Has closure of women’s health clinics affected cervical cancer screening?

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State-level restrictions on reproductive services led to shuttering of nearly 100 women’s health clinics in the United States over a 4-year period. Results of a new study suggest a connection between that reduction in service availability and lower rates of screening for cervical cancer, more advanced cancer at diagnosis, and more deaths from the disease.

The findings, by radiation oncologists from Missouri, were presented at the 61^st Annual Meeting of the American Society of Radiation Oncology (ASTRO). The investigators evaluated screening utilization and data using the Behavioral Risk Factors Surveillance Study (BRFSS) database and used data on stage at diagnosis and mortality from the Surveillance, Epidemiology, and End Results 18 Registry (SEER). States were divided into two cohorts: decrease in clinics (DIC) (n=37) and no decrease in clinics (NDIC) (n=13) based on changes in the number of facilities providing comprehensive reproductive services from 2010 to 2013.

The analyses included nearly 200,000 women in BRFSS and 10,000 women in SEER in 2008 and 2009. Outcomes were compared in women in the 2014-2015 DIC versus NDIC states, with the two cohorts assessed by time period via differences-in-differences (DID) analyses. A DID analysis estimates the effect of a specific intervention or treatment by comparing the changes in outcomes over time between a population that is enrolled in a program (the intervention group) and one that is not (the control group).

The authors found a 2% drop in cervical cancer screening in the DIC group versus the NDIC group. The greatest declines in screening occurred in women without insurance (-6.18 percentage points [PP], P = 0.01), Hispanic women (-5.32 PP, P < 0.01, women ages 21 to 34 (-4.81 PP, P < 0.01) and unmarried women (-4.37 PP, P < 0.01).

In the DIC group versus the NDIC group, early-stage diagnoses fell in women ages 18 to 34 (-13.2 PP, P = 0.031). A significant increase in the hazard ratio (HR) of death in DIC relative to NDIC states was noted by the investigators overall (HR: 1.36, 95% CI = 1.02 to 183, P = 0.037) and among metro residents (HR: 1.40, 95% CI = 1.04 to 1.9, P = 0.027).

Commenting on the findings in a press release, lead author Amir Srivastava, MD, MPH, said, “What is surprising about this study is that even though these closures occurred just a few years ago, we are already seeing clear differences versus survival from cervical cancer. That is both surprising and scary.”

While noting that the study “should raise serious flags,” the researchers acknowledged that their results were correlations and do not confirm a causal relationship between the health clinic closures and an increase in adverse health impacts for women.