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Current Trends Pap Smear Screening -- Behavioral Risk Factor Surveillance System, 1988

Data from the 1988 Behavioral Risk Factor Surveillance System (BRFSS) were used to characterize knowledge and prevalence of use of the Papanicolaou (Pap) smear--a primary screening test for cervical cancer--among women in 15 states and the District of Columbia. The 16 participating health departments* used standard questions and methods to conduct monthly random-digit-dialed telephone interviews of adults greater than or equal to 18 years of age (1). Respondents were asked whether they knew about Pap smear tests, whether they had ever had a Pap smear, and how long it had been since their last test.

The sample for this analysis included 8741 black women and white non-Hispanic women aged greater than or equal to 18 years who had not undergone a hysterectomy. Almost all (99.8%) women interviewed knew of the Pap smear, and 98.8% had had at least one such test. The frequency of Pap smear screening varied by age, income level, and race (Table 1). Women aged 18-39 years were 1.6 times more likely to have had a Pap smear within the preceding year than were women aged greater than or equal to 60 years. Also, 75% of women with incomes greater than or equal to $20,000 reported having had the test within the preceding year, compared with 65% of women with incomes less than $10,000.

For all age groups combined, a higher percentage of black women (82%; 95% CI plus or minus 3.5) than white women (71%; 95% CI plus or minus 1.6) reported receiving a Pap smear in the preceding year. These differences by race occurred within each of the eight geographic areas with a sufficient number of black respondents to allow race-specific comparisons. Reported by: The following BRFSS coordinators: L Parker, California; M Rivo, District of Columbia; B Steiner, Illinois; K Bramblett, Kentucky; R Schwartz, Maine; A Weinstein, Maryland; R Thurber, Nebraska; K Zaso, New Hampshire; L Pendley, New Mexico; H Bzduch, New York; C Washington, North Carolina; N Hann, Oklahoma; D Lackland, South Carolina; K Tollestrup, Washington; R Anderson, West Virginia; M Soref, Wisconsin. Div of Chronic Disease Control and Community Intervention and Office of Surveillance and Analysis, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In 1986, approximately 5000 U.S. women died from invasive cervical cancer, a disease that can be prevented by early detection and treatment (2). Incidence and mortality rates of invasive cervical cancer vary by socioeconomic factors, and unequal access to medical services may contribute to delayed diagnosis and death (3-5). The BRFSS finding that black women are more likely than white women to have had a recent Pap smear is consistent with data from the 1985 and 1987 National Health Interview Survey (NHIS) (6,7), even though overall NHIS estimates of yearly Pap smear screening frequency are lower than those produced by BRFSS (8).

Although National Cancer Institute data show that cervical cancer incidence and mortality rates increase with age (9), Pap smear screening decreases with age. Therefore, improving cervical cancer screening among older women should be emphasized. The American Cancer Society recommends annual Pap tests beginning with the onset of sexual activity; after three negative Pap tests, less frequent tests may be recommended by the woman's physician (10).

Despite higher rates of yearly Pap smears for black women in 1988, the age-adjusted incidence rate for invasive cervical cancer for blacks was twice that for whites in 1986, the last year for which data are available (9); the age-adjusted mortality rate for cervical cancer that year was nearly three times higher for blacks than for whites. NHIS data show black women have increasingly used this screening since 1973 (60% of black women, compared with 64% of white women, had had a Pap smear within the past 2 years in 1973 (6)), so recent changes in screening by race may not be directly related to invasive cervical cancer incidence and mortality patterns.

Medical-care delivery to underserved populations may be an especially challenging problem, since screening is only one of several key components to prevention. Other factors influencing incidence and mortality trends include prompt notification of Pap smear results, adequate patient follow-up, and appropriate treatment. To reduce undetected progression to invasive cervical cancer, comprehensive examination of Pap smear screening, follow-up, and treatment patterns is needed--especially for minorities, low-income groups, and older women (2).


  1. Remington PL, Smith MY, Williamson DF, et al. Design,

characteristics and usefulness of state-based behavioral risk factor surveillance: 1981-1986. Public Health Rep 1988;203:366-75.

2. CDC. Chronic disease reports: deaths from cervical cancer--United States, 1984-1986. MMWR 1989;38:650-4,659.

3. Cuello C, Correa P, Haenzel W. Socio-economic class differences in cancer incidence in Cali, Colombia. Int J Cancer 1982;29:637-43.

4. Devesa SS, Diamond EL. Association of breast cancer and cervical cancer incidence with income and education among whites and blacks. JNCI 1980;65:515-28.

5. Howard J. Avoidable mortality from cervical cancer: exploring the concept. Soc Sci Med 1987;24:507-14.

6. Makuc DM, Fried VM, Kleinman JC. National trends in the use of preventive health care by women. Am J Public Health 1989;79:21-6.

7. Thornberry OT, Wilson RW, Golden PM, NCHS. Health promotion data for the 1990 objectives. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1986. (Advance data from vital and health statistics; no. 126).

8. CDC. Provisional estimates from the National Health Interview Survey supplement on cancer control--United States, January-March, 1987. MMWR 1988;37:417-20,425.

9. National Cancer Institute. Cancer statistics review, 1973-1986. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1989; NIH publication no. 89-2789. 10. American Cancer Society. Summary of current guidelines for the cancer-related checkup: recommendations. Atlanta: American Cancer Society, 1988; ACS publication no. 3347.01-PE. *California, District of Columbia, Illinois, Kentucky, Maine, Maryland, Nebraska, New Hampshire, New Mexico, New York, North Carolina, Oklahoma, South Carolina, Washington, West Virginia, and Wisconsin.

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