Cancer Screening and Treatment in Women

Cervical Cancer

Despite new guidelines, most ob-gyns continue to overscreen low-risk women for cervical cancer.
Description: The American Cancer Society suggests that cervical cancer screening with Pap tests begin within 3 years after a woman becomes sexually active, or by age 21, whichever comes first. The ACS no longer recommends annual screening in women over 30 who have had three or more previous normal Pap tests. The American College of Obstetricians and Gynecologists has made similar recommendations. Yet 185 randomly selected ob-gyns said that they would begin screening girls who were not yet sexually active at age 18. Also, 60 percent of respondents said that they would continue annual screening in a 35-year-old woman with three or more normal tests.
Source: Saint, Gildengorin, Sawaya. Am J Obstet Gynecol 2005;192:414-21; see also Sawaya, McConnell, Kulasingam, et al. New Engl J Med 2003;349(16):1501-9 (AHRQ grant HS07373).

Rural women report satisfaction with telecolposcopy.
Description: Women living in rural Georgia felt that telecolposcopy saved them time and money and said they would recommend the procedure to a friend. The women believed that telecolposcopy improved the quality of their care, and they felt better about their health after the exam.
Source: Ferris, Litaker, Lopez. J Am Board Fam Pract 2003;16:405-11; see also Bishai, Ferris, Litaker. Med Decision Making 2003;23:463-70 (AHRQ grant HS08814).

Cervical cancer rates among younger women have decreased.
Description: According to this study, the rate of cervical cancer detected among women younger than 30 and the incidence rates of cervical cancer overall (and squamous cell cancer specifically) declined by nearly 1 percent per year from 1973 to 1999.
Source: Chan, Sung, Sawaya. Obstet Gynecol 2003;102(4):765-73 (AHRQ grant HS07373).

Task Force issues recommendation on cervical cancer screening.
Description: The U.S. Preventive Services Task Force issued a strong recommendation that women should be screened for cervical cancer 3 years after they begin sexual activity, or at the age of 21, whichever comes first. The Task Force concluded that screening should be performed at least every 3 years, but noted that annual screening is appropriate until a woman has had at least two to three consecutive normal Pap test results. The Task Force also recommends against screening women 65 and older who have had adequate recent screenings with normal results and are not otherwise at increased risk for cervical cancer.
Source: More information is available on the AHRQ Web site at http://www.ahrq.gov/clinic/prevenix.htm and from the National Guideline Clearinghouse™ at http://www.guideline.gov.

Conferees explore cost-effectiveness lessons of Pap smears.
Description: Conference participants explored public policy implications of cost-effectiveness analyses of cervical cancer screening and the challenges encountered when moving research results into the policy arena. Presentations focused on cost-effectiveness analysis and practice, the role of evidence in cost-effectiveness analysis, and the role of cost-effectiveness in a managed care organization.
Source: Does Cost-Effectiveness Make a Difference? Lessons from Pap Smears (NTIS Accession No. PB2002-108739), Michael Hagen, M.D., University of Kentucky (AHRQ grant HS10931).**

Telecolposcopy can maintain diagnostic accuracy.
Description: Reviewers examined the efficacy of telecolposcopy for women with abnormal Pap smears or other indications for colposcopy who were examined by local colposcopists at rural clinics. Images of colposcopic examinations were transmitted to a tertiary care center for interpretation by an expert colposcopist, and another colposcopist (site expert) examined the same patients, but did not share findings with the other colposcopists. Agreement ranged from 60, 56, and 53 percent for the local colposcopists, distant experts, and site experts, respectively.
Source: Ferris, Macfee, Miller, et al. Obstet Gynecol 2002;99(2):248-54 (AHRQ grant HS08814).

Cervical smears of previously screened postmenopausal women are poor predictors of cervical cancer.
Description: Researchers collected cervical smears during the Heart and Estrogen/Progestin Replacement Study of postmenopausal women who still had a uterus and were suffering from coronary artery disease. The researchers identified 2,561 women who had normal cervical smears at study entry and an abnormal smear at the first or second annual visit. Within 2 years of a normal smear, 110 women in the trial had a cytologic abnormality. Of these, all but one yielded false-positive results.
Source: Sawaya, Grady, Kerlikowski, et al. Ann Intern Med 2000;133(12):942-50 (AHRQ grant HS07373).

