Progress in Chronic Disease Prevention Screening for Cervical and Breast Cancer -- Southeastern Kentucky

Mortality rates for cervical cancer among white women in Kentucky are among the highest in the nation, and excess mortality is most pronounced in the 36-county area in the southeastern part of the state (1,2). As one component of a comprehensive program aimed at reducing mortality from cervical cancer, a population-based women's health survey was conducted in the 36-county area during the period May-July 1986. Interviews that included questions on the respondents' medical history, specific risk factors, and use of screening for cervical and breast cancer were conducted in person with 603 women aged 18 and older.

Respondents were selected using a four-stage random probability procedure that gave each household an approximately equal chance of being included (3). In households with more than one eligible respondent, a random procedure for selecting respondents was used. Interviews were completed in 85% of eligible households included in the sample. The study area is primarily rural and almost exclusively white. Fewer than 1% (three women) of those interviewed were black, and they have been excluded from this analysis.

Ninety-seven percent of respondents reported having heard of the Papanicolaou (Pap) test.* Older women were somewhat less likely to report such knowledge: 91% of women aged 65 and older compared with 99% of women aged 18-49. Ninety-one percent of women who had heard of the Pap test reported that they had had at least one test. However, the proportion that reported ever having had a Pap test declined with increasing age, from more than 96% of women under the age of 50 to 79% of women aged 65 and older (Table 1). The age-specific proportion of women in the survey who reported having had a Pap test since 1983 (within approximately 3.5 years) fell even more sharply, from 85% of women under age 50 to slightly more than one-half of women aged 50-64 and then to 39% of women aged 65 and older.

The higher proportion of women who have had a hysterectomy among the older age group does not explain the decreased usage of the Pap test. Thirty-four percent of women aged 50 and older reported having had a hysterectomy, while 14% of women under age 50 reported such histories. However, women who had had a hysterectomy were just as likely to report having had a recent Pap test. Similarly, the lower proportion of reported screening among the older women does not reflect adherence to the recommended discontinuation of regular periodic screening when women reach their sixties (4). The majority of the older women in the survey who did not report having had a recent Pap test also reported irregular screening during the earlier years of their life. Twenty percent of the 87 women aged 60 and older who did not report a Pap test within 3.5 years reported having had a Pap test at least every 3 years in any earlier decade.

Finally, the lower proportion of older women who reported recent screening was not a reflection of infrequent contact with the medical care system. Seventy-seven percent of the 118 women aged 50 and older who did not report a Pap test within 3.5 years did report having made at least one visit within the previous year to a medical facility other than an emergency room for reasons other than injuries.

As part of the survey, women were also questioned about screening for breast cancer, comprising breast self-examination, physical examination of the breasts by a health professional, and mammography.** Forty-eight percent (286) of the women in the study reported examining their breasts at least once a month, a proportion that was fairly consistent across age groups. However, the proportion of women reporting a recent breast examination declined with increasing age (Table 2). Eighty percent of women aged 18-40 and 60% of women over age 40 reported having had their breasts examined by a doctor or nurse within the past 3.5 years. Forty-two percent of women over age 40 reported having had their breasts examined within the past year. For all age groups, there was a strong association between having had a recent breast examination and having had a recent Pap test.

The majority of women who did not report having had a recent breast examination did report recent contact with the medical care system. Seventy-three percent of women over age 40 who did not report a breast examination within 12 months did report having made at least one visit within that period to a medical facility other than an emergency room for reasons other than injuries.

Sixty-eight percent of the women reported that they had heard of mammography. This proportion varied with age, with women aged 35-49 being the most likely to have heard of it (85%) and women aged 65 and older being the least likely (47%) (Table 3). Nineteen percent of the women who had heard of the mammogram reported having had the test. If women who have not heard of mammography are assumed never to have had it, 13% of all women surveyed and 16% of women aged 40 and older would have had a mammogram. Reported by: Kentucky Dept for Health Svcs; Univ of Kentucky Lucille Parker Markey Cancer Center; Univ of Kentucky Survey Research Center. Div of Chronic Disease Control, Center for Environmental Health and Injury Control, CDC.

Editorial Note

Editorial Note: In the United States and in many other countries around the world, the mortality rate from cervical cancer has declined markedly over the past several decades. Widespread screening with the Pap test is generally considered to have contributed to this decline (6). Yet cervical cancer remains a significant public health problem (7). Certain segments of the population, including black women, women with lower income and lower educational attainment, and women living in certain geographic areas (such as the women in this study) are at increased risk (8).

During the 1970s, Kentucky had the second highest average annual mortality rate for cervical cancer among white women. It was exceeded by neighboring West Virginia (1). While Kentucky's mortality rate has declined over the past 3 decades, evidence indicates that it has fallen more slowly than the national rates (2).

