Revitalizing Well-Woman Care to Prevent Late-Stage Cervical Cancers

Routine well-woman care is a cornerstone of preventing serious health issues, especially highly detectable and treatable diseases like cervical cancer. Yet, over the last decade fewer women in the U.S. are receiving this essential preventive care. Across all age, ethnic, and economic groups, more women missed guideline-specific recommended cervical screenings. Even before the COVID pandemic, the number of women seeking preventive or routine annual well women’s care from an OB/GYNs or primary care (PCPs) was trending downward. In 2015, 20.4% of women did not see an OB/GYN or other health care clinician, which represents a 4.4% increase since 2003.¹ This growing gap in routine preventive care delivery represents a pressing public health crisis. 

Cervical Cancer Screening Rates are Suboptimal and Continue to Decline

Although cervical cancer prevalence has declined substantially since the Pap test was first introduced into routine care in the 1940’s,² the incidence rate has recently plateaued and in some cases increased. Guidelines for screening over the last 40 years have been consistently updated, as have methods for screening and follow up with the recognized importance of Human Papillomavirus (HPV) as a factor in the majority of cervical cancers.^3-5 Yet, annually, nearly 14,000 women in the U.S. are newly diagnosed with cervical cancer, and more than 4,000 will die from it.⁶

Today, the most commonly used screening strategies are the Pap test every three years for women ages 21-29, and women ages 30-65 should receive the Pap and HPV tests together (co-testing) every five years.⁷ The U.S. Preventive Services Task Force reaffirmed support for these screening methods that continue to allow for shared decision-making between physicians and patients in their recently released cervical cancer screening draft recommendations. Unfortunately, we are seeing a growing number of women in the U.S. who are not only missing these recommended screenings but are also not following up when abnormal results are reported.

A 2021 study revealed that only 12.7% of screening-eligible women received co-testing, and 27.7% received the Pap test at the recommended intervals.⁷ The study highlights a “greater than fourfold increase in women being screened at an interval of more than 5 years and up to 7 years.”⁷ This trend corresponds with a broader analysis indicating screening rates decreased between 2005 and 2019, with women ages 21-29 showing a significantly higher rate of overdue screening compared to women aged 30 and older.⁸ In both age groups, the proportion of women without up-to-date screening increased overall by 8.6% during that period.⁸ These missed screenings are concerning to many in the OB/GYN and public and preventive health communities, who anticipate the follow-on effect of more late-stage cancer diagnoses and higher mortality rates if we do not reverse this trend.⁹

OB/GYNs Must Carefully Evaluate New Technologies

More recently, HPV self-sampling has been introduced as a potential option for those who are not currently able to participate in routine screening. However, the FDA approved this self-collection method for use only in healthcare settings when a clinician cannot collect a cervical sample.

While some see potential for HPV self-sampling to increase screening rates among certain populations, it is currently not a replacement for clinician-collected cervical samples. According to the FDA, “self-collected vaginal specimens appear less sensitive and specific in comparison to clinician-collected cervical specimens.”¹⁰ Additionally, switching from clinician-collected cervical specimens to self-collected vaginal specimens “could result in potential missed cervical disease.”¹⁰

HPV self-sampling may also introduce follow-up care challenges. Any patient who receives an HPV positive result would then need to return for a speculum exam and clinician-collected sample, a second visit that could be avoided if a cervical sample had been collected at the initial appointment. Given these considerations, the future role of HPV self-sampling in addressing underscreening and disease detection remains uncertain until more evidence becomes available. HPV self-collection will not address those individuals who have challenges in access to care in the current environment.

Follow-Up Care is Also Delayed

In addition to concerning underscreening trends, follow-up care is not sufficiently reaching women who receive an abnormal testing result. Annually, around 3.5 million cervical cancer screenings produce abnormal results, requiring follow-up examination like colposcopy to confirm diagnosis and begin treatment.⁸ However, follow-up adherence is clearly moving in the wrong direction.^11,12 In one Mississippi study, only 43% of women followed up for a colposcopy within 4 months of receiving an abnormal result.¹¹ We see a similar situation in Alabama with 42.3% of women who were not adherent to follow-up.¹² This exposes challenges in access to care in many communities and populations at greatest risk. A delay of more than four months in follow-up colposcopy may result in a 2.3 times increased risk of mortality for otherwise highly treatable Stage I cervical cancer. This risk escalates significantly when colposcopy is delayed with late-stage presentations, exceeding five times increased risk of mortality with Stage IV cases.¹³ Alarmingly, the incidence of distant-stage presentations, including both adenocarcinoma and squamous cell carcinomas, is on the rise.⁹ Over the past 18 years in the U.S., distant-stage cervical carcinoma has not decreased among any racial, ethnic, geographic, or age group.¹¹ Moreover, it is troubling that this relatively slow developing cancer presented more frequently in women under 50 between 2012 and 2019.¹⁴

The falling rate of comprehensive well-woman care also corresponds to increasing rates in both vulvar and uterine cancers, contributing to a rise in cancer-related mortality.^15,16 While there is no screening method for these cancers, early detection is possible with visual inspection and discussions about symptoms during routine annual well women’s preventive care visits. Overall, the concerning increase in late-stage gynecologic cancer presentation can largely be attributed to a decline in timely screenings and inadequate follow-up after abnormal results.¹⁷

Culturally Tailored Patient Education Improves Adherence

Studies in both rural and urban settings reveal that lack of knowledge is a primary barrier to women getting timely screening and adhering to follow-up. Ultimately, many women are unaware that they are missing easily obtainable, life-saving tests, and the underlying reasons for this lack of awareness indicate the need for a community-focused approach to education.

For example, data show the urgent need to increase education about screening among Asian, Black, and Hispanic women.⁸ Black women experience the highest mortality rate and often struggle with access to care,⁹ while both Black and Hispanic women report less communication from healthcare professionals (HCPs) regarding screening and follow-up examination.⁹ Hispanic women are the most likely to be unaware of screening opportunities, and Asian women represent the largest population without up-to-date screenings.⁸

These findings underscore HCPs’ responsibility to help navigate care with all women while recognizing that their educational needs, though universal, are not monolithic. In both urban and rural areas, a multifaceted approach is essential for achieving equitable access, including patient navigation and addressing basic needs that contribute to delayed consultation and screening.

Educational outreach tailored to specific communities has proven effective when paired with direct contact between HCPs and patients. For example, in Tucson, Ariz., the Community Preventive Services Task Force implemented a comprehensive strategy that included HCP education, multilingual community printouts, one-to-one clinician-to-patient communication, and same-day Pap tests to better serve a large, underserved Hispanic population.¹⁸ In Southeast Minnesota, a Saturday Pap testing clinic was opened to address barriers related to jobs and childcare demands. The Saturday hours, which demonstrated an 86.15% fill rate, provided cervical cancer screenings and other essential health maintenance like immunizations, lab tests, and medication refills.¹⁹ These examples of community engagement and partnerships with community-based organizations show that small steps like tailoring educational materials or expanding care delivery hours can improve screening rates and adherence to timely preventive care.

These initiatives shine a spotlight on the necessity for OB/GYNs and other HCPs to first recognize how many women require enhanced education on the importance of annual well-woman exams and regular preventive screenings; and second, contribute their observations and ideas to help provide tailored education in their communities. Providing well-woman care and screenings at recommended intervals can help reverse and significantly reduce the growing rate of late-stage cervical cancer presentations due to delayed diagnosis leading to increase mortality. Combined with strategies to enhance adherence to follow-up care, we can make significant strides toward eradicating cervical cancer and reducing other gynecologic cancers in the United States.

References

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