Abstract
A decline in incidence and mortality from cervical cancer has been observed over the last decades in the U.S. This decline has been primarily attributed to the introduction of the Papanicolaou (Pap) test. Despite the widespread use of the Pap test, the declining trend in the incidence of cervical cancer has leveled off in the recent years; cervical cancer remains the third most common gynecologic cancer, and important health disparities remain among minority underserved populations. Compared with non-Hispanic white women, cervical cancer incidence rates are five-times higher among Vietnamese women, nearly two-times higher among Hispanic women, and over 20% higher among African Americans and Island Puerto Ricans. Further, mortality rates from cervical cancer remained two-times higher among African American women than among non-Hispanic white women.
In the U.S., lack of Pap test is the single most important factor for the development of cervical cancer, and the disparities in the burden of cervical cancer are largely due to differences in Pap test coverage. The National Institutes of Health estimates that over 50% of the cases of cervical cancer are diagnosed among women who have never been screened or have not been screened in the previous five years. Further, it has been reported that more than 50% of the deaths from cervical cancer in the U.S. occurred among foreign-born women. Although the proportion of women receiving Pap screening has increased dramatically over the decades, current Pap smear screening rates remain below the 2010 Healthy People goal of 90% of women having received a Pap test within the 3 previous years; women from underserved, disadvantaged populations continue to be less likely to receive the recommended screening procedures.
Based on 2006 data from the Behavioral Risk Factors Surveillance System, the overall percentage of women 18 years and older reporting having had a Pap test within the previous 3 years was 84%. It was higher among African Americans (88.6%) followed closely by non-Hispanic whites (86.5%) and Hispanics (86.7%), but lower among other subgroups of the population. Puerto Rican women living on the island have one of the lowest Pap smear screening rates in the nation (72.5%). The role of race/ethnicity on cancer screening rates remains unclear. It has been suggested that race/ethnicity is a proxy for sociodemographic characteristics, psychosocial (intra-personal) factors, and environmental (external) factors responsible for the differences in screening rates.
In addition to race/ethnicity, sociodemographic factors associated with Pap screening rates include: age; income; marital status; education level; and poverty level; area of residence; and immigration status. Psychosocial factors include: embarrassment; uncomfortable examinations; low acculturation; fatalism; language barriers; physician distrust; lack of childcare; fear of the procedure; fear of the results; fear of pain; concern about confidentiality; lack of knowledge; perceived discrimination; perceived susceptibility; perceived severity of the disease; perceived partner disapproval; and self-efficacy. Whereas, environmental factors include: lack of physician referral; lack of health insurance; cost; lack of access to health care; no regular place of care; restrictive work policies; rigid clinic payment policies; poor transportation; long forms; and quality of care; and few social ties.
Cervical screening rates with Pap test in Puerto Rico are considerably lower than the nationwide median. These rates have remained unchanged from 2000 through 2006 in Puerto Rico. Based on data from the BRFSS, over one-third (28%) of Puerto Rican women aged 18+ years reported having not had a Pap test in the last 3 years. Screening rates were lower among women aged 18–20 years (26%) and women aged 61+ years (69%), single women (41%) and widows (68%), women with less than college education (69%), those with lowest household income (70%), and those without health insurance (66%) and those that did not have a regular physician check up in the past year (60%). The role of psychosocial and environmental factors on cervical cancer screening rates in Puerto Rico has not been studied.
Disparities in cervical cancer screening remain among racial/ethnic minorities and underserved populations. These disparities are multifactorial and complex relationships exist between these factors. Addressing these disparities requires understanding of these complex relationships and multi-component strategies tailored to the particular population of interest. Community intervention to reach underserved populations typically use mass media, small media group education settings, mobilization of lay health workers, influencing existing social networks, computer-generated printed feedback or a combination of these methods. Among Hispanic women, a multi-method approach has been shown to be an effective form of intervention. Additionally, there is growing evidence of the effectiveness of interactive multimedia interventions at increasing cancer screening intention and behavior among low-income and minority women.
Second AACR International Conference on the Science of Cancer Health Disparities— Feb 3–6, 2009; Carefree, AZ