According to the American Cancer Society, in 2007, an estimated 11,200 new cases of cervical cancer were diagnosed among U.S. women. In that same year, an estimated 3,600 U.S. women died as a result of the disease. Infections of the cervix with certain strains of the human papillomavirus (HPV) can increase the risk of cervical cancer and may, in fact, be a leading cause of most cervical cancers cases diagnosed. The recent FDA approval of an HPV vaccine for cervical cancer suggests that the incidence of cervical cancer will decline in the U.S. Clinical screening for cervical cancer, via the pap test, however, remains an essential tool in detecting cervical cancer cases, particularly among women beyond the recommended age group eligible to receive the HPV vaccine—that is, women 27 years of age and older. Through regular pap testing, pre-invasive lesions of the cervix can be detected more frequently than invasive cancer; therefore, early detection can improve the chances of an effective and successful treatment.

In recognition of January as Cervical Health Awareness Month, the following article presents information from PHMC’s 2006 Household Health Survey on cervical cancer screenings among women 18-64 years of age residing in the five-county Southeastern Pennsylvania (SEPA) region. This article focuses on women who have not received a pap test within the past two years as well as women who have not received a pap test within the past five years. In fact, according to the American Cancer Society, 60% to 80% of women with newly diagnosed invasive cervical cancer did not have a pap test within the past five years or have never had a pap test for cervical cancer. Based on recommendations from the U.S. Preventive Services Task Force for Cervical Cancer, women 65 years of age and older need not receive routine pap tests for cervical cancer. As a result, women of that age group were excluded from this analysis.

Cervical cancer screenings, SEPA
The overwhelming majority of women (85%) received their last pap test within the past two years; however, that leaves 15% of women whose last pap test was performed more than two years ago, which translates to approximately 186,000 women in the region. More specifically, nearly one-tenth of women (8%) received their last pap test more than five years ago or have never received a pap test for cervical cancer, which amounts to roughly 101,000 women in the SEPA region (Figure 1).

Demographic characteristics among women not screened, SEPA
·  Among women 18-26 years of age, who are eligible to receive the HPV vaccine, currently 15% received their last pap test more than two years ago. For women within this age group, it will remain important to track their screening practices in the future—once the vaccine is more readily available. Among women beyond the recommended age group eligible for the HPV vaccine, nearly one-fifth of women 41-64 years of age (18%) received their last pap test more than two years ago, compared to one-tenth of women 27-40 years of age (9%). In addition, 12% of women 18-26 years of age did not receive a pap test in the past five years, compared to 10% of women 41-64 years of age and 4% of women 27-40 years of age.

·  Nearly one-fifth of Latinas (18%) have not had a pap test in the past two years compared to white (16%) and Black (11%) women; in addition, 13% of Latinas did not have a pap test in the past five years, while only 8% of white women and 6% of Black women did not have a pap test in the past five years.

·  Women living below 150% of the Federal poverty level (23%) are nearly twice as likely as women at or above the poverty level (13%) to have received their last pap test more than two years ago. In addition, women living below poverty (13%) are twice as likely as women at or above poverty (7%) to have not had a pap test within the past five years.

·  Nearly one-fifth of women without a college degree (18%), compared to one-tenth of women with at least a college degree (10%), received their last pap test more than two years ago. In addition, 10% of women without a college degree, compared to 5% of women with at least a college degree, received their last pap test more than five years ago.

Access to care indicators among women not screened, SEPA
·  More than one-quarter of women with no regular source of care (27%), compared to 14% of women with a regular source of care, have not received a pap test in the past two years (Figure 2). Furthermore, 15% of women with no regular source of care, compared to 7% of women with a regular source of care, have not had a pap test within the past five years.

·  More than one-third of women with no public or private health insurance coverage (34%), compared to 13% of women with insurance coverage, have not received a pap test in the past two years (Figure 2). More specifically, among this group of uninsured women whose last pap test was more than two years ago, nearly two-thirds of these women (64%) have been uninsured for more than two years. In addition, about one-fifth of women with no insurance coverage (19%), compared to 7% of women with insurance coverage, received their last pap test more than five years ago.

Behavioral characteristics among women not screened, SEPA
·  Nearly one-third of women (30%) who report having no sexual partners within the past year and almost one-quarter of women (22%) who report having female sexual partners received their last pap test more than two years ago compared to 12% of women who report having male sexual partners. In addition, one-fifth of women (20%) with no sexual partners and more than one-tenth of women with female sexual partners (11%) had their last pap test more than five years ago compared to only 6% of women with male sexual partners.

·  According to literature of cervical cancer risk factors, women who smoke cigarettes are at an increased risk for cervical cancer. More than one-fifth of women (22%) who report smoking cigarettes every day have not had a pap test in the past two years. However, there is little difference in the percentages of women whose last pap test was more than two years ago among women who smoke cigarettes some days (15%), women who no longer smoke (14%), and women who have never smoked (13%). Similarly, while 12% of women who smoke cigarettes every day received their last pap test more than five years ago, there is little variation among women who smoke some days (8%), who no longer smoke (6%), and who never smoked (7%).

Conclusion
While incidence and mortality rates associated with cervical cancer are lower in the U.S. compared to some other nations, where women in the U.S. have greater access to routine pap tests, it remains vital that all women by age 21, regardless of their sexual behaviors, begin receiving routine pap tests to detect cervical cancer. Despite the lack of consensus within the medical community in defining “routine” pap tests, early detection remains the best available tool in identifying abnormal cervical cells. For information regarding PHMC’s Community Health Data Base’s 2006 Household Health Survey, or to learn more about cervical cancer screenings among women of the Southeastern Pennsylvania region, please contact Nicole Dreisbach at nicoled@phmc.org.

References
U.S. Prevention Services Task Force. Screening for Cervical Cancer: Recommendations and Rationale. AHRQ Publication No. 03-515A. January 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/cervcanrr.htm

American Cancer Society. Cancer Facts & Figures 2007. Atlanta: American Cancer Society; 2007.

American Cancer Society. Guidelines for the Early Detection of Cancer. Accessed September 2007. http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp