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RESEARCH AND PRACTICE |
Maria Hewitt is with the Institute of Medicine, National Cancer Policy Board, Washington, DC. Susan Devesa is with the Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Md. Nancy Breen is with the Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Md.
Correspondence: Inquires should be directed to Maria Hewitt, DrPH, Institute of Medicine, National Cancer Policy Board, 2101 Constitution Ave, NW, Washington, DC 20418 (e-mail: mhewitt{at}nas.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. This study assessed the relationship between risk factors for cervical cancer and Papanicolaou (Pap) test use within the past year among reproductive-age women.
Methods. The 1995 National Survey of Family Growth, a demographic and reproductive health survey of 10 847 women aged 15 to 44, was analyzed with multiple logistic regression.
Results. Of the women, 62% reported having had a Pap test within the past year. Use was significantly higher among women with risk factors and among African American women. Use was significantly lower among uninsured, poor, and foreign-born women and among women with lower educational attainment and of "other" race/ethnicity.
Conclusions. Strategies to improve Pap test use include (1) educational campaigns that inform women of cervical cancer risk factors and encourage screening and (2) increased support for programs that expand access to Pap tests.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Cervical cancer is one of the most preventable cancers because a precancerous condition can be identified early through the Papanicolaou (Pap) screening test.6,7 The incidence of precancerous lesions identified by the Pap test is highest among reproductive-age women.8 Of the 12 900 new US cases of cervical cancer in 2001, 44% occured among women aged 18 to 44 years.3,9 In the United States, most organizations recommend annual Pap tests once a woman has become sexually active (or has reached age 18), with some recommending less frequent screening following 3 normal test results.10
The objectives of this study were to describe the prevalence of selected risk factors for cervical cancer among reproductive-age women and to assess how the presence of risk factors is associated with Pap test use, controlling for sociodemographic characteristics and health insurance status.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Statistical Analyses
The National Survey of Family Growth has a complex survey design involving stratification, clustering, and disproportionate sampling. All proportions and population counts presented here were weighted to provide national estimates. Variance estimates for proportions and logistic regression model odds ratios (ORs) were calculated by use of the Taylor series approximation technique, taking into account the complex design of the survey.13
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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).
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). The finding in bivariate analyses that Pap test use was significantly higher among women with at least 1 risk factor, compared with women without risk factors (68.1% vs 57.2%), was confirmed in multivariate analyses (OR = 1.63) (Table 2). Pap test use was significantly lower among women who were uninsured (OR = 0.54), and was comparable among women who had Medicaid coverage (OR = 1.10), relative to privately insured women. Women who were poor (i.e., resided in family with incomes below 150% of the poverty level) had lower rates of Pap test use (OR = 0.63) than did women residing in families with incomes at or above 300% of the poverty level. Relative to women with at least a college degree, women with less education had lower rates of Pap test use (e.g., less than high school graduation, OR = 0.49).
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Location of Pap Tests
Pap tests were most often conducted at private doctors' offices or health maintenance organizations (78.9%; 95% confidence interval [CI] = 77.5%, 80.3%) and less often conducted in clinic settings (8.0%; 95% CI = 7.1%, 8.9% at publicly funded Title X family planning clinics; 10.2%; 95% CI = 8.9%, 11.5% at other clinics) or at hospitals, schools, or other settings (2.8%; 95% CI = 2.4%, 3.3%). Compared with women reporting no risk factors, women reporting at least 1 risk factor were more likely to have received their Pap tests at a clinic funded through the Title X program (10.1%; 95% CI = 8.8%, 11.4% vs 6.1%; 95% CI = 5.1%, 7.1%) and less likely to have been tested at a private doctor's office or at a health maintenance organization (74.6%; 95% CI = 72.9%, 76.4% vs 82.8%; 95% CI = 81.0%, 84.6%).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Higher-risk women might have enhanced opportunities for screening because of greater exposure to health care providers—nearly half (47.4%; 95% CI = 45.7%, 49.1%) of the women reporting risk factors said that they had used a reproductive health service (e.g., family planning services, prenatal care) in the previous year, compared with just over a third (34.9%; 95% CI = 33.6%, 36.2%) of the women who did not report any risk factors. Almost all (86.5%; 95% CI = 85.5%, 87.6%) women who had received a reproductive health service reported having received a Pap test, suggesting that the test is routinely provided during family planning and pregnancy-related visits.
