cervical cancer increasing in women 30-34

 There was a discouraging letter to the editor in JAMA recently, finding increased cervical cancer incidence in the US (see cervical ca incidence inc JAMA2022 in dropbox or doi:10.1001/jama.2022.17806) 

 

 

Details: 

-- data from the 2001 to 2019 National Program of Cancer Registries (NPCR) and the Surveillance Epidemiology and End Results (SEER) databases. Data included all 50 states and covers 98% of the US population 

-- based on this, they calculated the annual percent changes in the incidence rates and trends of cervical cancer screening by five-year age groups; this assessment was hysterectomy-corrected based on surveys of the general hysterectomy rates from the Behavioral Risk Factor Surveillance System database 

 

Results: 

-- from 2001 to 2019, 227,062 cervical cancer cases were reported 

-- hysterectomy-corrected cervical cancer incidence declined from 12.39 per 100,000 in 2001 to 9.80 per 100,000 in 2019, with an annual percent change (APC) of -1.2%; the most dramatic reductions were found in those 25-29 years old and 50 to 59 years old. The rest of the age groups were decreased but relatively stable. There was one exception: 

    -- 30-35 yo women (total of 20,679 cases): 

        -- 2000-2012: APC = -2.3% 

        -- 2012-2019: APC = +2.5% 

            -- i.e., there was actually an increase of 2.5% in the 2012-2019 analysis 

 

-- during 2012-2019, for 30-34 yo women, the incidence of hysterectomy-corrected cervical cancer incidence increased significantly: 

    -- Hispanic women: APC increased 3.0% (0.3%-5.7%) 

    -- non-Hispanic white: APC increased 2.8% (0.6%-5.0%) 

    -- Black women: APC decreased by 0.8% (-2.8% to 1.2%), a nonsignificant trend 

-- stage at cancer diagnosis, and type:  

    -- localized cancer: increased 2.8% (1.3%-4.3%) 

    -- regional cancer: increased 1.9% (0.7%-3.1%) 

    -- squamous cell carcinoma increased 2.6% (1.0%-4.2%) 

    -- adenocarcinoma increased 3.0% (0.9%-5.1%) 

 

Commentary: 

-- this study found that overall cervical cancer incidence declined or remained stable among US women, except the 30-34 age group which had an increase. 

-- An interesting article from 2017 found that beginning in 2013 there was a decline in screening participation among 21 -29-year-old women (see pap screening decreasing PrevMed2017 in dropbox, or https://www.sciencedirect.com/science/article/abs/pii/S0091743517301688?via%3Dihub):  

    --this study was based on the 2015 US National Health Interview Survey (NHIS), assessing Pap tests done within the prior three years in women 21 to 65 yo without a hysterectomy (10,596 women) and  those with co-testing with HPV (9125 women) 

        -- they examined cervical cancer testing during the year 2000, 2005, 2008, 2010, 2013, and 2015 

        -- 81% of women had a Pap test within the previous three years, leaving an estimated 14 million women aged 21 to 65yo not having been screened during that time

    -- there were lower odds of being up-to-date with screening in recent immigrants to the US, women without insurance, and women without a usual source of healthcare 

    -- about one-third of women up-to-date on Pap testing reported having a co-test with their most recent Pap (ie, most did not have the HPV component done and needed screening in the 3-year window)

    -- as a reference here, the Healthy People goal for women aged 21 to 65 was 93% of women 

    -- the trend in cervical cancer screening has in general been decreasing for the 2000 to 2015: 

 

 

 

-- A cross-sectional study of 20,557 women from 2005 to 2019 assessed adherence to the USPSTF cervical cancer screening guidelines, finding that the proportion of women without up-to-date screening significantly increased from 14.4% in 2005 to 23.0% in 2019 among all demographic groups; women age 21 to 29yo had significantly higher rates of overdue screening (29.1%) versus women age 30 to 65yo (21.1%). The highest rates of overdue screening was in women without insurance (41.7% versus 18.1%) and the most common reason for not receiving timely screening across all age groups was lack of knowledge about screening at 64.4% of some groups (see https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788175) 

-- so, why is this happening?

