Cervical Cancer Control -- Rhode Island

In 1987, 49 cases of invasive cervical cancer and 14 deaths from cervical cancer were reported in Rhode Island (1). Because progression to invasive disease and death from cervical cancer are regarded as preventable (2), in 1988, the Rhode Island Department of Health (RIDH) examined data from two recent surveys and from hospital records to assess the contributions of various circumstances to invasive cervical cancer.

Five circumstances* can lead to invasive cervical cancer: 1) the woman is not screened, 2) too long an interval elapses between screening tests, 3) the disease develops rapidly between a negative screening and a subsequent screening, 4) a test is interpreted as false-negative, or 5) the woman with a true-positive test result is not treated (3). To assess the importance of each of these circumstances, the RIDH used data from two 1987 cross-sectional surveys of Rhode Island women and from inpatient chart reviews of women diagnosed with cervical cancer from 1980 through 1986. To be consistent with the National Cancer Institute's (NCI) cancer-control objectives for cervical cancer screening (4), women aged 20-39 and 40-69 years were assessed separately. In Rhode Island, as elsewhere (5), more than half the invasive cervical cancers occurred in the older group (1). The first cross-sectional survey, part of CDC's Behavioral Risk Factor Surveillance System (random-digit-dialed telephone interviews of persons aged greater than or equal to 18 years), was administered from September through November 1987. Women were asked if they had received a Papanicolaou (Pap) test within the last 3 years--a screening interval that conforms with NCI's cancer-control objectives for cervical cancer screening (4). The response rate for this survey was 83% (n=259). The second survey, conducted statewide during September and October 1987, focused on the use of cancer screening tests, including the Pap test, among women aged greater than or equal to 40 (6). The response rate for this survey was 78% (n=852).

Medical records were reviewed for 153 women treated for newly diagnosed invasive cervical cancer from 1980 through 1986 at two major hospitals in Rhode Island. These women represented approximately two thirds of all Rhode Island women aged 20-69 years who were diagnosed with invasive cervical cancer during this period. RIDH collected information on sociodemographic characteristics and medical history. Screening histories were available in 81 (53%) of the medical records reviewed and were used to quantify the relative importance of the five circumstances.

The survey data indicate that more women aged 20-39 (87%) than aged 40-69 (76%) had been screened within the last 3 years (Table 1). Among the younger women, 13% had never been screened or had last been screened greater than 3 years previously. Among the older women, 4% had never been screened, and 20% had last been screened greater than 3 years previously.

Data from the medical record review corroborated the age differences in screening history observed in the survey data and suggested other problem areas for cervical cancer control (Figure 1). Each of these age groups--most notably women aged 40-69--included women who had never been screened or women who had been screened beyond the 3-year interval. However, among women aged 20-39, 22 (67%) had been negative on Pap smear screening within 3 years of diagnosis, and six (18%) had been screened positive within 3 years but had had a delay in treatment. Reported by: RB Kaufmann, MPH, JP Fulton, PhD, P Simon, MD, JS Buechner, PhD, A Cody, HD Scott, MD, Director of Health, Rhode Island Dept of Health. Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Screening with the Pap smear is widely accepted as the most effective way to detect cervical intraepithelial neoplasia at an early stage and prevent the morbidity and death associated with progression to late-stage cervical cancer. In the Rhode Island analysis, however, many women had not had a recent Pap test. Although younger women were more likely to have been recently screened, both groups included women who had never been screened with the Pap test (circumstance 1) and who had not been screened within the recommended interval (circumstance 2). Shorter screening intervals would not ensure that all cases of invasive cervical cancer would have been detected at an earlier stage of disease; nonetheless, findings in Rhode Island suggest opportunities for earlier detection, especially among women aged 40-69 years. A large proportion of the invasive cases of both age groups occurred among women who had had a negative Pap test within 3 years of diagnosis (circumstances 3 and 4). False-negative tests, which can be caused by inadequacies in cell collection, smear preparation, or smear interpretation, probably are the primary circumstance leading to invasive cervical cancer among women whose medical records indicate a normal test result within the appropriate interval. Because of concerns about the variability in cytologic interpretation and the variability in clinical responses to abnormal results, NCI sponsored a workshop in December 1988. The outcome of this workshop--the Bethesda system for reporting cervical/vaginal cytological diagnoses (7)--addresses problems of variability among several reporting systems and their variable terminology.

Eighteen percent of younger women with invasive cervical cancer had a previous positive Pap test but were not treated (circumstance 5). Some women with a positive Pap smear test may not have received appropriate follow-up care because they were not notified of their results, refused to return for treatment, or failed to receive follow-up care for other reasons. Because younger and less educated women are less likely to receive appropriate follow-up care after being notified of an abnormal Pap test (8), public health efforts should be strengthened to ensure these women are contacted, making further evaluation and treatment possible.

The RIDH, in cooperation with CDC, has developed a quality-assurance program in cervical cancer screening for the state. Results from this examination of cytologic quality assistance and screening outcomes will help shape a cervical cancer-control program for Rhode Island.

References

1. Rhode Island Department of Health. Cancer: Rhode Island, 1987. Providence: Rhode Island Department of Health, 1989.

2. Guzick DS. Efficacy of screening for cervical cancer: a review. Am J Public Health 1978;68: 125-34.

3. Janerich DT, Hadjimichael O, Flannery J. Strategy for elimination of invasive cervical cancer in Connecticut. Conn Med 1985;49:746-53.

4. National Cancer Institute. Cancer control objectives for the nation: 1985-2000. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1986; NIH publication no. 86-2880. (NCI monographs, no. 2).

5. Saunders LD. Differences in the timeliness of diagnosis, breast and cervical cancer, San Francisco 1974-85. Am J Public Health 1989;79:69-70.

6. CDC. Use of mammography for breast cancer screening--Rhode Island, 1987. MMWR 1988; 37:357-60.

7. National Cancer Institute Workshop. The 1988 Bethesda system for reporting cervical/vaginal cytological diagnoses. JAMA 1989;262:931-4.

8. Michielutte R, Diseker RA, Young LD, May WF. Noncompliance in screening follow-up among family planning clinic patients with cervical dysplasia. Prev Med 1985;14:248-58. *Based on a model developed in Connecticut that describes four circumstances leading to invasive cervical cancer (3).

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