It was an intentionally simple question the clinical nurse in the examining room heard. “Lynn,” I said, “Have you ever been bullied?” There came a pause. Then, she responded with a torrent of emotions reflecting anger and disappointment that took her back to the start of her career 23 years ago. I posed the question as she prepped me for the ECG my doctor ordered.
After completing her nursing degree, Lynn went to work as a registered nurse in the emergency department at a suburban hospital in North Carolina. For the next two years, she was abused, intimidated, openly berated, and humiliated by staff nurses with more seniority and the nurse manager.
“What was that like?”
She said it was just how you were treated. “You were made to feel stupid when you sought clarification of a physician’s charted instructions, for example, or asked for input to correctly respond to a patient’s request. Eventually, I left.”
What happened to Lynn is not a rare occurrence among nurses, unfortunately. On July 9, 2008, The Joint Commission, which provides oversight to over 20,000 hospitals and other care facilities, issued a policy directive to its membership called a Sentinel Event Alert. Its instruction was to have procedures in place to deal with “behaviors that undermine a culture of safety” by January 1, 2009. It described “intimidating and disruptive behaviors” in great detail, which is the most widely accepted definition of bullying. Its rationale was clearly embedded within the body of the policy: “There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.”
With mounting evidence that bullying was surprisingly prevalent within the health care sector, the intended purpose of the Sentinel Event Alert was to amend its leadership standards. Accredited health care organizations would be required to create codes of conduct that define disruptive and inappropriate workplace behaviors as well as establish and implement procedures for managing such behaviors. Additionally, the institutions The Joint Commission accredits were expected to make their data available for review, according to Gerard M. Castro, PhD, The Joint Commission’s project director for patient safety initiatives.
Nursing’s Dirty Little Secret
“Nurses eat their young,” wrote Theresa Brown, a registered nurse, in an article in The New York Times in February 2010. “The expression is standard lore among nurses, and it means bullying, harassment, whatever you want to call it. It’s that harsh, sometimes abusive treatment of new nurses that is entrenched on some hospital floors and schools of nursing. It’s the dirty little secret of nursing.”
Her story is not exceptional, and it prompted me to contact Gina, a clinical nurse in Worcester, Massachusetts, with a master of science degree in nursing education and 35 years of experience—15 of which were on a nursing school’s faculty.
“There are nurses that I do not assign a new-to-nursing nurse to because of what I know would be their experience,” Gina tells me. Then, she describes her very recent experience where she accepted a per diem assignment in the operating room (OR) of a local hospital with which she is very familiar: “I almost never survived a month because of the bullying that went on. I had never seen anything like it and never experienced anything like it in my years in nursing.”
It seems that there had not been an assignment of someone new to the OR in 10 years, so Gina was treated as an outsider and not part of the clique. So targeted was the hostility that after three months of enduring the treatment, she says, “I began to feel myself spiraling down, losing my self-confidence. I endured badgering criticism; I couldn’t do anything right; there was an absence of kindness.”
Fortunately, there was a change of supervisor who observed the climate in the OR and stepped in to end the intimidation by referring the preceptor for retraining.
An Occupational Hazard
Scenarios similar to the one Gina describes must have been alarmingly common to have prompted The Joint Commission to issue a specific directive regarding workplace bullying, or lateral violence, as it is technically referenced. Diverse studies identify nursing as a risk group for workplace bullying; further, they confirm that the problem of hostility in the workplace is very common in the health care sector.
Indeed, health systems are aware of this hostility and responding to the Commission’s directive. Duke University and the University of North Carolina, for instance, have policies and procedures to deal with workplace behavior. Duke shies away from describing intimidating and disruptive behaviors as bullying per se—and perhaps may have tacitly not reinforced the implications that bullying is specific and disruptive conduct that impacts the delivery of care.
Carole Akerly, BSN, director of accreditation and regulatory affairs at Duke University Hospital, responded to my inquiry. “Duke,” she says, “has identified behaviors that are appropriate and has not specifically described intimidating and disruptive behaviors, and I don’t know whether we have identified it as that close.” But if bullying is as prevalent as the research and reports indicate—and there are many—it is unlikely that Duke and other health care providers have an incident pattern less than the norm.
