By Robert L. Coleman, MD
Professor, University of Texas; M.D. Anderson Cancer Center, Houston
Dr. Coleman reports no financial relationships relevant to this field of study.
Cervical cancer screening in the United States is underpacing targets to meet the Healthy People 2020 objectives of 93% compliance with guidelines. While overall incidence rates of cervix cancer have decreased slightly, mortality has not, and underserved, underinsured, and minority/ethnic populations continue to be at highest risk for cervical cancer development.
Benard VB, et al. Vital signs: Cervical cancer incidence, mortality and screening – United States, 2007-2012. MMWR Morb Mortal Wkly Rep 2014;63:1004-1009.
Significant effort and progress has been made in cervical cancer screening in the United States, with dramatic effects on cancer burden. However, the disease continues to be diagnosed, with highest risks for late-stage diagnosis and death observed in under-resourced demographics and individuals. As part of an ongoing evaluation of disease burden, the authors from the Centers for Disease Control and Prevention surveyed (by phone) 133,851 women across all 50 states and the District of Columbia to ascertain cervical cancer screening rates over a 5-year period (2007-2011). Outcome measures were cervical cancer incidence and mortality, current screening percentages, factors associated with higher incidence and death rates, and inadequate screening. Percentages of women who had not been screened for cervical cancer in the past 5 years were estimated using data from the 2012 Behavioral Risk Factor Surveillance System survey. The sample, consisting of women ages 21-65 years who had complete Pap data and no hysterectomy, corresponded to a U.S. population of more than 70 million at-risk women. In 2012, 8.2 million women (11.4%) had not been screened for cervical cancer in the past 5 years. The percentage was larger for women without health insurance (23.1%) and for those without a regular health care provider (25.5%). From 2007 to 2011, the cervical cancer incidence rate decreased by 1.9% per year, while the death rate remained stable. Geographically, Southern states, such as New Mexico, Texas, Oklahoma, Louisiana, and Mississippi, had the highest incidence rate (8.5 per 100,000), death rate (2.7 per 100,000), and percentage of women who had not been screened in the past 5 years (12.3%). The proportion of inadequately screened women was higher among older women, Asians/Pacific Islanders, and American Indians/Alaska Natives. The authors conclude that despite well-described and disseminated screening guidelines, there continue to be women who are not screened as recommended. Efforts to improve catchment are required to meet the Healthy People 2020 (HP2020) targets.
Commentary
There are few “wins” in the cancer business. Period. However, if there ever was a poster child for an intervention that can dramatically impact the natural trajectory of cancer development and saving lives, it’s the Pap smear. This simple test was introduced into the public domain (to some notable resistance) in the late 1940s, and outside of the addition of some processing improvements and HPV genomics, the test has remained largely unchanged since that time.1 It’s effective, not only in identifying at-risk or affected women with cervix pathology, but also in reducing the rate of incurable or highly advanced disease requiring extensive, expensive, and morbid treatment. These facts are overt and reproducible. Thus, this report is nothing short of distressing; and it’s probably worse than presented, as this survey was limited to those women reachable by phone. While prevalence rates were limited to those with a uterus, the incidence rates of cancer were not adjusted for prior hysterectomy. When one also acknowledges the poor uptake of preventive vaccination (38% in girls, 14% in boys), it’s not surprising greater progress to the HP2020 goals have not been made.2,3
Nevertheless, these survey data, by state, are informative and can be used as powerful leverage to individually resource initiatives impacting public health. The emergence and implementation of the Affordable Care Act has led to historically low rates of uninsured Americans, which in addition to the availability of free cancer screening through the National Breast and Cervical Cancer Early Detection Program,4 provides hope for greater compliance with accepted guidelines. In addition, for the first time in 2012, all national screening organizations, including the U.S. Preventive Services Task Force, the American Cancer Society, and the American College of Obstetrics and Gynecology, have come to consensus on when and how often women should be screened for cervical cancer.5 As new technology and age-dependent screening recommendations emerge, consensus messaging will be necessary to maintain traction to meet the HP2020 target of 93% compliance.
References
- Ronco G, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: Follow-up of four European randomised controlled trials. Lancet 2014;383:524-532.
- Perkins RB, et al. Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls. Vaccine 2014 Nov. 24; [Epub ahead of print].
- Kim HW. Knowledge about human papillomavirus (HPV), and health beliefs and intention to recommend HPV vaccination for girls and boys among Korean health teachers. Vaccine 2012;30:5327-5334.
- Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program. Available at: http://www.cdc.gov/cancer/nbccedp. Accessed Jan. 2, 2015.
- Centers for Disease Control and Prevention. Cervical Cancer Screening Guidelines for Average-Risk Women. Available at http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf. Accessed Jan. 2, 2015.
