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Testimony on Cervical Cancer by Nancy C. Lee, M.D.
Associate Director for Science
National Center for Chronic Disease and Health Promotion
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Before the House Committee on Commerce, Subcommittee on Health and Environment
March 16, 1999


Good Morning, I am Dr. Nancy Lee, Associate Director for Science, within the Division of Cancer Prevention and Control of the National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. I am pleased to be here this morning to discuss how CDC approaches cervical cancer early detection through CDC's, National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

Background

Cervical cancer is nearly 100 percent preventable, yet according to the American Cancer Society, an estimated 12,800 new cases of invasive cervical cancer will be diagnosed in 1999 with about 4,800 women dying of the disease. The cervical cancer death rate declined 45 percent between the periods 1972-74 and 1992-94 and the overall incidence of the disease has decreased steadily from 14.2 per 100,000 in 1973 to 7.4 per 100,000 in 1995. This is largely attributed to the effectiveness of Pap smear screening for cervical cytology.

Even with this success, there remains significant disparities in the incidence and mortality of cervical cancer among some racial and ethnic minority women, when compared to the rate in white women. The incidence rate for all U.S. women is about 8 per 100,000; however, the highest age-adjusted incidence rate of 43 per 100,000 occurs among Vietnamese women, probably reflecting lack of appropriate screening. Incidence rates of 15 per 100,000 or higher also occur among Alaska Native, Korean, and Hispanic women. The death rate of 6.7 per 100,000 in African American women continues to be more than twice that of whites even though their incidence rate is slightly lower.

Early Detection

Cervical cancer occurs at an average age of 54; however, cervical intraepithelial neoplasia (or CIN), the precursor lesion to cervical cancer, most often occurs in much younger women. For a woman with CIN, her likelihood of survival is almost 100 percent with timely and appropriate treatment. The fact that CIN occurs at a younger age tells us that it usually takes a substantial amount of time for cervical cancer to develop. This means that screening younger women is an important strategy that actually prevents cervical cancer from ever developing. Furthermore, when cervical cancer is detected at its earliest stage, the 5-year survival rate is more than 90 percent.

Risk Factors

Studies that have identified risk factors associated with cervical cancer have shown that cervical cancer is closely linked to sexual behaviors, human papillomavirus (or HPV) infection, immunosuppressive disorders such as HIV/AIDS, as well as a failure to receive regular Pap smear screening. The sexual behaviors specifically associated with greater risk are intercourse at an early age, multiple male sexual partners, and sex with a male partner who has had multiple sexual partners. Experts agree that infection with certain strains of the HPV is one of the strongest risk factors for cervical cancer, but the most important risk factor for developing cervical cancer, at least from the point of view of what we can do about it, is the failure to receive regular screening with a Pap smear.

Screening Tests

The principal screening test for cervical cancer is the Pap smear. Since its introduction 50 years ago by Dr. Papanicolaou, the Pap smear has been widely used and is credited with the steady decline in cervical cancer deaths in the United States . Nationwide estimates from 1994 indicated that well over 90 percent of all U.S. women had received a Pap test at least once in their lives and that 80 percent had obtained one within the preceding 3 years.

Despite the ability of the Pap test to help reduce cervical cancer mortality, the test is far from 100 percent accurate. Approximately half of the inaccuracies are due to inadequate collection of the Pap smear by the health care provider and the other half are due to errors at the laboratory. Detecting a precancerous lesion such as CIN does not always mean that a cancer has been prevented because only some of the early precancerous lesions progress to cancer. Thus, the search for a more efficient means of screening for cervical cancer and precancer is ongoing.

The Food and Drug Administration has approved three new technologies for Pap smears: ThinPrep, AutoPap, and Papnet. The technologies all appear to do a somewhat better job of detecting cervical disease than conventional Pap tests. They are rapidly being adopted by laboratories nationwide and at least double the price of the conventional Pap test. However, there are concerns that the extra costs associated with these technologies will overshadow their benefits.

Two evaluations of cervical cytology were released in January: one done for the Agency for Health Care Policy and Research, and the other published in the Journal of the American Medical Association. Although the analyses were independently done, each determined that new screening technologies were cost-effective only if screening was infrequent, done every 3-4 years. They also found that the new technologies increased life expectancy by a relatively small amount compared with conventional Pap testing.

In spite of the promise of these new technologies, the American College of Obstetricians and Gynecologists stated last year that their routine use "[could] not be recommended based on costs and the lack of sufficient data demonstrating whether they reduce the incidence of or improve the survival rate from invasive cervical cancer." The college also concluded that the main focus should remain screening women who are not receiving regular screening, as they account for the majority of cervical cancer cases.

