Vital Signs: Mammography Use and Association with Social Determinants of Health and Health-Related Social Needs Among Women - United States, 2022.

Introduction: Approximately 40,000 U.S. women die from breast cancer each year. Mammography is recommended to screen for breast cancer and reduce breast cancer mortality. Adverse social determinants of heath (SDOH) and health-related social needs (HRSNs) (e.g., lack of transportation and social isolation) can be barriers to getting mammograms. Methods: Data from the 2022 Behavioral Risk Factor Surveillance System were analyzed to estimate the prevalence of mammography use within the previous 2 years among women aged 40-74 years by jurisdiction, age group, and sociodemographic factors. The association between mammography use and measures of SDOH and HRSNs was assessed for jurisdictions that administered the Social Determinants and Health Equity module. Results: Among women aged 50-74 years, state-level mammography use ranged from 64.0% to 85.5%. Having health insurance and a personal health care provider were associated with having had a mammogram within the previous 2 years. Among women aged 50-74 years, mammography prevalence was 83.2% for those with no adverse SDOH and HRSNs and 65.7% for those with three or more adverse SDOH and HRSNs. Life dissatisfaction, feeling socially isolated, experiencing lost or reduced hours of employment, receiving food stamps, lacking reliable transportation, and reporting cost as a barrier for access to care were all strongly associated with not having had a mammogram within the previous 2 years. Conclusions and Implications for Public Health Practice: Identifying specific adverse SDOH and HRSNs that women experience and coordinating activities among health care providers, social services, community organizations, and public health programs to provide services that help address these needs might increase mammography use and ultimately decrease breast cancer deaths.

Breast and cervical cancer programs' success in maintaining screening during periods of high COVID-19: A qualitative multi-case study analysis.

Objective: During the first year of the COVID-19 pandemic, most of the Centers for Disease Control and Prevention (CDC)'s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) funded programs (recipients) experienced significant declines in breast and cervical cancer screening volume. However, 6 recipients maintained breast and/or cervical cancer screening volume during July-December 2020 despite their states' high COVID-19 test percent positivity. We led a qualitative multi-case study to explore these recipients' actions that may have contributed to screening volume maintenance. Methods: We conducted 22 key informant interviews with recipients, screening provider sites, and partner organizations. Interviews explored organizational and operational changes; screening barriers; actions taken to help maintain screening volume; and support for provider sites to continue screening. We documented contextual factors that may have influenced these actions, including program structures; clinic capacity; and state COVID-19 policies. Results: Thematic analysis revealed crosscutting themes at the recipient, provider site, and partner levels. Recipients made changes to administrative processes to reduce burden on provider sites and delivered tailored technical assistance to support safe screening. Provider sites modified clinic protocols to increase patient safety, enhanced patient reminders for upcoming appointments, and increased patient education on the importance of timely screening during the pandemic. Partners worked with provider sites to identify and reduce patients' structural barriers to screening. Conclusion: Study findings provide lessons learned to inform emergency preparedness-focused planning and operations, as well as routine operations for NBCCEDP recipient programs, other cancer screening initiatives, primary care clinics, and chronic disease prevention programs.

Breast, cervical, and colorectal cancer screening test use in the US territories of Guam, Puerto Rico, and the US Virgin Islands.

