Invasive cervical cancer and screening: what are the rates of unscreened and underscreened women in the modern era?

Objective: It has been reported that approximately 50% of invasive cervical malignancies are diagnosed in patients who have never been screened and that 10% of the remaining cervical cancer patients have not had a Pap smear in the 5 years before diagnosis. We sought to determine whether this holds true among a university-based gynecologic oncology patient population.

Methods: After institutional review board approval, a retrospective chart review of women in a university-based gynecologic oncology group with cervical cancer from 2002 to 2007 was conducted. Patients' demographics, referral Pap smear, method of diagnosis, histology, clinical stage, treatment, and time since last Pap smear were collected. Descriptive statistics were used during data analysis.

Results: A total of 419 women with cervical cancer were identified. Of these women, 67% of patients were white, 18% Hispanic, and 6% African-American. The most common referral Pap smear to our institution was high-grade squamous intraepithelial lesion (21%). Diagnosis was primarily made by cervical punch biopsy (47%). The most common histologic type was squamous cell carcinoma (70%). Of all patients, 80% were diagnosed with stage I and 9% with stage II cervical cancer, whereas stage III and IV were uncommon. The most common therapy was radical hysterectomy with lymph node dissection performed in 250 patients (60%). The length of time from last reported Pap smear to diagnosis of invasive cervical cancer ranged from 1 to 65 years, with a median of 3 years. Stage IA1 patients ranged from 1 to 12 years from last reported Pap with a median of 1 year (SD = 3.38), whereas stage III/IV patients ranged from 1 to 20 years since last screening, with a median of 4 years (SD = 6.39). Regarding length of time since last reported Pap smear, 235 patients (56%) were unable to report the length of time since their last Pap smear. Of those who reported their last Pap smear, 4 patients (1%) reported never having a Pap smear, 39 patients (9%) reported last Pap smear more than 10 years ago, and 10 patients (2%) reported a Pap smear more than 20 years ago. Of all patients, 85 (20%) reported a Pap smear within 2 years. Of these 85 patients, 71 patients (84%) were diagnosed at stage I, whereas more advanced stages were uncommon.

Conclusions: Traditionally, patients diagnosed with an invasive cervical malignancy are either unscreened or underscreened with cervical cytology. Our patient population was noncompliant with the screening measures. A fraction of our patients were compliant with screening within the last 2 years, yet still developed a cervical malignancy--albeit early stage disease. As such, our data suggest that compliance continues to be an issue. However, even with adherence to screening guidelines, cervical cancer continues to develop.