Meeting the cervical cancer screening needs of underserved women: The National Breast and Cervical Cancer Early Detection Program, 2004–2006
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- Tangka, F.K.L., O’Hara, B., Gardner, J.G. et al. Cancer Causes Control (2010) 21: 1081. doi:10.1007/s10552-010-9536-3
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To examine the extent to which the only national organized screening program in the US, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), has helped to meet the cervical cancer screening needs of underserved women.
Low-income, uninsured women 18–64 years of age are eligible for free cervical cancer screening services through NBCCEDP. We used data from the US Census Bureau to estimate the number of eligible women, based on insurance status and income. The estimates were adjusted for hysterectomy status using the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. We used administrative data from NBCCEDP to obtain the number of women receiving NBCCEDP-funded Papanicolaou (Pap) tests. We then calculated the percentage of NBCCEDP-eligible women who received free cervical cancer screening through NBCCEDP. We also used the NHIS to calculate the percentage of NBCCEDP-eligible women screened nationally and the percentage unscreened.
In 2004–2006, nearly 9% (775,312 of 8.9 million) of NBCCEDP-eligible women, received NBCCEDP-funded Pap test. Rates varied substantially by age groups, race, and ethnicity. NBCCEDP-eligible women 40–64 years of age had a higher screening rate (22.6%) than eligible women 18–39 years of age (2.3%). Non-Hispanic women had a higher screening rate (9.3%) than Hispanic women (7.3%). Among non-Hispanics, the screening rate was highest among American Indian and Alaska Native (AIAN) women (36.1%) and lowest among women of different race combinations (4.6%), The percentage of eligible women screened in each state ranged from 2.0 to 38.4%.
Although NBCCEDP provided cervical cancer screening services to 775,312 low-income, uninsured women, this number represented a small percentage of those eligible. In 2005, more than 34% of NBCCEDP-eligible women (3.1 million women) did not receive recommended Pap tests from either NBCCEDP or other sources.
KeywordsCervical cancerPap tests utilizationScreening ratesMedically underserved
Recent trends indicate that mortality from cervical cancer has declined significantly in the United States (US) due to screening and treatment of precursor lesions and early-stage disease [1–3]. However, much progress remains to be made: In 2004, 11,999 women were diagnosed with cervical cancer, and nearly 3,924 women died from the disease . Although timely cervical cancer screening with the Papanicolaou (Pap) test reduces mortality , screening rates in the United States are low among low-income women who lack insurance coverage for Pap tests, particularly Hispanic women, those living in geographically isolated areas, and foreign-born women [3–6]. Based on data from the National Health Interview Survey (NHIS), in 1992, among women 18 years of age and older, 77.9% of women with health insurance and 68.6% of women without health insurance had received a Pap test during the previous 3 years. Among those women with family incomes above the federal poverty threshold, 78.9% had received a Pap test during the previous 3 years, and 71.3% of women from families with income below the poverty threshold had received this service (Trevor Thompson, personal communication, August 2008).
To address the disparities in screening rates and to help low-income, uninsured women gain access to cervical cancer screening services, the US Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101–354), authorizing the Centers for Disease Control and Prevention (CDC) to establish the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) . This program provides services through cooperative agreements with 68 grantees located in all 50 states, the District of Columbia (DC), 5 US territories, and 12 American Indian and Alaska Native organizations. In this article, states include residents of the 50 states and the District of Columbia. The CDC provides grants directly to each state department of health or tribal organization. The grantees coordinate delivery of clinical services provided within local clinical settings. A detailed description of the program’s history is available on NBCCEDP’s website .
Overall screening rates for either breast or cervical cancers for earlier time periods  and recent breast cancer screening rate for NBCCEDP-eligible women through the program have been published previously . The purpose of this report was to examine the extent to which NBCCEDP has helped meet the cervical cancer screening needs of low-income, uninsured women in the United States. Specifically, we estimated the numbers and percentages of women eligible for cervical cancer screening through NBCCEDP at both the state and national levels and the percentage of these eligible women who received NBCCEDP-funded Pap tests. In addition, because racial and ethnic disparities in access to screening services have been commonly reported in the United States [7, 10–12], we examined the extent to which NBCCEDP provided services to women of different racial and ethnic backgrounds at the national level. Finally, we assessed the extent to which NBCCEDP-eligible women received Pap tests from other sources. This is the first report describing the ability of the nation’s only organized screening program to provide cervical cancer screening services to underserved women in the United States.