BACKGROUND: The United States Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer screening among eligible adults, but information on screening use in the US territories is limited. METHODS: To estimate the proportion of adults up-to-date with breast, cervical, and colorectal cancer screening based on USPSTF recommendations, we analyzed Behavioral Risk Factor Surveillance System data from 2016, 2018, and 2020 for the 50 US states and DC (US) and US territories of Guam and Puerto Rico and from 2016 for the US Virgin Islands. Age-standardized weighted proportions for up-to-date cancer screening were examined overall and by select characteristics for each jurisdiction. RESULTS: Overall, 67.2% (95% CI: 60.6-73.3) of women aged 50-74 years in the US Virgin Islands, 74.8% (70.9-78.3) in Guam, 83.4% (81.7-84.9) in Puerto Rico, and 78.3% (77.9-78.6) in the US were up-to-date with breast cancer screening. For cervical cancer screening, 71.1% (67.6-74.3) of women aged 21-65 years in Guam, 81.3% (74.6-86.5) in the US Virgin Islands, 83.0% (81.7-84.3) in Puerto Rico, and 84.5% (84.3-84.8) in the US were up-to-date. For colorectal cancer screening, 45.2% (40.0-50.5) of adults aged 50-75 years in the US Virgin Islands, 47.3% (43.6-51.0) in Guam, 61.2% (59.5-62.8) in Puerto Rico, and 69.0% (68.7-69.3) in the US were up-to-date. Adults without health care coverage reported low test use for all three cancers in all jurisdictions. In most jurisdictions, test use was lower among adults with less than a high school degree and an annual household income of < $25,000. CONCLUSION: Cancer screening test use varied between the US territories, highlighting the importance of understanding and addressing territory-specific barriers. Test use was lower among groups without health care coverage and with lower income and education levels, suggesting the need for targeted evidence-based interventions.

Trends in breast cancer mortality by race/ethnicity, age, and US census region, United States─1999-2020.

BACKGROUND: Breast cancer remains a leading cause of morbidity and mortality among women in the United States. Previous analyses show that breast cancer incidence increased from 1999 to 2018. The purpose of this article is to examine trends in breast cancer mortality. METHODS: Analysis of 1999 to 2020 mortality data from the Centers for Disease Control and Prevention, National Center for Health Statistics, among women by race/ethnicity, age, and US Census region. RESULTS: It was found that overall breast cancer mortality is decreasing but varies by race/ethnicity, age group, and US Census region. The largest decrease in mortality was observed among non-Hispanic White women, women aged 45 to 64 years of age, and women living in the Northeast; whereas the smallest decrease in mortality was observed among non-Hispanic Asian or Pacific Islander women, women aged 65 years or older, and women living in the South. CONCLUSION: This report provides national estimates of breast cancer mortality from 1999 to 2020 by race/ethnicity, age group, and US Census region. The decline in breast cancer mortality varies by demographic group. Disparities in breast cancer mortality have remained consistent over the past two decades. Using high-quality cancer surveillance data to estimate trends in breast cancer mortality may help health care professionals and public health prevention programs tailor screening and diagnostic interventions to address these disparities.

Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity.

Cervical cancer is highly preventable when precancerous lesions are detected early and appropriately managed. However, the complexity of and frequent updates to existing evidence-based clinical guidelines make it challenging for clinicians to stay abreast of the latest recommendations. In addition, limited availability and accessibility to information technology (IT) decision supports make it difficult for groups who are medically underserved to receive screening or receive the appropriate follow-up care. The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC), is leading a multiyear initiative to develop computer-interpretable ("computable") version of already existing evidence-based guidelines to support clinician awareness and adoption of the most up-to-date cervical cancer screening and management guidelines. DCPC is collaborating with the MITRE Corporation, leading scientists from the National Cancer Institute, and other CDC subject matter experts to translate existing narrative guidelines into computable format and develop clinical decision support tools for integration into health IT systems such as electronic health records with the ultimate goal of improving patient outcomes and decreasing disparities in cervical cancer outcomes among populations that are medically underserved. This initiative meets the challenges and opportunities highlighted by the President's Cancer Panel and the President's Cancer Moonshot 2.0 to nearly eliminate cervical cancer.

Trends in Breast Cancer Incidence, by Race, Ethnicity, and Age Among Women Aged ≥20 Years - United States, 1999-2018.