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Cancer Screening

Noninvasive tests may miss breast cancer.
Description: Four common noninvasive tests for breast cancer are not accurate enough to replace biopsies for women who receive abnormal findings from mammography or a clinical breast exam, according to a new report from AHRQ. The four tests are: magnetic resonance imaging (MRI); ultrasonography, or ultrasound; positron emission tomography scanning (PET scan); and scintimammography (nuclear medicine scan). The report is from AHRQ's new Effective Health Care Program, which compares the effectiveness of different treatments for health conditions. Researchers found that each of the four tests would miss a significant number of cases of cancer, compared with immediate biopsy for women at high enough risk to warrant evaluation for breast cancer.
Source: Bruening,Launders, Pinkney, et al. Online at http://www.effectivehealthcare.ahrq.gov/reports/final.cfm. Copies of an executive summary are also available (AHRQ Publication No. 06-EHC005-1).**

Task Force recommends against routine testing for genetic risk of breast or ovarian cancer.
Description: According to the U.S. Preventive Services Task Force, primary care physicians should only refer certain women for genetic counseling and DNA testing to detect the presence of specific BRCA1 and BRCA2 gene mutations that may be associated with breast and ovarian cancer. Physicians should suggest counseling and DNA testing only for women who have specific family history patterns which put them at risk for these gene mutations.
Source: Nelson, Huffman, Fu, et al. Ann Intern Med 2005;132(5):362-79; also see pages 355-61 in the same journal (AHRQ contract 290-97-0011).

Women may not agree with clinicians about genetic testing for breast cancer risk.
Description: In this study, five focus groups that included both black and white women ages 30 to 79 discussed their opinions and knowledge about genetic testing for breast cancer risk. The women's understanding of risk, genetics, and genetic testing were affected by personal experience and beliefs and differed considerably from clinical definitions and interpretations. The women gave more emphasis to the emotional and social consequences of positive test results than to physical outcomes.
Source: Vuckovic, Harris, Valanis, et al. Am J Obstet Gynecol 2003;189:S48-53 (AHRQ grant T32 HS00069).

Researchers evaluate the costs and benefits of breast cancer screening of older women.
Description: The optimal age to stop breast cancer screening has not been determined. This study found that lifetime screening is not cost effective at $151,434 per life year saved if women receive idealized treatment (treatment and survival that are comparable to clinical trials). The researchers used a model to simulate the life history of women to evaluate the incremental societal costs and benefits of biennial screening from age 50 to age 70, to age 79, and for lifetime. The researchers concluded that if all women received idealized treatment, the benefits of mammography beyond age 79 would be too low relative to cost to justify continued screening.
Source: Mandelblatt, Schechter, Yabroff, et al. J Gen Intern Med 2005;20:487-96 (AHRQ Publication No. 05-R072) (Intramural).*

Study reveals shortage of radiologists at community mammography facilities.
Description: In a 2000-2001 survey of mammography facilities in three States, nearly half of the 45 facilities reported radiologist staffing shortages. Almost two-thirds (60 percent) of not-for-profit facilities reported shortages, compared with less than one-third (28 percent) of for-profit facilities. Waiting times for diagnostic mammography ranged from less than 1 week to 4 weeks. Forty-seven percent of facilities had a waiting time of 2 or more weeks for screening mammography, and some had waiting times of 1 to 2 months.
Source: Orsi, Tu, Nakano, et al. Radiology 2005;235:391-5 (AHRQ grant HS10591).

Accuracy in reading mammograms is not associated with volume or years of experience.
Description: For this study, researchers linked nearly 500,000 screening mammograms interpreted by 124 radiologists with breast cancer outcomes data. Within 1 year of mammography, 2,402 breast cancers were identified, a rate of 5.12 per 1,000 screening mammograms. There was no significant association between accuracy and radiologists' years of interpreting mammograms or volume of reading mammograms. The researchers suggest that training prior to practice may be the most important determinant of accuracy in mammogram interpretation.
Source: Barlow, Chi, Carney, et al. J Natl Cancer Inst 2004;96(24):1840-50 (AHRQ grant HS10591).