    -- is it because cervical cancer screening has moved progressively from yearly to every 3 years and now to every 5 years with HPV screening? it is certainly great for women not to have to be screened so frequently. but do primary care providers become less comfortable doing pelvic exams/screening since they are doing fewer? are they too busy with other things and put it off? or they don't have systems that remind them? of because they are seeing more women who do not have adequate insurance?

        -- we do have a huge problem with primary care in this country, and it is getting worse.  providers are overworked, underpaid, and often have a boundless amount of work to do (different from hospitalists or most specialists, who have much more hospital/office support and have much better systems to deal with patients who have problems late in the afternoon/night, have abnormal labs, need prescription refills/paperwork filled out; and primary care physicians typically see patients in about 15 minutes to deal with the array of their problems (vs many specialists who have 30-60 minutes to deal with one problem) etc etc. (i should emphasize that i truly love primary care, and the intense and powerful relationships with patients and families; it's just a lot of work...). as per https://www.mhqp.org/2022/09/06/mhqp-to-produce-states-first-ever-primary-care-dashboard-for-chia/ (thanks to Cheralyn McKee):

            -- not so many people are going into primary care these days/many leaving it: in 2020, in Massachusetts 3.6% of physicians left primary care (vs 3.3% nationally)

            -- primary care spending by insurance companies was <8% of overall medical spending and declined from 2019 to 2020

            -- cancer and other preventive screening rates declined from 2019-2020

            -- which all paint a pretty terrible picture for now and the future: really functional health care systems promote primary care as the bedrock of their systems and have much better access to primary care (in several countries i know, the vast majority of their physicians do primary care)

   

Limitations: 

-- this study was not a prospective one designed to assess the outcomes measured, but a large data-mining study, which limits its information on the specifics of cervical cancer screening and cannot therefore determine causality, only associations

    -- there were limited data on the specifics of screening done, and those over age 30 many had co-testing and may not need another test for five years (in this study about one-third of the patients report having had a co-test, but this was not corroborated through objective data. Of note they found that co-testing reports were highest in those younger than 40 years old ). and no information on the individuals who had prior cervical cancer screening over the years (had some had no prior screening ever?). or what cervical cancer risk factors they had. or if they had had HPV vaccines. or if they had HIV ....

-- the infomration on hysterectomies was self-reported. likely accurate but ??

 

So, 

-- the overall decline in screening participation in women is of considerable concern in the 2017 article (especially in women under 40), and this is likely associated with the 3% or so increase in cervical cancer in those 30-34yo 

    -- one thing that may make it easier to make sure that these tests are done is to have home-based or office-based HPV screening (which could be done by the woman herself without involving providers), which have a reported 99.9% accuracy 

    -- HPV testing by itself has been in the offing in the United States since 2014: http://gmodestmedblogs.blogspot.com/2014/04/fda-approval-of-stand-alone-hpv-testing.html 

    -- the 2018 USPSTF recommendations on cervical cancer screening adopted primary HPV testing every five years (i.e. without cervical Pap smears) as a grade A recommendation: http://gmodestmedblogs.blogspot.com/2018/09/uspstf-guidelines-on-cervical-cancer.html 

        -- the American Cancer Society in 2020 recommended primary HPV testing every five years from age 25 to 65 as their preferred screen

 

-- This study reinforces the importance of cervical cancer screening and the results of this study reinforced the importance of HPV prevention, best done by HPV immunization and general risk factor reduction

-- And it really reinforces the inadequacies of our piece-meal health care system, where a huge number of people are uninsured, have less access to health care, have higher morbidity and mortality, and much of this could be prevented in an inclusive, government-sponsored system for everyone (such as an enhanced Medicare) with a real emphasis on making primary care its center (with its more holistic care dealing with the array of medical and psychosocial issues, having better outcomes than by our fragmented system, and being much cheaper).....

geoff

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