Breast cancer is commonly diagnosed among women, accounting for approximately 30% of all cancer cases reported among women.* A slight annual increase in breast cancer incidence occurred in the United States during 2013-2017 (1). To examine trends in breast cancer incidence among women aged ≥20 years by race/ethnicity and age, CDC analyzed data from U.S. Cancer Statistics (USCS) during 1999-2018. Overall, breast cancer incidence rates among women decreased an average of 0.3% per year, decreasing 2.1% per year during 1999-2004 and increasing 0.3% per year during 2004-2018. Incidence increased among non-Hispanic Asian or Pacific Islander women and women aged 20-39 years and decreased among non-Hispanic White women and women aged 50-64 and ≥75 years. The U.S. Preventive Services Task Force currently recommends biennial screening mammography for women aged 50-74 years (2). These findings suggest that women aged 20-49 years might benefit from discussing potential breast cancer risk and ways to reduce risk with their health care providers. Further examination of breast cancer trends by demographic characteristics might help tailor breast cancer prevention and control programs to address state- or county-level incidence rates† and help prevent health disparities.

Breast Cancer Survival Among Males by Race, Ethnicity, Age, Geographic Region, and Stage - United States, 2007-2016.

Breast cancer among males in the United States is rare; approximately 2,300 new cases and 500 associated deaths were reported in 2017, accounting for approximately 1% of all breast cancers.* Risk for male breast cancer increases with increasing age (1), and compared with women, men receive diagnoses later in life and often at a later stage of disease (1). Gradual improvement in breast cancer survival from 1976-1985 to 1996-2005 has been more evident for women than for men (1). Studies examining survival differences among female breast cancer patients observed that non-Hispanic White (White) females had a higher survival than non-Hispanic Black (Black) females (2), but because of the rarity of breast cancer among males, few studies have examined survival differences by race or other factors such as age, stage, and geographic region. CDC's National Program of Cancer Registries (NPCR)† data were used to examine relative survival of males with breast cancer diagnosed during 2007-2016 by race/ethnicity, age group, stage at diagnosis, and U.S. Census region. Among males who received a diagnosis of breast cancer during 2007-2016, 1-year relative survival was 96.1%, and 5-year relative survival was 84.7%. Among characteristics examined, relative survival varied most by stage at diagnosis: the 5-year relative survival for males was higher for cancers diagnosed at localized stage (98.7%) than for those diagnosed at distant stage (25.9%). Evaluation of 1-year and 5-year relative survival among males with breast cancer might help guide health care decisions regarding early detection of male breast cancer and establishing programs to support men at high risk for breast cancer and male breast cancer survivors.

Estimating the impact of increasing cervical cancer screening in the National Breast and Cervical Cancer Early Detection Program among low-income women in the USA.

PURPOSE: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides free cervical cancer screening to low-income women. This study estimated the health benefits gained in terms of life years (LYs) saved and quality-adjusted life years (QALYs) gained if cervical cancer screening by the NBCCEDP increased to reach more eligible women. METHODS: Data from Surveillance, Epidemiology, and End Results, NBCCEDP, and Medical Expenditure Panel Surveys were used. LYs saved and QALYs gained/100,000 women were estimated using modeling methods. They were used to predict additional health benefits gained if screening by the NBCCEDP increased from 6.5% up to 10-25% of the eligible women. RESULTS: Overall, per 100,000 women screened by the NBCCEDP, 1,731 LYs were saved and 1,608 QALYs were gained. For white women, 1,926 LYs were saved and 1,780 QALYs were gained/100,000 women screened by the NBCCEDP. For black women, 1,506 LYs were saved and 1,300 QALYs were gained/100,000 women screened. If the proportion of eligible women screened by the NBCCEDP increased to 10-25%, the estimated health benefits would range from 6,626-34,896 LYs saved and 6,153-32,407 QALYs gained. CONCLUSIONS: The reported estimates emphasize the value of cervical cancer screening program by extending LE in low-income women. Further, it demonstrates that screening a higher percentage of eligible women in the NBCCEDP may yield more health benefits.

