Group pushes to wipe out cervical cancer
■ Physicians say numbers can certainly go lower, particularly if the vaccine is introduced, but doubt disease can be eliminated completely.
By Victoria Stagg Elliott — Posted Feb. 21, 2005
Myer Bornstein, MD, a gynecologist in Taunton, Mass., doesn't diagnose cervical cancer very often these days. When he does, it means one thing: The patient is one of the few women in the state who hasn't had recent screening.
"The only ones we see who have cervical cancer are those who don't come and get Pap smears," said Dr. Bornstein.
With the widespread use of Pap tests and, more recently, the introduction of tests for the presence of human papillomavirus, rates of cervical cancer have plummeted from 7.7 per 100,000 women in 1969 to 2.7 per 100,000 in 2001, according to data from the National Cancer Institute.
A women's group now says these numbers may represent significant progress, but it's not enough.
Women in Government, a bipartisan Washington, D.C. -based organization of women in state government, is challenging every state to take action to bring cervical cancer rates down to zero.
The group launched this campaign last month with the first in a planned series of annual reports. "A Call to Action: The 'State' of Cervical Cancer in America," ranks each state in efforts against the disease.
"This is the first cancer that we have the opportunity to truly eliminate," said Susan Crosby, the group's acting executive director and president. "We know what causes it. We know what can be done to prevent it."
Dr. Bornstein's home state of Massachusetts topped the organization's list because of legislation mandating coverage for Pap smears from both private and public payers. More than 86% of the state's women have been screened within the past three years. The state also has a cervical cancer commission and leads the way in using cancer prevalence data to track prevention efforts.
Such steps are consistent with American Medical Association policy, which advocates the availability of public programs for cervical cancer screening, the inclusion of the Pap smear in a standard health insurance benefits package and greater patient education about routine screening.
"I've never had one insurance company refuse to pay for a Pap smear," Dr. Bornstein said. "And the state has a program where patients can get mammograms and Pap smears paid for by the state, so there's no reason why they can't have that done."
Meanwhile, both Texas and Tennessee languished near the bottom of the list.
Texas has a screening rate of slightly more than 80% with a mortality rate of 3.5 per 100,000, much higher than the national average of 2.7.
Tennessee has a screening rate of just over 85% but a mortality rate of 3.6 per 100,000. Women in Government criticized both states for not having legislation mandating coverage of screening.
But some physicians say the issue is complicated. For example, Tennessee is suffering a current crisis in TennCare, its expanded Medicaid program, that may leave thousands of adults without coverage.
"It's abysmal that any state would have such a low percentage of getting appropriate Pap smears for women who need them," said Ted Anderson, MD, PhD, a Nashville, Tenn., obstetrician-gynecologist. "But if insurance doesn't pay for services, then it's much more difficult to get people to avail themselves of those services."
Texas also struggles with the impact of a significant immigrant population from neighboring Mexico.
"If the screening just a few miles south of here was better, we would have fewer cases," said John Jennings, MD, professor of gynecology at University of Texas Medical Branch in Galveston and immediate past president of the Texas Assn. of Obstetricians and Gynecologists.
Experts say some issues may not be resolved by policy changes. They also acknowledge that reaching a zero incidence rate is an admirable if unreachable goal.
"Theoretically it is a cancer that could be eradicated if everybody got the best screening all the time," said J. Thomas Cox, MD, director of the women's clinic at the University of California, Santa Barbara, and the physician spokesman for Women in Government. "But there's always going to be some people who, no matter what you do, you can't get them in to be screened."
Many also feel that medicine may have achieved all it can with screening alone and that what is needed to lower numbers further are improvements in technology rather than policy. A vaccine against two variants of the human papillomavirus, currently in phase III trials, may do the job.
The most recent data available was published in the Nov. 13, 2004, Lancet and suggested the vaccine was safe and prevented 100% of persistent infection with HPV 16 and 18, which lead to the majority of cervical cancers.
"With the vaccines and the Pap screening system we have in place, we really could eliminate cervical cancer," said Diane Harper, MD, MPH, lead author on the Lancet paper and an associate professor of obstetrics-gynecology and community and family medicine at Dartmouth Medical School in Hanover, N.H.