US women without health insurance are more likely to have late stage cervical cancer

BMJ 2012; 345 doi: (Published 23 July 2012) Cite this as: BMJ 2012;345:e5011
  1. Michael Day
  1. 1Milan

Lack of health insurance has been strongly linked to the risk of late stage cervical cancer among US women in a new study in the American Journal of Public Health.1 The researchers say that the heightened risk is almost certainly due to uninsured women not being screened for the disease, which is associated with low mortality if detected early.

Their sample of 70 000 women from the US national cancer database who were given a diagnosis of cervical cancer between 2000 and 2007 found that lack of insurance was second only to age as a risk factor for a late stage (stages III and IV) cancer at diagnosis.

The American Cancer Society team, led by the epidemiologist Stacey Fedewa, said that the results show the need for the United States to boost its provision of a clinically and financially effective health prevention measure.

The report noted that “advanced-stage disease leads not only to poorer quality of life and greater morbidity, but often to higher treatment costs as well.”

It concluded, “Screening should be made accessible and affordable for all women for whom it is recommended, especially for those at higher risk of advanced-stage disease, such as middle-aged women, Medicaid [the health insurance programme for people on low incomes] recipients, and uninsured women.”

Fedewa told the BMJ: “What we actually need is more locally available centres that provide very low cost services, so that poorer women can get to them easily and aren’t charged beyond their means.”

The results showed that the proportion of patients with stage I cancer at diagnosis was 55% among privately insured patients, 40% among Medicaid recipients, and 36% among uninsured patients.

Late stage cancer was diagnosed in 24% of women with private insurance, 34% of those with Medicaid (relative risk 1.37 (95% confidence interval 1.34 to 1.41), compared with women with private insurance), and 35% of those without insurance (relative risk 1.44 (1.4 to 1.49).

Black and Hispanic women were more likely to be uninsured or on Medicaid. The risk of advanced stage cancer at diagnosis also rose with age. Women over 34 years were between 1.25 and 2.5 times more at risk than women aged 21 to 34.

American Cancer Society figures indicate that the five year relative survival rate is 91% among patients with localised disease but only 58% among patients with regional disease and 17% among those with distant disease.

Socioeconomic status, race, marital status, and geographic location have all been previously identified as factors related to late stage at diagnosis among women with cervical cancer. But the effects of age and insurance status had not been compared in a major study.

Fedewa said that Barack Obama’s healthcare reforms, which were upheld by the Supreme Court last month,2 had the potential to boost screening rates by increasing the number of women with healthcare insurance.

John Curtin, director of gynaecological oncology at New York University School of Medicine, told the US press that it remained to be seen whether the healthcare reforms would increase screening rates among women on lower incomes. But he emphasised that cervical cancer could be virtually eliminated in the US if all eligible women were screened and given the follow-up care they needed.

“Many decades after its arrival, the Pap smear remains a great public health tool that saves lives,” he said.


Cite this as: BMJ 2012;345:e5011