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Women's Clinic Closings Negatively Impacted Cervical Cancer Outcomes

Samson, Kurt

doi: 10.1097/01.COT.0000615236.67095.21
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CHICAGO—Cervical cancer outcomes grew worse where women's clinics have been forced to close as a result of state-legislated restrictions on abortion providers, according to research presented at the 2019 ASTRO Annual Meeting (Radiat Oncol 2019;105:Supp,PS98).

Following the closing of almost 100 women's health clinics across the U.S. between 2010 to 2013, fewer women were screened for cervical cancer, more women were diagnosed with advanced stages of the disease, and mortality rates increased, researchers told a press briefing.

“The data are troubling. Reducing the availability of cervical cancer screening has very real, negative consequences for women,” said lead author Amar Srivastava, MD, MPH, a resident physician in radiation oncology at Washington University School of Medicine in St. Louis.

The wave of clinic closings was largely due to changes in funding structures in the Title X Family Planning Program and enactment of state laws regulating standards at clinics, such as requiring all pregnancy terminations to be performed only by physicians with hospital privileges.

“As these clinics closed over time, it appears that fewer women were getting screened, and this trend appears to be associated with a greater number of women ultimately dying from cervical cancer,” he noted.

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Srivastava and his colleagues first separated the states into two groups: those that had experienced a decline in the number of clinics per capita over the 3-year period (a total of 37 states), and those where the number of such clinics remained unchanged or increased (13 states). Then, using recorded data for about 200,000 women enrolled in the Behavioral Risk Factor Surveillance Study, they examined data on cervical cancer screening utilization, cancer stage at diagnosis, and related mortality for more than 10,000 women enrolled in the Surveillance, Epidemiology and End Results Registry. In each of the two datasets, the team compared figures for the years 2008 to 2009, with outcomes from 2014 to 2015.

States that experienced clinic closures saw a 2 percent decrease in cervical cancer screenings relative to states without clinic closures, with the greatest declines in uninsured women (-6.18 percentage points [PP]), Hispanic women (-5.32 PP), women between the ages of 21 and 34 years (-4.81 PP), and unmarried women (-4.37 PP).

While overall cervical cancer survival rates improved in states that had no clinic closings, they fell in those that did, the data showed. This was accompanied by a significant increase in the risk of dying from cervical cancer, especially in states with closings in urban areas.

Srivastava also reported that they found an increase in early-stage diagnoses among 18- to 34-year-old women in states that lost no clinics, but a decrease in states with closures. In states with closings, 13 percent fewer women were diagnosed with early-stage disease and there was a corresponding trend toward more late-stage diagnoses, with 8 percent more patients diagnosed in states with clinic closures.

“At first we thought it sounded good that there were fewer early-stage diagnoses,” noted Srivastava. “But then we saw the trend toward later-stage diagnoses, for which patients need more invasive treatments, all of which have side effects. Even more concerning, we saw a higher risk of mortality in states with decreasing numbers of clinics. A story started to come together looking at these two sets of data: association between clinics closing and fewer women undergoing screening and an association between clinics closing and more women dying from cervical cancer.”

Srivastava said that the findings were startling because of the short time period within which serious adverse effects occurred.

“In order to see a difference in cancer survival rates, you usually need very mature, long-term follow-up data—15-20 years in some cases,” the researcher noted. “What was surprising and scary is that even though these closures occurred just a few years ago, we are already seeing clear differences in death versus survival from cervical cancer.”

While a correlational study such as this cannot establish an actual causal relationship, the findings should raise serious concerns, he said.

“I think these findings should give us some pause. Overall, we're seeing improved survival for cervical cancer relative to other cancers, but in the states with clinic closures we are seeing just the opposite. It should make us think—not just as medical providers and practitioners, but as people broadly—about why this is happening and what we can do to increase rather than limit access to health care.”

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Geraldine M. Jacobson, MD, FASTRO, Chair and Professor of Radiation Oncology at the West Virginia University School of Medicine, who moderated the press briefing, said the findings are troubling.

“This is extremely serious,” she told Oncology Times. “We're talking about women between the ages of 18 and 34 who, following decreased access to screening, are presenting with more advanced cervical cancer and consequently having higher death rates.”

It is especially noteworthy that these poor outcomes were able to be measured in such a short interval, she continued. “The implications of this study are that decreasing health care services that provide effective screening methods for early detection of cancer have real effects on people's health and mortality. Reduction in proven screening programs is a step backward in public health.”

Jacobson said that she is not aware of any comparable studies, although there might be studies looking at such trends.

“This study is novel in that it retrospectively evaluated the health consequences of a change in policy that decreased access to health clinics in selected states, allowing a comparison of health outcomes in states with and without decreased access. In contrast to studies that evaluate the health benefits of screening, the researchers used historical data to evaluate the consequences of decreased screening.”

She noted that it is clear access to effective screening for detection and early treatment of cervical cancer should be widely implemented. “The authors of this study have taken an important step in addressing the problem by analyzing and publicly presenting this data.”

She emphasized that the findings illustrate the link between health care policy and access to services, as well as the very real impact that such changes can have on health and mortality.

Kurt Samson is a contributing writer.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
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