Despite higher rates of Pap test use among women with risk factors, nearly one third of the higher-risk women reported that they did not have a Pap test in the past year, leaving much room for improvement. Strategies to improve Pap test use include implementation of educational campaigns that inform women of cervical cancer risk factors and encourage screening and provision of increased support for programs that expand access to Pap tests. The largest program to promote cancer screening among low-income and underserved women is the National Breast and Cervical Cancer Early Detection Program, which operates in all states with support from the Centers for Disease Control and Prevention. From 1991 to 1997, more than a million Pap tests were performed as part of the program, but estimates are that fewer than 15% of the women eligible for the program are served.16–18 Family planning clinics that offer services on a free and reduced-fee basis (e.g., Title X clinics) also provide opportunities to increase the use of Pap tests, especially among women at higher risk for cervical cancer.19
One caution to interpreting results of cancer screening behavior from surveys is the problem of respondents misrepresenting their actual behavior.20–23 An inability to recall events, the desire on the part of respondents to provide socially desirable answers, or the failure to correctly date events in memory can all contribute to misrepresenting Pap use in surveys.24 Despite these shortcomings, the 1995 National Survey of Family Growth provided valuable information on the determinants of Pap tests and descriptive information on where tests are conducted.
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Acknowledgments |
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Footnotes |
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M. Hewitt conducted analyses of the National Survey of Family Growth and drafted the paper. S. Devesa provided tabulations from the Surveillance, Epidemiology, and End Results Program on the epidemiology of cervical cancer and assisted in the analysis plan and the writing of the paper. N. Breen reviewed background literature and assisted in the analysis plan and the writing of the paper.
Accepted for publication November 14, 2001.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2.
Cain JM, Howett MK. Preventing cervical cancer. Science.2000;288:1753–1754.
3. American Cancer Society. Cancer Facts & Figures—2001. Atlanta, Ga: American Cancer Society; 2001.
4. American Cancer Society. Cancer Risk Report: Prevention and Control. Atlanta, Ga: American Cancer Society; 1998.
5. Devesa SS. Cancer in women. In: Goldman MB, Hatch MC, eds. Women and Health. San Diego, Calif: Academic Press; 2000:863–870.
6. National Institutes of Health Consensus Program. Cervical cancer. NIH Consensus Statement.1996;14(1):1–38.[Medline]
7. Hunter RD. Carcinoma of the cervix. In: Peckham M, Pinedo H, Veronesi U, eds. Oxford Textbook of Oncology. Vol 2. Oxford, England: Oxford University Press; 1995:1324–1337.
8. Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. SEER*Stat 41. Available at: http://seer.cancer.gov/ScientificSystems/SEERStat/ [special tabulation]. Accessed October 24, 2000.
9. Ries LAG, Eisner MP, Kosary CL, eds. SEER Cancer Statistics Review, 1973–1997. Bethesda, Md: National Cancer Institute; 2000.
10. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996.
11. Abma JD, Chandra A, Mosher WD, Peterson LS, Piccinino LJ. Fertility, Family Planning, and Women's Health: New Data From the 1995 National Survey of Family Growth. Hyattsville, Md: National Center for Health Statistics; 1997.
12. National Center for Health Statistics. National Survey of Family Growth, Cycle V 1995 [CD-ROM Series 23 (no. 3)]. Hyattsville, Md: National Center for Health Statistics; 1997.
13. Stata Statistical Software: Release 6.0 [computer program]. College Station, Tex: Stata Corp; 1999.
14. Martin LM, Wingo PA, Calle EE, Heath CW. Comparison of mammography and Pap test use from the 1987 and 1992 National Health Interview Surveys: are we closing the gaps? Am J Prev Med.1996;12:82–90.[Medline]
15. Potosky AL, Breen N, Graubard BI, Parsons PE. The association between health care coverage and the use of cancer screening tests: results from the 1992 National Health Interview Survey. Med Care.1998;36:257–270.[Medline]
16. The National Breast and Cervical Cancer Early Detection Program: At-a-Glance 2000. Atlanta, Ga: Centers for Disease Control and Prevention; 2000.
17. Blackman DK, Bennett EM, Miller DS. Trends in self-reported use of mammograms (1989–1997) and Papanicolaou tests (1991–1997)—Behavioral Risk Factor Surveillance System. MMWR Morb Mortal Wkly Rep CDC Surveill Summ.1999;48(SS-6):1–22.
18. Lawson HW, Lee NC, Thames SF, Henson R, Miller DS. Cervical cancer screening among low-income women: results of a national screening program, 1991–1995. Obstet Gynecol.1998;92:745–752.[Abstract]
19. Frost JF. Family planning clinic services in the United States, 1994. Fam Plann Perspect.1996;28:92–100.[Medline]
20. Sudman S, Warnecke R, Johnson T, O'Rourke D, Davis AM. Cognitive aspects of reporting cancer prevention examinations and tests. Vital Health Stat 6. 1994;No. 7.
21. Bowman JA, Sanson-Fisher R, Redman S. The accuracy of self-reported Pap smear utilization. Soc Sci Med.1997;44:969–976.
22.
Montano DE, Phillips WR. Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey, and chart audit. Am J Public Health.1995;85:795–800.
23. Suarez L, Goldman DA, Weiss NS. Validity of Pap smear and mammogram self-reports in a low-income Hispanic population. Am J Prev Med.1995;11:94–98.[Medline]
24. Groves RM. Survey Errors and Survey Costs. New York, NY: John Wiley & Sons; 1989.
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