Materials and methods
Eligibility for NBCCEDP cervical cancer screening services
Women 18 years of age and older who have not had their uterus removed by hysterectomy and who do not have health insurance or whose insurance does not cover Pap tests are eligible for free cervical cancer screening through NBCCEDP if their family incomes are ≤250% of the federal poverty guidelines. Twenty-one states set eligibility criteria at ≤200% of the poverty guidelines. The annual income levels for a family of four at 200 and 250% of the poverty guidelines in 2006 were approximately $41,000 and $51,000, respectively . Since 98.5% of women 65 years of age and older were covered by Medicare or Medicaid  and were therefore not served by NBCCEDP, our analysis included only women 18–64 years of age who had not had a hysterectomy.
We obtained estimates of the number of women eligible for NBCCEDP-funded cervical cancer screening, based on their insurance status and income, from the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC). This survey provides national and state-level estimates of health insurance coverage and income-to-poverty ratios for the civilian, non-institutionalized US population. We used CPS ASEC data for calendar years 2004–2006. The data are mostly collected in March, with some data being collected in February and April. About 77,000 interviewed households in the CPS ASEC are asked a set of questions about their health insurance coverage and income during the previous year .
People were considered uninsured if they were not covered by any type of private or government health insurance for the entire previous year. As with all federally sponsored surveys, income-to-poverty ratios were computed by dividing total family income by the poverty threshold. The poverty threshold depends on family size and the age composition of the family . The US Preventive Services Task Force (USPSTF) does not recommend screening for women who have had a complete hysterectomy for benign disease , and these women are not eligible for cervical cancer screening through the NBCCEDP. Because the CPS ASEC does not include questions concerning cancer or whether a woman has had a hysterectomy, we used additional data sources. These auxiliary data are described below.
The National Health Interview Survey (NHIS) is a multipurpose health survey conducted annually by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention. NHIS collects health information during in-person interviews of a nationally representative sample of the civilian, non-institutionalized US population. From each selected family, information is collected using a core questionnaire for one randomly selected adult. The core questionnaire has remained nearly the same from year to year, with revisions approximately every decade. Each year, one or more supplements are included in the NHIS that focus on specific health topics. In 2005, a supplement on cancer control was administered to each sample adult to collect detailed information on cancer screening. Data for the NHIS are obtained from a multistage sample design involving stratification, clustering, and oversampling. A full description of the 2005 NHIS and these methods are available online . We used the 2005 NHIS data to estimate the proportion of the population that were NBCCEDP-eligible based on the criterion of not having had a hysterectomy. Because of the small numbers of women in many of the race and ethnicity categories, we used the percentages of all women in those race and ethnicity categories who were 18–64 years of age and who had had a hysterectomy, irrespective of income and insurance status. For age-only categories (18–39 and 40–64), we used the percentages of all women who had had a hysterectomy in that age category. For instance, the NHIS hysterectomy rate for low-income, uninsured, Hispanic women 18–64 years of age is identical to the estimated hysterectomy rate of Hispanic women 18–64 years of age. Similarly, the NHIS hysterectomy rate for low-income, uninsured women 40–64 years of age is identical to the hysterectomy rate of women 40–64 years of age. We also used the 2005 NHIS to calculate the percentage of low-income and uninsured women, 18–64 years of age, who had not undergone a hysterectomy and had received a Pap test within the past 3 years.
Because NHIS does not provide state-level information, we used the Behavioral Risk Factor Surveillance System (BRFSS) to obtain state-level prevalence information on hysterectomy status. The BRFSS, a state-based telephone survey of the civilian, non-institutionalized adult population, collects information on health practices and risk behaviors . Because of the small numbers of women in many age, race, and ethnicity categories, we used the percentages of women who had had a hysterectomy for each age category, irrespective of income and insurance status. For instance, the BRFSS hysterectomy rate for low-income, uninsured women 18–64 years of age is similar to the estimated hysterectomy rate of all women 18–64 years of age.