Geographic Co-Occurrence of Mesothelioma and Ovarian Cancer Incidence.

Background: Asbestos is an established cause of several cancers, including mesothelioma and ovarian cancer. Incidence of mesothelioma, the sentinel asbestos-associated cancer, varies by state, likely reflecting different levels of asbestos exposure. We hypothesized that states with high mesothelioma incidence may also have high ovarian cancer incidence. Materials and Methods: Using data from the Centers for Disease Control and Prevention National Program for Cancer Registries and the National Cancer Institute Surveillance, Epidemiology, and End Results Program, we examined the geographic co-occurrence of mesothelioma and ovarian cancer incidence rates by U.S. state for 2003-2015. Results: By state, mesothelioma incidence ranged from 0.5 to 1.3 cases per 100,000 persons and ovarian cancer incidence ranged from 9 to 12 cases per 100,000 females. When states were grouped by quartile of mesothelioma incidence, the average ovarian cancer incidence rate was 10% higher in states with the highest mesothelioma incidence than in states with the lowest mesothelioma incidence. Ovarian cancer incidence tended to be higher in states with high mesothelioma incidence (Pearson correlation r = 0.54; p < 0.0001). Conclusions: Data from state cancer registries show ovarian cancer incidence was positively correlated with mesothelioma incidence, suggesting asbestos may be a common exposure. The potential for asbestos exposure has declined since the 1970s because fewer products contain asbestos; however, some products, materials, and buildings may still release asbestos and thousands of workers may be exposed. Ensuring that people are protected from exposure to asbestos in their workplaces, homes, schools, and communities may reduce the risk of several cancers.

Cost-effectiveness of patient navigation for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program.

OBJECTIVES: Patient navigation (PN) services have been shown to improve cancer screening in disparate populations. This study estimates the cost-effectiveness of implementing PN services within the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: We adapted a breast cancer simulation model to estimate a population cohort of women aged 40-64 years from the NBCCEDP through their lifetime. We incorporated their screening frequency and screening and diagnostic costs. RESULTS: Within the NBCCEDP, Program with PN (vs. No PN) resulted in a greater number of mammograms per woman (4.23 vs. 4.14), lower lifetime mortality from breast cancer (3.53% vs. 3.61%), and fewer missed diagnostic resolution per woman (0.017 vs. 0.025). The estimated incremental cost-effectiveness ratios for a Program with PN was $32,531 per quality-adjusted life-years relative to Program with No PN. CONCLUSIONS: Incorporating PN services within the NBCCEDP may be a cost-effective way of improving adherence to screening and diagnostic resolution for women who have abnormal results from screening mammography. Our study highlights the value of supportive services such as PN in improving the quality of care offered within the NBCCEDP.

The effect of delivery structure on costs, screening and health promotional services in state level National Breast and Cervical Cancer Early Detection Programs.

PURPOSE: We estimated the costs and effectiveness of state programs in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) based on the type of delivery structure. METHODS: Programs were classified into three delivery structures: (1) centralized, (2) decentralized, and (3) mixed. Centralized programs offer clinical services in satellite offices, but all other program activities are performed centrally. Decentralized programs contract with other entities to fully manage and provide screening and diagnostic services and other program activities. Programs with mixed service delivery structures have both centralized and decentralized features. Programmatic costs were averaged over a 3 year period (2006-2007, 2008-2009, and 2009-2010). Effectiveness was defined in terms of the average number of women served over the 3 years. We report costs per woman served by program activity and delivery structure and incremental cost effectiveness by program structure and by breast/cervical services. RESULTS: Average costs per woman served were lowest for mixed program structures (breast = $225, cervical = $216) compared to decentralized (breast = cervical = $276) and centralized program structures (breast = $259, cervical = $251). Compared with decentralized programs, for each additional woman served, centralized programs saved costs of $281 (breast) and $284 (cervical). Compared with decentralized programs, for each additional woman served, mixed programs added an additional $109 cost for breast but saved $1,777 for cervical cancer. CONCLUSIONS: Mixed program structures were associated with the lowest screening and diagnostic costs per woman served and had generally favorable incremental costs relative to the other program structures.

