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.,
Univesity 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/report
s/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
Select for more information about AHRQ's research portfolio and funding opportunities.
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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
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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