We obtained data on the number of women screened during the three-year period from January 2004 through December 2006 from NBCCEDP service records. We used data from a 3-year period because the USPSTF recommends that women initiate screening for cervical cancer within 3 years of onset of sexual activity or at age 21 (whichever comes first) and receive screening at least every 3 years . NBCCEDP grantees routinely collect information on income, family size, and insurance to determine eligibility. Grantees also compile screening information on each woman participating in NBCCEDP , including screening location, demographic characteristics, service dates, and outcomes. For the purposes of our study, these data represent counts of women who had at least one NBCCEDP-related screening service. Women were counted based on their state of residency within the 50 states and DC. Demographic data are self-reported, and reporting of race and Hispanic origin is optional. Race/ethnicity data was unavailable for 1.8% of the women who received NBCCEDP-funded Pap tests. We classified women who received at least one NBCCEDP-funded Pap test during 2004–2006 into age, race, and Hispanic-origin groups. The structure of NBCCEDP and methods for collecting and reporting NBCCEDP data have been described on NBCCEDP’s website .
We categorized age as either 18–64, 18–39, or 40–64 years of age. Race and ethnicity were categorized the same way in all of the datasets used in this research: Hispanic, non-Hispanic white alone, non-Hispanic black alone, non-Hispanic American Indian and Alaska Native alone (AIAN), non-Hispanic Asian and Native Hawaiian and other Pacific Islander (ANHOPI), and non-Hispanic race combinations. Our non-Hispanic ANHOPI race category includes those who reported that they were only Asian or only Native Hawaiian or other Pacific Islander, as well as those who reported that they were Asian combined with Native Hawaiian or other Pacific Islander. The non-Hispanic race combinations category includes those who reported more than one race, with the exception of those included in our ANHOPI group.
Using CPS ASEC estimates of the number of women who were uninsured and who had low income (low income being defined by the state’s threshold), we estimated the number of women eligible for NBCCEDP. Using the hysterectomy rates from NHIS (at the national level) and BRFSS (at the state level), we then adjusted the low-income, uninsured estimates to account for the prevalence of hysterectomies and obtain an estimate of the number of women eligible for NBCCEDP-funded Pap tests. Specifically, we calculated the number of eligible women as a percentage of those who have not had a hysterectomy multiplied by the total number of low-income, uninsured women. The number of eligible women based on the auxiliary data from the NHIS differed from the estimated number of eligible women from the BRFSS; because the surveys differ, we expected a small difference. For consistency across estimates, we calibrated the aggregated number of NBCCEDP-eligible women as defined by the BRFSS to equal the national number of eligible women as defined by the NHIS.
Based on the number of women screened and estimates of the numbers of women 18–64, 18–39, and 40–64 years of age for both the US population and NBCCEDP-eligible population, we estimated the percentage of all US women and NBCCEDP-eligible women who received a NBCCEDP-funded Pap test at least once in 2004, 2005, or 2006. We examined the distribution of cervical cancer screening among women from different racial and ethnic backgrounds at the national level, as well as screening rates at the state level for women 18–64 years of age. Using our estimates of the number of women eligible for NBCCEDP-funded Pap tests, the percentage of eligible women screened nationally according to our 2005 NHIS analyses and the percentage screened via the NBCCEDP, we estimated the percentage of NBCCEDP-eligible women screened outside the program and the percentage not screened within 3 years. All comparative statements in this study have undergone statistical testing (mean and mean difference hypothesis testing) and are significant at the 90% confidence level unless otherwise noted . We reported the 90% confidence interval to be in accord with the US Census Bureau’s Standard .