Awardee-specific economic costs of providing cancer screening and health promotional services to medically underserved women eligible in the National Breast and Cervical Cancer Early Detection Program.

OBJECTIVES: To estimate awardee-specific costs of delivering breast and cervical cancer screening services in their jurisdiction and to assess potential variation in the cost of key activities across awardees. METHODS: We developed the cost assessment tool to collect resource use and cost data from the National Breast and Cervical Cancer Early Detection Program awardees for 3 years between 2006 and 2010 and generated activity-based cost estimates. We estimated awardee-specific cost per woman served for all activities, clinical screening delivery services, screening promotion interventions, and overarching program support activities. RESULTS: The total cost per woman served by the awardees varied greatly from $205 (10th percentile) to $499 (90th percentile). Differences in the average (median) cost per person served for clinical services, health promotion interventions, and overarching support activities ranged from $51 to $125. CONCLUSIONS: The cost per woman served varied across awardee and likely reflected underlying differences across awardees in terms of screening infrastructure, population served, and barriers to screening uptake. Collecting information on contextual factors at the awardee, health system, provider, and individual levels may assist in understanding this variation in cost.

Cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program.

PURPOSE: To estimate the cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: Using a modified CISNET breast cancer simulation model, we estimated outcomes for women aged 40-64 years associated with three scenarios: breast cancer screening within the NBCCEDP, screening in the absence of the NBCCEDP (no program), and no screening through any program. We report screening outcomes, cost, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and sensitivity analyses results. RESULTS: Compared with no program and no screening, the NBCCEDP lowers breast cancer mortality and improves QALYs, but raises health care costs. Base-case ICER for the program was $51,754/QALY versus no program and $50,223/QALY versus no screening. Probabilistic sensitivity analysis ICER for the program was $56,615/QALY [95% CI $24,069, $134,230/QALY] versus no program and $51,096/QALY gained [95% CI $26,423, $97,315/QALY] versus no screening. CONCLUSIONS: On average, breast cancer screening in the NBCCEDP was cost-effective compared with no program or no screening.

Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program: Increasing Access to Screening.

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast and cervical cancer screening and diagnostic services to low-income, uninsured, and underinsured women across the nation. Although the program has provided services to more than 5 million women since 1991, there remains a significant burden of breast and cervical cancer with inequities among certain populations. To reduce this burden and improve health equity, the NBCCEDP is expanding its scope to include population-based strategies to increase screening in health systems and communities through the implementation of patient and provider evidence-based interventions, connecting women in communities to clinical services, increasing opportunities to access screening, and enhancing the targeting of women in need of services. The goal is to reach more women and make sure women are getting the right screening test at the right time.

Prevalence of Out-Of-Pocket Payments for Mammography Screening Among Recently Screened Women.

