Cervical Cancer Screening Among Young Adult Women in the United States

1Division of Cancer Prevention and Control, Centers for Disease Control and Prevention.
Cancer Epidemiology Biomarkers & Prevention (Impact Factor: 4.13). 01/2013; 22(4). DOI: 10.1158/1055-9965.EPI-12-1266
Source: PubMed
ABSTRACT
BACKGROUND: Cervical cancer screening guidelines have evolved significantly in the last decade for young adult women, with current recommendations promoting later initiation and longer intervals. METHODS: Using self-reported cross-sectional National Health Interview Survey (NHIS) 2000-2010 data, trends in Papanicolaou (Pap) testing among women aged 18-29 years were examined. NHIS 2010 data were used to investigate age at first Pap test (N=2,198), time since most recent Pap test (n=1,622), and predictors of Pap testing within the last 12 months (n=1,622). RESULTS: The percentage of 18-year-olds who reported ever having a Pap test significantly decreased from 49.9% in 2000 to 37.9% in 2010. Mean age at first Pap test in 2010 was significantly younger for non-Hispanic black women (16.9 years), women <high school education (16.9 years), women who received the HPV vaccine (17.1 years), and women who have ever given birth (17.3 years). The majority reported their last Pap test within the previous 12 months (73.1%). Usual source of healthcare (OR 2.31) and current birth control use (OR 1.64) significantly increased chances of having a Pap test within the previous 12 months. CONCLUSIONS: From 2000 to 2010 there was a gradual decline in Pap test initiation among 18-year-olds, however, in 2010 many women reported ≤12 months since last screening. Evidence-based guidelines should be promoted, as screening young adult women for cervical cancer more frequently than recommended can cause considerable harms. Impact: A baseline of cervical cancer screening among young adult women in the United States to assess adherence to evidence-based screening guidelines.

Full-text

Available from: Katherine B Roland, Aug 25, 2014
Research Article
Cervical Cancer Screening Among Young Adult Women in the
United States
Katherine B. Roland
1
, Vicki B. Benard
1
, Ashwini Soman
2
, Nancy Breen
3
, Deanna Kepka
4
, and Mona Saraiya
1
Abstract
Background: Cervical cancer screening guidelines have evolved significantly in the last decade for young
adult women, with current recommendations promoting later initiation and longer intervals.
Methods: Using self-reported cross-sectional National Health Interview Survey (NHIS) 2000–2010 data,
trends in Papanicolaou (Pap) testing among women ages 18–29 years were examined. NHIS 2010 data were
used to investigate age at first Pap test (N ¼ 2,198), time since most recent Pap test (n ¼ 1,622), and predictors of
Pap testing within the last 12 months (n ¼ 1,622).
Results: The percentage of 18-year-olds who reported ever having a Pap test significantly decreased from
49.9% in 2000 to 37.9% in 2010. Mean age at first Pap test in 2010 was significantly younger for non-Hispanic
black women (16.9 years), women < high school education (16.9 years), women who received the HPV vaccine
(17.1 years), and women who have ever given birth (17.3 years). The majority reported their last Pap test within
the previous 12 months (73.1%). Usual source of healthcare (OR, 2.31) and current birth control use (OR, 1.64)
significantly increased chances of having a Pap test within the previous 12 months.
Conclusions: From 2000 to 2010, there was a gradual decline in Pap test initiation among 18-year-olds;
however, in 2010, many women reported 12 months since last screening. Evidence-based guidelines should
be promoted, as screening young adult women for cervical cancer more frequently than recommended can
cause considerable harms.
Impact: A baseline of cervical cancer screening among young adult women in the United States to assess
adherence to evidence-based screening guidelin es. Cancer Epidemiol Biomarkers Prev; 22(4); 580–8. 2013 AACR.
Introduction
During the last 6 decades, reductions in cervical cancer
incidence and mortality have been achieved, due to inte-
gration of cytology into women’s preventive healthcare (1,
2), and increased understanding that cervical cancer is
caused by persistent infection with human papillomavi-
rus (HPV; refs. 3–6). HPV is the most common sexually
transmitted infection, with peak prevalence among
females ages 14–24 years (7). Persistent HPV infections
occur within a few years of first sexual intercourse (8) but
can take years to develop into invasive cervical cancer (9–
11). Although the prevalence of HPV is greater among
younger women than among women of older ages (7),
cervical cancer incidence is very rare in women younger
than 29 years of age (4, 12) because the majority of HPV
infections are transitory and usually regress spontaneous-
ly within 2 years (9).
Cervical cancer screening guidelines for average-risk
women have evolved significantly over the last decade
promoting later initiation and longer intervals. In 2000,
guidelines recommended to begin screening at 18 years
of age or at initiation of sexual activity (13–15), with
annual (14, 15) to triennial (13) intervals. By 2003, the
U.S. Preventive Services Task Force issued recommenda-
tions and rationale for later starting age and triennial
screening intervals (16). In November 2012, concurrence
across organizations was achieved; average-risk women
should avoid screening before 21 years of age, with tri-
ennial screening intervals until 65 years of age (17–19).
