Increasing Cervical Cancer Screening Rates to Halt Rising Incidence
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Among the 200+ types of cancers that can impact the human body, cervical cancer stands out due to its unique screening tests. These tests serve not only to diagnose the disease but also to prevent it by identifying abnormal cervical cells early that could potentially progress into cervical cancer.1
Since the introduction of the Pap test, cervical cancer, once the primary cause of cancer-related deaths among women in the U.S., has seen a remarkable shift. With a reduction of over 70% in its incidence, it has now receded to the 15th position among causes of female mortality.2,3 Yet, our efforts must persist in educating women about the importance of screenings and subsequent care. Despite considerable progress linked to screenings, it is estimated that nearly 14,000 women will face a cervical cancer diagnosis in 2023, with over 4,300 succumbing to the disease.4
What makes this situation even more concerning is that cervical cancer screening tests are among the most successful cancer prevention tools in history. The Pap test, introduced in 1941, and the later introduction of co-testing (Pap+HPV together), changed everything and became the accepted standard of care.2,3 A 2023 survey of providers’ beliefs about screening method effectiveness reaffirmed the Pap test for women ages 21-29 and co-testing for women 30-65 as the most effective screening methods.5 These screening modalities have given women a way to protect themselves against cervical cancer like never before and gave physicians a way to protect their patients – saving thousands of lives.
That’s why it’s so troubling that even when we have the tools to prevent this devasting disease with proper screening, according to the Centers for Disease Control and Prevention (CDC), fewer women today are getting screened.6 The rate of screening is declining, most significantly in women ages 21 to 29 years, but also among women ages 30 to 65. It is also declining across racial and ethnic populations. An analysis of data from the US National Health Interview Survey (NHIS) of the National Center for Health Statistics of the Centers for the CDC reports that the percentage of women overdue for cervical cancer screening rose approximately 60% between 2005 and 2019.7
Now the extraordinary success that began with the introduction of the Pap test is at risk. In fact, after decades of declining rates of cervical cancer, we are now observing an increase in the incidence of cervical cancer in the U.S. Since 2012, there has been an increase in cervical cancer rates among women under 50.3 The occurrence of lower rates of cervical cancer screening at the same time as we’re seeing higher incidence of cervical cancer cannot be ignored and is further exacerbated by the disparities in cervical cancer incidence across ages, races, ethnicities and the stage at which women are diagnosed.
- Age: In 2019 women ages 21 to 29 had a higher rate of overdue screening than women ages 30 to 65.7 While very few cervical cancers are diagnosed in women under the age of 25, the goal of screening women in this age is to detect precancerous lesions that can be monitored or treated, preventing disease progression.
- Stage at diagnosis: Another worrisome disparity is the stage of cancer at which women are diagnosed. We’ve seen a steady rise in Stage IV cervical cancer in the U.S. over the past two decades. Increased disease detection at this later stage, when women are likely already symptomatic, is further evidence of underscreening. This is especially concerning because the earlier cervical cancer is diagnosed, the better chance it is treatable and that women have of surviving it – with Stage I diagnoses, there is a 92% survival rate vs. a 17.5% survival of Stage IV cervical cancer. Stage IV rates continue to be highest in Black and Hispanic women.8
- Race and ethnicity: Compared to incidence of cervical cancer in white women, the rate is 25% higher for Black women and 49% higher for Hispanic women. 5-year survival rates are also lower for Black women and Hispanic women.3 In fact, Black women in the U.S. die from cervical cancer more than two times the rate of white women.9 These various disparities exist because of inequities these populations experience related to lack of access to care, and failure to provide education and culturally appropriate screening awareness programs.
Ultimately, the question becomes: when we have widely adopted, preferred and proven methods for cervical cancer screening with the Pap test and co-testing, why are fewer women undergoing screenings compared to earlier years? How can we reverse this troubling trend?
The data analysis from the NHIS of the National Center for Health Statistics for the CDC notes that the most commonly reported reason for why screening rates could be declining, which had already begun to fall before the COVID-19 pandemic, across all groups was lack of knowledge.7 Furthermore, the numerous updates to the screening guidelines we’ve seen over the past two decades, including lengthening the recommended interval between screenings from 1 to 3 years, and eventually to 5 years, may have played a role (and may continue to play a role) in women not knowing when they’re due for their next screening.
Over the last 15 years alone, there have been significant changes introduced into multiple screening guidelines. More recently, additional changes have been suggested by other organizations, including the idea of delaying screening until age 25, not allowing for the opportunity to possibly detect precancerous lesions earlier in these women.10,11,12,13 Recent research shows that healthcare providers continue to recommend co-testing for women 30-65 and cytology alone for women under 30, and they consider these screening strategies to be most effective.5
So, how have changes to the guidelines – especially those that have lengthened intervals between screenings – impacted cervical cancer screening rates? What may have been some of those unintended consequences?
Observing the latest data, it’s not a huge leap to see that when women are told they do not have to be screened as often, they may believe they do not need to see their OB/GYN for regular gynecologic care, either. In addition, longer intervals between screenings may make it more challenging for women to keep track of their screenings and remain adherent to these necessary life-saving screenings and follow-up care, especially when they are seeing their OB/GYN less frequently. This problem was reiterated in a 2021 study, which noted that “a new and alarming observation was the increasing percentage of women being screened at too long an interval.”14 An unintended consequence of the extended screening interval may have been a decrease in screening compliance. With rising cervical cancer rates, it is more important than ever to address these reasons for underscreening, especially lack of knowledge, to get women back into their doctor’s office for necessary screening.
The only way we can reverse the alarming increase in cervical cancer rates is by addressing the equally alarming decrease in screening rates. Recent modeling data has shown that increasing screening compliance will have the most significant impact on reducing cervical cancer incidence. Other prevention methods, such as vaccination, are an important component of our comprehensive approach to eliminating cervical cancer but will have less impact on the speed at which we can achieve eradication.15
As physicians, our approach needs to be multifaceted and culturally sensitive, meeting women on their terms. We must not only boost the interest in cervical cancer screening but also improve accessibility to healthcare providers offering women's health screenings and subsequent care. This holistic strategy ensures effectiveness and long-term sustainability.
Patient and provider education is needed to address missed opportunities and reduce preventive screening gaps. Enhancing communication and education about the crucial role of screening is imperative to encourage more women to schedule visits with their OB/GYNs. A wide variety of strategies have proven successful in increasing adherence, ranging from education to client reminders to social media. Improving access may require introducing interventions that help women surmount structural barriers, such as reducing administrative barriers and assisting with appointment scheduling.16 Strategies aimed at tackling this issue must ensure that women not only have greater access to screening, but to the appropriate screening for them based on their individual needs.
It would be heartbreaking to let what has been one of the most successful responses to cervical cancer continue to decline. The existing cervical cancer screening methods are highly effective. It's within our capacity and responsibility to reverse the downward trend in screening rates and the rise in incidence rates—this commitment stands as a year-round imperative. Women across the country deserve nothing less.
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