Follow-up of women screened for cervical cancer in São Paulo, Brazil: An analysis of the times to diagnostic investigation and treatment

Abstract

Background - Cervical cancer incidence and mortality rates are higher in Brazil than in western countries. Access to cytology-based screening has increased in the country in recent decades, but few studies have assessed the quality of the follow-up care of women with abnormal screening tests that require further investigation. Methods - A record-linkage cohort study was conducted in São Paulo state. Women aged 25+ years, who were screened in 2010, and whose test revealed a high-grade, or more severe, lesion were eligible. Follow-up information on diagnostic investigations, treatments and mortality was obtained through record-linkage of health databases. The Kaplan-Meier method was used to estimate median times between screening and diagnostic investigation, and diagnosis and treatment initiation. Cox survival models were used to identify correlates of the length of these time intervals. Results - 4300 women had a high-grade, or more severe, test result. Of these, 2788 (64.8 %) had a diagnostic investigation record, 1763 (41 %) a confirmed diagnosis of a precursor lesion or cancer, and 1247 (70.7 %) a treatment record. The median time to diagnosis was 190 days, with the probability of undergoing a diagnostic investigation within 30 days of the abnormal screening test being 7%. The median time to treatment was 81 days, with the probability of undergoing treatment within 60 days of a confirmed diagnosis being 44 %. Delays in diagnosis and treatment were associated with area-based healthcare indicators. Conclusion - Times to diagnosis and treatment were long, well above recommendations. Strategies to improve follow-up care must be prioritized to ensure screening reduces cervical cancer incidence and mortality.