Comparative Effectiveness of the Cervical Screening Process:
Past, Present, and Future
Although Pap smear screening has reduced cervical cancer incidence in the United States, cervical cancer continues to be associated with substantial morbidity and mortality, contributes to racial and ethnic disparities, and imposes high economic costs. Advances in cancer epidemiology and medical technology provide a remarkable opportunity to improve upon the effectiveness and efficiency of the cervical cancer screening process. However, critical challenges remain with respect to clinical decision-making and adoption of best practices, pertaining to patient behavior, provider incentives, health systems, and the real-world clinical effectiveness of emerging technologies.
We are employing a decision-analytic approach, adapting an existing modeling framework by leveraging data from clinical provider networks and a state-of-the-art registry of cervical cancer screening information in New Mexico. We will evaluate and weigh the tradeoffs (benefits and harms) of alternative cervical interventions across the continuum of care; explore the uncertainty around their outcomes; incorporate information on patient behavior and real-world practice; and inform timely clinical and policy questions. By achieving our specific aims, we expect to have an impact on:
- the effectiveness and efficiency of the cervical cancer screening process by investigating the effects of acceptability, delivery, and adoption of best practices;
- cervical cancer outcomes, including reduced incidence, enhanced quality of life through earlier detection, improved survival, and reduced disparities;
- the equitable distribution and rationale use of new technology;
- the financial and economic profile of health care organizations related to cervical cancer control.
Deficiencies, Opportunities and Geography of Cervical Screening
While prophylactic vaccination is likely to provide important future health gains, cervical cancer screening will need to be continued for the whole generation of women that is already infected with the HPV types included in vaccines. Potential reductions in cervical cancer screening due to misconceptions about HPV vaccine protection could result in an increase in cervical cancer rather than the anticipated reductions. Many alterations in cervical cancer screening practices per recent clinical guideline recommendations are anticipated both in the near term and over the long-term. Population-based U.S. surveillance is critical to assessing the safety and effectiveness of these changes as well as to address continuing failures in the cervical screening, diagnosis and treatment process. Sustained population-based surveillance enables the assessment of system and practice failures and successes prior to and coincident with a variety of anticipated overlapping changes in cervical cancer prevention programs (e.g. vaccination, lengthened screening intervals and new HPV tests and applications).
Data from our cervical cancer screening surveillance unit, the New Mexico HPV Pap Registry (NMHPVPR) can describe screening, diagnosis and treatment histories of women diagnosed with incident invasive cervical cancer. The NMHPVPR data forms the cornerstone of our PROSPR Screening Process Documentation Unit (SPDU). Through partnerships with the University of New Mexico (UNM) Geospatial and Population Studies (GPS) program and Dr. Dan Goldberg, who is now with Texas A&M Geography Department, we will also identify and evaluate the impact of geographic barriers on failures in screening and prevention practices and invasive cervical cancer outcomes. New Mexico offers a rich opportunity in which this surveillance is conducted among diverse multi-cultural populations suffering a variety of health disparities including those attributable to high levels of poverty and rural living.
Failures to screen, diagnose, and treat women for cervical precancer and cancer are well documented. The current U.S. screening program fails to reach small pockets of populations living mainly in low-resource, medically underserved regions as part of a complex of diseases linked to poverty and/or racial disparities. It is reasonable to suggest that the current cervical cancer prevention program has reached its limits and innovative strategies are needed to overcome these barriers and further reduce the disease burden in underserved populations.
NM-HOPES-PROSPR will fully describe the current cervical screening, diagnostic, and treatment care continuum, and identify areas needing improvement for targeted interventions.