Cervical cancer screening among women with comorbidities: a cross-sectional examination of disparities from the Behavioral Risk Factor Surveillance System

Methods

To conduct this observational study, we combined the 2018 and 2019 BRFSS datasets and performed a cross-sectional analysis to examine CC screening prevalence among women with and without comorbid conditions. BRFSS (https://www.cdc.gov/brfss/about/index.htm) is a national telephone survey that collects demographic, behavioral, and health-related information from noninstitutionalized individuals from all 50 states, Guam, Puerto Rico, and the District of Columbia. Surveys are administered through cell and landline phones, which are divided into strata based upon proximity to other area codes, and randomly sampled. With this method of data collection, it should be noted that the data could have inaccuracies and response biases, preventing conclusions from being made directly from data analysis. BRFSS collects data from approximately 450,000 respondents across the United States and applies a weighting schema to approximate the total US population.

Respondents were classified as having a CC screening through the following questions: “Have you ever had a Pap [smear] test?” or “Have you ever had an HPV test?” Those answering affirmatively to either of those questions and affirming that they were conducted within the past 3 years were coded as having been screened. Those responding “no” to both of those questions or reporting that their cervical examination occurred outside of the 3-year window were coded as not having a current screening. We concurrently extracted sociodemographic data, including education level, race/ethnicity, healthcare coverage, age (in 5-year increments), and gender, as well as the previously mentioned comorbidities. The reason that race/ethnicity was assessed in the study was to identify a potential racial health disparity in CC screening. Race/ethnicity of study participants was classified by the participants themselves. Given the 3-year window and the United States Preventive Services Task Force’s (USPSTF) recommendation for CC screening to occur starting at 21 years of age and continuing every 3 years until age 65, individuals aged 24 and under, and those 65 and over were excluded from this study. Further, we excluded women with hysterectomies because they would no longer require CC screening.

Utilizing the combined datasets, including sampling weights provided by BRFSS (adjusted to match the multiple cycles of data), we calculated the unweighted (within sample; n) and weighted (representative of the United States resident population; N) prevalence of CC screening among individuals with and without comorbidities. We then constructed multivariate logistic regression models to determine the adjusted odds ratios (AORs) of persons who completed CC screening with and without comorbidities. To assess our secondary objective, we constructed a regression model to determine the likelihood of individuals with multiple comorbidities (1, 2–4, 5+) having completed a CC screening. Regression models were adjusted for race, age, healthcare coverage, and education level. A post hoc binary logistic regression model was constructed to assess the association of race, via odds ratios (ORs), on CC screening. Sampling weights, provided by BRFSS, were adjusted to account for the combined datasets for population-level estimates. Statistical analyses were performed utilizing Stata 16.1 (StataCorp, LLC, College Station, TX) in December 2020.

Results

Discussion

Our results showed that women between the ages of 25 and 65 had differing rates of CC screening completion by co-occurring diagnoses—with lower rates of screening completion among those with diagnoses of obesity, COPD, or kidney disease, and higher rates among those with skin cancer. We identified no significant difference in CC screening completion among persons with diabetes, hypertension, cardiovascular disease, arthritis, depression, or multiple comorbidities. Our post hoc analysis found that White women between the ages of 25 and 65 were less likely to complete a CC screening when compared to Black or Hispanic women.

Our results are consistent with a smaller preceding study highlighting similar rates of screening completion for CC among women with comorbidities [8]. Notably, the present study analyzed more comorbid conditions, in addition to utilizing a nationally representative sample, and it identified a particularly concerning feature; women with BMI ≥30 kg/m² were significantly less likely to complete CC screening. This is especially worrisome due to the associations between obesity and the risk of CC [9, 10]. Interestingly, in a systematic review by Fagan et al. [10], five studies examined associations between CC screening completion and obesity among White women—all reporting negative correlations—although studies of Black women showed either no relationship or a possible interaction in screening completion rates and socioeconomic status. Although this was specific to obesity and CC, we posit that there may be several reasons for our findings, including personal factors such as perceived costs, lack of healthcare access [11], and health literacy [12].

Our findings are also consistent with previous literature regarding the associations between CC screening and healthcare coverage [11]. Insufficient healthcare coverage is often accompanied by or is a product of poverty or chronic illnesses [13]. Evidence has shown that healthcare costs are a primary barrier to healthcare coverage and access [14]. Another study found that perceptions of screening costs varied widely, including the expense of appointments, transportation, time missed from work, and future treatment [15]. Lastly, whereas previous literature has reported low CC screening among women with comorbidities [16, 17], our study contributes new findings suggesting that Black and Hispanic women are more likely to complete screening for CC compared to White women. This may indicate that targeted preventative education and community efforts are working [18], especially considering that these groups have higher rates of CC risk factors [19, 20].

Poor health literacy may also be impacting uptake of CC screening. A study by Akinlotan et al. [14] found that risk factor knowledge and educational attainment were significantly associated with decreased rates of CC screening. This study showed that less than half of the 433 women included were able to identify that smoking, long-term birth control, and multiple children were factors that increased the risk for CC, yet only 60.5% identified multiple sex partners as a risk. Further, 69% of White women reported cost as a barrier to CC screening completion compared to 59.7% of Black women and 57.6% of Hispanic women [14].

Health literacy may be impeded due to conflicting recommendations among professional organizations. Some women may be unaware that a “Pap smear” is often included in “routine pelvic exams” in clinical settings [21]. However, ACOG, the American College of Physicians, the American Academy of Family Physicians, the Society of Gynecologic Oncology, and the USPSTF do not include cancer screenings as components of pelvic examinations, although they are often performed at the same time. ACOG recommendations regarding the frequency of pelvic examinations are left to patient-provider determination (unlike CC screenings at specified intervals) [21, 22] stating that there is insufficient evidence “to support a recommendation for or against performing a routine screening pelvic examination among asymptomatic, nonpregnant women who are not at increased risk of any specific gynecologic condition.” [23] Therefore, clear and concise terminology regarding Pap smears and pelvic examinations may be crucial in evaluating CC screening rates.

As ACOG recommends annual visits to the obstetrician-gynecologist, they note that this is an opportune time to enhance patient-provider relationships and reassure women of their health status [23]. This is a time in which providers and skilled teams may improve patients’ health literacy and together make the most suitable health plan for the patients. Further, as a result of patient-related time constraints, improvements in skilled communication, patient-centered language, complete wrap-around services, and collaboration with other healthcare team members may improve the quality of care. Another factor that may impede CC screening is the quality of care for currently diagnosed medical conditions. The relationship between quality of care and preventive cancer screenings has shown a positive correlation among a previous study of women with diabetes that showed a positive association with more complete diabetes care and was related to the completion of CC screenings [24].

Conclusions

We identified key findings among women with comorbidities who completed CC screenings utilizing a nationally representative sample. Women with BMI ≥30 kg/m², COPD, and kidney disease were significantly less likely to receive guidelines recommending CC screening. We found no significant associations between CC screening completion and women with multiple, compared to zero, comorbidities. Improving CC screening uptake is critical for reducing the morbidity and mortality of CC. Physicians should be aware of the disparities in CC screening completion among patients with comorbid diagnoses to recognize when there may be an increased need for Pap tests during well-woman visits.