Cervical Cancer: Uninsured Are Diagnosed Later

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Lack of Insurance Linked to Late-Stage Diagnosis

By Salynn Boyles
WebMD Health News

Reviewed by Louise Chang, MD

July 19, 2012 -- Women without health insurance are far more likely to receive a diagnosis of advanced cervical cancer, a new study from the American Cancer Society shows.

Lack of health insurance was second only to age as the strongest predictor of advanced-stage disease.

Once a leading cancer killer of women, deaths from cervical cancer in the United States dropped dramatically after Pap test screening became a common practice.

But about 1 in 3 cervical malignancies are still diagnosed after the cancer has spread outside the cervix, and 1 in 10 is found in the disease's latest stages, when treatment is far less likely to lead to a cure.

About 90% of women diagnosed with early-stage disease live for five years or longer after the cancer is diagnosed, compared to less than 20% of women diagnosed in the latest stages, when their disease has spread to distant organs.

No Insurance, Less Screening

Older age, race, and economic status have long been identified as risk factors for advanced cervical cancer diagnosis, and lack of health insurance is a well recognized barrier to Pap test screening.

But the new study is among the first to examine the impact of health insurance status on disease stage at diagnosis in a large, nationally representative group of women.

Researchers with the American Cancer Society (ACS) reviewed the medical histories of close to 70,000 women whose newly diagnosed cervical cancers were reported to the National Cancer Database between the years 2000 and 2007.

They found that:

• Just over half of the women (55%) who had private health insurance had a stage I diagnosis, compared to 36% of women who were uninsured. Twenty-four percent of privately insured women were diagnosed with advanced disease (stage III and IV), compared to 35% of uninsured women.
• Economically disadvantaged women covered by Medicaid had rates of late-stage diagnosis similar to that of uninsured women.
• Older age was still the strongest predictor of late-stage disease, though, with risk being up to 2.5 times greater in women 50 years and older compared to women 21 to 34 years of age.

American Cancer Society epidemiologist Stacey Fedewa, MPH, says it is common for screening to decline or stop altogether when women approach the age of menopause.

ACS recommends that:

• All women begin cervical cancer screening by the age of 21, and that women between the ages of 21 and 29 have a Pap test every three years.
• Women between the ages of 30 and 65 have a Pap test and a human papillomavirus (HPV) test every five years or a Pap test alone every three years.
• Women over the age of 65 who have had regular screenings should not continue screening unless they have had abnormal results indicative of an increased risk for the cancer.

'Pap Screening Saves Lives'

NYU School of Medicine Director of Gynecologic Oncology John Curtin, MD, says older women who did not have regular Pap tests when they were younger should be screened but often aren't.

Curtin is a past president of the Society of Gynecologic Oncology.

"For these women, the guidelines that say you can stop screening at 65 do not apply," he tells WebMD.

Fedewa tells WebMD that the larger risk for late-stage diagnosis in uninsured women is probably due to the fact that these women aren't being screened at all.

When they do get screened, uninsured and underinsured women also have higher rates of abnormal screening results and lower rates of abnormal screening follow-up than women with insurance.

Curtin adds that it remains unclear if the health care reforms upheld by the Supreme Court last month will increase screening rates among lower-income women.

What is clear, he says, is that cervical cancer could be eliminated in the U.S. if all eligible women were screened and got the follow-up care they needed.

"Many decades after its arrival, the Pap smear remains a great public health tool that saves lives," he says.

SOURCES: Fedewa, S.A. American Journal of Public Health, July 19, 2012. Stacey A. Fedewa, MPH, epidemiologist, American Cancer Society, Atlanta. John Curtin, MD, director of gynecologic oncology, NYU Medical Center; past president, Society of Gynecologic Oncology. News release, American Cancer Society.

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