High rates of cervical cancer are indicators of larger problems in access to health care

A new report released by the National Cancer Institute finds that high rates of cervical cancer are indicators of larger problems in access to health care.

The report also finds that cervical cancer mortality, which is higher in certain geographic areas and populations, is a marker for other health disparities. The authors of the new report, compiled by NCI's Center to Reduce Cancer Health Disparities (CRCHD) and titled Excess Cervical Cancer Mortality: A Marker for Low Access to Health Care in Poor Communities, conclude that the nation's public health system must improve its delivery of cervical cancer education, screening, and treatment and related health care to women at risk.

Despite a consistent decline in cervical cancer deaths in the United States overall, patterns of high cervical cancer mortality have existed for decades in specific geographic areas and populations. Those groups with the highest mortality rates include African American women in the South, Hispanic women along the Texas-Mexico border, and white women in Appalachia, American Indians of the Northern Plains, Vietnamese American women, and Alaska Natives.

The authors of this report hypothesize that cervical cancer is an indicator of larger health system concerns, including medical care access, cultural issues, and health communication and education issues. To examine the underlying causes of this ongoing disparity, CRCHD embarked on a two-phase project, the Cervical Cancer Mortality Project. In the first phase, researchers reviewed the literature and analyzed both historical and current data on cervical cancer incidence, screening, treatment and mortality in the United States. An analysis of the literature showed that women suffering from high cervical cancer mortality share several life conditions: they tend not to have a usual source of health care; have lower rates of preventative health services, including cancer screening; have low incomes and educational levels; and live in regions with high rates of screenable and treatable diseases, such as breast cancer, colorectal cancer, cerebrovascular disease, and infant mortality.

CRCHD Director Harold P. Freeman, M.D., emphasized the importance of efforts to find a solution to this problem. "Effectively addressing cervical cancer mortality can provide a model for action and an opportunity to address not only the health problems facing women who are dying from cervical cancer, but also the full set of human circumstances that lead to health disparities."

The authors of the report outline specific actions and targeted interventions to eliminate cervical cancer mortality disparities. These actions fall into four key strategy areas: access (services, outreach, and navigation); information and communication; collaborations, partnerships, and advocacy; and research.

The authors recommend that health care workers intensify outreach to women who have rarely or never been screened for cervical, breast, or colon cancer and other screenable diseases. To achieve this outreach, the report suggests that it is very important for women at risk for cervical cancer and other cancers to have a "medical home"-- a usual source of medical care where they can receive screening and counseling, experience continuity of care, and build relationships with the medical caregivers. The authors also recommend pairing all women with patient navigators at local hospitals or primary health centers, who can help at-risk women through the health system once an abnormality has been detected. Increased patient navigator programs would help improve communication between primary care, screening services, and follow-up/treatment at hospitals.

The report also suggests strategies to remove cultural and economic barriers to care. When only male physicians are available to conduct examinations, distrust and cultural taboos may cause at-risk women to avoid screening. Increasing the number of female providers, particularly those of the patient's race/ethnicity, is an important step in breaking down resistance to screening. The report also calls for improved coverage and reimbursement for cancer-related services. Specifically, the report recommends that any uninsured woman with cervical or other cancer should be considered eligible for Medicaid or Medicare for the duration of her treatment and follow-up care.

Native-born populations in high cervical cancer mortality areas tend to reach lower educational status and require materials written at a level that matches their reading levels. The authors of the report recommend working with community members to develop linguistically and culturally appropriate information about this disease. Effective translation is an integral part of reaching women in high-risk populations, and the report recommends improving provider-patient communication through provider tools and availability of language translation.

Additional research is needed to study the effects of numerous factors on cervical cancer mortality, including insurance status, transportation, lack of a medical home, human papillomavirus (HPV) prevalence, smoking, sexual practices, and condom use. The authors emphasize the need to optimize HPV testing and vaccine development to eliminate the cause of 90 percent to 95 percent of all cervical cancers. They also noted a need for additional research to develop better and more affordable screening tests for all women.

The authors recommend that all government, state, and local programs with an interest in women's health pursue collaborations which promote a "whole woman" approach to health care. "The problem of cervical cancer mortality underscores the urgent need to analyze our entire health care system," said Freeman. "Change can occur if the will exists to make it happen. We need to courageously craft the changes that will eliminate disparities and save lives."