According to the U.S. Centers for Disease Control, cervical cancer was at one time the leading cause of death for women in the United States (1). However, in the past 40 years there has been a significant decline in both the number of cases of cervical cancer and the number of deaths from cervical cancer—a decline that is largely the result of many women receiving regular cervical cancer screenings (also known as Pap tests).

A more recent development in the field of cervical cancer prevention has been the introduction of new vaccines combating selected strains of the human papillomavirus (HPV) that are responsible for the majority of cases of cervical cancer. Vaccination against HPV is currently recommended for girls and women ages 11-26, and has recently been approved by the U.S. Food and Drug Administration for boys and men ages 9-26. However, even for those who fall within the recommended age range, the HPV vaccine may not be covered by health insurance and can be costly. For many women, regular Pap testing for early signs of cervical cancer will continue to be an essential component of cervical cancer prevention.

This month, in honor of National Cervical Health Awareness Month, the Community Health Data Base takes a look at the current state of cervical cancer screening among women in Southeastern Pennsylvania, as well as trends over the past eight years. Data presented here are from the Southeastern Pennsylvania Household Health Survey, a biennial, random digit dial telephone survey of over 10,000 households in the five county area of Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties. Except where otherwise noted, the data presented below come from the 2008 Household Health Survey, the most recent survey conducted.

CERVICAL CANCER SCREENING AMONG SEPA WOMEN

Based on the 2008 Household Health Survey information, the vast majority of SEPA women—about four in five—received a cervical cancer screening within the previous two years. This means, however, that one in five women (19.7%) ages 18 and older had not received this screening in the previous two years, representing approximately 307,000 women in the region.

TRENDS IN CERVICAL CANCER SCREENING, 2000-2008

Since 2000, the percentage of women (18 years of age and older) who have not received a cervical cancer screening in the previous two years has grown (Figure 1). In 2000, about one in six (16.2%) women 18 years of age and older had not received a cervical cancer screening in the previous two years. By 2008, this had increased to nearly one in five (19.7%).  Since 2004, this percentage seems to be leveling off; subsequent survey years will allow us to see whether the proportion of women not receiving the screening continues to rise, stays level, or declines. 

THE ROLE OF AGE IN CERVICAL CANCER SCREENING ACCESS

Age is an important factor in terms of both need for and accessibility of cervical cancer screening. Figure 2 examines trends in cervical cancer screening by age group.

Younger women are considered at higher risk for acquiring HPV, and therefore at higher risk of cervical cancer. Younger women are also the target age group for HPV vaccination. As HPV vaccination becomes more widespread, there may be a corresponding decline in the frequency of cervical cancer screenings, starting among younger women. In our region, we do see an increase since 2000 in the percent of women ages 18-26 who did not receive a cervical cancer screening between 2000 and 2008, with a larger jump between 2006 and 2008 (Figure 2).

Cervical cancer screening is typically considered less beneficial for women in older age groups. The U.S. Prevention Services Task Force recommends against routinely screening women 65 and older for cervical cancer if they have had adequate recent screenings with normal Pap tests and are not otherwise at high risk for cervical cancer (2). Figure 2 shows that in Southeastern Pennsylvania, women 65 and older are much more likely than all other age groups to not be receiving routine cervical cancer screening. For example, in 2008 nearly four in ten women ages 65+ (37.5%) had not received a cervical cancer screening in the previous two years, compared to 21.5% of women 55-64, 19.7% of women 18-26, 16.7% of women 40-54, and 8.9% of women ages 27-39. However, given that having multiple sexual partners can be a risk for HPV, and thus cervical cancer, it is also important to note that older women who are sexually active with multiple partners or having unprotected sex with a new partner may still be at increased risk for cervical cancer, and thus should consider regular Pap testing.

DEMOGRAPHIC DIFFERENCES IN CERVICAL CANCER SCREENING (WOMEN 18-64)

The following findings include only women ages 18-64, since current recommendations for cervical cancer screening apply specifically to this age range. Overall, according to the 2008 Household Health Survey, 15.9% of women ages 18-64 had not received a cervical cancer screening in the previous two years, representing approximately 205,000 women in Southeastern Pennsylvania.

By County
There is little variation in prevalence of cervical cancer screening across SEPA counties. Philadelphia and Bucks Counties had the highest proportion of women 18-64 who had not received screenings (17.3% and 16.2%, respectively), followed by Delaware (15.2%), Montgomery (14.5%), and Chester (14.1%) Counties.

By Race/Ethnicity
In 2008, over one in five Asian/Asian-American women had not received a cervical cancer screening in the previous two years (21.0%). This is a higher proportion than other racial/ethnic groups. In comparison, 16.9% of Latina women, 16.4% of white women, and 13.1% of Black/African-American women had not received a cervical cancer screening in the previous two years.

By Poverty Status
Over one in five women (21.8%) ages 18-64 living below the federal poverty level (3) had not received a cervical cancer screening in the previous two years, compared to 15% of women living at or above the federal poverty level.

By Insurance Status
Health insurance is a powerful predictor of access to care. Among women under age 65 with no health insurance, 35% had not received a cervical cancer screening in the previous two years, compared to 14.1% of insured women.

SUMMARY

The above selected findings from the 2008 Southeastern Pennsylvania Household Health Survey reveal a mixed picture when it comes to women receiving cervical cancer screenings in our region. Overall, the majority of women continue to receive routine cervical cancer screening, but since 2000 there has been an increase in the proportion of women who are not receiving this important screening.

When breaking this trend out by age we saw that this rise is due in part to younger women, who are in the target demographic for HPV vaccination and possibly decreased use of cervical cancer screening. At the same time, younger women are also more likely to lack health insurance than older women, which offers another explanation for decreased use of cervical cancer screening. Indeed, the findings presented here reinforce that there is a significant disparity in access to care between insured and uninsured individuals: uninsured women are over three times more likely to lack a recent cervical cancer screening than insured women. Although there are more tools than ever to prevent cervical cancer, a sizeable portion of women in Southeastern Pennsylvania continue to experience barriers to care and otherwise lack access to these important prevention services.

For more information about the findings presented here or the Community Health Data Base, please contact CHDB Associate Allegra Gordon at agordon@phmc.org.

REFERENCES

1. 1. U.S. Centers for Disease Control, 2009. http://www.cdc.gov/cancer/cervical/statistics/ (accessed 1/4/10).

2. US Prevention Services Task Force. http://www.ahrq.gov/Clinic/3rduspstf/cervcan/cervcanrr.htm (accessed 1/4/10)

3. Poverty status is defined as below or above 100% of the Federal Poverty Level. Poverty level is calculated based on family size and household income. For example, a family of four with an annual income of $21,200 in 2008 was considered living in poverty.