Cancer of the cervix is the 13th most commonly diagnosed cancer among females in Colorado.  Cervical cancer mortality declined by more than 70% in the U.S. since adoption of the Papanicolaou test in the 1940s.  The Papanicolaou test (also called Pap smear, Pap test, cervical smear, or smear test) is a screening test used in gynecology to detect premalignant and malignant processes in the cervix.  The test aims to detect potentially pre-cancerous changes such as cervical intraepithelial neoplasia (CIN) or cervical dysplasia, both of which are usually caused by sexually transmitted human papillomaviruses (HPVs).  The test is inexpensive to do and remains an effective, widely used method for early detection of pre-cancer and cervical cancer.

Smoking and age influences both cervical cancer incidence and death rates.  Smoking exposes the body to many cancer-causing chemicals.  Tobacco by-products have been found in the cervical mucus of women who smoke.  Women who smoke are about twice as likely as non-smokers to get cervical cancer.  In Colorado, the majority (more than two-thirds) of invasive cervical cancers are diagnosed in women age 20 to 54.  While a smaller number of cases are diagnosed in women age 55 and older, older women are more likely than younger women to be diagnosed at later stages of the disease and to die from it. 

High-risk HPV types, specifically 16, 18, 31, 33 and 45, act as carcinogens in the development of cervical and other anogenital cancers.  Infection with a high-risk HPV type is considered necessary for the development of cervical cancer.  Seventy percent of cervical cancers worldwide are caused by high-risk HPV types 16 and 18.  More than a decade ago, standards were introduced to guide the delivery of vaccinations for children and adults.  Under the leadership of the National Vaccine Advisory Committee, standards were revised with a focus on making vaccines easily accessible, effectively communicating vaccination information, implementing strategies to improve vaccination rates and developing community partnerships to reach target patient populations.  There are two HPV vaccines approved by the Food and Drug Administration (FDA) for the prevention of infection: Gardasil™ (Merck) and Cervarix™ (GlaxoSmithKline). Vaccine administration recommendations are available on the Centers for Disease Control and Prevention (CDC) website at http://www.cdc.gov/vaccines/.

The U.S. Preventive Services Task Force (http://www.ahrq.gov/clinic/uspstf/uspscerv.htm ) strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix.  Other organizations, such as American Cancer Society (ACS) and the American Academy of Family Physicians (AAFP), have similar recommendations. They may differ on when screening begins as well as the screening interval based on type of test used.  In general, cervical cancer screening is advised at least every three years, and there is evidence that low-risk older women can stop screening after age 65 if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer. Interestingly, Colorado Central Cancer Registry data show that age-specific cervical cancer rates do not begin to decline until after age 80.

Colorado Burden

Despite the fact that nearly all cervical cancer cases can be prevented, Colorado still averages about 160 new cervical cancer cases and about 40 cervical cancer deaths each year.  Incidence rates for invasive cervical cancer differ by race/ethnicity in Colorado women.  Although rates fluctuate from year to year, blacks and Hispanics in Colorado generally have higher rates compared to whites.  Compared to the United States., Colorado incidence rates are significantly lower in all race/ethnicity groups.

 

Mortality rates for cervical cancer in Colorado are significantly lower than U.S. rates for whites and blacks; rates for Hispanic women are similar.  In Colorado, death rates for Hispanic women are generally higher than those for whites.  Annual rates for blacks cannot be calculated due to small numbers (fewer than 3 deaths per year).

 

Source:  Health Statistics Section, Colorado Department of Public Health and Environment, 2010

While the cost for cervical screening is relatively inexpensive as compared to other cancer screening tests, women may not be taking full advantage of this screening due to barriers such as lack of insurance, obesity, disability and cultural issues. 

For women without insurance, there are public programs, such as the Women's Wellness Connection that will fully cover the cost of testing.  Women enrolled in this public health program may be eligible for treatment if a cervical cancer is diagnosed.  Low-cost or free screenings can also be obtained through Family Planning agencies and community health centers. 

Insurance coverage does not automatically translate to adequate screening rates.  As reported in the Colorado Health Plan & Hospital Quality Report Health Matters 2009, health plans have opportunities to increase rates of cervical screening among their insured population.  Of the seven health maintenance organizations reporting rates of cervical screening using the Health Plan Employer Data and Information Set (HEDIS), five were below standard; one was at standard; and one reported above the National Committee for Quality Assurance (NCQA) benchmark. (NCQA is a nationally recognized assessment of key measures of health care quality; http://www.ncqa.org/ ). 

Although Colorado has lower incidence and mortality rates than the United States, Colorado must still focus on eliminating this preventable cancer.  In accordance with Healthy People 2020 proposed goals, the overarching goals for Colorado are to decrease the incidence and mortality of cervical cancer in Colorado women by focusing on two major complementary and synergistic objectives:  1) Increase screening for cervical cancer with Pap smears; and 2) Increase the number of young women receiving more than one dose of HPV vaccine.