The University of North Carolina Health Care System, on the other hand, provides a detailed description of intimidating and disruptive behavior and a very specific description of what constitutes appropriate behavior, so the employee has no room to allege ambiguity. The rationale for its disruptive and inappropriate behavior policy admits that disruptive behavior “intimidates others and affects morale or staff turnover [and] can be harmful to patient care and satisfaction as well as employee satisfaction and safety.” Further, the policy acknowledges the possible presence of such behavior: “While this kind of conduct is not pervasive in our facilities, no hospital or clinic is immune.”
Carol F. Rocker, PhD, RN, the lead investigator of a study of nurse-to-nurse bullying and its impact on retention in Canada, reported in OJIN: The Online Journal of Issues in Nursing in September 2008 that Canadian nurses are not alone when it comes to workplace bullying and emphasized that workplace bullying among nurses is now recognized as a major occupational health problem in the United Kingdom, Europe, and Australia. Why did The Joint Commission go to the trouble of defining bullying if it was not to delineate behaviors that threatened patient safety and care quality? The answer is embedded in what led the Commission to do this in the first place. It’s found in the promulgation of the Universal Protocol (UP).
In addressing the need to create a climate of safety related to wrong site, wrong patient, and wrong procedure within a health care facility, the Commission became aware that one of the contributing factors was the failure to speak up. What stops a clinician from speaking up? Oftentimes, it’s the deference to the physician and other clinicians.
“We have heard of abusive behavior by physicians when clinicians in the operating room, for example, have corrected the physician. Not speaking up is the result of deference to the physician,” says Castro. The UP team became aware at that time that this harmful behavior within care facilities was a safety issue.
A 2003 survey on workplace intimidation conducted by the Institute for Safe Medication Practices found that 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator. Elaborating on this issue, the Commission’s Sentinel Event Alert cites several reasons why disruptive behaviors go unreported, such as fear of retaliation, the stigma associated with “blowing the whistle” on a colleague, and leniency towards physicians who generate high amounts of revenue.
But, so serious is the epidemic of workplace bullying—with particular emphasis on the nursing sector—that 26 state legislatures have proposed legislation to address this concern, beginning with California in 2003. The model, the Healthy Workplace Bill, provides very specific employee and employer remedies, protections, and sanctions. There is clearly a movement to expand safety in the workplace from the purely physical aspect to the equally important emotional and psychological aspects.
When Nurses Hurt Nurses
Kathleen Bartholomew, RN, MN, renowned for nursing consulting and training, cites episodes of nurse bullying that astonishes: a nurse hides a surgeon’s favorite instrument when a substitute fills in as the scrub; a circulator, a nurse who makes preparations for an operation and continually monitors the patient and staff during the surgery, doesn’t tell a new nurse who is scrubbed that she knows the shunt the surgeon selected has fallen on the floor; a newly hired RN who was previously a scrub technician is shunned by both camps. These episodes, Bartholomew says, pose the question whether this is what life is like in the OR.
When the administration at Indiana University Ball Memorial Hospital studied the issue of bullying, it was clear that the problem existed beyond nursing units. “It starts with physician to physician and then trickles down the chain of command,” says Renee Twibell, PhD, the lead investigator and an associate professor of nursing at Ball State University. “If the doctor kicks the nurse, that nurse turns around and kicks the new nurse or the CNA.”
The consequences of adult bullying have led investigators to name it as a significant occupational stressor in the workplace. Moreover, the Center for American Nurses labels workplace bullying a serious issue affecting the nursing profession in particular, and defines it as any type of repetitive abuse in which the victim suffers verbal abuse, threats, humiliating or intimidating behaviors, or behaviors that interfere with the victim’s job performance and are meant to place the health and safety of the victim at risk.
Are all nursing sectors equally at risk? Specifically, I was curious to know whether military nurses have a similar experience. Having spoken with Lieutenant Colonel Angelo D. Moore, PhD, the deputy chief for the Center for Nursing Science and Clinical Inquiry at Fort Bragg Womack Army Medical Center for a previous story, I remembered what he had said. Moore turned my inquiry around and wondered whether gender issues might be at work in some bullying episodes. The ratio of male to female nurses in the military is thrice that of the nonmilitary nursing sector and, according to Moore, the combination of having been to war and the culture of the military contributes to very few incidents where bullying was alleged.
