). These teams are composed of the clinical group—for example, gynecologists, radiologists, and pathologists—all of whom contribute to the care of the patients who present.

The choice of the See, Test & Treat target population is largely determined by the geographic setting of the hospital or catchment area. Because TuftsMC is situated in the Chinatown area of downtown Boston, Massachusetts, it was an obvious choice to provide the residents of this location with free cervical and breast-cancer screening. Asian women in Chinatown are faced with several challenges. Although language barriers are most common, additional barriers, such as lack of child care, difficulty in taking time off work, and a reluctance to present to a health care practitioner without an obvious, severe medical difficulty, are not uncommon. Women, in particular, perform the role of caregiver for their families and may not be comfortable with the role of needing care. Several of the patients who came to our See, Test & Treat program with extended family (sisters or mothers) explained to us that, for their mothers, the concept of “screening” for potential disease or wellness checks was not within their cultural upbringing; seeing a doctor was only necessary when symptoms interfered with activities of daily living. The initial flyers advertising the program (Figure) attracted women from outside the immediate Chinatown community, as well as those who had ties to other Asian communities within the metro Boston, Massachusetts region.

Once a target population has been defined, the major hospital departments have to agree on a date for the event. Many programs choose October because it is breast cancer awareness month, but, in fact, if more of these programs are funded by the CAP Foundation and their support is required at each event, then any time of the year in which department schedules and weather permit will suffice. Although it suited the medical center to offer the program on a Saturday, it also suited the patients. Part of the challenge for underserved and underinsured populations is finding health care services outside of the traditional Monday to Friday offerings. Preventive care programs are typically not offered on the weekend, thus, eliminating the opportunity to educate and prevent latter-stage diagnosis of disease. Holding a program on Saturday allows the patient to avoid conflicts with work schedules, and for the participating clinical staff, a Saturday venue does not interfere with their regularly scheduled workload.

The choice for partners in the program includes more than pathology, gynecology (and or primary care), and radiology. Additional help from other departments allows questions, such as registration, nutrition, and follow-up care, to be addressed (Table 1). Pathology and laboratory medicine, in addition to processing and interpreting laboratory tests, can also provide education for patients. Education can take the form of sitting one to one at the microscope to explain what the pathologist sees on the Pap slide using a normal slide or reviewing a patient's specific slide. Many patients are fascinated with being able to view cells through a microscope. This exercise can be supplemented with posters or literature on the Pap tests, breast cancer, and cervical cancer. and any additional information that might be relevant for patients.

Creating a timeline for the work is critical to propelling the event forward. Initial planning for the first See, Test & Treat event held will require more rigorous planning than subsequent events. Although subsequent programs have the advantage of experience, medical or support staff sometimes leave positions, and other circumstances may change that require a fair amount of planning. In addition, any deficiencies identified in earlier programs can be rectified during the planning of subsequent programs. An example of a modified (modified to remove specific individuals' names), first-year timeline (Table 2) and a modified version of meeting minutes from an event offered 5 years later (Table 3) detail the all-encompassing nature of See, Test & Treat planning. The scope of the program must be mapped, and event details, such as location, participating providers, volunteer recruitment, patient registration, marketing, community outreach, supplies/equipment, interpreters, health fair vendors, food, entertainment, child care, and mutually agreed upon meeting dates, must be determined. It is suggested that initial meetings could be monthly, with emails to communicate in between meetings, and as the time approaches, meetings could advance from every other week to weekly, right before the event. During the final weeks, media interviews for radio, newsprint, or television may require added time for the pathologist or other physicians participating in the event and should be factored in to the total time commitment. Support from the CAP Foundation and from critical players on the team, who take primary responsibility for the arrangements, is essential to the event's success. Identifying an event or program coordinator, who establishes event milestones and synchronizes communications between the event's stakeholders, is necessary for the program to function seamlessly. At TuftsMC, our clinical laboratory director of operations stepped into this role. This individual had extensive contacts throughout the hospital and was able to assemble managers from diverse areas (security, registration, media relations, among others) whose contributions were necessary for the program's seamless operation.

Representatives from the various specialties (Table 1) met for several months to plan for the single-day event. Cytology equipment needed for the event was located within the hospital laboratory (Table 4). Additional material was prepared before the event. This included flyers (Figure), signs indicating that See, Test & Treat was being conducted at a specific location, signs indicating where mammography was conducted, and various educational posters created by pathology and other residents and fellows (eg, the Pap test, nutritional information).

A See, Test & Treat Playbook was created and used from year to year to ensure seamless program development. The playbook consisted of a notebook with tabbed program components, which can vary, depending on the location of the program. The TuftsMC playbook contained the following components.

For sites that will include a health fair, it is imperative to ensure that there are enough tables, chairs, and tablecloths for the participants. At our facility, we secured this through our hospitality department and had them set up the day before the event.

