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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
Rhode Island Department of Health. Cancer: Rhode Island, 1987.
Providence: Rhode Island Department of Health, 1989.
Guzick DS. Efficacy of screening for cervical cancer: a review.
Am J
Public Health 1978;68: 125-34.
Janerich DT, Hadjimichael O, Flannery J. Strategy for
elimination of
invasive cervical cancer in Connecticut. Conn Med 1985;49:746-53.
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).
Saunders LD. Differences in the timeliness of diagnosis, breast
and
cervical cancer, San Francisco 1974-85. Am J Public Health
1989;79:69-70.
CDC. Use of mammography for breast cancer screening--Rhode
Island,
1987. MMWR 1988; 37:357-60.
National Cancer Institute Workshop. The 1988 Bethesda system for
reporting cervical/vaginal cytological diagnoses. JAMA
1989;262:931-4.
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).
Disclaimer
All MMWR HTML documents published before January 1993 are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices. **Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov. Page converted: 08/05/98
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