Women's clinic closures associated with higher cervical cancer mortality, lower screening
Following the closure of nearly 100 women's health clinics across the United States from 2010 to 2013, fewer women were screened for cervical cancer, more women were diagnosed with advanced stages of the disease and mortality rates rose. Findings from a new analysis combining several nationwide datasets were presented at the 61st Annual Meeting of the American Society for Radiation Oncology (ASTRO).
"The data are troubling," said Amar Srivastava, MD, MPH, a resident physician in radiation oncology at Washington University School of Medicine in St. Louis, and lead author on the study. "Reducing the availability of cervical cancer screening has very real, negative consequences for women. Cervical cancer is largely preventable because of the wide availability of the HPV vaccine and screening that can detect precancerous lesions. The pressing issue now is to ensure that all women have access to screening."
Cervical cancer was once the most common cause of cancer death for American women, according to the American Cancer Society. Mortality rates dropped significantly with increased use of the pap test, which can detect changes in the cervix prior to the development of cancer or in its early stages, when the disease is easier to treat. Still, cervical cancer today claims the greatest number of years of life lost to cancer among American women, often cutting short the lives of women who would otherwise have many healthy years of life remaining. Each year, there are more than 13,000 new cervical cancer cases diagnosed and 4,250 deaths from the disease.
Nearly 100 comprehensive women's clinics closed between 2010 and 2013 due primarily to changes in funding structures (e.g., regulations for Title X funding) and the passage of laws that regulated standards at these clinics. "As these clinics closed over time, it appears that a fewer women were getting screened, and this trend appears to be associated with a greater number of women ultimately dying from cervical cancer," said Dr. Srivastava.
Dr. Srivastava and his team grouped states into two cohorts: those that experienced a decrease in the number of women's health clinics per capita from 2010 to 2013 (n=37), and those with either no decrease in the number of clinics or an increase in the number of clinics providing reproductive and other health services to women (n=13). The researchers relied on data for nearly 200,000 women in the Behavioral Risk Factors Surveillance Study (BRFSS) to evaluate screening utilization, and data for more than 10,000 women in the Surveillance, Epidemiology and End Results Registry (SEER) to evaluate cancer stage at diagnosis and mortality. For each cohort of states, the analyses compared data for women in both data sets from 2008 to 2009 with outcomes from 2014 to 2015.
They found that states that experienced clinic closures also saw a 2% drop in cervical cancer screenings, relative to states without clinic closures, with the greatest declines in screening for patients without insurance (-6.18 percentage points (PP), p=0.01), Hispanic women (-5.32 PP, p<0.01), women ages 21 to 34 (-4.81 PP, p<0.01and unmarried women (-4.37 PP, p<0.01).
Overall, cervical cancer survival rates improved in states without clinic closures but dropped in those with a reduction in the number of clinics. There was a significant increase in the risk of dying from cervical cancer (HR 1.36, 95% CI 1.02-1.83, p=0.04) in states where clinics were closing, especially among residents in urban areas (HR 1.40, 95% CI 1.04- 1.90, p=0.03).
Researchers also found an increase in early-stage diagnoses among 18-34-year-old women in states in which no clinics had closed, but a decrease in early-stage diagnoses for this same age group in states in which clinics had closed. In those states, 13% fewer women were diagnosed in the early stages of cervical cancer than in states without closures. Correspondingly, there was a trend toward increased late-stage diagnoses in this age group women, with 8% more women being diagnosed with late-stage disease in states with clinic closures (p=0.14). Patients diagnosed with later stages of cancer generally face worse prognoses and must undergo more aggressive treatment.
"At first we thought it sounded good that there were fewer early-stage diagnoses," said Dr. Srivastava. "But then we saw the trend toward later-stage diagnoses, for which patients need more invasive treatments, all of which have side effects. Even more concerning, we saw a higher risk of mortality in states with decreasing numbers of clinics. A story started to come together looking at these two sets of data, of this association between clinics closing and fewer women undergoing screening and an association between clinics closing and more women dying from cervical cancer."
The findings, were startling, said Dr. Srivastava, because of the short period of time it took for serious adverse effects to occur. "In order to see a difference in cancer survival rates, you usually need very mature, long-term follow-up data," he said. "It can be 15-20 years in some cases. What is surprising about this study is that even though these closures occurred just a few years ago, we are already seeing clear differences in death versus survival from cervical cancer. That was both surprising and scary."
While the correlational study cannot confirm a causal relationship between the health clinic closures and an increase in adverse health impacts for women, the findings should raise serious flags, said Dr. Srivastava.
"I really do think these findings should give us some pause. Overall, we're seeing improved survival for cervical cancer relative to other cancers, but in the states with clinic closures we are seeing just the opposite. It should make us think—not just as medical providers and practitioners, but as people broadly—about why this is happening and what we can do to increase rather than limit access to health care."