Papanicolaou Smear History and Diagnosis of Invasive Cervical Carcinoma Among Members of a Large Prepaid Health Plan

Cancer 2000;88(10):2283–9 These authors from the Kaiser Permanente Medical Care Program of Northern California have shown us something that, unfortunately, has been true for many years. Though the rate of incidence of invasive cervical carcinoma (ICC) has fallen from 14.2 to 7.8 per 100,000 women from 1973 to 1994, and deaths from ICC have decreased from 5.2 to 2.8 per 100,000 in the United States, following recommended screening guidelines would result in even greater decreases. The authors identified all members of a health plan diagnosed with ICC from 1988 to1994. The authors investigated multiple epidemiologic and demographic factors, including the Pap smear history for these patients—defined as a Pap smear within 6 to 36 months of diagnosis—and: Of 455 women who were diagnosed and had adequate inclusion criteria (long-term plan membership), the mean age at diagnosis was 50 years. Those who had not adhered to a “recommended” screening program (at least one Pap smear within 3 years) varied by age. The younger ICC group—those less than 40 years old—had a non-adherence rate of 34%, the group ages 40 to 54 years had a 54% non-adherence rate, and the group older than 55 years had a non-adherence rate of 65%. A total of 138 minority patients had a non-adherence rate of 60%, compared to an overall rate of 50% in non-Hispanic, white women. A total of 127 patients (28%) had normal Pap smears during the 3-year interval preceding diagnosis. Only 17 (5%) fell into the group with an abnormal Pap smear and inadequate follow up. Only 134 (29%) of ICC patients were totally without symptoms suspicious for ICC during the six months preceding diagnosis. The authors conclude that despite the universal access to Pap smear screening offered by their medical group, non-adherence to screening recommendations is the most common modifiable antecedent to ICC in their prepaid health plan. Comment: This study emphasizes what has been known about cervical cancer screening for 50 years: there is a decreased incidence of cancer and cancer-related mortality in women who get screened. Efforts to improve cervical cancer detection and decrease ICC mortality should be aimed at universal screening rather than new technologies, whether you live in the third world, second world, or first world. (TMJ)