High mortality from cervical cancer can be the result of a high incidence of precursor lesions, detection of disease at later stages, inadequate follow-up and treatment, or a combination of these factors. The Kentucky Department for Health Services, in collaboration with the University of Kentucky Lucille Parker Markey Cancer Center, is currently examining the impact of these factors on the high mortality rate in southeastern Kentucky and will use this information to design and implement programs to reduce the problem. A population-based registry has been developed to identify all cases of cervical dysplasia and neoplasia occurring in the study area. This registry, which includes all newly diagnosed cases of cervical dysplasia, carcinoma in situ of the cervix, and invasive cancer of the cervix that have been histologically confirmed among women residing in the 36-county area, will allow calculation of incidence rates and will provide a basis for investigating risk factors.

The survey reported here indicates underusage of screening tests for cervical and breast cancer, except for Pap tests among younger women. This finding is consistent with data from national and other local surveys (9,10). In the 1973 National Center for Health Statistics' National Health Interview Survey (NHIS), 75% of women aged 17 and older reported having had at least one Pap test (11). Since then, the percentage of women who have reported being screened has increased, especially for black women. In the 1985 NHIS, 93% of women aged 18 and older reported having been screened, and 73% reported having been screened within less than 3 years. However, fewer older women reported being screened; 15% of women aged 65 and older reported never having had a Pap test, and an additional 35% of this group had not had one within less than 3 years (12).

While mortality from cervical cancer has declined, the age-adjusted mortality rate from breast cancer in the United States has not changed significantly in the past 10 years. Breast cancer was only recently surpassed by lung cancer as the leading cause of mortality due to cancer among females. Although mammography and physical examination by a health professional have been established as effective screening methods in reducing mortality due to breast cancer, their use has not yet become widespread (6).

Most surveys suggest that about 15% to 20% of women aged 50 and older have ever had a mammogram and that a much smaller proportion are being examined regularly. These estimates, as well as those from the Kentucky survey, undoubtedly include those mammograms that are obtained for diagnostic rather than screening purposes and, thus, overestimate screening activity (13). In the 1985 NHIS, 50% of women reported having had a breast examination by a health professional within less than 1 year, and the proportion reporting recent breast examinations decreased with increasing age. One in three women reported examining their breasts more than six times a year (12).

The low level of screening for both breast and cervical cancer among older women is of great concern because of their high risk for these diseases (14). Special efforts should be directed at these women to ensure their participation in screening. Both the Kentucky study and others indicate that many of the women who are not being screened are receiving medical care (10). Medical visits for nonacute conditions should be viewed as opportunities to inquire about screening histories and to encourage screening for breast and cervical cancer.

References

1. Riggan WB, Van Bruggen J, Acquavella JF, Beaubier J, Mason TJ. U.S. cancer mortality rates and trends, 1950-1979. Washington, DC: National Cancer Institute, US Environmental Protection Agency, 1983.

2. Hinds MW, Skaggs JW, Hernandez C. Cervical cancer mortality trends in Kentucky, 1971-83. J Ky Med Assoc 1985;83:186-92.

3. Sudman S. Applied sampling. New York: Academic Press, 1976.

4. American Cancer Society. Guidelines for the cancer-related checkup: recommendations and rationale. CA 1980;30:194-240.

5. American Cancer Society. Mammography guidelines 1983: background statement and update of cancer-related checkup guidelines for breast cancer detection in asymptomatic women age 40 to 49. CA 1983;33:255.

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

7. Silverberg E, Lubera J. Cancer statistics, 1987. CA 1987;37:2-19.

8. Devesa SS. Descriptive epidemiology of cancer of the uterine cervix. Obstet Gynecol 1984;63:605-12.

9. Celentano DD, Shapiro S, Weisman CS. Cancer preventive screening behavior among elderly women. Prev Med 1982;11:454-63.

10. Howe HL, Bzduch H. A survey of Pap smear screening in upstate New York. NY State J Med 1986;86:291-6.

11. National Center for Health Statistics. Use of selected medical procedures associated with preventive care: United States--1973. Washington, DC: US Department of Health, Education and Welfare, Public Health Service, 1977. DHEW publication no. (HRA)77-1538. (Vital and health statistics; series 10; no. 110).

12. National Center for Health Statistics. Health promotion data for the 1990 objectives: estimates from the National Health Interview Survey of Health Promotion and Disease Prevention: United States, 1985. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1986; DHHS publication no. (PHS)86-1250. (Advance data from vital and health statistics; no. 126).

13. Howard J. Using mammography for cancer control: an unrealized potential. CA 1987;37:33-48.

14. National Cancer Institute. SEER program: cancer incidence and mortality in the United States 1973-81. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1984; NIH publication no. 85-1937. *From 1980 until 1987, the American Cancer Society (ACS) recommended that all asymptomatic women aged 20 and older and those under 20 who are sexually active have a Pap test annually for two negative examinations and then at least every 3 years until the age of 65 (4). **Since 1980, the ACS has recommended monthly breast self-examination for all adult women, breast examination by a physician every 3 years for women aged 20-40 and annually for women over age 40, a baseline mammogram for women between the ages of 35 and 40, and annual mammography for women aged 50 and older (4). In 1983, the recommendations were modified to include mammography every 1 to 2 years for women aged 40-49 (5).

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