Radiologists' access to previous mammograms improves the accuracy of mammography readings.
Description: When radiologists have access to women's previous mammograms, the incidence of false-positive mammogram readings is reduced by at least half. The researchers examined 1999 medical data on screening and diagnostic mammograms for 5,000 patients at a single Southern hospital.
Source: Kleit, Ruiz. Health Serv Res 2003;38(4):1207-28 (AHRQ grant HS10068).

Researchers find international variations in mammography accuracy.
Description: Compared with community-based mammography screening programs around the world, North American screening programs appear to interpret a higher percentage of mammograms as abnormal. However, they do not appear to detect more cancers per 1,000 screens. The variations found in this study are likely due to many factors, including characteristics of the women screened, features of the mammography exam, characteristics of physicians interpreting the mammograms, and features of each country's health care system.
Source: Elmore, Nakano, Koepsell, et al. J Natl Cancer Inst 2003;95(18):1384-93 (AHRQ grant HS10591).

Obesity affects breast cancer screening rates.
Description: Obesity is associated with a higher risk of cancer death, yet according to this study, white women who are obese are less likely than non-obese white women to obtain a mammogram, a relationship not seen in black women. Among the 5,277 eligible women aged 50 to 75, 72 percent reported mammography use. White women who were obese were more likely than those who were not to report feelings of worthlessness in the preceding 30 days. Black women did not report these feelings.
Source: Wee, McCarthy, Davis, et al. J Gen Intern Med 2004;19:324-31 (AHRQ grant HS11683).

Screening mammography is less accurate in overweight and obese women.
Description: In this study, overweight women had a 14 percent increased risk and obese women had more than 20 percent increased risk of having a false-positive mammogram, compared with underweight and normal-weight women. A false-positive rate increase of 2 percent would lead to about 200,000 additional women with false-positive mammography results entailing an additional $20 million to evaluate the results, or about $600 per false-positive result. These costs are over and above the anxiety involved for the women.
Source: Elmore, Carney, Abraham, et al. Arch Intern Med 2004;164:1140-7 (AHRQ grant HS10591).

Screening relatively healthy elderly women for breast cancer every 2 years is cost effective.
Description: This review conducted for the U.S. Preventive Services Task Force shows that for women aged 65 and older who do not have significant health problems, breast cancer screening every 2 years reduces mortality at reasonable costs.
Source: Mandelblatt, Saha, Teutsch, et al. Ann Intern Med 2003;139(10):835-42 (AHRQ contract 290-97-0011).

Physician specialty influences use of screening mammography and Pap smears in gatekeeper plans.
Description: The impact of gatekeeper plans—which require that patients have a referral before seeing a specialist—on cancer screening varies by the specialty of a woman's primary care physician, according to this study. For example, the use of mammography to screen for breast cancer and Pap smears to screen for cervical cancer among patients of internal medicine physicians were unaffected by enrollment in a gatekeeper plan. On the other hand, screening rates were increased if family practice physicians were in gatekeeper plans. The researchers note that different cultures of practice may explain the study findings.
Source: Haggstrom, Phillips, Liang, et al. Cancer Causes Control 2004;15:883-92 (AHRQ grants HS10771 and HS10856).

Breast and cervical cancer screening rates are higher in areas with greater HMO market share.
Description: After taking into account individual and area factors, women in high HMO market share areas were nearly twice as likely as women in other areas to have recently had a mammogram or Pap smear, according to this study. Also, these women were 58 percent more likely to have had a recent clinical breast exam. The study revealed a spillover effect to nearby women not enrolled in managed care. The researchers linked data on cancer screening from the 1996 Medical Expenditure Panel Survey with data on HMO market share and HMO competition in metropolitan statistical areas.
Source: Baker, Phillips, Haas, et al. Health Serv Res 2004;39(6, part I):1751-72 (AHRQ grants HS10771, HS10856, and HS10925).

Personalized form letters may improve breast and cervical cancer screening among some women.
Description: According to this study of more than 1,500 urban low-income and minority women, sending them a personalized form letter with general cancer information increases the likelihood that they will be screened for cervical and breast cancer.
Source: Jibaja-Weiss, Volk, Kingery, et al. Patient Educ Couns 2003;50:123-32 (AHRQ grant HS08581).