Screening Guidelines

There are several different recommendations from national, professional and governmental organizations on the frequency that women should receive a Pap test. The American Cancer Society, National Cancer Institute, American College of Obstetricians and Gynecologists, American Medical Association, American Academy of Family Physicians, and others developed a consensus agreement regarding cervical cancer screening. These organizations recommended annual Pap testing for all women who have been sexually active, or have reached the age of 18.

After three consecutive annual exams with normal findings, the Pap test could be performed less frequently at the discretion of the physician.

The U.S. Preventive Services Task Force recommends regular Pap tests for all women who are or have been sexually active, or who are 18 or older, and who have a cervix. The Pap test should be performed at least every 3 years. However, the interval for each patient should be determined by the physician, based on the woman's history of risk factors.

National Breast and Cervical Cancer Early Detection Program

Recognizing the value of appropriate cancer screening, Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101-354). This Act authorized the Centers for Disease Control and Prevention (CDC) to establish a national screening program to ensure that low income women who are uninsured or underinsured receive regular screening for breast and cervical cancer and prompt followup when necessary. In fiscal year 1999, with Congressional appropriations of $159 million, the CDC entered into the ninth year of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This landmark program brings critical breast and cervical cancer screening services to underserved women, including older women, women with low income, and women of racial and ethnic minorities.

CDC supports early detection programs in all 50 states, five U.S. territories, the District of Columbia, and 15 American Indian/Alaska Native organizations. The goal of the national program is to establish, expand, and improve community-based screening services for women at risk. The goal is achieved by screening medically underserved women for breast and cervical cancer, providing appropriate and timely diagnostic evaluations for women with abnormal screening tests and treatment services if needed, developing and disseminating public information and education related to the detection and control of breast and cervical cancer, improving training of health professionals in the detection of these cancers, and finally, evaluating program activities through the establishment of surveillance systems.

The program targets cervical cancer screening services to women who are hard to reach and are unlikely to seek a Pap test because of cultural, language, monetary or institutional barriers. As a major public health program, our overall concern must be to reach the largest number of unscreened, eligible women as possible. Thus, we also consider all women who do not receive regular Pap tests a priority population for the program. Currently, the national program follows cervical cancer screening guidelines that are consistent with the consensus guidelines developed by the American Cancer Society and others.

Providing cervical and breast cancer health education and outreach services is an essential component to the NBCCEDP. With technical guidance, our funded programs have developed projects that are focused on specific at-risk populations and cover a wide range of prevention and research activities. For example, many programs are involved with developing low literacy, bilingual and culturally appropriate educational materials that are used in a myriad of unique training and outreach programs and educational campaigns. These various strategies used by the different programs result in the common goal of increasing knowledge and awareness of breast and cervical cancer and promoting screening for early detection.

CDC partners with many national organizations to address issues related to breast and cervical cancer screening in priority populations. For instance, CDC funds the American Social Health Association to formulate a national model for the prevention of cervical cancer, using two counties in North Carolina as pilot sites and focusing upon economically disadvantaged Hispanic and African-American populations and women living in hard-to-reach urban and rural areas. This cervical cancer prevention project consists of developing and delivering culturally appropriate media messages, educational materials, client support services, and health education workshops in the community setting.

CDC is committed to increasing the awareness, availability and use of cervical cancer screening services for women. The main purpose of cervical cancer screening is not to find cancer, but to find precancerous lesions. Early detection and treatment of precancerous cervical lesions identified by Pap screening can actually prevent cervical cancer; thus, the success of any cervical cancer screening program depends on the early detection, case management and treatment of precancerous cervical lesions.

The breast and cervical cancer program has provided more than 1.1 million Pap test to a total of more than 700,000 women. With existing resources, the national program is able to screen 12%-15 percent of the eligible population annually. Almost half of the women screened are from minority racial and ethnic groups. Of Pap tests provided, about 3 percent were abnormal; more than 31,000 cases of precancerous lesions were ultimately diagnosed, and 508 women were diagnosed with invasive cervical cancer. These statistics illustrate a key point for this essential public health program. The main purpose of cervical cancer screening is to find precancerous lesions, treat them, and cure them, so that these women do not go on to be diagnosed with cervical cancer. Of all the women diagnosed with cervical disease through our program, fewer than 2 percent actually had a diagnosis of cancer. The program has potentially averted cancer in more than 31,000 women! This underscores the success of Pap testing and emphasizes the proven strategy that we as public health practitioners can use to fight this cancer.

As mentioned earlier, the success of any cervical cancer screening program depends on the early detection and treatment of precancerous cervical lesions. But we must also work hard to screen those women who are not regularly screened elsewhere. Research has shown that they are at the greatest risk for developing cervical cancer. This is the hardest part of our job, but one we cannot ignore. The National Breast and Cervical Cancer Early Detection Program will continue to develop strategies to find those women and provide the life-saving benefit of Pap smear screening.

Thank you for your interest in the cervical cancer early detection activities at CDC. I would be pleased to answer any questions you may have.


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