Still, bullying is a complex phenomenon. Although bullies are responsible for their behaviors, investigators have analyzed several potential factors that prime the workplace for bully behaviors, which include organizational leadership and culture, the social system, character traits of the victim, and character traits of the bully. Bullying clearly qualifies as hostile workplace behavior, and if the target can claim protected class status, it becomes a major legal issue for hospitals and care centers. A 2011 study of student nurses by the American Nursing Association reported that 53% of study participants had been “put down” by a staff nurse, and 52% had been threatened or experienced verbal violence at work.
Cheryl Dellasega, PhD, faculty member at the Penn State University College of Medicine and author of When Nurses Hurt Nurses: Recognizing and Overcoming the Cycle of Bullying, provides significant research that led her to state that there are cases where the nurse manager or charge nurse—often a highly competent, valuable nurse that the administration does not want to lose—may act as a bully, playing favorites when it comes to assignments or time off. “If they are role modeling this stuff, it will be worse among the staff,” Dellasega told NurseZone.com. “If they get the message that it’s OK to treat people like this, everybody will.”
Moving Forward
So, what’s the remedy? Bullying in the workplace is both an awareness and a leadership issue. Moreover, as is so often the case in workplace practices, the leadership should be careful not to be caught being party to making case law by a complainant seeking to link hostile workplace to bullying as a protected class member. Hospital management might address the presence or prevalence of bullying behavior by examining how it is factored into their training in root-cause analysis, as well as what their whistleblowing protection policy provides.
Nurse leaders must establish clear guidelines about what behaviors will not be tolerated and what is unacceptable, Dellasega believes. She also recommends creating a suggestion system so nurses can anonymously report things that happen on the unit, and asking for feedback about what would make the work environment better.
Gabriela Cora, MD, takes a harder stand, saying hospital administrators should have zero tolerance for bullying behavior. “Lay a plan for improvement,” Cora adds. “Reward them when they improve their behavior and be ready to fire them if they continue the bullying behavior. Second, avoid praising or rewarding nurses for their work performance if they are bullies. Instead, respectful treatment of patients and positive interactions with colleagues should be rewarded.”
Ultimately, it’s all about modeling positive behaviors and holding employees accountable. If the policy is zero tolerance for bullying, it should mean just that—zero tolerance.
Sometimes the most compassionate care a nurse can give to a dying patient is to quiet the room. Cheryl Thaxton, RN, MN, CPNP, FNP-BC, CH-PPN, a nurse practitioner on the supportive and palliative care team at the Baylor Regional Medical Center at Grapevine, says when a patient is near death, care providers need to be attentive to personal desires and family traditions regarding those final moments.
“Sometimes death is such a new experience to families that they don’t know what to expect or what to ask for, so we have to dig deeper into what their beliefs are,” Thaxton explains. “Some people want privacy in the moment of death. They don’t want someone coming into the room to change the garbage can or bring a lunch tray. They see this moment as sacred, and they want to have prayer or peace without interruptions.”
Among Asian Pacific Islanders (APIs), choices about end-of-life care often are made by the family as a whole, or by a designated decision maker within the family, says Merle Kataoka-Yahiro, DrPH, MS, APRN, an associate professor of nursing at the University of Hawaii at Manoa.
“There needs to be improved crosscultural intervention—using culturally appropriate and sensitive communication and behavioral change approaches—for health professionals as they interact and engage with API patients and families on topics related to palliative, hospice, and end-of-life care,” says Kataoka-Yahiro.
The Institute of Medicine (IOM) counts attention to patients’ cultural, social, religious, and spiritual needs as core components of quality end-of-life care, along with management of pain and symptoms and support for family members. This holistic view of hospice care lends itself to a collaborative, team approach that’s guided by respect for each patient’s identity and autonomy.
The State of Hospice Care
In 2012, 1.5 million to 1.6 million patients received hospice services, according to the most recent report from the National Hospice and Palliative Care Organization (NHPCO). The number had steadily increased since 2008, when it stood at 1.2 million. About 66% of hospice patients received care where they lived, whether that was a private residence, nursing home, or residential facility. Roughly 27% were in a hospice inpatient facility, and nearly 7% were in an acute care hospital. The median length of hospice service in 2012 was 18.7 days, while the average was 71.8 days.
