ORIGINAL PAPER

Meeting the cervical cancer screening needs of underservedwomen: The National Breast and Cervical Cancer Early DetectionProgram, 2004–2006

Florence K. L. Tangka • Brett O’Hara • James G. Gardner •

Joanna Turner • Janet Royalty • Kate Shaw •

Susan Sabatino • Ingrid J. Hall • Ralph J. Coates

Received: 29 July 2009 / Accepted: 6 March 2010 / Published online: 2 April 2010

� US Government 2010

Abstract

Objective To examine the extent to which the only

national organized screening program in the US, the

National Breast and Cervical Cancer Early Detection Pro-

gram (NBCCEDP), has helped to meet the cervical cancer

screening needs of underserved women.

Methods Low-income, uninsured women 18–64 years of

age are eligible for free cervical cancer screening services

through NBCCEDP. We used data from the US Census

Bureau to estimate the number of eligible women, based on

insurance status and income. The estimates were adjusted

for hysterectomy status using the National Health Interview

Survey and the Behavioral Risk Factor Surveillance Sys-

tem. We used administrative data from NBCCEDP to

obtain the number of women receiving NBCCEDP-funded

Papanicolaou (Pap) tests. We then calculated the percentage

of NBCCEDP-eligible women who received free cervical

cancer screening through NBCCEDP. We also used the

NHIS to calculate the percentage of NBCCEDP-eligible

women screened nationally and the percentage unscreened.

Results In 2004–2006, nearly 9% (775,312 of 8.9 million)

of NBCCEDP-eligible women, received NBCCEDP-

funded Pap test. Rates varied substantially by age groups,

race, and ethnicity. NBCCEDP-eligible women 40–64 years

of age had a higher screening rate (22.6%) than eligible

women 18–39 years of age (2.3%). Non-Hispanic women

had a higher screening rate (9.3%) than Hispanic women

(7.3%). Among non-Hispanics, the screening rate was

highest among American Indian and Alaska Native (AIAN)

women (36.1%) and lowest among women of different race

combinations (4.6%), The percentage of eligible women

screened in each state ranged from 2.0 to 38.4%.

Conclusions Although NBCCEDP provided cervical can-

cer screening services to 775,312 low-income, uninsured

women, this number represented a small percentage of those

eligible. In 2005, more than 34% of NBCCEDP-eligible

women (3.1 million women) did not receive recommended

Pap tests from either NBCCEDP or other sources.

Keywords Cervical cancer � Pap tests utilization �Screening rates � Medically underserved

Introduction

Recent trends indicate that mortality from cervical cancer

has declined significantly in the United States (US) due to

The findings and conclusions in this report are those of the authors

and do not necessarily represent the official position of the Centers for

Disease Control and Prevention or the US Census Bureau.

F. K. L. Tangka (&) � J. G. Gardner � J. Royalty � S. Sabatino �I. J. Hall

Division of Cancer Prevention and Control, Centers for Disease

Control and Prevention, DCPC, 4770 Buford Highway, NE,

Mailstop K-55, Atlanta, GA 30341-3717, USA

e-mail: fbt9@cdc.gov

K. Shaw

Division for Heart Disease and Stroke Prevention, Centers

for Disease Control and Prevention, Atlanta, GA, USA

R. J. Coates

Office of Public Health Genomics, Centers for Disease Control

and Prevention, Atlanta, GA, USA

B. O’Hara

Data Integration Division, US Census Bureau, Washington,

DC, USA

J. Turner

Housing and Household Economic Statistics Division,

US Census Bureau, Washington, DC, USA

123

Cancer Causes Control (2010) 21:1081–1090

DOI 10.1007/s10552-010-9536-3

screening and treatment of precursor lesions and early-

stage disease [1–3]. However, much progress remains to

be made: In 2004, 11,999 women were diagnosed with

cervical cancer, and nearly 3,924 women died from the

disease [1]. Although timely cervical cancer screening with

the Papanicolaou (Pap) test reduces mortality [2], screening

rates in the United States are low among low-income

women who lack insurance coverage for Pap tests, partic-

ularly Hispanic women, those living in geographically

isolated areas, and foreign-born women [3–6]. Based on

data from the National Health Interview Survey (NHIS), in

1992, among women 18 years of age and older, 77.9% of

women with health insurance and 68.6% of women without

health insurance had received a Pap test during the previ-

ous 3 years. Among those women with family incomes

above the federal poverty threshold, 78.9% had received a

Pap test during the previous 3 years, and 71.3% of women

from families with income below the poverty threshold had

received this service (Trevor Thompson, personal com-

munication, August 2008).

