Cervical Cancer Mortality Rises as Women's Health Clinics Close

Roxanne Nelson, RN, BSN

September 19, 2019

CHICAGO — Cervical cancer declined dramatically in recent years in the United States, both in incidence and mortality, due to widespread availability of screening. But now researchers are reporting a trend toward more women being diagnosed with late-stage disease and significantly increased mortality.

The trend follows the closure of nearly 100 women's health clinics across the country from 2010 to 2013. This has led to an associated decrease in screening for cervical cancer and fewer women being diagnosed with early-stage disease.

While cervical cancer survival rates continued to improve in states without clinic closures, there was a 36% increase in risk of dying from cervical cancer in states where women's health clinics were closed.

"Most concerning is how the closures translated into survivorship," commented study author Amar Srivastava, MD, MPH, a resident physician in radiation oncology at Washington University School of Medicine in St. Louis, Missouri.

This is a major public health problem in the US. Dr Amar Srivastava

"There was a relative reduction of women undergoing screening, which led to a reduction in diagnoses, less early diagnoses, more late-stage disease, and more death," he said.

Srivastava emphasized that these data are retrospective, so causality cannot be determined. "But the data we saw and the findings we are seeing is concerning enough to pause and consider what is going on," he said.

He explained that the closure of women's health clinics over the past decade has been primarily the result of restrictions placed by state legislatures related to reproductive services, as well as changes in funding structures (eg, regulations for Title X funding) and the passage of laws that regulated standards at these clinics.

"From a Google search alone during the past two weeks, hundreds of articles came up from different media, including The New York Times and The Washington Post, highlighting this issue," said Srivastava. "This is a major public health problem in the US."

He was speaking here at the American Society for Radiation Oncology (ASTRO) annual meeting.

Downstream Effects of Closures

Discussant Geraldine Jacobson, MD, MPH, MBA, from the West Virginia University Department of Radiation Oncology in Morgantown, said: "This is a thought-provoking study . . . of how lack of access to screening has led to increased mortality."

Cervical cancer is a disease that can be prevented and treated in its early stages, Jacobson noted. "It was a major cause of death and with screening, that was reversed," she said.

"Changes of legislation are reversing that and having downstream health effects," she commented.

This study puts a human face on it. Dr Geraldine Jacobson

This study raises broader questions, she emphasized. "We are always being engaged in dialogues about healthcare and costs, but this study puts a human face on it," said Jacobson. "If we make changes, we are impacting people's health and people's lives."

For their study, the authors divided states into two cohorts based on changes in the number of facilities providing comprehensive reproductive services between 2010 and 2013.

The cohorts included the states that had a decrease in clinics (DIC, n = 37) and the states that had no decrease in clinics (NDIC, n = 13) in that period.

Data for nearly 200,000 women were obtained using the Behavioral Risk Factors Surveillance Study (BRFSS) to evaluate screening utilization, while information on more than 10,000 women came from the Surveillance, Epidemiology and End Results Registry (SEER) to evaluate cancer stage at diagnosis and mortality.

The analyses then compared data for both groups from 2008 to 2009 with outcomes from 2014 to 2015.

The authors found that the DIC states had a 2% decrease in cervical cancer screenings as compared with NDIC states. The greatest declines in screening were for patients without insurance (–0.18 percentage points [PP]; P = .01), Hispanic women (–5.32 PP; P < .01), women ages 21 to 34 (–4.81 PP; P < .01), and unmarried women (–4.37 PP; P < .01).

The most marginalized women were the most affected, Srivastava noted. "Hispanic, uninsured, young women — these are the women who were most dramatically hit by these changes."

Overall, survival rates for cervical cancer improved in states without clinic closures but declined in the DIC states — and there was a significant increase in mortality risk from cervical cancer in DIC states (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.02 - 1.83; P = .04). This trend was particularly observed among women living in urban areas (HR, 1.40; 95% CI, 1.04 - 1.90; P = .03).

When looking at stage at diagnosis, the authors noted that there was a decline in early-stage diagnoses among patients aged 18 to 34 years in DIC relative to NDIC states (–13.2 PP; P = .031).

Indicator of Real Concern

Approached for comment, Krisha J. Howell, MD, assistant professor, Department of Radiation Oncology, Fox Chase Cancer Center in Philadelphia, Pennsylvania, pointed to the limitations in identifying causality between the closure of women's health clinics with lower screening and higher cervical cancer mortality rates. But that said, she added that this study is a large indicator of a real concern.

"The authors should be commended for identifying the issue and a method for analyzing early indicators of increased restrictions on women's clinics intended to service the public," Howell told Medscape Medical News. "To fathom that increased regulations in Title X funding is impacting public health by reversing healthcare advances designed decades ago is a trend we do not wish to continue."

"Availability of low-cost screening for cervical cancer via the Pap test enabled early detection of, and increased survival from, this disease," she added. "All this in a younger-than-average cancer population, and, in a manner that even when cancer is detected, it is detected early enough to limit aggressive curative management."

Srivastava and Jacobson disclosed no relevant financial relationships. Howell reported that her husband is employed by Medtronic and that they own stock in the company.

61st Annual Meeting of the American Society for Radiation Oncology (ASTRO): Abstract 202. Presented September 17, 2019.

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