White women who are obese may avoid having Pap tests.
Description: This study found that white women who are obese are more likely than normal-weight white women to delay Pap testing and to find Pap tests to be painful, uncomfortable, and/or embarrassing. The researchers examined Pap testing in the preceding 3 years for 6,419 white women, 1,715 black women, and 1,859 Hispanic women aged 18 to 75 years. Overall, 86 percent of white, 88 percent of black, and 78 percent of Hispanic women reported Pap testing in the previous 3 years. After accounting for other factors, white women who were extremely obese (BMI greater than 40) were 9 percent less likely to have a Pap test compared with white women who were normal weight. BMI was not associated with screening in black or Hispanic women.
Source: Wee, Phillips, McCarthy. Obes Res 2005;13(7):1275-80 (AHRQ grant HS11683).

South Asian women should be targeted to receive cervical cancer screening.
Description: Despite the high socioeconomic status of Indian and other South Asian women living in the United States, this study found that one-fourth of them had not had a Pap smear in more than 3 years. Regions with large South Asian populations should be targeted with messages promoting cervical cancer screening. The messages should be aimed particularly at unmarried South Asian women of low socioeconomic status who have been in America for only a short time.
Source: Chaudhry, Fink, Gelberg, et al. J Gen Intern Med 2003;18:377-84 (AHRQ grant HS10597).

Screening sigmoidoscopy may be less effective for detecting colorectal cancer in women and older people.
Description: This study found that screening for colorectal cancer with a 60-cm flexible sigmoidoscope resulted in inadequate exams for 18 percent of patients of all ages. The percentage of inadequate exams increased progressively with age, from 10 percent for ages 50 to 59 to 22 percent for ages 80 and older. Inadequate exams were more common in women of all ages, ranging from 19 percent (ages 50-59) to 32 percent (ages 80 and older). Women are more likely than men to experience pain during the exam, and they have longer colons in a smaller abdominal cavity.
Source: Walter, deGarmo, Covinsky. Am J Med 2004;116:174-8 (AHRQ grant K02 HS00006).

Up to 12 percent of tissues examined by pathologists for cancer result in diagnostic errors.
Description: Researchers examined pathology errors over a 1-year period in patients at four hospitals who underwent laboratory tests to determine the presence or absence of cancer or precancerous lesions. Cancer diagnosis errors were dependent on the hospital and ranged from approximately 2 to 20 percent of gynecologic cases and from approximately 5 to 12 percent of nongynecologic cases. Errors due to pathologic misinterpretation ranged from 5 to 51 percent. The remaining errors were due to clinical sampling problems. Overall, 45 percent of gynecologic pathology errors and 39 percent of nongynecologic errors were associated with harm. The researchers estimate that nearly 128,000 patients per year in the United States will suffer harm as a result of cancer diagnosis errors.
Source: Raab, Grzybicki, Janosky, et al. Cancer 2005;104(10):2205-13 (AHRQ grant HS13321).

Disabled women who have trouble walking are less likely than other women to receive Pap tests and mammograms.
Description: Women who have difficulty walking are significantly less likely than other women to receive Pap tests, mammograms, and clinician inquiries about smoking habits. Inaccessible examination tables and physician concerns about positioning the women on exam tables may account for some of the disparity, but inadequate knowledge, biased attitudes of clinicians, and time pressures in busy practices also may be involved.
Source: Iezzoni, McCarthy, Davis, et al. Am J Med Qual 2001;16(4):135-44 (AHRQ grant HS10223).

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More Information

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* Items in this program brief marked with an asterisk (*) are available free from AHRQ's Publications Clearinghouse; to order, call 800-358-9295, or write to the AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.

** Items in this program brief marked with two asterisks (**) are available from the National Technical Information Service. Please call NTIS at (703) 605-6000 or visit its Web site at http://www.ntis.gov for more information.

AHRQ Publication No. 06-P015
Replaces Publication No. P03-P021
Current as of June 2006

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Internet Citation:

Cancer Screening and Treatment in Women. Program Brief. Agency for Healthcare Research and Quality, Rockville, MD. AHRQ Publication No. 06-P015, June 2006. http://www.ahrq.gov/research/cancerwom.htm

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