Keeping a list of health fair vendors with contact information was essential in organizing this section of the program. We contacted local community groups to determine whether they had an interest in participating in the event. Over the years, we have had a variety of organizations represented, including the local Young Men's Christian Association (Chicago, Illinois); the Special Supplemental Nutrition Program for Women, Infants, and Children (Washington, DC); the American Cancer Society (Atlanta, Georgia); Susan G. Komen (Dallas, Texas); Asian Community Development Corporation (Boston, Massachusetts); and the Breast Health Center and the Frances Stern Nutrition Center at our hospital. The TuftsMC departments involved in the program also set up informational tables, providing material in both English and Chinese.

Our program was fortunate to have child care volunteers who were trained and/or employed in child care settings. Activities for all ages should be addressed. Suggestions for child care activities include face paints, play dough, coloring pages, and books. We also obtained a television and a DVD player to watch age-appropriate videos. Hand sanitizer, disinfecting wipes, and age-appropriate snacks should also be available in the children's area. A clipboard was used to sign children in and out of the child care room, and each child was given a name tag.

As this was a daylong event, our team provided breakfast, lunch, snacks, and beverages throughout the day for both staff and patients. We realized after the first 2 years that providing ethnically appropriate food, if possible, for the specific patient population was appreciated. Donations from large food chains and from small, local, ethnic bakers provided a variety that appealed to most people.

Providing activities for the women and their families to do while waiting for their test results was a challenge. Over the years, we tried various undertakings, such as stretching, yoga, ethnic magazines, and a television with DVD player. One of the most successful and educational opportunities was showing the women a Pap or blood smear under the microscope.

We created a facility map of the See, Test & Treat event space, so we could preplan placement of tables and outline which rooms would be designated for what functions. There was a patient registration area, multiple exam rooms, a phlebotomy suite, patient waiting rooms, a child care room, and a room for the pathologists to review Pap test slides; a room that was private and could also serve as a consultation area was designated for giving results to the patients.

Our team distributed gift bags (goodie bags) to participating women after they received their test results, which included a T-shirt, a CAP bracelet inscribed with “every number is a life,” Tufts Medical Center brochures from various departments, and a gift card to a local retail store.

Signage directing patients and their families to the See, Test & Treat event was placed strategically throughout the hospital. Each of our signs was numbered and where it was placed was documented for easy setup and take down. Our signs were in both English and Chinese, and it is recommended that signs should include the specific language representative of the population being tested (as applicable).

On the day of the event, signage was placed throughout the facility, the child care area was prepared, and microscopes were brought to the clinic area (2 double-headed scopes, 1 for signing out cases and 1 to be left in the main waiting area to review slide material with patients and family members).

As described above, activities on the day of the event included the help of a volunteer certified personal trainer, educational demonstrations at the various display tables (eg, how to do a breast exam using a model of a breast with and without small lumps, reviewing normal Pap slides under the microscope or on a poster-board display), and movies set up in the children's activity center.

Although most patients preregistered via information on the flyer, we welcomed walk-ins as well. Preregistration gave us an opportunity to determine whether the patient had ever been seen at TuftsMC in the past and, in subsequent years, whether they had been seen at a previous See, Test & Treat program. Paper and computerized charts were created for each of the patients, regardless of whether he or she had preregistered. Having an electronic record facilitates both long-term tracking of each patient (as this becomes the standard of health care across the nation) and tracking of patients who pursued future care through TuftsMC.

Although the State of Massachusetts is known for providing access to universal health insurance, not all eligible patients had health insurance or qualified for insurance privileges. Therefore, access to financial counseling and insurance information was also available on the day of the event.

Two hundred and three patients attended the See, Test & Treat program offered at TuftsMC between 2010 and 2014 (Table 5). Of these, 175 (86.2%) were Asian, predominantly Chinese (speaking both Cantonese and Mandarin). Although the program was extended to the Asian community, the program was open to any woman interested in the offered screenings. The remaining racial distribution of the women presenting during the 5-year period was 18 white (8.9%), 5 Hispanic (2.5%), and 3 African American (1.5%).

Of the 203 patients, slightly more than half (n = 105; 51.7%) were between the ages of 25 and 50, followed by 89 patients (43.8%) 50 years and older. Only 9 patients (4.4%) were between 18 and 25 years.

In the initial year (2010) of the program, the percentage of women who had insurance was only 23.5% (8 of 34). Subsequent years showed an increase to 62.5% (20 of 32 patients) in 2011, which then stabilized at 40.7% (22 of 54) in 2012, 41.7% (20 of 48) in 2013, and 40.0% (14 of 35) in 2014.