In 2012, 57.4% of hospices were freestanding, independent agencies; 20.5% were part of a hospital system; 16.9% were part of a home health agency; and 5.5% were part of a nursing home, according to NHPCO.
The NHPCO report found that 56.4% of hospice patients were female, 43.6% were male. More than 6% were of Hispanic or Latino origin (with Hispanic origin reported separately from race). Eighty-one and a half percent were White/Caucasian; 8.6% Black/African American; 2.8% Asian, Hawaiian, or Other Pacific Islander; 0.3% American Indian or Alaskan Native.
While cancer patients made up the largest percentage of US admissions when hospice care began in the 1970s, today cancer diagnoses make up only about 37% of hospice admissions. Unspecified disabilities accounted for 14% of admissions in the NHPCO survey. Dementia was 12.8%; heart disease, 11.2%; and lung disease, 8.2%.
These changes are having an impact on access to hospice care, says Brian Guthrie, MD, associate medical director at Burke Hospice & Palliative Care in Burke County, North Carolina. The standard of eligibility for hospice care benefits from Medicare is that the patient must have consulted two doctors who agree that life expectancy is six months or less if the illness progresses normally.
“That’s easier to do with cancer than it is with heart or lung disease, and it’s especially difficult to do with people with advancing dementia,” says Guthrie, who is board certified in hospice and palliative medicine. “There are admission guidelines with as many numbers and algorithms as we can figure out as to who might die in six months, but it’s a bigger challenge all the time.”
Guthrie’s wife, Birgit Lisanti, RN, MSN, MBA, is CEO of Burke Hospice. With an average daily census of about 120, the facility employs another physician who works full-time, while Guthrie fills in when needed. Guthrie was formerly a hospice physician at Tidewell Hospice in Sarasota, Florida, which had an average daily census of 1,200.
“The tremendous growth of hospice nationally has been a challenge for [the Centers for Medicare and Medicaid Services] because they had not planned that it would be this big an industry—and that they would be financially responsible for so much care,” Guthrie says. “They’ve had to be vigilant—or you could say heavy-handed if you want—in trying to ensure that we don’t treat people for years and years on hospice when they are continuing to survive.”
Jennifer Gentry, RN, MSN, ANP-BC, ACHPN, FPCN, president of the Hospice and Palliative Nurses Association, says one of the biggest changes in hospice care is that it is now viewed as part of a continuum that begins with earlier stages of palliative care. She notes that a number of hospice agencies have added nonhospice palliative care to their services.
“The unfortunate thing is that sometimes we don’t recognize the benefits of hospice soon enough, and patients are not referred for hospice care until days before they die,” says Gentry, who is a clinical associate at the Duke University School of Nursing. “They don’t get the full benefit of what hospice has to offer, not only for the patient but for their family unit.”
Holistic, Patient-Centered
Both palliative and hospice care are most effective when they take into consideration the patient’s physical, emotional, social, and spiritual needs, says Maureen Leahy, RN, BSN, MHA, CHPN, clinical nurse manager in the Wiener Family Palliative Care Unit at The Mount Sinai Hospital in New York City.
Staff for the 13-bed unit includes nurses, physicians, geriatric and palliative care fellows, a nurse practitioner, and art, music, and pet therapists. There are even doulas that Leahy calls “midwives to the soul.” Rather than helping women give birth, these volunteer doulas are trained to help patients and their families transition to the end of life.
“They may serve coffee,” Leahy says. “They may sit a vigil with a dying patient. They may spend time with grandchildren of the patient doing painting and drawing.”
Guthrie notes that Medicare-approved, independent hospice agencies are required to have a multidisciplinary staff that meets at least every two weeks to discuss each patient.
“The social workers, chaplains, aides, nurses, and physician all meet together and talk about the plan of care, challenges, what we expect to see next, and they try and work together to ensure that all of the patient’s needs—medical, emotional, spiritual, and social—are met,” Guthrie says. “The focus is on the family as well.”
Listening is one of the most important services end-of-life caregivers provide, in Leahy’s view, but time-pressured health care professionals don’t always do it well.