Guidelines that promote recommendations for less
intervention can be difficult for physicians and the public
to understand and support (20). However, as screening
increases, so do false-positive test results and colposco-
pies, with more false-positive test results occurring in
women aged younger than 21 years (21). Consequent
unnecessary procedures conducted for treatment of pre-
invasive lesions that would regress or were falsely
Authors' Afliations:
1
Centers for Disease Control and Prevention;
National Center for Chronic Disease Prevention and Health Promotion;
Division of Cancer Prevention and Control; Epidemiology and Applied
Research Branch, Atlanta, Georgia;
2
Northrop Grumman, Atlanta, Georgia;
3
National Cancer Institute; Division of Cancer Control and Population
Sciences; Applied Research Program; Health Services and Economics
Branch, Rockville, Maryland; and
4
University of Utah; Huntsman Cancer
Institute, College of Nursing, Salt Lake City, Utah
Note: The ndings and conclusions in this report are those of the authors
and do not necessarily represent the ofcial position of the Centers for
Disease Control and Prevention.
Corresponding Author: Katherine B. Roland MPH, Centers for Disease
Control and Prevention, 4770 Buford Hwy, NE, MS K-55, Atlanta, GA
30341. Phone: 770-488-1089; Fax: 770-488-4639; E-mail:
kroland@cdc.gov
doi: 10.1158/1055-9965.EPI-12-1266
2013 American Association for Cancer Research.
Cancer
Epidemiology,
Biomarkers
& Prevention
Cancer Epidemiol Biomarkers Prev; 22(4) April 2013
580
Page 1
identified may have adverse reproductive and pregnancy
outcomes (22) are especially salient for younger adult
women who anticipate future pregnancy. In addition,
screening women aged younger than 21 years, and all
women annually can cause undue patient anxiety (23, 24)
and costs to both patients and the healthcare infrastruc-
ture (25–27).
By adhering to evidence-based guidelines, clinicians
can minimize t he physical, emotional, and financial
costs of overscreening and overtreatment (20, 22, 28–
30). A national baseline of cervical cancer screening
among you ng adult women before the 2012 screening
guidelines update is necessary to measure implemen-
tation of current evidence-based guidelines for screen-
ing onset and frequency. To meet this need, national
survey data from 2000–2010 were analyzed to estimate
the prevalence of cervical cancer screening among
women ages 18–29 years in the United States, focusing
on these ages because of the distinction made in screen-
ing initiatio n a nd test recommendations on the basis of
patient age.
Materials and Methods
Study population
The National Health Interview Survey (NHIS) is an
annual survey of the civilian, noninstitutionalized U.S.
population, conducted by the Centers for Disease Control
and Prevention (CDC), National Center for Health Statis-
tics (NCHS). Using multistage cluster sample design, a
representative sample of households is selected for par-
ticipation, and a personal household interview is con-
ducted by U.S. Census Bureau interviewers according to
procedures specified by NCHS. CDC’s Division of Cancer
Prevention and Control and National Cancer Institute’s
Division of Cancer Control and Population Sciences spon-
sor the Cancer Control Supplement of NHIS. Analyses
that use public-use data do not require CDC Institutional
Review Board approval.
NHIS collects self-reported information about Papani-
colaou (Pap) test use from a randomly selected adult
participant through the adult core and supplemental
cancer control modules. Two distinct study samples based
on survey data years were used for analysis. For the trend
analysis (years 2000, 2005, 2008, and 2010), the study
sample was restricted to women ages 18–29 years who
reported never having a hysterectomy and ever having a
Pap test (n ¼ 11,248). This analysis was to estimate Pap test
use over time. The second analysis focused only on 2010
data and was restricted to women ages 18–29 years who
reported never having a hysterectomy and ever having a
Pap test (n ¼ 2,198). This analysis was to estimate age of
first Pap test, time since most recent Pap test, and pre-
dictors of having a Pap test in the previous 12 months. To
examine time since most recent Pap test and predictors of
having a Pap test in the previous 12 months, the study
sample was further restricted to women who both
reported their most recent Pap test was a part of a regular
screening exam, and no abnormal Pap test in previous 3
years (n ¼ 1,622).
Data measures
Two distinct outcome measures were created for the
analysis of cervical cancer screening practices of women
ages 18–29 years. First, to provide an historical assessment
of Pap test participation, responses to the question, "Have
you ever had a Pap test?" were analyzed. Respondents
were read a definition of the Pap test before responding:
"A Pap smear or Pap test is a routine test for women in
which the doctor examines the cervix, takes a cell sample
from the cervix with a small stick or brush, and sends it to
the lab." Rates of women who reported they ever received
a Pap test in 2000, 2005, 2008, and 2010 are presented, the
years that NHIS included this question in the supplemen-
tal cancer control module.
Second, to provide a baseline for measuring future
changes in screening initiation and frequency among
women ages 18–29 years, 2010 data concerning reported
age at first Pap test, time since most recent Pap test, and
predictors of having a Pap test within the previous 12
months were examined. Respondents who reported ever
having a Pap test were asked "At what age did you have
your first Pap test?" and "When did you have your most
recent Pap test?" Age of first Pap test was a new question
on the 2010 NHIS, providing novel data findings and an
opportunity for comparison with future screening initia-
tion data.
