Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

Wrong Agenda: Early Detection Program’s Failure to Promote the Early Detection of Cervical Cancer Among at Risk Women in Florida–Emily Butler

Cervical cancer was once a leading cause of cancer death for women in the United States. The availability of the Papanicolaou smear (Pap test) as an early detection tool is largely credited for reducing the mortality rate by 74% between the years 1955 and 1992 (1). Despite the availability of early detection, it is estimated that 11,150 women will be diagnosed with cervical cancer in the United States during the year 2007. Furthermore, although cervical cancer treatments may be curative or life extending, approximately 3,670 women are expected to die of the disease during the same year. The Pap test allows cervical cancer to be detected and treated before it becomes cancerous, in its earliest most curable stage, (2). Although it does not yield perfect results, it is believed that the vast majority of cervical cancer cases can be prevented if women participate in regular screening with the Pap test. Approximately 60% to 80% of new cervical cancer diagnoses occur in women who report not having a Pap test in the last five years (3).

In an effort to improve access to screenings for breast and cervical cancer, Congress passed The Breast and Cervical Cancer Mortality Prevention Act of 1990. The Act established the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to provide early detection screenings for low income and uninsured women in all 50 states. The expressed goal of the program is to provide breast cancer screenings for women between the ages of 40 and 64 and cervical cancer screenings for women between 18 and 64 years of age, and at or below 250% of federal poverty level. The program has to date provided more than 6.9 million screenings (4).

Although a success in many respects, the NBCCEDP’s lack of funding prohibits many categorically eligible women from accessing free screenings. Nationally, funding is only available to offer screenings to four out of five women who should be eligible according to the program’s age and financial qualifications. Some states match or contribute to program funding with state funds, thereby allowing as many eligible women to participate as possible. Eleven states, however, do not contribute any state funds to their state’s screening program (5).

Without adequate funding, many states choose to limit the availability of screenings to women in select geographic areas and in particular age groups, thereby excluding at risk women from accessing free screenings. The availability of cervical cancer screenings in the state of Florida serves as a case example for the limitations of the program under budgetary constraints. Florida is one of the eleven states that does not contribute any state funds to the program (4). The Florida Breast and Cervical Cancer Early Detection Program (FBCCEDP) limits cervical cancer screenings to women between the ages of 50 and 64, narrows financial eligibility to women at or below 200% of Federal Poverty Level, and offers the program in only 16 sites in the state (6). Due to these limitations, the FBCCEDP is ineffective in screening young, low-income, and rural women who are at risk for developing cervical cancer. It is estimated that there were 842 new cases of invasive cervical cancer diagnosed in Florida in the year 2003. Florida’s incidence rate of cervical cancer in 2003, 9.2 new cases per 100,000 women, is above the national incidence rate of 8.1 and ranks 14th highest in the nation (8). Although the incidence of cervical cancer is lower than many other types of cancer, early detection efforts warrant attention as many of these cases might be prevented with increased access to and use of the Pap test.

Geographic Inaccessibility Prohibits Utilization of Screenings
Although the FBCCEDP offers services to women in all 67 Florida counties who meet program requirements, there are only 16 sites where the screening services are actually offered (6). Even if a woman qualifies for a screening, she may not have the means to travel to a program site to have the screening done. Eligible women, between the ages of 50 and 65, are of working age and may find it difficult to take time off work to travel to a site. Furthermore, eligible women with incomes less than 200% of Federal Poverty level may not have transportation or the means to afford the expense of travel. The geographic distribution of screening sites may effectively prohibit eligible women from traveling to access a site that offers screenings. It is also highly possible that these women in more rural or remote areas may be less able to afford a Pap test from an alternate provider, if there is even a provider available within the local community. Women living in rural counties, especially in counties not adjacent to a county with an urban area, are less likely to have health insurance coverage or have access to employer-sponsored health insurance (9). Compared to the urban population, people in rural areas also earn lower incomes and are less healthy in general (9.)

