Understanding Over- and Under-Screening of Cervical Cancer Among a National Sample of Commercially Insured Women: Implications for Health Equity



Cervical cancer screening guidelines have changed frequently in recent years. Different adherence patterns by screening modalities (e.g., cytology-only, HPV testing-only, co-testing) could lead to overuse and underuse of care. It is unclear if receipt of guideline adherent screening varies among racial/ethnic minorities and those with low socioeconomic status (SES), which can exacerbate existing disparities. 


Optum Clinformatics Data Mart from 2013-2021 was used to identify women aged 30-65 to examine over- and under-screening to understand national patterns of guideline adherence. Average-risk women with continuous enrollment for 6 years for years starting in 2012-2016 and at least one claim were included. Those with history of hysterectomy and cervical cancer were excluded. According to the 2012 U.S. Preventive Services Task Force guideline, adherence was defined as screening interval of 4.5-5.5 years for co-testing/HPV testing as the index screening modality and 2.5-3.5 years for cytology-only, and over-screening as <4.5 years and <2.5 years, and under-screening as > 5.5 years and > 3.5 years including lack of subsequent screening, respectively. We compared distribution of screening adherence by screening modality, race, education level, and household net worth using chi-squared test. 


A total of 1,422,258 individuals ages 30-65 were included. Among the eligible sample, 1,016,067 women received at least one cervical cancer screening from 2013-2017. Of these, 830,549 (81.7%) were considered average-risk. About half (48.4%) received an index screening with cytology-only, 51.0% with co-testing and 0.6% with HPV testing. Overall, 7.4% were guideline adherent, 62.1% were over-screened and 30.5% were under-screened. 12.7% of the women screened with cytology-only were adherent compared to 2.5% of those screened with co-testing, 59.2% vs. 64.9% were over-screened, and 28.1% vs. 32.6% were under-screened, respectively. Unadjusted differences in the distribution of adherence were statistically significant by race, education level, and household net worth (p < 0.01). 


The study identified high rates of over-screening and under-screening among a national cohort of commercially insured women, signaling the need for interventions to improve guideline adherent screening. Furthermore, over- and under-screening varied by screening modalities, race and SES factors, which highlights the need to study specific patterns of adherence among subpopulations to address cervical cancer inequities.

The full study can be viewed at JCO Oncology Practice.

Shin, M., Axeen, S., & Tsui, J. (2023). Understanding over-and under-screening of cervical cancer among a national sample of commercially insured women: Implications for health equity.

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