Correlates
Self-reported sociodemographic variables, namely
age, race/ethnicity, educational attainment, poverty
level (imputed income data), marital status, healthcare
coverage (public, private, or none), and access to usual
source of h eal thcare (a place other than emergency
room where routine care is sought), were analyzed in
relation to cervical cancer screening outcome measures.
To adjust for their potential impact on age of initiation
and frequency of Pap testing, awareness of HPV, HPV
vaccine status, having ever given birth to a live born
infant (increased visits with a provider, and Pap testing
may occur during antepartum care), current birth con-
trol use (pills, implants, shots), and whether a physician
recommended the most r ecent Pap test were included in
the model.
Statistical analysis
NHIS has a complex survey design involving stratifi-
cation, clustering, and disproportionate sampling. To
provide national estimates of cervical cancer screening
outcome measures, SAS version 9.2 and SUDAAN release
10.0.1 (Research Triangle Institute, Research Triangle
Park, NC) were used to apply sampling weights and
account for stratified survey design.
Linear trends for years 2000–2010 for all women ages
18–29 years were tested using unadjusted logistic regres-
sion models. Differences between years 2000 and 2005,
Cervical Cancer Screening among Women Ages 1829 in the United States
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Page 2
2000 and 2008, and 2000 and 2010 were tested separately
for each age group (18, 19, 20, 21, 22–29 years) using linear
test for contrast.
For the 2010 anal ysis of women who have ever had a
Pap test, examining age at first Pap test by sociodemo-
graphic varia bles, the mean, median, and range, and
95% confidence intervals (CI) were reported. The differ-
ence between mean age for all covariate s was tested
using the t test for mean and corresponding P values
were noted. Fo r the univariable analysis of time since
most recent Pap test, weighted proportio ns with 95%
CIs were reported. Assoc iation between last reported
scre ening and sociodemographic variabl es was assessed
using c
2
statistics.
To better understand the determinants of a more fre-
quent interval for average-risk women ages 18–29 years,
potential predictors of having a Pap test in the previous 12
months using multivariable logistic regression model
were examined. To construct the multivariable model, a
univariable analysis comparing last Pap test reported
within 12 versus 13–36 months (data not shown) was
conducted. Only statistically significant variables with
P < 0.05 were included in the multivariable models.
Associations were assessed with Wald-F statistics and
differences among the age groups were tested using linear
contrast and footnoted as significant. In addition, esti-
mates based on 30 or fewer sample cases are considered to
be unreliable and were suppressed and footnoted in the
tables when necessary.
Results
Pap test trends among women ages 18–29 years,
2000–2010
Pap test trends for all ages combined reporting ever
having a Pap test from 2000–2010 were not significant (P ¼
0.243). However, the percentage of 18-year-old women
who ever had a Pap test significantly decreased from
49.9% in 2000 to 37.9% in 2010 (P ¼ 0.045), and among
22–29-year-old women, the percentage significantly
decreased from 91.3% in 2000 to 89.3% in 2008 (P ¼
0.034; Fig. 1).
Participant demographics, 2010
The 2010 study sample comprised mostly of non-His-
panic white (63.4%) women between the ages of 22–29
years (76.6%), who reported completing at least some
college (39.7%), were living <200% above the federal
poverty level (55.2%), never been married (48.2%), or were
married/living with a partner (48.0%). Many were
enrolled in a private health insurance plan (32.0%),
reported a usual source of healthcare (79.0%), reported
awareness of HPV (82.6%), or reported never receiving the
HPV vaccine (81.4%). Most had never given birth to a live
born infant (55.7%), and less than half were currently
using non-barrier birth control (41.3%). Most reported
having received a physician recommendation for their
most recent Pap test (54.0%; Table 1).
Age at first Pap test, 2010
Reported mean age at first Pap test was significantly
younger for 18-year-olds (15.9 years; P < 0.001) compared
with women ages 19–29 years. Mean age at first Pap test
was significantly younger for non-Hispanic blacks (16.9
years; P < 0.001), and older for Hispanics (18.1 years; P <
0.001) and Asians (19.8 years; P < 0.001) compared with
non-Hispanic whites (17.4 years). Mean age at first Pap
test was significantly younger for those with <high school
education (16.9 years) compared with those with a college
degree or greater (18.5 years; P < 0.001), for those reporting
HPV vaccination (17.1 years; P 0.002), and having ever
given birth (17.3 years; P < 0.001; Table 2). Among women
ages 18–29 years who reported receiving the HPV vaccine,
20.6% (n ¼ 80) also reported a history of an abnormal Pap
test in the previous 3 years (data not shown).
30
40
50
60
70
80
90
100
2000 2005 2008 2010
Percentage
National Health Interview Survey year
18
19
20
21
22–29
37.9
91.3
89.3
49.9
Age of participant
Figure 1. Trends in the percentage
of women ages 1829 years who
report ever having a Pap test,
NHIS, 20002010. NOTE:
Excludes women reporting
hysterectomy. Hysterectomy
status of respondents was not
asked in NHIS 2003 so data from
the 2003 survey were not included
in the trend analysis of Pap test
receipt for years 20002010.