Although the event was held at TuftsMC in the Chinatown community, other associated communities within the Boston, Massachusetts regional area have Asian populations. Between 18.8% (6 of 32 in 2011) and 37.1% (13 of 35 in 2014) of the patients seen came from Boston, Massachusetts, and the remaining came from outlying communities and suburbs.

During the 5-year course of the program, 36 of 169 patients (21.3%) had abnormal Pap test results (Table 6). Twenty-two of the 36 patients (61%) had findings of atypical squamous cells of undetermined significance, 12 patients (33%) had findings of low-grade dysplasia, and 2 patients (6%) had high-grade dysplasia. One of the patients with atypical squamous cells of undetermined significance also had atypical glandular cells present. Of note, on one slide, a diagnosis of Candida yeast was made (not included in the abnormal findings data). During the 5-year span of the program, 118 human papillomavirus (HPV) tests were ordered. Of those, 18 (15%) had positive results.

Based on the Pap test results, colposcopy was performed on 12 patients with suspected dysplasia. Of those, there were 3 patients (25%) with negative results, 6 patients (50%) with cervical intraepithelial neoplasia I, and 3 women (25%) with cervical intraepithelial neoplasia II/III (Table 7). One patient in the last year of the program underwent a Pap test evaluation, a colposcopy exam, and a loop electrosurgical excision procedure to treat the dysplasia.

If, during the course of the gynecologic exam, the clinician noted an abnormal polyp, those lesions were biopsied and processed for confirmation by the pathologist for the following week (not same-day reporting). All polyps biopsied were benign, with 1 exhibiting atypical squamous metaplasia.

Table 8 reflects additional laboratory results ordered by the physician examining the patient. Of the 108 tests for thyroid-stimulating hormone levels determined in the 5 years, only 7 (6.5%) had abnormal results. There was only one positive result identified for chlamydia growth. Nine of 32 complete blood cell counts (28.1%) ordered had abnormal results. There were no positive human immunodeficiency virus or rapid plasma reagin results in the 11 patients who had orders for these tests.

Because hepatitis B is endemic in the Asian population, we offered hepatitis testing (B, A, and C) if requested by the clinician (Table 9). Of note, 15 of 34 patients (44.1%) tested had hepatitis B surface antibodies present, 1 of 18 patients (5.5%) tested had hepatitis B surface antigens present, and 2 of 8 patients (25.0%) tested had hepatitis B core antigens present.

During the 5-year period, 130 mammograms were performed at the See, Test & Treat event (Table 10). Mammograms were ordered based on the age of the patient or to evaluate specific findings identified at the time of the physical examination or from the patient's history. Sixteen mammograms (12.3%) were determined to have abnormal findings. Abnormal findings consisted primarily of architectural distortion (n = 1), bilateral asymmetric densities (n = 5), microcalcifications (n = 5), noncalcified masses (n = 5 patients, 1 patient was imaged in 2 years; several patients had >1 mass), and unilateral axillary adenopathy (n = 1). In some of these patients, we were able to obtain prior films for comparison to document stability; some patients did receive follow-up mammograms to confirm stability. One patient underwent follow-up ultrasound, and the mass was documented to be a simple cyst of no clinical concern. Most patients did not receive additional imaging or further evaluation at our institution.

Four patients had palpable lumps and negative mammograms (there is a false-negative rate with mammography, and management of palpable abnormalities must be based on clinical grounds. We do not know if these palpable abnormalities were investigated further). One patient reported a palpable abnormality at the site of a surgical scar from prior breast conservation therapy, and although no discrete mass was identified, comparison with prior films (with or without ultrasound) was recommended for further evaluation.

Cancer-screening rates remain lower in Asian Americans in the United States when compared with other racial or ethnic groups. In general, women from ethnic populations have barriers that prevent them from participating in cancer screening. However, the CAP See, Test & Treat program is designed to reduce the barriers for these women by providing care that addresses cultural, financial, and practical issues. Studies have shown that being educationally disadvantaged, not having health insurance, and lack of English fluency were significant barriers to obtaining cervical or breast cancer screening in Asian populations.^1–4  Our data showed that, even though health insurance was available in Massachusetts, during most years the program was offered, fewer than 50% of the patients had coverage.