“We sometimes dictate to them what they need in terms of their health care, their medical treatment,” says Leahy. “Patients lose their autonomy very quickly when they become sick. . . . They often lose the sense of their ability to decide for themselves what is right or good.”
As professionals who “lay hands on people,” as Leahy says, nurses are in a unique position to hear the needs and wants of dying patients.
“The ethical constructs that drive our care are things like autonomy and justice and beneficence, our duty to do good and . . . to do no harm,” says Leahy. “Nurses often can identify early on when our well-intended treatment and care . . . become harmful, when people stop living and begin dying.”
Thaxton says nurses and other care providers at Baylor Regional Medical Center help patients and their families with advance care planning. They discuss choices, such as whether the patient wishes to have intertracheal or long-term feeding tubes.
“We can offer a lot of things, because we know a lot of things and we have the technology,” says Thaxton. “But are those really beneficial, and are those things what the patient and family really want?”
Pam Malloy, project director and co-investigator for the End-of-Life Nursing Education Consortium (ELNEC), says patients have become more knowledgeable about the options they have.
“They’ve heard lots of horror stories about people not dying well,” Malloy says. “It gets them thinking: I don’t want to die in the ICU with tubes in me. . . . They realize that if they don’t make their own decisions about their end-of-life care, someone else will.”
Regulatory change—especially the requirement to provide measurable evidence of quality—is one of the biggest issues in hospice care today, says Danielle Pierotti, RN, MSN, AOCN, CHPN, director of clinical practice and chief nurse at HCI Care Services, an independent hospice agency in West Des Moines, Iowa.
“Hospice is probably the last frontier for the cost-quality revolution of health care,” Pierotti says, noting that hospitals, nursing homes, home health agencies, and physicians’ offices faced the issue years earlier.
She says hospice agencies are taking “baby steps” to learn how to collect data that will help them demonstrate their value in ways that can be measured. They are learning a lot from the experience of quality experts in hospital settings.
“There are a lot of great conversations happening at the national level to help decide what those indicators are and help to put our arms around what it means to provide good end-of-life care,” Pierotti says.
Training End-of-Life Caregivers
“Dying in America,” a new study from the IOM released in September 2014, lauds the improvements over the last few decades in the education of health professionals providing end-of-life care. Unfortunately, the IOM committee also found that “recent knowledge gains have not necessarily translated to improved patient care,” and that the small number of hospice and palliative care specialists in the field means patients are often treated by clinicians who lack sufficient training and expertise.
“The committee recommends that educational institutions, professional societies, accrediting organizations, certifying bodies, health care delivery organizations, and medical centers take measures to both increase the number of palliative care specialists and expand the knowledge base for all clinicians,” the report states.
Since 2000, ELNEC has been developing curricula for nursing students, nursing faculty, practicing nurses, and nursing researchers, says Malloy. With a reach that extends to 84 countries, the consortium has taught more than 19,000 professionals over the last 14 years in its train-the-trainer courses.
“Our goal is to promote this education,” Malloy says. “We will never change practices until people are educated.”
Patricia Ropis, MSN, RN, teaches the “Dying with Dignity” course at the College of Nursing at Seton Hall University in South Orange, New Jersey. The two-hour class focuses on a different topic each week—for example, holistic health care; religion, culture, and ritual; grief theory; comforting the dying; pain and symptom management; and communication. That last topic is one Ropis believes is especially important for hospice nurses.
“In caring for the dying, communication is our tool,” Ropis says. “People often don’t realize when they take care of the dying that the support we give to other people is a nursing intervention. You need to be very skilled in communication to take care of this population.”
HCI’s continuing education program, the Hospice of Central Iowa Institute, presents educational conferences to nurses, home health and hospice aides, and other health care professionals.
“Educating the community—meaning everybody, including health care providers . . . lay people, patients, families, and neighbors—about what end of life is and what it means and how hospice can be supportive in that period of time has always been a central tenet of what we do,” explains Pierotti.
Hospice and palliative care providers have entered the specialty via many different paths, but they seem to share the view that what they do is not just a career but a calling. Years ago, when Guthrie was a physician in an emergency department in his native Saskatchewan, Canada, he became involved in treating the husband of the ER director for kidney cancer. Guthrie began working with the hospital pharmacist to try to control the patient’s tremendous pain.