Signicant linear trends include
percentages to measure change.
Roland et al.
Cancer Epidemiol Biomarkers Prev; 22(4) April 2013 Cancer Epidemiology, Biomarkers & Prevention
582
Page 3
Time since most recent Pap test and predictors of
last Pap test within 12 months, 2010
Most women ages 18–29 years reported their last Pap
test was within the previous 12 months (73.1%; 95% CI,
70.4%–75.6%); few reported last Pap test within the pre-
vious 2 to 3 years (7.6%; 95% CI, 6.3%–9.2%). Usual source
of healthcare (P < 0.001) and current birth control use (P <
0.001) were significantly associated with screening fre-
quency (Table 3). Multivariable regression modeling to
examine the odds of reporting a Pap test during the
previous 12 months, compared with greater than 12
months found that current use of birth control (P <
0.001; OR, 2.31; 95% CI, 1.74%–3.06%) and usual source
of healthcare (P ¼ 0.002; OR, 1.64; 95% CI, 1.20%–2.25%)
were significant (Table 4).
Discussion
Because of how rare cervical cancer is among young
women, and the harms associated with overscreening and
treatment, national organizations are consistently recom-
mending initiating cervical cancer screening at age 21
years, with longer intervals between screenings (17–19).
These data showed a significant continuing decline in Pap
testing among 18-year-old women during 2000–2010. This
may reflect early adoption of later screening initiation
recommendations among women younger than 21 years
of age (31), possibly due to provider acceptance of, or
the growing awareness among the public of the harms
associated with premature screening and intervention.
However, most young adult women reported screening
within the previous 12 months, signaling the possibility of
too-frequent Pap testing. Having a usual source of
Table 1. Demographic characteristics among
women ages 1829 years who have ever had a
Pap test, NHIS, 2010 (N ¼ 2,198)
Participant
demographics
n % (95% CI)
Age of respondent, y
18 64 3.8 (2.84.9)
19 105 6.2 (4.97.7)
20 120 6.3 (5.17.9)
21 156 7.2 (5.88.8)
2225 823 38.2 (35.840.6)
2629 930 38.4 (36.140.7)
Race/ethnicity
Non-Hispanic White 1088 63.4 (60.866.1)
Non-Hispanic Black 462 15.9 (14.117.9)
Asian 105 3.3 (2.64.2)
Hispanic or Latino 529 16.5 (14.718.4)
Other
abb
Education
<High school 306 12.0 (10.513.6)
High school graduate/GED 513 23.1 (20.825.4)
Some college 863 39.7 (37.342.1)
College graduate or greater 513 25.3 (23.227.5)
% Poverty level
<200% 1399 55.2 (52.458.0)
200%<400% 417 20.7 (18.423.2)
400% 382 24.1 (21.626.8)
Marital status
Never married 1140 48.2 (45.750.6)
Married/living with a partner 920 48.0 (45.450.5)
Widowed/divorced/separated 134 3.8 (3.14.8)
Healthcare coverage
Private only 657 32.0 (29.634.5)
Public only
c
527 20.5 (18.522.8)
Public and private 479 24.4 (22.226.6)
None 529 23.1 (21.125.4)
Usual source of healthcare
Yes 1721 79.0 (76.881.2)
No 476 21.0 (18.923.2)
Ever heard of HPV
Yes 1771 82.6 (80.684.5)
No 420 17.4 (15.519.4)
HPV vaccine status
Vaccinated 395 18.6 (16.520.8)
Not vaccinated 1775 81.4 (79.283.5)
Currently taking birth control
d
Yes 849 41.3 (38.744.0)
No 1336 58.7 (56.061.3)
Ever given birth to a
live born infant?
Yes 1096 44.3 (41.746.9)
No 1101 55.7 (53.158.3)
(Continued on the following column)
Table 1. Demographic chara cteristics among
women ages 1829 years who have ever had
a Pap test, NHIS, 2010 (N ¼ 2,198) (Cont'd )
Participant
demographics
n % (95% CI)
Doctor recommended
most recent Pap test
e
Yes 1185 54.0 (51.256.7)
No 951 43.8 (41.046.6)
NOTE: Excludes women reporting hysterectomy and
includes all women who report ever having a Pap test
(including those with abnormal Pap test history).
a
"Other" ¼ non-Hispanic all other race groups.
b
Estimates are considered statistically unreliable and are
suppressed if the cell size is based on fewer than 30 sample
cases.
c
Medicare, Medicaid (Military dened as private)
d
Pills, implants, shots.
