Cervical cancer is not a very common cancer in the developed world and is even rarer in younger populations, with an average of only 14 carcinomas per year among those aged 15–19 years, and 125 carcinomas per year among those aged 20–24 years. Precancerous lesions are frequently found among these age groups and are more likely to regress than at older ages.9,10 Based on the rarity of invasive disease and the potential harms of overscreening and treating this young population, national organizations have all moved toward a later starting age to screen for cervical cancer regardless of onset of sexual activity. However, studies have shown that providers are continuing to overscreen and overtreat this young population.11,12 With the introduction of the human papillomavirus vaccine, the prevalence of true cancer precursors is expected to decrease, thereby increasing the rate of false-positive results and unnecessary treatment.21
Studies have shown that cervical cancers arising among young females are often less detectable by traditional screening or are more aggressive and thus more likely to arise during screening intervals.5 In our study, histology varied according to age, with a larger proportion of noncarcinomas (defined as all histologies not included in International Classification of Disease codes 8010–8671 and 8940–8941) among the youngest age groups (data not shown). These noncarcinomas were often childhood cancers and would not be detected through screening. For the youngest age group, the most common tumor diagnosis was embryonal rhabdomyosarcoma.
Additionally, cervical cancer incidence varied by race or ethnicity and age. Overall, Hispanic females had the highest rates, although the magnitude of difference by race or ethnicity was lower among younger females than in previous studies examining all ages.14 We found that black females had lower rates overall than white females, contrary to analyses including all ages. Black females also had the lowest rate of glandular carcinomas, consistent with other studies.13,14 These differences in race and ethnicity may be attributable to a combination of screening and follow-up rates as well as hormonal-based risk factors such as obesity, parity, and use of oral contraceptives.22,23
Although screening occurs less often in the youngest age group (15–19 years), an alarming 2.7 million Pap tests still are conducted annually among this age group to detect an average of 14 cases of cancer that occur annually, or just less than 200,000 Pap tests per cervical cancer diagnosed (Table 2). Assuming a screening cost of approximately $60 (Pap test with office visit),24 the total cost of screening in this age group is estimated to be approximately $164,220,000, or approximately $11,646,800 per cancer case. For women aged 20–24, the cost is $3,285,200 per cancer case diagnosed. As age increases, the rate and number of cancers per year increase, and Pap testing becomes more effective, with women in their 30s averaging approximately 5,000–6,000 Pap tests to detect one cancer case and an estimated cost per cancer case of approximately $300,000-$375,000.
We acknowledge that abnormal Pap test findings and subsequent follow-up ideally result in detecting precancerous lesions before they become cancer; thus, our calculation does not take into account cancers that may have been avoided. However, analyses examining the effect of screening on future cancer risk have found cervical cancer screening to be less effective for younger women.25,26 As found in our data, there was no change in the incidence of invasive cervical cancer across the 36-year and 10-year time periods for this younger population of females. The updated screening guidelines were based on a systematic evidence review that also provided rationale of the rarity of cervical cancer in young women.1 Additionally, a recent article by Habbema et al provides a cross-national case study of cervical cancer prevention efforts in both the United States and the Netherlands describing cancer-related outcomes to screening intensity.27 The authors found that even though women in the United States undergo more than three-times as much Pap testing as do women in the Netherlands, the decrease in cervical cancer mortality over the past five decades has been nearly identical and the rates of cancer comparable, noting that in the Netherlands women are not screened until age 30. A commentary to this article cites that the implication is clear: women in the United States typically undergo far too much screening (as well as too many false-positive results, colposcopies, and other downstream consequences).28
The goal of cervical cancer screening is to detect and treat preinvasive lesions that begin to peak in women in their late 20s.3 Colposcopy with biopsy is performed when evaluation of an abnormal Pap test result is needed.30 Recent data suggest that the risk for adverse effects from this procedure is not trivial, including pain, bleeding, and discharge.31 In addition, once precancers are identified they must be treated, and this includes potential harms both in the short-term (pain, discharge, bleeding)30 and in the long-term (increased risk of preterm delivery).7,8 Given these short-term and long-term risks and the high likelihood of regression among young women, available data suggest that screening women younger than 21 years would result in more harms than benefits;3 therefore, all screening organizations now recommend against screening before age 21 years. Therefore, comprehensive vaccination in young women may be a better and more efficacious solution for preventing cancers in young women, because we can expect that it will be 70%–80% effective and without the harms of screening.
Data from two federal cancer surveillance programs were used in this analysis. The SEER data, which only cover 9% of the U.S. population, was used to give a longer time span (36 years) to observe changes in cervical cancer rates. However, the combined data covering 92% of the population were presented to give a more complete picture of the burden of the disease. Although population-based registries covering a majority of the U.S. population provide an excellent system to measure invasive cancers, they do not capture patient-level risk factors, including tobacco use, oral contraceptive use, or screening history, which could provide additional information for reasons for cervical cancer incidence by age or race or ethnicity.31 Additionally, race and ethnicity data come from medical records that may not be accurate for a small number of cases.32 However, our findings with regard to race and ethnicity were similar to other studies.13,14 A final limitation to the collected data may be in the reproducibility of histologic classification of these cervical cancers and may affect the observed case distribution.33
Self-reported data (National Survey of Family Growth) were used to estimate the annual number of Pap tests because the United States does not currently have a national cervical cancer screening surveillance system. Additionally, the time period for current Pap tests (2006–2010) was not the same for the incidence data (1999–2008). However, we did examine the 2002 National Survey of Family Growth data and found a slight increase in the number of Pap tests, because this was before organizations updated their guidelines to suggest later initiation and longer screening intervals. Therefore, by using the current estimates of Pap test use, we are presenting a more conservative estimate.
As noted, invasive cervical cancer is extremely rare in females younger than 25 years of age. However, this age group has higher rates of transient human papillomavirus infection and regressive cervical abnormalities, the treatment of which possibly having harmful effects on future reproduction. Screening organizations have weighed the balance between potential harms associated with diagnosis and treatment with any potential benefits, and all agree that screening should not occur before age 21 years.
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