Forty per cent of women not getting Pap tests

Nearly 40 per cent of women living in Ontario’s metropolitan areas are not getting appropriate cervical cancer screening. New research from the Institute for Clinical Evaluative Sciences (ICES) and St. Michael’s Hospital found that despite Ontario’s system of universal health insurance, appropriate cervical cancer screening is significantly lower among women who are older, living in low-income areas, or recent immigrants.

“Cervical cancer can, for the most part, be readily detected by regular screening. Efforts to reduce disparities in cervical cancer screening should focus on women who are older, living in low-income neighbourhoods or recent immigrants,” says principal investigator Aisha Lofters, a Research Scholar at the University of Toronto and St. Michael’s departments of family and community medicine.

The Pap test has proven to be a highly effective screening tool for cervical cancer. Due to its widespread use in Canada, incidence and mortality rates for cervical cancer decreased by 39 per cent and 53 per cent, respectively, between 1981 and 2002. In Ontario, evidence-based guidelines recommend the initiation and frequency of screening, stating that Pap tests should begin within three years of first vaginal sexual activity and should be performed at least every two to three years until the woman reaches 70 years of age.

“Ontario has a single, government-run, universal health insurance plan that pays for all medically necessary services, including cervical cancer screening. In spite of an effective screening tool, established guidelines and a universal health plan, certain groups of women in our setting appear to be inadequately screened,” says Rick Glazier, co-author and senior scientist at ICES.

The population-based study of 2.3 million women aged 25–69 who lived in Ontario's metropolitan areas during the calendar years 2003, 2004 and 2005, all of whom should have been screened for cervical cancer at least once during that time period found that:

• Appropriate cervical cancer screening occurred for only 61.1 per cent of all women in the cohort
• Despite adjusting for physician contact and pregnancy rates, screening was especially low among women aged 50–69, women living in low-income neighbourhoods, and women who had registered with OHIP in the preceding 10 years, a group consisting largely of immigrant women
• Women with all three of these characteristics (aged 50+, low income, new to OHIP) had a screening rate of only 31.0 per cent as compared to 70.5 per cent among women with none of these characteristics

“Our findings have found that age, income and immigrant status all play significant roles in cervical cancer screening in Ontario’s metropolitan areas, despite a universal healthcare system. Targeted interventions with particular focus on the immigrant composition of various health regions may be essential to closing the screening gap,” says Glazier.

Author affiliations: ICES (R. Moineddin, R.H. Glazier); Dept. of Family and Community Medicine, University of Toronto (A.K. Lofters, R. Moineddin, R.H. Glazier); Dept. of Family and Community Medicine, St. Michael’s Hospital (A.K. Lofters, R.H. Glazier); Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital (A.K. Lofters, S.W. Hwang, R.H. Glazier); Canadian Institutes of Health Research Strategic Training Fellow (student) in the Transdisciplinary Approach to the Health of Marginalized Populations (A.K. Lofters); Dalla Lana School of Public Health, University of Toronto (R. Moineddin, R.H. Glazier); Dept. of Medicine, University of Toronto (S.W. Hwang).

The study “Low rates of cervical cancer screening among urban immigrants: a population-based study in Ontario, Canada,” appears in the July 20, 2010, issue of Medical Care.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

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