EXECUTIVE SUMMARY

Results of a recent analysis indicate that more women were diagnosed with advanced stages of cervical cancer, mortality rates increased, and fewer women were screened for the disease following the closure of nearly 100 women’s health clinics across the United States from 2010 to 2013.

• Nearly 100 comprehensive women’s clinics closed from 2010 to 2013, primarily due to changes in Title X funding regulations and new legislation regarding clinic standards.

• There also was a trend toward increased late-stage diagnoses in women ages 18-34, with 8% more women being diagnosed with late-stage disease in states with clinic closures.


Results of a recent analysis indicate that more women were diagnosed with advanced stages of cervical cancer, mortality rates increased, and fewer women were screened for the disease following the closure of nearly 100 women’s health clinics across the United States from 2010 to 2013.1

The findings are “troubling,” said Amar Srivastava, MD, MPH, a resident physician in radiation oncology at Washington University School of Medicine in St. Louis, and lead author of the study. Reducing the availability of cervical cancer screening has very real, negative consequences for women, noted Srivastava, who presented the study at the 2019 annual meeting of the American Society for Radiation Oncology in Chicago.

“Cervical cancer is largely preventable because of the wide availability of the HPV vaccine and screening that can detect precancerous lesions,” said Srivastava in a statement. “The pressing issue now is to ensure that all women have access to screening.”2

Nearly 100 comprehensive women’s clinics closed between 2010 and 2013, primarily due to changes in Title X funding regulations and new legislation regarding clinic standards. Srivastava and his team grouped states into two cohorts. One cohort (37 states) experienced a decline in women’s health clinics per capita from 2010 to 2013, while the second (13 states) experienced either no decrease in clinic numbers or saw an increase.

Researchers used data for nearly 200,000 women enrolled the Behavioral Risk Factors Surveillance System to evaluate screening utilization, with data for more than 10,000 women enrolled in the Surveillance, Epidemiology, and End Results Program to evaluate cancer stage at diagnosis and mortality. For each cohort of states, scientists compared data for women in both data sets from 2008 to 2009 with outcomes from 2014 to 2015.

Study findings indicate that states that experienced clinic closures also saw a 2% drop in cervical cancer screenings, relative to states without clinic closures, with the greatest declines in screening for patients without insurance (-6.18%), Hispanic women (-5.32%), women ages 21 to 34 (-4.81%) and unmarried women (-4.37%).

Overall, cervical cancer survival rates improved in states without clinic closures but dropped in those with clinic closures, researchers report. Findings suggest an increase in mortality risk from cervical cancer (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.02-1.83, P = 0.04) in states where clinics were closing, especially among residents in urban areas (HR 1.40, 95% CI 1.04- 1.90, P = 0.03).

Scientists also reported a rise in early-stage diagnoses among women ages 18-34 in states in which no clinics had closed, with a decrease in early-stage diagnoses for this same age group in states in which clinics had been shuttered. In those states, 13% fewer women were diagnosed in the early stages of cervical cancer than in states without closures. There also was a trend toward increased late-stage diagnoses in this age group, with 8% more women being diagnosed with late-stage disease in states with clinic closures.1

“At first we thought it sounded good that there were fewer early-stage diagnoses,” Srivastava said. “But then we saw the trend toward later-stage diagnoses, for which patients need more invasive treatments, all of which have side effects.”2

Follow Screening Guidance

According to the latest U.S. Preventive Services Task Force (USPSTF) cervical cancer screening recommendations, all women ages 21 to 29 should be tested every three years with cervical cytology. For women ages 30 to 65, recommendations call for screening with the Pap test alone every three years, screening with the high-risk human papillomavirus (hrHPV) test alone every five years, or screening with both tests together every five years.3

Regular screening for women ages 21 to 65 greatly reduces the rate of cervical cancer and the number of deaths resulting from cervical cancer.4 The most effective screening test depends on a woman’s age, according to USPSTF’s evidence search. For women ages 21-29, many HPV infections will resolve on their own, so the Pap test is most effective.5 For women ages 30-65, HPV infections are more likely to lead to cancer, so either Pap tests or hrHPV tests are effective for screening, the evidence review noted.6

Results from a recent analysis suggested that when it comes to screening for cervical cancer, the percentage of women who receive care may be far lower than national data reflect.7 Less than 66% of women ages 30-65 were current with their cervical cancer screenings in 2016, with more than half of women ages 21 to 29 current during the same time period. Such numbers fall below the 81% screening compliance rate self-reported in the 2015 National Health Interview Survey.8

Findings from the current study may help justify more rapid adoption of home self-collected screening tests, says Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA. Clinicians should continue to advocate for HPV vaccination, she notes.

REFERENCES

  1. Srivastava A, Barnes JM, Markovina S, et al. The impact of the closure of women’s health clinics on cervical cancer in the United States. Intl J Rad Onc 2019;105:S98.
  2. Women’s clinic closures associated with higher cervical cancer mortality, lower screening. Sept. 26, 2019. Available at: https://bit.ly/2PahQBN.
  3. U.S. Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. JAMA 2018; 320:674-686.
  4. Safaeian M, Solomon D. Cervical cancer prevention — cervical screening: Science in evolution. Obstet Gynecol Clin North Am 2007;34:739-760.
  5. Kotaniemi-Talonen L, Anttila A, Malila N, et al. Screening with a primary human papillomavirus test does not increase detection of cervical cancer and intraepithelial neoplasia 3. Eur J Cancer 2008;44:565-571.
  6. Melnikow J, Henderson JT, Burda BU, et al. Screening for cervical cancer with high-risk human papillomavirus testing: Updated evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA 2018;320:687-705.
  7. MacLaughlin KL, Jacobson RM, Radecki Breitkopf C, et al. Trends over time in Pap and Pap-HPV cotesting for cervical cancer screening. J Womens Health (Larchmt) 2019;28:244-249.
  8. Watson M, Benard V, King J, et al. National assessment of HPV and Pap tests: Changes in cervical cancer screening, National Health Interview Survey. Prev Med 2017;100:243-247.