Getting screened for cervical cancer isn't fun. And getting an alert that your initial exam showed a potential sign of trouble, and that you need to go back for a test or procedure to rule out cancer, is even less fun.
Plus, those follow-up procedures can cost hundreds of dollars, even though a law makes the initial cervical cancer screening test free to all eligible patients.
So it's no wonder that many of those eligible don't get screened in the first place – and that among those who get screened and have initial abnormal results that put them at increased risk for cancer, many don't go back for additional tests.
But if every eligible person did get the full screening and follow-up tests recommended for them, a new study suggests, up to 23% fewer people would be diagnosed with cervical cancer at all. And 20% fewer people would die of this preventable cancer.
The study, published by a University of Michigan team in the new journal O&G Open published by the American College of Obstetrics and Gynecology, is based on a computer model using the latest data about screening, surveillance, and diagnostic procedures for cervical cancer, and the current population of non-pregnant people with intact cervixes aged 26 to 65 who are eligible for screening.
The researchers say the findings should inform efforts to help more patients get the full scope of cervical cancer prevention and detection – including increasing reminders and removing costs and other factors that might get in the way.
Cancer screening as a process
The researchers point to a recent change for another type of cancer screening – colorectal cancer – that made follow-up colonoscopy free to patients if a stool test conducted at home shows signs of potential cancer. That change to see screening as a process, rather than a one-time test, is projected to save not only lives but millions of dollars in costs to insurers.
The researchers behind the new study know that getting to 100% for cervical cancer screening, surveillance, and diagnostic procedures known as colposcopy and LEEP is probably impossible. However, they find that even some improvements from the current rates will save many years of life for patients nationwide.
"This study quantifies the cervical cancer cases and lives that could be saved under the ideal, yet improbable, scenario of every single person completing the diagnostic process that can determine whether an individual has cancer or not," said A. Mark Fendrick, M.D., director of the U-M Center for Value-Based Insurance Design and a professor of internal medicine. "Follow-up is part of screening, and in the case of cervical cancer it can take multiple steps to complete."
He and colleagues previously published research showing that costs for colposcopy have grown in recent years, and can total hundreds of dollars even in women with private insurance.
A shifting landscape for prevention and testing
"Our new findings show what we could achieve if we could reduce the costs and hassles of going back in for additional cervical exams or diagnostic procedures such as colposcopy," said Diane Harper, M.D., M.P.H., a professor of obstetrics and gynecology and of family medicine who has studied all aspects of cervical cancer vaccination, screening, diagnosis and treatment.
She added, "The changes that are coming, such as the shift to more precise initial screening, and the potential for at-home screening, should not impede us from helping women get through the entire process with as few barriers as possible."
Harper also notes that the study takes into account the fact that some women now in their 20s and early 30s may have gotten vaccinated as tweens or teens against HPV, the virus that causes most cases of cervical cancer.
That means their risk of cancer is lower than for older women who didn't have the option of getting vaccinated. But current guidelines say vaccinated women should still get screened because the vaccine does not guard against all strains of the virus and the non-vaccine HPV types are now more prevalent. That's especially true for those who have new HPV exposures later in life.
The new results could inform the U.S. Preventive Services Task Force, which is currently reviewing the cervical cancer screening guideline last updated in 2018. The task force's evidence-based guidelines form the basis for which individuals can get preventive services at no cost to them under the Affordable Care Act.
More about the study
The study modeled the potential impacts of screening all eligible individuals on the recommended schedule for them, whether it's the schedule for those with no previous abnormal results or the schedule for those with a previous abnormal result.
Currently, 70% are screened routinely and 40% return for their shortened interval or procedural follow up if the initial screen was abnormal.
The study also modeled what would happen if all women whose screening identified abnormalities received care in line with recommendations for colposcopy or an outpatient excisional surgical procedure known as LEEP.
Currently, about 70% of women who should get a colposcopy actually do get one; the percentage for LEEP is even lower.
The authors note that previous research has shown that women of color and women with lower incomes are less likely to get regular screening for cervical cancer and that they have a higher chance of developing cancer, getting diagnosed with a cancer that has already progressed, or dying of cervical cancer. Thus, enhanced initial screening along with improvements in follow-up rates could reduce these disparities, they say.
Harper notes that women with low incomes who have Medicaid coverage don't face major costs for follow-up tests after abnormal screening, so other factors may need to be addressed to increase their participation. But women with private insurance, who make up two-thirds of all insured people may face the kinds of costs identified in the previous study, especially those with high-deductible health plans.
And no matter what insurance they have, she says health care systems should do more to ensure that all women receive reminders to schedule the screenings recommended for them based on their history and the follow up needed if the screen is abnormal.
In addition to Harper and Fendrick, the study team also included Tiffany Yu, B.S. from Guidehouse, a consulting firm which received funding from Roche Diagnostic Solutions for the study and the fee to publish the study under open access; Roche makes several types of cervical cancer diagnostic tests and Harper has served as a consultant to the company in the past.
In addition to the Roche funding, the study was also funded by the National Institutes of Health through funding received by Harper via the Michigan Institute for Clinical Health Research (TR004404) and the National Cancer Institute (CA046592), as well as an American Cancer Society Research Scholar Grant.
Citation: Lives Saved Through Increasing Adherence to Follow-Up After Abnormal Cervical Cancer Screening Results, O&G Open 2024, DOI:10.1097/og9.0000000000000001
