Missed Opportunities for Cervical Cancer Screening of HMO Members Developing ICC

Abstract & Commentary

Synopsis: Many women who develop invasive cervical cancer have not had Pap smears at the time of their routine primary care visits.

Source: Kinney W, et al. Gynocol Oncol 1998;71: 428-430.

The purpose of this article was to determine whether there were opportunities for Pap smear screening at the time of routine preventive health care visits that were missed in women who later developed invasive cervical cancer (ICC). Kinney and associates reviewed the medical records of all 642 members of the Permanente Health Plan in northern California to determine who had been seen in one of their facilities in the three years prior to the development of ICC during the years 1988-1994. Kinney et al examined the time period beginning 36 months prior to the diagnosis to six months prior to the diagnosis. The interval from six months to diagnosis was not examined in order to eliminate Pap smears that were part of the workup of the disease.

The cohorts comprised 8,498,000 woman-years of follow-up in the 642 cases of invasive cervical cancer between 1988 and 1994. Sixty percent of the women had not had a Pap smear during the study time. Of those women who met the membership criteria, 75% had outpatient visits to internal medicine, family practice, obstetrics and gynecology, or urgent care. Indeed, during the study period, the average number of clinic visits was slightly greater than five. Seventy percent of the women attending the internal medicine or family practice clinics had not had a Pap smear during the study interval, compared to 7% of the women seen by obstetrics and gynecology physicians and 20% of the women seen by urgent care physicians.

In the discussion section of the paper, Kinney et al review the fact that many efforts nationally are aimed at improving screening rates by attempting to encourage women who have not been seen for a Pap smear to do so. Much less effort has been expended trying to be certain that women who are seen in a health system for any reason have Pap smear screening at regular intervals. Kinney et al believe that their study suggests a need for increased efforts to improve screening among women who attend a medical facility.

COMMENT BY KENNETH NOLLER, MD

Despite a few limitations, this is an excellent article. The subject matter is good, the design is clear, the results are understandable and meaningful, and the writing is succinct (2 pages) and crisp. The one major limitation of the study was pointed out by Kinney et al: Some women would have had a screening in the six months prior to diagnosis, and, thus, the percentages quoted in the article are almost certainly somewhat low. Kinney et al are performing additional studies to examine this time interval.

I doubt very much whether anyone is reading this unless he or she is a dedicated advocate of women’s health. Whether we call ourselves an obstetrician/gynecologist, family physician, internist, nurse clinician, or some other name, we must be advocates among our colleagues for Pap smear screening. There is simply no justification for a woman to be seen repeatedly year after year and not have cervical cancer screening. The Pap smear is, by far, the best cancer screening tool ever developed. Mammography is good but pales in comparison to Pap smear screening. Indeed, we could nearly wipe out cervical cancer if every woman had a Pap smear at regular intervals. This year alone, 15,000-20,000 new cases of invasive cancer of the cervix will occur in the United States.