Age Criteria Creates a Public Agenda
Under the FBCCEDP program, women under the age of 50 are not eligible to receive screenings despite financial eligibility (6). Although it is rare for a woman under the age of 20 to develop cervical cancer, it is estimated that 50% of cases occur in women between age 35 and 55 (2). Therefore, a significant number of at risk women are not eligible for program services. By systematically excluding younger women, the program may be inadvertently setting a public agenda to promote screening-seeking behavior primarily in older women. A public program’s emphasis on a particular public health issue may direct the public’s attention to perceive the issue as being “high on the agenda” (7). In this case, the availability of a public program to offer cervical cancer screenings for women only between the ages of 50 and 64 may inadvertently set the public’s agenda to view cervical cancer as a risk primarily in this age group. It is then possible that younger, excluded women might not seek screenings from other providers because they do not perceive that their risk as “high on the agenda,” or of significant proportion. Although likely unintended, the program’s age restrictions may be creating a public perception that younger women are not as at risk of developing cervical cancer, when in fact they represent a significant proportion of new cases.

Lack of an Alternative Screening Option
The NBCCEDP and the FBCCEDP do not offer an alternate screening option for the approximate 80% of women that should, but do not qualify for screening services. Women that cannot access screenings are left to navigate the patchwork system of charitable medical services offered by other organizations and institutions. If the program offered a solution, such as a sliding scale fee for excluded women, more women might access reduced cost services even though they could not qualify for a free screening. Without a viable alternative, many women may choose to forgo screenings altogether.

According to the theory of Diffusion of Innovations, health behaviors may be increasingly adopted over time as more people begin to perform the behavior (7). By neglecting to offer a low cost or alternate screening option for ineligible women, the FBCCEDP fails to utilize the potential benefits of this theory. If more women were able to access screenings, perhaps at a small personal cost, adoption of the behavior might increase more rapidly.

The FBCCEDP fails to offer cervical cancer screenings to a large population of at risk women in the state of Florida. Although funding may be limited, careful attention should be paid to the way that screenings are made available so that the most at risk women have the opportunity to stop cervical cancer at its earliest stage. The systematic disqualification of younger women and women in rural areas may prevent some of these at risk women from accessing a Pap test altogether. Furthermore, this inaccessibility may consequently portray a message that younger women are not as at risk of developing cervical cancer. The program does not seize the opportunity to encourage an early habit of annual Pap test screening. The FBCCEDP should be revised to more equitably distribute screening services and encourage more women to access cervical cancer screenings.

Compared to other cancer screening tools, the Pap test is a relatively inexpensive intervention. Although cervical cancer incidence rates have declined rapidly since its innovation, there is no reason why rates should not continue to fall. With appropriately designed public health interventions, the Pap test could be made available to more at risk women.

1. National Cancer Institute. Cancer Advances in Focus: Cervical Cancer. National Cancer Institute: 2006. Accessed 8 December 2007, from
2. American Cancer Society. Detailed Guide: Cervical Cancer. Atlanta, GA: American Cancer Society: 2007. Accessed 8 December 2007, from
3. American Cancer Society. Cancer Facts & Figures. Atlanta, GA: American Cancer Society: 2007.
4. Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program. Atlanta, GA: Centers for Disease Control and Prevention: 2007. Accessed 8 December 2007, from
5. The American Cancer Society Cancer Action Network. How Do You Measure Up?: A Progress Report on State Legislative Activity to Reduce Cancer Incidence and Mortality, August 2007. Washington, DC: ACS CAN: 2007.
6. Florida Department of Health. Program Overview: the Florida Breast and Cervical Cancer Early Detection Program. State of Florida: 2007. Accessed 8 December 2007, from
7. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. State Cancer Profiles. Incidence Rate Report by State. National Cancer Institute: 2007. Accessed 8 December 2007, from
9. Kaiser Commission on Medicaid and the Uninsured. The Uninsured in Rural America: Key Facts. The Henry J. Kaiser Family Foundation. April 2003.

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