Number and percent eligible
Estimated number and percentage of US women eligible for National Breast and Cervical Cancer Early Detection Program (NBCCEDP)-funded Pap tests, 2004–2006
Women eligible for NBCCEDP Pap testa
Number (in thousands)
Number (in thousands)
90% Confidence interval
90% Confidence interval
Race and ethnicity
Non-Hispanic race combinations
Number and percent screened
Number and percentage of women eligible for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and US women provided with at least one Pap test through NBCCEDP, between 2004 and 2006
Number of women screened
Percentage of US women screeneda
Percentage of NBCCEDP-eligible women screenedb
90% Confidence interval
Race and ethnicity
Non-Hispanic race combinations
Unknown race and ethnicity
Among all women eligible for NBCCEDP, approximately 8.7% were screened one or more times (Table 2). The percentage of all eligible women who were screened in NBCCEDP varied by age group, race, and ethnicity. NBCCEDP-eligible women 40–64 years of age had a higher screening rate (22.6%) than eligible women 18–39 years of age (2.3%). Non-Hispanic women had a higher screening rate (9.3%) than Hispanic women (7.3%). Among non-Hispanics, the screening rate was highest among AIAN women (36.1%) and lowest for multiracial women (4.6%), with intermediate rates for white women (9.7%), ANHOPI women (9.0%), and black women (6.5%). Differences among rates for non-Hispanic women, non-Hispanic white women, and non-Hispanic ANHOPI women were not statistically significant at the 90% level.
Number and percent eligible
Number of women 18–64 years of age and number of women eligible for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), cervical cancer screening, by state: 3-year averages for 2004–2006
Number (in thousands)
Number (in thousands)
90% CI (in thousands)
% of totalc
90% CI (%)
District of Columbia
Number and percent screened
Percent screened from other sources
According to our analysis of the 2005 NHIS, 65.3% of NBCCEDP-eligible women had a Pap test during the previous 3 years. We estimated that the NBCCEDP screened 9% of its eligible population. Consequently, using the NHIS analysis, we estimated that approximately 56.2% of NBCCEDP-eligible women received a Pap test from other sources, and 34.8% received no Pap test from any source. A large number of federally funded community health centers, hospitals, clinics, and voluntary associations provide cervical cancer screening services to underserved women outside of NBCCEDP.
We estimated the number of women eligible for cervical cancer screening services through the only national organized screening program in the US, NBCCEDP, the percentage screened within and outside the program, and the percentage not screened through any source. Overall, the program was successful in screening more than 775,000 women between 2004 and 2006. However, fewer than 10% of the eligible population received NBCCEDP-funded Pap tests. An earlier study found that during 1994–1996, NBCCEDP provided either breast or cervical cancer screening services to about 12–15% of eligible women 50–64 years of age but that research did not estimate the proportion of women who were provided Pap tests specifically nor did it provide estimates by race/ethnicity, state, or for the 18–49 age group . The numbers and percentages of eligible women who were screened varied widely by age, race/ethnicity, and state of residence. The program was most successful in meeting the needs of women in the 40–64 age group, although eligibility rates for services are higher in the 18–39 age group. Nineteen programs offer no cervical cancer screening services to women under the age of 40. More than half of the eligible women screened were racial and ethnic minorities. These findings are consistent with the program’s focus on screening women 40 years and older and women from racial and ethnic minority populations .
The percentage of the eligible women screened by the NBCCEDP is small. Although program-eligible women, particularly those 18–39 years of age, receive cervical screening services from other providers such as family planning clinics, the finding that nearly 35% of program-eligible women did not receive screening from any source highlights the importance of the program. Possible reasons why more program-eligible women do not receive cervical cancer screening through the program include fear of painful procedures, fear of having cancer, lack of knowledge about need for screening or recommended screening intervals, inadequate provider capacity, and lack of accessibility to services in geographically isolated areas . It is conceivable that factors such as low literacy, non-English language preference, transportation or dependent care issues, which are likely correlated with low-income and being un- or underinsured, may persist as barriers to accessing the program. Evidence suggest that among women using the NBCCEDP services, low education level and foreign-born status were associated with not returning for repeat screening within the program, suggesting that low education and factors associated with foreign-born status may remain as barriers to use of the program . Others have found a strong association between physician recommendation and having had a recent Pap smear [4, 21]. Underserved women do not have usual source of care, thus are less likely to be screened. Another reason why eligible women do not receive cancer screening services through the NBCCEDP is lack of knowledge and awareness of the program .
The percentage of eligible women screened in each state ranged from 2 to 38.4%.
