Trends in Cervical Cancer Screening in Title X-Funded Health Centers - United States, 2005-2015

Abstract

Cervical cancer screening is critical to early detection and treatment of precancerous cells and cervical cancer. In 2015, 83% of U.S. women reported being screened per current recommendations, which is below the Healthy People 2020 target of 93% (1,2). Disparities in screening persist for women who are younger (aged 21-30 years), have lower income, are less educated, are uninsured, lack a source of health care, or who self-identify as Asian or American Indian/Alaska Native (2). Women who are never screened or rarely screened are more likely to develop cancer and receive a cancer diagnosis at later stages than women who are screened regularly (3). In 2013, cervical cancer was diagnosed in 11,955 women in the United States, and 4,217 died from the disease (4). Aggregated administrative data from the Title X Family Planning Program were used to calculate the percentage of female clients served in Title X-funded health centers who received a Papanicolaou (Pap) test during 2005-2015. Trends in the percentage of Title X clients screened for cervical cancer were examined in relation to changes in cervical cancer screening guidelines, particularly the 2009 American College of Obstetricians and Gynecologists (ACOG) update that raised the age for starting cervical cancer screening to 21 years (5) and the 2012 alignment of screening guidelines from ACOG, the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) on the starting age (21 years), screening interval (3 or 5 years), and type of screening test (6-8). During 2005-2015, the percentage of female clients screened for cervical cancer dropped continually, with the largest declines occurring in 2010 and 2013, notably a year after major updates to the recommendations. Although aggregated data contribute to understanding of cervical cancer screening trends in Title X centers, studies using client-level and encounter-level data are needed to assess the appropriateness of cervical cancer screening in individual cases.

FIGURE

Cervical cancer screening recommendations in effect, including major changes in 2009 and 2012, and percentages of female Title X clients in receipt of cervical cancer screening, chlamydia testing,^§ and clinical breast exams,^¶ and continued use or adoption of effective contraception** among, by year — Family Planning Annual Report,^†† 50 states and the District of Columbia, 2005–2015 Abbreviations: ACS = American Cancer Society; ACOG = American College of Obstetricians and Gynecologists; CBE = clinical breast exam; USPSTF = U.S. Preventive Services Task Force. * During 2005–2012, cervical cancer screening recommendations from ACS, ACOG, and USPSTF for women at average risk with a cervix varied in terms of starting age (within 3 years of first sex or age 21 years), stopping age (65–70 years), and interval (annually, every 2 years, or every 3 years), based on age, prior negative test results, or type of screening test (conventional or liquid cytology or co-testing using a combination of cytology plus human papillomavirus DNA testing [HPV co-test]). During this period, there were two major changes in screening recommendations that are notable. In 2009, ACOG updated its cervical cancer screening recommendation by raising the starting age for screening to 21 years. In 2012, cervical cancer screening recommendations from ACS (March 2012), USPSTF (March 2012), and ACOG (November 2012) were congruent. The recommendations were that screening start at age 21 years, that it occur at the following intervals using specific methods; 21–29 years: every 3 years using cytology alone; 30–65 years: every 3 years (cytology) or every 5 years (HPV co-test); >65 years: stop screening if there is an adequate negative prior screening history, defined as two (co-test) or three (cytology) consecutive negative results within the past 10 years and the most recent test was performed within 5 years. https://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf. ^† Percentage of females who received a Pap test in the calendar year. ^§ Percentage of females aged ≤19 years or 20–24 years who received a chlamydia test in the calendar year. During 2005–2014, CDC recommended routine annual chlamydia screening for sexually active women aged ≤25 years and for sexually active older women at increased risk for infection (e.g., new or multiple partner[s]). In June 2015, CDC lowered the age range for routine annual screening to ≤24 years. During 2007–2015, the USPSTF recommended screening for sexually active women aged ≤24 years and for sexually active older women at increased risk for infection; evidence was insufficient to recommend an optimal screening interval. ^¶ Percentage of females who received a CBE in the calendar year. During 2005–2015, ACOG recommended annual CBE for women aged ≥19 years and ACS recommended CBE with a periodic health exam every 3 years (aged 20–39 years) or annually (aged ≥40 years). In 2002, USPSTF concluded that evidence was insufficient to recommend for or against routine CBE alone to screen for breast cancer. In 2009, USPSTF concluded that current evidence was insufficient to assess the additional benefits and harms of CBE beyond screening mammography in women aged ≥40 years. ** Percentage of females aged ≤19, 20–29, and 30–44 years, at risk for unintended pregnancy (not pregnant or seeking pregnant, or not using method for “other” reason), who adopted or continued using effective contraception (female sterilization; vasectomy; intrauterine device; hormonal implant, injectable, pills, ring, or patch; and diaphragm) at their last encounter. ^†† The Family Planning Annual Report is a reporting requirement of Title X service grantees. This study uses data for 64 grantees that received continuous funding during the study period. https://www.hhs.gov/opa/title-x-family-planning/fp-annual-report/index.html.