“Very quickly, I realized the pharmacist had a set of knowledge I didn’t even know about,” Guthrie recalls. “He started telling me that he was from Montreal and that he’d studied under Cicely Saunders, the very famous British nurse/doctor/social worker who started hospice and palliative care in Britain. We worked together and did what we could to make this guy comfortable. I thought, ‘If I ever get a chance, I’m going to do this full-time. This is the best medicine I’ve ever seen.’”
Pierotti began her career as an oncology nurse, a specialty she notes is often intertwined with hospice care.
“As a frontline nurse, what impressed me over and over again was how much impact I could have for people at the end of their life,” says Pierotti. “I think that was a surprise to me at the beginning, and it’s continuously a surprise to patients and families.”
Thaxton became a palliative care nurse about five years ago, after 23 years in ICU nursing. She notes that nurses who are new to the death experience need special attention to ensure they are emotionally prepared.
“Some people think: Am I still a good nurse if this patient is going to die on my watch?” Thaxton says. “The first death experience for a nurse can be really life-changing. We get into medicine and nursing because we want to save people. But helping them to die peacefully and free of pain, respecting their dignity, and making sure their wishes are honored, is a noble thing to do.”
Sonya Stinson is a freelance writer based in New Orleans.
The American Nurses Association (ANA) calls for stronger collaboration between registered nurses (RNs) and their employers to reduce the risks of nurse fatigue for patients and nurses associated with shift work and long hours, and emphasizes strengthening a culture of safety in the work environment in a new position statement.
ANA contends that evidence-based strategies must be implemented to proactively address nurse fatigue and sleepiness. Such strategies are needed to promote the health, safety, and wellness of RNs and ensure optimal patient outcomes.
“Research shows that prolonged work hours can hinder a nurse’s performance and have negative impacts on patients’ safety and outcomes,” says ANA President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN. “We’re concerned not only with greater likelihood for errors, diminished problem solving, slower reaction time, and other performance deficits related to fatigue, but also with dangers posed to nurses’ own health.”
Research links shift work and long working hours to sleep disturbances, injuries, musculoskeletal disorders, gastrointestinal problems, mood disorders, obesity, diabetes mellitus, metabolic syndrome, cardiovascular disease, cancer, and adverse reproductive outcomes.
ANA offers numerous evidence-based recommendations for RNs and employers to enhance performance, safety, and patient outcomes, such as the following suggestions:
•Involve nurses in the design of work schedules and use a regular and predictable schedule so nurses can plan for work and personal responsibilities.
•Limit work weeks to 40 hours within seven days and work shifts to 12 hours.
•Eliminate the use of mandatory overtime as a “staffing solution.”
•Promote frequent, uninterrupted rest breaks during work shifts.
•Enact official policy that confers RNs the right to accept or reject a work assignment based on preventing risks from fatigue. The policy should include conditions that a rejected assignment does not constitute patient abandonment, and that RNs should not suffer adverse consequences in retaliation for such a decision.
•Encourage nurses to manage their health and rest, including sleeping seven to nine hours per day; developing effective stress management, nutrition, and exercise habits; and using naps in accordance with policy.
The position statement was developed by a Professional Issues Panel, established by the ANA Board of Directors. The panel was comprised of 15 ANA member nurses with expertise on the issue, with additional input from an advisory committee of about 350 members who expressed interest in participating. The statement was distributed broadly for public comment to nursing organizations, federal agencies, employers, individual RNs, safety and risk assessment experts, and others, whose suggestions were evaluated by the panel for incorporation in the statement. The new position statement replaces two 2006 position statements—one for employers and one for nurses. The statement clearly articulates that health care employers and nurses are jointly responsible for addressing the risks of nurse fatigue.
Despite evidence that cervical cancer screening saves lives, about 8 million women ages 21 to 65 years have not been screened for cervical cancer in the past five years, according to a new Vital Signs report from the Centers for Disease Control and Prevention (CDC). More than half of new cervical cancer cases occur among women who have never or rarely been screened.
“Every visit to a provider can be an opportunity to prevent cervical cancer by making sure women are referred for screening appropriately,” says CDC Principal Deputy Director Ileana Arias, PhD. “We must increase our efforts to make sure that all women understand the importance of getting screened for cervical cancer. No woman should die from cervical cancer.”