Variation in screening rates across states could be explained by differences in amount of funding from CDC and other sources; clinical costs; program infrastructure for management and service delivery; and the number of eligible women. Programs receive varying levels of funding from the CDC, state government and other sources, which directly influence the number of women served. Clinical cost also varies by state, tribe, and territory. Within national guidelines for program eligibility, each program implements strategies to recruit underserved women. For example, states use different income eligibility criteria. Thirty states and the District of Columbia set income eligibility at 250% of poverty, 19 states at 200% of poverty, 1 state at 225%, and 1 state at 185% of poverty. The estimated number of eligible women for the NBCCEDP is based on the eligibility criteria used in each state .
Following the passage of the Breast and Cervical Cancer Prevention and Treatment Act in 2000, women diagnosed with breast and cervical cancer through the NBCCEDP have access to treatment via Medicaid . In the event that the woman is not Medicaid-eligible (i.e., non-citizen), the program identifies other treatment resources. However, few statewide alternatives to Medicaid coverage are available to NBCCEDP-eligible women who are ineligible for Medicaid. According to the US Government Accountability Office (GAO) May 2009 report, only four states have a statewide program that pays for cancer treatment or provides broader health insurance or free or reduced-fee care. Most states identify other local resources as alternatives such as donated care, funding from charity organizations, reduced-fee care from charity hospital system, and county assistance. In fourteen states, physicians donate health care services to eligible residents in local areas . Through the GAO survey, twenty states reported having charity funds available to pay for cancer treatment; eleven states reported having county indigent funds, public assistance programs, and county hospitals paying for cancer screening, diagnostic services, and treatment for low-income, uninsured women .
Our study is subject to a number of limitations. First, the CPS ASEC may underestimate the number of NBCCEDP-eligible women because women who are underinsured (those whose insurance does not cover preventive services) are eligible for NBCCEDP but are not included in the CPS ASEC uninsured estimates and thus are not included in the denominators of our screening percentages. No general definition of being underinsured exists, and the number of low-income, underinsured women in the population is unknown. On the other hand, health insurance coverage could be underreported due to recall bias in the CPS ASEC: the survey uses annual retrospective questions, and respondents may have difficulty recalling the information . Analyses that further stratify the data (by age group at the state level and by age group for individual race/ethnic groups) were not possible due to small sample size. Second, we used BRFFS and NHIS data to adjust the estimates of the eligible population derived from the CPS ASEC data on hysterectomy status. Using data from different sources may introduce some errors in the estimates because the questionnaires, data collection methods, and sampling methods are different. Third, because BRFSS collects data through telephone-based surveys, less affluent groups, such as low-income uninsured women, may be underrepresented because they are less likely to have a telephone . In contrast, NHIS is conducted by in-person interview. This survey provides a nationally representative sample of the civilian, non-institutionalized US population and allows researchers to produce national estimates using sample weights which reflect probabilities of selection, along with adjustments for non-response and post-stratification by age, sex, and race/ethnicity . Although income and insurance coverage are not specifically included in these adjustments, NHIS data are frequently used to provide national estimates of being uninsured and of having various types of insurance coverage , which has included estimates of uninsured persons with low family income . Last, a small percentage of women were excluded from eligibility because they were thought to have had a total hysterectomy, but actually had partial hysterectomies  and therefore are eligible for cervical cancer screening through NBCCEDP.
In 2000, when Healthy People 2010 first set out its objectives of eliminating health disparities and increasing to 97% the proportion of women 18 years of age and older who had received a Pap test within a three-year period , the greatest disparities in cervical cancer screening were among women who had no health insurance, those who had no usual source of care, and recent immigrants . Although progress has been made since 1987 in increasing cervical cancer screening among low-income and uninsured women, screening rates among low-income women have increased more slowly than those among higher-income women, and screening rates among the uninsured still lag far behind those among women with private or public health insurance . CDC, through the NBCCEDP, funds programs to recruit women and improve access to screening and diagnostic services. Since the program reaches underserved women, the program provides a unique opportunity to reduce disparities in cervical cancer screening and increase screening rates among the underserved population. For the first time since its establishment in 1990, this report provides estimates of the number of women eligible for the NBCCEDP-funded Pap tests and the percentage screened at both national and state levels, and by age groups and race/ethnicity. Such information is vital for planning, monitoring, and evaluating the only national organized screening program in the United States. Furthermore, the findings indicate groups of eligible women that have benefited relatively more from Program screening services and groups for whom efforts to increase awareness of Program availability or recruitment may be particularly helpful.