Racial and Ethnic Disparities in Cervical Cancer Screening From Three U.S. Healthcare Settings

Abstract

Introduction: This study sought to characterize racial and ethnic disparities in cervical cancer screening and follow-up of abnormal findings across 3 U.S. healthcare settings.

Methods: Data were from 2016 to 2019 and were analyzed in 2022, reflecting sites within the Multi-level Optimization of the Cervical Cancer Screening Process in Diverse Settings & Populations Research Center, part of the Population-based Research to Optimize the Screening Process consortium, including a safety-net system in the southwestern U.S., a northwestern mixed-model system, and a northeastern integrated healthcare system. Screening uptake was evaluated among average-risk patients (i.e., no previous abnormalities) by race and ethnicity as captured in the electronic health record, using chi-square tests. Among patients with abnormal findings requiring follow-up, the proportion receiving colposcopy or biopsy within 6 months was reported. Multivariable regression was conducted to assess how clinical, socioeconomic, and structural characteristics mediate observed differences.

Results: Among 188,415 eligible patients, 62.8% received cervical cancer screening during the 3-year study period. Screening use was lower among non-Hispanic Black patients (53.2%) and higher among Hispanic (65.4%,) and Asian/Pacific Islander (66.5%) than among non-Hispanic White patients (63.5%, all p<0.001). Most differences were explained by the distribution of patients across sites and differences in insurance. Hispanic patients remained more likely to screen after controlling for a variety of clinical and sociodemographic factors (risk ratio=1.14, CI=1.12, 1.16). Among those receiving any screening test, Black and Hispanic patients were more likely to receive Pap-only testing (versus receiving co-testing). Follow-up from abnormal results was low for all groups (72.5%) but highest among Hispanic participants (78.8%, p<0.001).

Conclusions: In a large cohort receiving care across 3 diverse healthcare settings, cervical cancer screening and follow-up were below 80% coverage targets. Lower screening for Black patients was attenuated by controlling for insurance and site of care, underscoring the role of systemic inequity. In addition, it is crucial to improve follow-up after abnormalities are identified, which was low for all populations.

Figure 1.

Estimated RR (95% CIs) for any screening within 3 years by race and ethnicity. RRs and 95% CIs for each race or ethnic group using the non-Hispanic White group as the reference are estimated from logistic regression models with Poisson log-link. Covariates are added progressively: M1 includes the main independent variable (race/ethnicity) only; M2 adjusts for age, pregnancy, smoking, Charlson comorbidity score, and BMI; and M3 additionally adjusts for insurance type, number of primary care provider visits in 2 years before the study period, and site of care. Full regression results are available in Appendix Table 2 (available online). M1, Model 1; M2, Model 2; M3, Model 3.

Figure 2.

Estimated RR (95% CIs) for screen-detected abnormality and 6-month follow-up among those with abnormalities by race or ethnicity. RRs and 95% CIs for each race or ethnic group using the non-Hispanic White group as the reference are estimated from logistic regression models with Poisson log-link. Covariates are added progressively: M1 includes the main independent variable (race/ethnicity) only; M2 adjusts for age, pregnancy, smoking, Charlson comorbidity score, and BMI; and M3 additionally adjusts for insurance type, number of primary care provider visits in 2 years before the study period, and site of care. Full regression results are available in Appendix Tables 4 and 5 (available online). M1, Model 1; M2, Model 2; M3, Model 3.