e
Response "Did not see a doctor on the past 12 months"
included in analysis, but not included in this table
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Table 2. Age of rst Pap test among women ages 1829 years, NHIS, 2010 (N ¼ 2,198)
Age of rst Pap test
n Mean age (95% CI)
a
P Median age Age range
Age of respondent, y
18 62 15.9 (15.516.3)
b
<0.001 16.0 1218
19 103 17.1 (16.817.4) 17.0 1419
20 117 17.0 (16.717.3) 17.0 1320
21 153 17.5 (17.117.8) 18.0 1121
2225 788 17.5 (17.317.7) 17.0 1125
2629 866 17.9 (17.718.2) 18.0 629
Race/ethnicity
Non-Hispanic White 1048 17.4 (17.317.6) 17.0 829
Non-Hispanic Black 431 16.9 (16.717.1)
d
<0.001 17.0 627
Asian 101 19.8 (19.020.5)
c
<0.001 19.0 1328
Hispanic or Latino 495 18.1 (17.818.4)
d
<0.001 18.0 826
Other
dee
ee
Education
<High school 288 16.9 (16.517.2)
f
<0.001 17.0 926
High school graduate/GED 476 17.4 (17.117.7) 17.0 8 26
Some college 830 17.2 (17.017.4) 17.0 627
College graduate or greater 492 18.5 (18.218.8) 18.0 1129
% Poverty level
g
<200% 1337 17.3 (17.117.5) ——
200%<400% 393 17.8 (17.518.2) ——
400% 359 17.9 (17.618.2) ——
Marital status
Never married 1086 17.5 (17.417.7) 18.0 627
Married/living with a partner 878 17.6 (17.417.8) 17.0 8 29
Widowed/divorced/separated 122 17.1 (16.617.7) 17.0 1226
Healthcare coverage
Private only 629 17.7 (17.818.0) 18.0 828
Public only
h
488 17.0 (16.817.3) 17.0 626
Public and private 462 17.8 (17.518.1) 18.0 1127
None 504 17.5 (17.217.8) 17.0 629
Usual source of healthcare
Yes 1635 17.5 (17.317.7) 17.0 628
No 453 17.7 (17.418.0) 18.0 629
Ever heard of HPV
Yes 1704 17.5 (17.417.7) 17.0 629
No 383 18.0 (17.718.4) 18.0 626
HPV vaccine status
Vaccinated 388 17.1 (16.817.4)
i
0.002 17.0 1126
Not vaccinated 1680 17.6 (17.517.8) 18.0 629
Currently taking birth control
j
Yes 828 17.4 (17.217.6) 18.0 629
No 1253 17.6 (17.417.8) 18.0 828
Ever given birth to a live born infant?
Yes 1020 17.3 (17.117.5)
k
<0.001 17.0 628
No 1069 17.8 (17.617.9) 18.0 829
Doctor recommended
most recent Pap test
l
Yes 1134 17.5 (17.317.6) 17.0 628
No 901 17.7 (17.417.9) 18.0 629
NOTE: Excludes women reporting hysterectomy, and includes all women who report ever having a Pap test (including those with abnormal Pap test
history)
a
Unlike median and age range estimates, analyses of mean age were conducted taking into account weighting and complex survey design.
b
Compared with all other ages, P < 0.001.
c
Compared with non-Hispanic White, P < 0.001.
d
"Other" ¼ non-Hispanic all other race groups.
e
Estimates are considered statistically unreliable and are suppressed if the cell size is based on fewer than 30 sample cases.
f
Compared with college graduate or greater, P < 0.001.
g
Poverty is an imputed variable, therefore median age and age range is not available.
h
Medicare, Medicaid (Military dened as private).
i
Compared with nonvaccinated, P ¼ 0.002.
j
Pills, implants, shots.
k
Compared with never giving birth, P < 0.001.
l
Response "Did not see a doctor on the past 12 months" included in analysis, but not included in this table.
Roland et al.
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Table 3. Time since most recent Pap test among women ages 1829 years by demographic
characteristics, NHIS, 2010 (n ¼ 1,622)
12 mo 1324 mo 2536 mo
a
Time since most recent Pap P (c
2
) n % (95% CI) n % (95% CI) n % (95% CI)
Age, y 0.057
1829 1182 73.1 (70.475.6) 317 19.3 (17.021.9) 123 7.6 (6.39.2)
1821 270 78.3 (72.583.1) 56 15.8 (11.621.2)
b
2225 445 74.7 (70.178.8) 110 18.4 (14.623.0) 41 6.9 (4.89.7)
2629 467 68.0 (63.572.1) 151 22.6 (19.026.5) 57 9.5 (6.912.8)
Race/ethnicity 0.052
Non-Hispanic White 584 72.4 (68.675.9) 161 20.2 (17.023.8) 59 7.4 (5.79.6)
Non-Hispanic Black 254 78.6 (72.483.7) 58 16.2 (11.921.7)
b
Asian 54 66.8 (52.278.8)
bb
Hispanic or Latino 285 71.7 (66.576.5) 75 17.7 (14.022.1) 39 10.6 (7.315.0)
Other
cbbb
Education 0.167
<High school 146 69.5 (61.776.3) 51 19.5 (14.326.1)
b
High school graduate 273 69.0 (63.074.4) 76 22.3 (17.428.1)
b
Some college 474 76.9 (72.280.6) 105 15.9 (12.719.7) 47 7.2 (5.29.8)
College graduate 289 72.4 (65.978.1) 84 21.7 (16.627.7)
b
% Poverty level 0.666
<200% 735 73.9 (70.377.3) 200 19.5 (16.423.0) 72 6.6 (5.08.6)
200%<400% 234 71.9 (64.977.9) 62 20.1 (14.826.7)