Transportation issues have also been identified as barriers to obtaining health care screening.³  Several studies in California have underscored the limitations in providing care for Asian women in the state.^1,2,5  Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese women were surveyed to understand their adherence to Pap test guidelines.²  The study used the Andersen behavioral model, which identifies how health services are used based on a person's perceived need for care, and characteristics and resources that enable (or not) that woman to use the service. A woman's cultural background is critical in this context because Asian American women generally wait for physical symptoms before seeking care. Cervical cancer, however, is largely asymptomatic, and education regarding preventative care may go unheeded in this population. Attitudinal barriers in minority women consist of the perceived need for screening: for example, a perceived low risk of cervical cancer because of sexual inactivity; fear of cancer, that is, what the screening might find; concerns about the test, that is, the tests were embarrassing; and practical considerations, that is, they intend to go, but do not get around to it.⁴ 

Although breast cancer occurs less frequently in China than it does in Western countries, it has been increasing.⁶  Screening mammography did not identify any cancers in our series of screenings during the See, Test & Treat events. Multiple abnormalities were identified for which additional imaging was recommended; in most cases, this additional imaging did not occur. Possible reasons for this deficiency include (1) the patient may not have understood the need for additional imaging because of difficulty in communication (written reports were printed in English, although the reports were interpreted for the patient on the day of the study); (2) lack of primary care physicians and the lack of any infrastructure to encourage patients to make/keep appointments for follow-up; (3) difficulty in access to health care because of cultural differences, financial limitations, and lack of support from family and work; and (4) denial and other issues similar to those occurring in the general population.

Health literacy is an important consideration in detecting cervical and breast cancers in women. The ability to understand information, such as written instructions from a doctor's office or reading instructions on a prescription bottle, has been used to assess health literacy.⁵  In conjunction with other obstacles, such as language constraints and cultural biases, the need for cancer screening education is largely dependent on education level, cultural influences, and language barriers. To improve follow-up after screening studies, it may be helpful to have letters regarding results written in the language of the patient. If possible, it might be helpful to find out from the patients how best to contact them regarding any necessary follow-up. The presence of a “point person” on the day of the event and thereafter may help to “close the loop” on screening that cannot be completed in 1 day. The point person might be a physician, nurse, social worker, or a community leader.

Other studies have noted that simply providing low-cost (and in our case no-cost) Pap tests may be insufficient. More comprehensive health care services that increase contact between these women and health care professionals may be needed.²  Although the Affordable Care Act of 2010 has presumably given all Americans the ability to obtain health insurance coverage, not all people living in the United States are eligible, particularly if their immigration status is questionable or illegal. Questionable immigration status may also present barriers in obtaining follow-up care, as may distance needing to be traveled. Although patients with urgent needs were given follow-up appointments with the appropriate clinical staff as necessary, patients were lost to follow-up. A strong push should be made to keep in touch with women who attend these programs to ensure that they receive the additional care needed. For future programs, someone should be designated as a “case manager,” who can not only work with the women in need of additional care but also is fluent in financial programs that provide care to patients who cannot afford the treatment options. This may require different and additional resources and could be negotiated with the base hospital hosting the event.

Pathologists have a key role in the diagnosis of cancer. As part of a team of treating physicians proficient at presenting diagnostic findings at institutional tumor boards, pathologists are in a unique position to lead a See, Test & Treat event. Existing relationships between the pathologist and other physicians (gynecologists, family medicine physicians, radiologists) needed to create a successful program already exist in a hospital environment and can be harnessed for community-outreach screening programs. Intervention is needed in the health care process for those with clear barriers. Education that focuses on cultural biases toward the perceived need for care should also be addressed in screening programs and health care literature generated to reach specific communities. Follow-up care is necessary to evaluate the true success of a screening program.

This study was supported in part by the College of American Pathologists and a grant from the CAP Foundation. We would like to thank the many volunteers from Tufts Medical Center, including the Departments of Pathology and Laboratory Medicine (in particular Farhad Askarian, MD; Barbara Weinstein, MD; Stephen Naber, MD, PhD), Obstetrics and Gynecology, Radiology (in particular Marc Homer, MD), General Medical Associates (in particular Deborah Blazey-Martin, MD, MPH), and Public Affairs and Communications (in particular Jeremy Lechan, MS); the Community Health Improvement Programs (in particular Sherry Dong, MPA); the Tufts Medical Center Trust; and the various supporting services at Tufts Medical Center: the Frances Stern Nutrition Center, Preregistration (patient registration), and the Department of Public Safety (security). Special thanks to Kristi Bedrossian, CT(ASCP), anatomic pathology manger and cytopathology supervisor, and her team for organizing and screening Pap testing for our patients and to YimTan Wong, MFA, for event coordination and assistance in preparing the manuscript. We would also like to thank various community and vendor sponsors who donated time, food, or laboratory reagents (donations in kind) to ensure the success of the See, Test & Treat program, some of which are recognized here: Siemens Healthcare Diagnostics (Tarrytown, New York), Abbott Diagnostics (Lake Forest, Illinois), BD TriPath (Franklin Lakes, New Jersey), Qiagen (Valencia, California), Hologic Inc. (Marlborough, Massachusetts), Sekisui Diagnostics, LLC (Lexington, Massachusetts), CareStream Health, Inc (Rochester, New York), and Whole Foods (Boston, Massachusetts).