Background: Because cost may be a barrier to receiving mammography screening, cost sharing for "in-network" screening mammograms was eliminated in many insurance plans with implementation of the Affordable Care Act. We examined prevalence of out-of-pocket payments for screening mammography after elimination in many plans. Materials and Methods: Using 2015 National Health Interview Survey data, we examined whether women aged 50-74 years who had screening mammography within the previous year (n = 3,278) reported paying any cost for mammograms. Logistic regression models stratified by age (50-64 and 65-74 years) examined out-of-pocket payment by demographics and insurance (ages 50-64 years: private, Medicaid, other, and uninsured; ages 65-74 years: private ± Medicare, Medicare+Medicaid, Medicare Advantage, Medicare only, and other). Results: Of women aged 50-64 years, 23.5% reported payment, including 39.1% of uninsured women. Compared with that of privately insured women, payment was less likely for women with Medicaid (adjusted OR 0.17 [95% CI 0.07-0.41]) or other insurance (0.49 [0.25-0.96]) and more likely for uninsured women (1.99 [0.99-4.02]) (p < 0.001 across groups). For women aged 65-74 years, 11.9% reported payment, including 22.5% of Medicare-only beneficiaries. Compared with private ± Medicare beneficiaries, payment was less likely for Medicare+Medicaid beneficiaries (adjusted OR 0.21 [95% CI 0.06-0.73]) and more likely for Medicare-only beneficiaries (1.83 [1.01-3.32]) (p = 0.005 across groups). Conclusions: Although most women reported no payment for their most recent screening mammogram in 2015, some payment was reported by >20% of women aged 50-64 years or aged 65-74 years with Medicare only, and by almost 40% of uninsured women aged 50-64 years. Efforts are needed to understand why many women in some groups report paying out of pocket for mammograms and whether this impacts screening use.

Uterine Cancer Incidence and Mortality - United States, 1999-2016.

Uterine cancer is one of the few cancers with increasing incidence and mortality in the United States, reflecting, in part, increases in the prevalence of overweight and obesity since the 1980s (1). It is the fourth most common cancer diagnosed and the seventh most common cause of cancer death among U.S. women (1). To assess recent trends in uterine cancer incidence and mortality by race and ethnicity, CDC analyzed incidence data from CDC's National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and mortality data from the National Vital Statistics System (2). Most recent data available are through 2015 for incidence and through 2016 for mortality. Uterine cancer incidence rates increased 0.7% per year during 1999-2015, and death rates increased 1.1% per year during 1999-2016, with smaller increases observed among non-Hispanic white (white) women than among women in other racial/ethnic groups. In 2015, a total of 53,911 new uterine cancer cases, corresponding to 27 cases per 100,000 women, were reported in the United States, and 10,733 uterine cancer deaths (five deaths per 100,000 women) were reported in 2016. Uterine cancer incidence was higher among non-Hispanic black (black) and white women (27 cases per 100,000) than among other racial/ethnic groups (19-23 per 100,000). Uterine cancer deaths among black women (nine per 100,000) were higher than those among other racial/ethnic groups (four to five per 100,000). Public health efforts to help women achieve and maintain a healthy weight and obtain sufficient physical activity can reduce the risk for developing cancer of the endometrium (the lining of the uterus), the most common uterine cancer. Abnormal vaginal bleeding, including bleeding between periods or after sex or any unexpected bleeding after menopause, is an important symptom of uterine cancer (3). Through programs such as CDC's Inside Knowledge* campaign, promoting awareness among women and health care providers of the need for timely evaluation of abnormal vaginal bleeding can increase the chance that uterine cancer is detected early and treated appropriately.

Disparities in breast cancer survival in the United States (2001-2009): Findings from the CONCORD-2 study.

BACKGROUND: Reducing breast cancer incidence and achieving equity in breast cancer outcomes remains a priority for public health practitioners, health care providers, policy makers, and health advocates. Monitoring breast cancer survival can help evaluate the effectiveness of health services, quantify inequities in outcomes between states or population subgroups, and inform efforts to improve the effectiveness of cancer management and treatment. METHODS: We analyzed breast cancer survival using individual patient records from 37 statewide registries that participated in the CONCORD-2 study, covering approximately 80% of the US population. Females were diagnosed between 2001 and 2009 and were followed through December 31, 2009. Age-standardized net survival at 1 year, 3 years, and 5 years after diagnosis was estimated by state, race (white, black), stage at diagnosis, and calendar period (2001-2003 and 2004-2009). RESULTS: Overall, 5-year breast cancer net survival was very high (88.2%). Survival remained remarkably high from 2001 through 2009. Between 2001 and 2003, survival was 89.1% for white females and 76.9% for black females. Between 2004 and 2009, survival was 89.6% for white females and 78.4% for black females. CONCLUSIONS: Breast cancer survival was more than 10 percentage points lower for black females than for white females, and this difference persisted over time. Reducing racial disparities in survival remains a challenge that requires broad, coordinated efforts at the federal, state, and local levels. Monitoring trends in breast cancer survival can highlight populations in need of improved cancer management and treatment. Cancer 2017;123:5100-18. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Cervical cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in four US-Affiliated Pacific Islands between 2007 and 2015.