b
400% 213 72.3 (65.478.3) 55 18.2 (13.224.7)
b
Marital status 0.426
Never married 611 73.5 (69.277.3) 162 18.6 (15.422.4) 69 7.9 (5.910.5)
Married/living with partner 511 73.0 (68.776.8) 139 20.4 (17.024.1) 45 6.7 (4.89.2)
Widowed/divorced/separated 59 68.7 (53.880.5)
bb
Healthcare coverage 0.072
Private only 361 73.3 (68.177.8) 91 18.3 (14.323.1) 39 8.4 (5.812.2)
Public only
d
299 78.5 (72.483.6) 56 16.5 (11.822.6)
b
Both private and public 291 75.3 (69.979.9) 74 18.4 (14.423.2)
b
None 228 66.6 (60.872.0) 93 22.7 (18.127.9) 41 10.7 (7.714.7)
Usual source of healthcare <0.001
Yes 978 75.8 (72.978.6) 237 18.0 (15.520.9) 75 6.2 (4.87.8)
No 203 61.5 (55.167.6) 80 24.8 (19.231.3) 48 13.7 (9.918.5)
Ever heard of HPV 0.366
Yes 962 73.9 (70.876.7) 243 18.6 (16.021.5) 97 7.5 (6.19.3)
No 216 69.0 (62.674.8) 74 23.0 (17.829.2)
b
HPV vaccine status 0.606
Vaccinated 220 75.6 (68.681.5) 52 17.9 (12.624.9)
b
Not vaccinated 950 72.5 (69.675.2) 260 19.6 (17.222.3) 106 7.9 (6.39.9)
Ever given birth to a live born infant 0.238
Yes 565 70.2 (66.074.1) 162 21.5 (18.025.5) 61 8.2 (6.111.0)
No 616 75.1 (71.378.6) 155 17.7 (14.721.2) 62 7.2 (5.49.4)
Currently taking birth control
e
<0.001
Yes 534 82.5 (79.185.4) 100 13.4 (10.816.5) 32 4.1 (2.76.1)
No 642 65.9 (62.169.5) 214 23.7 (20.327.4) 91 10.4 (8.512.8)
Doctor recommended
most recent Pap test
f
0.043
Yes 618 73.2 (69.276.9) 168 20.3 (17.024.1) 57 6.4 (4.78.7)
No 555 74.0 (70.077.6) 142 18.2 (15.221.7) 55 7.8 (5.910.3)
NOTE: Includes all women who report ever having a Pap test, excludes women reporting hysterectomy, women who report an abnormal
Pap in last 3 years, and women who reported their last Pap was not part of a regular screening exam.
a
Does not include responses "more than 3 years but not more than 5 years"; "over 5 years" because this study sample excludes women
who reported an abnormal Pap in the last 3 years, thereby excluding women who report most recent Pap > 3 year ago. "Refused" and
"don't know" excluded from analysis.
b
Estimates are considered statistically unreliable and are suppressed if the cell size is based on fewer than 30 sample cases.
c
"Other" ¼ non-Hispanic all other race groups.
d
Medicare, Medicaid (Military dened as private).
e
Pills, implants, shots.
f
"Did not see a doctor on the past 12 months" included in analysis, but suppressed in this table.
Cervical Cancer Screening among Women Ages 1829 in the United States
www.aacrjournals.org Cancer Epidemiol Biomarkers Prev; 22(4) April 2013 585
Page 6
healthcare and current use of birth control methods
requiring provider administration or provision (pills,
implants, or shots) were strongly associated with the
likelihood of having a Pap test in the previous year.
Although fewer 18-year-olds reported ever receiving a
Pap test in 2010, those who did had a younger age of
initiation, compared with those ages 19–29 years who
were surveyed. Upon further examination of the 18-
year-olds who did report ever having a Pap test, 15.6%
had a history of abnormal screening results (data not
shown). Previous studies have shown greater Pap test
use among women reporting risky sexual behaviors (32),
possibly explaining earlier Pap test initiation among these
young women. Following younger users of the Pap test is
important to understanding whether guidelines that dis-
courage screening on the basis of sexual history are being
implemented.
Non-Hispanic black women and women with less than
a high school education reported a significantly younger
age of Pap test initiation. Because 2010 was the first time
data on age of first Pap test were collected on the NHIS,
there is no previous screening initiation data available
with which to compare these findings. Lower Pap testing
rates have been documented among women with less
education, Hispanic ethnicity, and shorter length of
U.S. residency (33–36). Women who were vaccinated with
the HPV vaccine also reported a younger age of first Pap
test. Vaccine and Pap test receipt may be correlated,
potentially indicating vaccination and screening in the
same visit. In addition, age of first Pap test was younger
for women who reported ever giving birth, as antepartum
care increases visits with a provider and the potential for
Pap testing.