Researchers reviewed data from the 2012 Behavioral Risk Factor Surveillance System to determine women who had not been screened for cervical cancer in the past five years. They analyzed the number of cervical cancer cases that occurred during 2007 to 2011 from CDC’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. Cervical cancer deaths were based on death certificates submitted to the National Vital Statistics System.
Key findings include:
• In 2012, 11.4% of women reported they had not been screened for cervical cancer in the past five years; the percentage was larger for women without health insurance (23.1%) and for those without a regular health care provider (25.5%).
• The percentage of women not screened as recommended was higher among older women (12.6%), Asians/Pacific Islanders (19.7%), and American Indians/Alaska Natives (16.5%).
•From 2007 to 2011, the cervical cancer incidence rate decreased by 1.9% per year while the death rate remained stable.
•The Southern region had the highest rate of cervical cancer (8.5 per 100,000), the highest death rate (2.7 per 100,000), and the largest percentage of women who had not been screened in the past five years (12.3%).
Using the human papillomavirus (HPV) vaccine as a primary prevention measure could also help reduce cervical cancer and deaths from cervical cancer. Another recent CDC study showed that the vaccine is underused; only 1 in 3 girls and 1 in 7 boys had received the 3-dose series in 2013. The HPV vaccine is recommended as a routine vaccine for children 11–12 years old. Modeling studies have shown that HPV vaccination and cervical cancer screening combined can prevent as many as 93% of new cervical cancer cases.
Even with improvements in prevention and early detection methods, most cervical cancers occur in women who are not up-to-date with screening. Addressing financial and non-financial barriers can help increase screening rates and, in turn, reduce new cases of and deaths from this disease.
Efforts to Prevent Cervical Cancer
CDC’s National Breast and Cervical Cancer Early Detection Program provides low-income, uninsured, and underinsured women access to breast and cervical cancer screening and diagnostic services in all 50 states, the District of Columbia, five US territories, and 11 American Indian/Alaska Native tribes or tribal organizations.
To learn more about recommended ages and tests for cervical cancer screening, visit www.cdc.gov/cancer/cervical.
Five- and 10-year cancer survival rates were lower among American Indians and Alaskan Natives (AIANs) compared with non-Hispanic whites even when they had approximately equal access to health care, according to data presented at the American Association for Cancer Research conference on The Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved.
“Our preliminary analysis suggests that with presumed equal access to health care, five- and 10-year cancer survival among mostly urban-dwelling AIANs was lower than among non-Hispanic whites,” says Marc Emerson, MPH, a cancer research training award fellow in the Division of Cancer Control and Population Sciences at the National Cancer Institute in Bethesda, Maryland. “Our study focused on AIANs who live largely in urban areas, a population often hidden to researchers.
“The AIAN population experiences some of the greatest disparities in health and health outcomes, yet this remains an understudied area of research,” adds Emerson. “Future research should focus on factors other than health care access that may be driving disparity in the cancer outcomes observed.”
Emerson and colleagues found that the top four cancer diagnoses among AIANs and non-Hispanic whites were the same: prostate, breast, lung, and colorectal cancers. The fifth most common cancer type among AIANs was non-Hodgkin lymphoma, while it was melanoma for non-Hispanic whites.
The researchers also found that the five-year survival rates for AIANs and non-Hispanic whites were 52% and 58%, respectively, and the 10-year survival rates were 37% and 44%, respectively.
The most common comorbidities were the same for both races—chronic pulmonary disease, diabetes, and congestive heart disease—but the rates of these comorbidities were higher among AIANs compared with non-Hispanic whites. “In future analyses, we will examine the extent to which prevalence of comorbidities and other factors may account for the survival differences observed,” says Emerson.
The researchers collected data from Kaiser Permanente Northern California electronic health records for 1,022 AIANs and 139,725 non-Hispanic whites diagnosed with primary invasive cancer between 1997 and 2012. They used sociodemographic and health data of the study participants, including age at diagnosis, race, cancer site, type of treatment, comorbidities, and treatment follow-up time, for their study.
This study was funded by the National Cancer Institute.