BACKGROUND: Cervical cancer incidence in the US-Affiliated Pacific Islands (USAPIs) is double that of the US mainland. American Samoa, Commonwealth of Northern Mariana Islands (CNMI), Guam and the Republic of Palau receive funding from the Centers for Disease Control (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to implement cervical cancer screening to low-income, uninsured or under insured women. The USAPI grantees report data on screening and follow-up activities to the CDC. MATERIALS AND METHODS: We examined cervical cancer screening and follow-up data from the NBCCEDP programs in the four USAPIs from 2007 to 2015. We summarized screening done by Papanicolaou (Pap) and oncogenic human papillomavirus (HPV) tests, follow-up and diagnostic tests provided, and histology results observed. RESULTS: A total of 22,249 Pap tests were conducted in 14,206 women in the four USAPIs programs from 2007-2015. The overall percentages of abnormal Pap results (low-grade squamous intraepithelial lesions or worse) was 2.4% for first program screens and 1.8% for subsequent program screens. Histology results showed a high proportion of cervical intraepithelial neoplasia grade 2 or worse (57%) among women with precancers and cancers. Roughly one-third (32%) of Pap test results warranting follow-up had no data recorded on diagnostic tests or follow-up done. CONCLUSION: This is the first report of cervical cancer screening and outcomes of women served in the USAPI through the NBCCEDP with similar results for abnormal Pap tests, but higher proportion of precancers and cancers, when compared to national NBCCEDP data. The USAPI face significant challenges in implementing cervical cancer screening, particularly in providing and recording data on diagnostic tests and follow-up. The screening programs in the USAPI should further examine specific barriers to follow-up of women with abnormal Pap results and possible solutions to address them.

Trends in Cervical Cancer Screening in Title X-Funded Health Centers - United States, 2005-2015.

Cervical cancer screening is critical to early detection and treatment of precancerous cells and cervical cancer. In 2015, 83% of U.S. women reported being screened per current recommendations, which is below the Healthy People 2020 target of 93% (1,2). Disparities in screening persist for women who are younger (aged 21-30 years), have lower income, are less educated, are uninsured, lack a source of health care, or who self-identify as Asian or American Indian/Alaska Native (2). Women who are never screened or rarely screened are more likely to develop cancer and receive a cancer diagnosis at later stages than women who are screened regularly (3). In 2013, cervical cancer was diagnosed in 11,955 women in the United States, and 4,217 died from the disease (4). Aggregated administrative data from the Title X Family Planning Program were used to calculate the percentage of female clients served in Title X-funded health centers who received a Papanicolaou (Pap) test during 2005-2015. Trends in the percentage of Title X clients screened for cervical cancer were examined in relation to changes in cervical cancer screening guidelines, particularly the 2009 American College of Obstetricians and Gynecologists (ACOG) update that raised the age for starting cervical cancer screening to 21 years (5) and the 2012 alignment of screening guidelines from ACOG, the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) on the starting age (21 years), screening interval (3 or 5 years), and type of screening test (6-8). During 2005-2015, the percentage of female clients screened for cervical cancer dropped continually, with the largest declines occurring in 2010 and 2013, notably a year after major updates to the recommendations. Although aggregated data contribute to understanding of cervical cancer screening trends in Title X centers, studies using client-level and encounter-level data are needed to assess the appropriateness of cervical cancer screening in individual cases.