The finding that most women reported their last Pap
test within 12 months is not surprising. While at least one-
third of the sample should report their last Pap test within
the previous 12 months, even if all women were screened
every 3 years, annual cervical cancer screening is com-
monly reported by young adult women (37–40) and pro-
viders (41, 42). Usual source of healthcare and current
birth control use as significant variables impacting cervi-
cal cancer screening frequency has also been supported by
previous research (36, 43, 44). Pap tests and pelvic exams
often are used as a prerequisite for birth control prescrip-
tions, despite guidelines indicating they are unnecessary
(45, 46). The relationship between birth control use and
Pap test receipt among young adults is significant, con-
sidering 36.6% of all women ages 18–29 years in the 2010
NHIS (data not shown) and 41.3% of this study sample
report current birth control use. If the relationship
between birth control use and Pap test receipt among
younger adults is linked (38), it would be important to
discourage providers from offering Pap testing during
visits for prescribing and administering contraception
and to inform providers that an annual Pap test is not a
necessary prerequisite to prescribe birth control through
system-level intervention and incentive.
Table 4. Multivariate analysis of characteristics
associated with Pap test screening in the last 12
months among women ages 1829 years, NHIS,
2010 (n ¼ 1,622)
Most recent Pap test 12 mo
a
OR (95% CI) P (Wald-F)
Age, y 0.086
1821 1.54 (1.032.31
b
)
2225 1.24 (0.921.69)
2629 1.00
Healthcare coverage 0.219
Private only 1.00
Public only
c
1.57 (0.932.66)
Both private and public 1.13 (0.791.61)
None 0.99 (0.661.48)
Usual source of
healthcare
0.002
Yes 1.64 (1.202.25)
No 1.00
Ever heard of HPV 0.620
Yes 1.09 (0.771.54)
No 1.00
Ever given birth to a
live born infant
0.534
Yes 0.90 (0.641.26)
No 1.00
Currently taking
birth control
d
<0.001
Yes 2.31 (1.743.06)
No 1.00
Doctor recommended
most recent Pap test
e
0.094
Yes 0.96 (0.721.29)
No 1.00
NOTE: Excludes women reporting hysterectomy, women
who report an abnormal Pap in last 3 years, and women
who reported their last Pap was not part of a regular screen-
ing examination. To construct our multivariable model, we
conducted a separate bivariate analysis comparing last Pap
test reported within 12 versus 1336 months (data not
shown). Statistically signicant variables with P < 0.05 from
this separate bivariate analysis were included in the multi-
variate analysis. as covariates.
a
Among women who have ever had a Pap, odds of reporting
most recent Pap within 12 months, compared to all other
intervals (>12, >23, >35, >5years).
b
Because the condence interval does not overlap the ref-
erent group, we ran a contrast test for 1821 versus 2629
and the Wald-F P ¼ 0.036.
c
Medicare, Medicaid (Military dened as private).
d
Pills, implants, shots.
e
Response "Did not see a doctor on the past 12 months"
included in analysis, but suppressed in this table.
Roland et al.
Cancer Epidemiol Biomarkers Prev; 22(4) April 2013 Cancer Epidemiology, Biomarkers & Prevention
586
Page 7
We acknowledge several limitations with this study.
While self-report is a common method used to assess Pap
test utilization in national surveys, social desirability bias,
recall bias, and overreporting of Pap test use possibly due
to women equating any examination of the pelvic area
with Pap test (43, 47–49) could potentially impact results.
The number of women ages 18 and 19 years included in
the 2010 study sample was small and should be noted.
Because of the small percentage of women who reported
HPV vaccination (18.6%), consistent with the lower
uptake of the vaccine throughout the United States (50),
the variable could not be further examined in this analysis.
However, we believe it is crucial to provide baseline
estimates of HPV vaccination for this age group, antici-
pating future analyses will have larger sample sizes to
evaluate relationships. In addition, we were not able to
control for screening in this age group that could occur in
the context of prenatal and post-partum care (38).
NHIS is the principal source of information on the
health of the civilian noninstitutionalized population of
the United States and provides self-reported screening
rates to evaluate trends and determine whether collec-
tively we are progressing toward meeting Healthy People
2020 objectives. This analysis presents an opportunity to
nationally track screening behaviors among young adult
women. It is significant because it is the first study using
NHIS data to assess cervical cancer screening among
women ages 18–29 year, and includes results from a novel
NHIS question regarding age at initiation of cervical
cancer screening. Studying this age cohort is important
because of the distinct changes to screening guidelines
that have occurred and the growing evidence base for less
frequent intervention among young adult women.
Conclusions
Given the growing body of scientific evidence, women
and clinicians should feel comfortable adopting later and
less frequent intervention for cervical cancer detection
among young adult women. As evidence-based screening
guidelines gradually become more accepted among
patients and providers, we anticipate continued decreases
in the percentage of 18-year-old women reporting ever
being screened and 18- to 29-year-old women reporting
their last Pap test 12 months before survey. These antic-
ipated changes signal research opportunities, including
examining the characteristics and predictors of women
who report their most recent Pap test 2 to 3 years before
survey, and whether their reported interval was due to
their provider implementing screening according to
guidelines, or irregular healthcare access. In addition,
understanding how the HPV vaccine and Pap test are
used together in clinical practice will be of increasing
public health significance as girls who were vaccinated
become old enough for Pap testing. It will also be impor-
tant to understand the content and delivery of cervical
cancer screening guidance providers are offering to their
patients after HPV vaccination. Continued unnecessary
clinical services can lead to evaluation and treatment that
generate physical, emotional, and financial costs. Imple-
mentation of evidence-based cervical cancer screening
would increase the quality of cervical cancer prevention
services for all women and reduce costs throughout
society.
