OP-ED: Increasing Health Equity for Cervical Cancer in the U.S.

Findings from a survey conducted by The Harris Poll of more than 2,000 women ages 18+ from the U.S., U.K., and Sweden reveal significant issues with regard to perceived access to cervical cancer screening, confusion around screening guidelines and prevention, and suggest potentially life-threatening misconceptions about the connection between HPV and cervical cancer.
 
The majority of respondents think health care access is equitable in their respective countries (79% Sweden, 76% U.K., and 60% U.S.). It wouldn’t be much of a stretch to presume that the 60% in the U.S. who feel access is equitable, were not among the 19% of the women who say they have delayed a gynecology visit because they lacked insurance coverage (compared to 8% U.K., 3% Sweden). Yet in the U.S., for example, we know there are substantial racial and ethnic health care inequities throughout the country, even in states that are recognized as providing high-quality health care to their residents.
 
How can we fix a problem that the majority does not think exists?
 
Something is clearly missing when it comes to women’s health care and cervical cancer prevention more broadly. The more we look at the data, the more we realize the amount of difficulty that could be mitigated through equitable access and better education about cervical cancer and its causes, as well as making available more comfortable and convenient screening options, like self-collection.
 
According to the World Health Organization (WHO), cervical cancer is the fourth most common cancer among women, resulting in the death of more than 340,000 women globally each year. However, at the same time, we also know that we could virtually eliminate this alarming mortality rate through a comprehensive approach that includes effective human papillomavirus (HPV) screening before it can cause cancer.

Breaking Barriers to Access and Understanding

To make any meaningful progress toward preventing cervical cancer, we must address the lack of access to health care that persists around the world. The simple fact is that women in low- and middle-income countries, as well as racial and ethnic minorities in high-income countries like the U.S., remain disproportionately affected by cervical cancer diagnoses and death. U.S. women surveyed are about twice as likely to say they didn’t have an OB/GYN (27% U.S. vs. 16% Sweden, 14% UK) or insurance coverage.
 
The reasons for this are of course manifold; however, the combination of a lack of accurate information and the absence of convenient, accessible, and less invasive screening solutions for women in marginalized communities seems to play a significant role.
 
Deficiency in knowledge clearly remains a major barrier to underserved women following guidelines around testing and receiving screening in a timely manner. Moreover, it has been shown that upwards of 60% of cervical cancer cases in the U.S. have occurred in populations of unscreened or under-screened women, whose challenges around factors such as childcare and transportation to health care facilities from remote or rural areas further exacerbate the issue. And what this tells us is that while access to education promoting appropriate testing guidelines and broader information around cervical cancer is indeed crucial, it doesn’t solve the lack of options and sheer inconvenience and discomfort associated with traditional screening processes.
 
Many women stated that they don’t understand the difference between a Pap test and an HPV test (77% U.K., 70% Sweden, 58% U.S.), and frequently find the overall guidance around cervical cancer screening to be confusing (59% Sweden, 57% U.S., 55% U.K.). Even more disconcerting is the fact that a similar majority simply have no idea how often to get screened, a persistent and troubling knowledge gap that disproportionately negatively impacts women in underserved communities, particularly Black and Hispanic women in the U.S.
 
In fact, it’s impossible to talk about the broader challenges facing cervical cancer prevention without highlighting the barriers to access and information.

Self-Collection: A Breakthrough in Women’s Health Care

Many countries have taken rapid actions to address the disparity in access by empowering women to self-collect for cervical cancer screening. Unfortunately, the U.S. has fallen behind countries like Denmark, Sweden, the Netherlands, Kenya, Australia and New Zealand, just to name a few, where women may self-collect without visual supervision. The FDA has not yet approved self-collection tests for cervical cancer screening in the US.
 
More specifically, these advances in non-traditional care settings and at-home medical technology have helped introduce an alternative, self-collection-based method to cervical cancer testing that removes the need for women to undergo traditional in-clinic testing. These options are not trivial when you consider that when most women surveyed delayed having a gynecology visit (67% U.S., 62% Sweden, 59% UK), they cited discomfort with pelvic exams (U.S., Sweden) or embarrassment (U.K.) among the primary factors.
 
Equally viable and effective, self-collection solutions allow women to collect their own samples without clinician assistance, and in some cases, from the privacy of their homes, foregoing not only the inconvenience but also the added expenses and discomfort often associated with in-person pelvic exams. Self-collection is less invasive. It does not require stirrups and a speculum — just a small swab. The more women can get screened, the more we can detect precancer early and prevent cervical cancer.
 
In fact, beyond widespread misconceptions around cervical cancer and screening, the survey also revealed support among most participants for at-home testing solutions (70% U.K., 69% Sweden and 66% U.S.). In addition to citing added privacy and overall convenience, women in the U.S. were found twice as likely to want to test at home for cost-related reasons, while Black and Hispanic women in the U.S. specifically were more likely to agree that at-home testing could remove the pain and discomfort of traditional Pap tests.
 
In short, by redefining the diagnostic setting, self-collection for cervical cancer screening alongside improved provision and clarity of information and guidelines, will build bridges over long-established barriers to access to create greater equity across all racial and socioeconomic groups and ultimately prevent a significant majority of cervical cancer deaths.
 

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Jeff Andrews, MD, FRCSC is Medical and Scientific Affairs VP for BD Life Sciences. A Board-Certified Obstetrician and Gynecologist, Dr. Andrews has provided care in community settings in both metropolitan Toronto, Ontario, Canada and Washington, DC. He has also provided care in academic settings as an Associate Professor at Duke University Medical Center and at Vanderbilt University Medical Center. At BD, Dr. Andrews has focused on molecular diagnostics and the prevention of cervical cancer through early detection of cancer precursors, and on novel approaches to the diagnosis of infectious diseases in women. In 2020-2021, Dr. Andrews worked with the BD teams delivering SARS-CoV-2 diagnostics to meet the needs for molecular testing and for rapid point-of-care testing.