Disclosure of Potential Conict of Interest
No potential conflicts of interest were disclosed.
Authors' Contributions
Conception and design: K.B. Roland, V. Benard, A. Soman, N. Breen, D.
Kepka, M. Saraiya
Development of methodology: K.B. Roland, V. Benard, A. Soman, N.
Breen
Acquisition of data (provided animals, acquired and managed patients,
provided facilities, etc.): N. Breen
Analysis and interpretation of data (e.g., statistical analysis, biostatis-
tics, computational analysis): K.B. Roland, A. Soman, N. Breen, D. Kepka,
M. Saraiya
Writing, review, and/or revision of the manuscript: K.B. Roland, V.
Benard, A. Soman, N. Breen, D. Kepka, M. Saraiya
Administrative, technical, or material support (i.e., reporting or orga-
nizing data, constructing databases): K.B. Roland, A. Soman
Study supervision: K.B. Roland
Grant Support
The study was supported by the U.S. Government.
The costs of publication of this article were defrayed in part by the
payment of page charges. This article must therefore be hereby marked
advertisement in accord ance with 18 U.S.C. Section 1734 solely to indicate
this fact.
Received November 14, 2012; revised January 10, 2013; accepted January
11, 2013; published OnlineFirst January 25, 2013.
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  • Source
    • "Furthermore, cervical cancer screening guidelines have changed over the duration of data collection, with the introduction of co-testing HPV and Pap screening in women older than 30 years and recommendation against screening in women less than 21 years regardless of first sexual contact [33,34]. Despite these changes, these data and several studies indicate that the guidelines are not being followed as testing is still frequently performed on an annual basis, in women under 21 years of age, and in women following hysterectomy [28,35,36]. Another final limitation is that the Hybrid Capture 2 method does not differentiate genotypes and differentiation of specific high-risk vaccine preventable HPV strain was not possible [37,38]. "
    [Show abstract] [Hide abstract] ABSTRACT: Nationwide positivity rates of high-risk human papillomavirus for the United States before and since the introduction of a Human Papillomavirus (HPV) vaccine in 2006 would provide insight into the population impact of HPV vaccination. Data for high-risk HPV testing results from January 1, 2004 to June 1, 2013 at a national reference laboratory were retrospectively analyzed to produce 757,761 patient records of women between the ages of 14 and 59. Generalized linear models and finite mixture models were utilized to eliminate sources of bias and establish a population undergoing standard gynecological screening. Unadjusted positivity rates for high-risk HPV were 27.2% for all age groups combined. Highest rates occurred in women aged 14 to 19. While the positivity rates decreased for all age groups from 2004 to 2013, the higher age categories showed less downward trend following vaccine introduction, and the two age categories 20 to 24 and 25 to 29 showed a significantly different downward trend between pre- and post-vaccine time periods (-0.1% per year to -1.5% per year, and 0.4% per year to -1.5% per year, respectively). All other age groups had rates of change that became less negative, indicating a slower rate of decline.
    Full-text · Article · Dec 2014
  • Source
    • "Furthermore, cervical cancer screening guidelines have changed over the duration of data collection, with the introduction of co-testing HPV and Pap screening in women older than 30 years and recommendation against screening in women less than 21 years regardless of first sexual contact [33,34]. Despite these changes, these data and several studies indicate that the guidelines are not being followed as testing is still frequently performed on an annual basis, in women under 21 years of age, and in women following hysterectomy [28,35,36]. Another final limitation is that the Hybrid Capture 2 method does not differentiate genotypes and differentiation of specific high-risk vaccine preventable HPV strain was not possible [37,38]. "
    Full-text · Article · Apr 2014
  • Source
    [Show abstract] [Hide abstract] ABSTRACT: Objective: Cervical cancer screening using the human papillomavirus (HPV) test and Pap test together (co-testing) is an option for average-risk women ≥ 30 years of age. With normal co-test results, screening intervals can be extended. The study objective is to assess primary care provider practices, beliefs, facilitators and barriers to using the co-test and extending screening intervals among low-income women. Method: Data were collected from 98 providers in 15 Federally Qualified Health Center (FQHC) clinics in Illinois between August 2009 and March 2010 using a cross-sectional survey. Results: 39% of providers reported using the co-test, and 25% would recommend a three-year screening interval for women with normal co-test results. Providers perceived greater encouragement for co-testing than for extending screening intervals with a normal co-test result. Barriers to extending screening intervals included concerns about patients not returning annually for other screening tests (77%), patient concerns about missing cancer (62%), and liability (52%). Conclusion: Among FQHC providers in Illinois, few administered the co-test for screening and recommended appropriate intervals, possibly due to concerns over loss to follow-up and liability. Education regarding harms of too-frequent screening and false positives may be necessary to balance barriers to extending screening intervals.
    Full-text · Article · Apr 2013 · Preventive Medicine
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