To address the disparities in screening rates and to help

low-income, uninsured women gain access to cervical

cancer screening services, the US Congress passed the

Breast and Cervical Cancer Mortality Prevention Act of

1990 (Public Law 101–354), authorizing the Centers for

Disease Control and Prevention (CDC) to establish the

National Breast and Cervical Cancer Early Detection Pro-

gram (NBCCEDP) [7]. This program provides services

through cooperative agreements with 68 grantees located

in all 50 states, the District of Columbia (DC), 5 US

territories, and 12 American Indian and Alaska Native

organizations. In this article, states include residents of

the 50 states and the District of Columbia. The CDC

provides grants directly to each state department of health

or tribal organization. The grantees coordinate delivery

of clinical services provided within local clinical settings.

A detailed description of the program’s history is available

on NBCCEDP’s website [8].

Overall screening rates for either breast or cervical can-

cers for earlier time periods [9] and recent breast cancer

screening rate for NBCCEDP-eligible women through the

program have been published previously [7]. The purpose of

this report was to examine the extent to which NBCCEDP

has helped meet the cervical cancer screening needs of low-

income, uninsured women in the United States. Specifically,

we estimated the numbers and percentages of women eli-

gible for cervical cancer screening through NBCCEDP at

both the state and national levels and the percentage of these

eligible women who received NBCCEDP-funded Pap tests.

In addition, because racial and ethnic disparities in access to

screening services have been commonly reported in the

United States [7, 10–12], we examined the extent to which

NBCCEDP provided services to women of different racial

and ethnic backgrounds at the national level. Finally, we

assessed the extent to which NBCCEDP-eligible women

received Pap tests from other sources. This is the first report

describing the ability of the nation’s only organized

screening program to provide cervical cancer screening

services to underserved women in the United States.

Materials and methods

Eligibility for NBCCEDP cervical cancer screening

services

Women 18 years of age and older who have not had their

uterus removed by hysterectomy and who do not have

health insurance or whose insurance does not cover Pap

tests are eligible for free cervical cancer screening through

NBCCEDP if their family incomes are B250% of the

federal poverty guidelines. Twenty-one states set eligibility

criteria at B200% of the poverty guidelines. The annual

income levels for a family of four at 200 and 250% of the

poverty guidelines in 2006 were approximately $41,000

and $51,000, respectively [13]. Since 98.5% of women

65 years of age and older were covered by Medicare or

Medicaid [13] and were therefore not served by NBC-

CEDP, our analysis included only women 18–64 years of

age who had not had a hysterectomy.

Data sources

CPS ASEC

We obtained estimates of the number of women eligible for

NBCCEDP-funded cervical cancer screening, based on

their insurance status and income, from the Annual Social

and Economic Supplement to the Current Population

Survey (CPS ASEC). This survey provides national and

state-level estimates of health insurance coverage and

income-to-poverty ratios for the civilian, non-institutional-

ized US population. We used CPS ASEC data for calendar

years 2004–2006. The data are mostly collected in March,

with some data being collected in February and April.

About 77,000 interviewed households in the CPS ASEC are

asked a set of questions about their health insurance

coverage and income during the previous year [13].

People were considered uninsured if they were not

covered by any type of private or government health

insurance for the entire previous year. As with all federally

sponsored surveys, income-to-poverty ratios were com-

puted by dividing total family income by the poverty

threshold. The poverty threshold depends on family size

and the age composition of the family [13]. The US

Preventive Services Task Force (USPSTF) does not

1082 Cancer Causes Control (2010) 21:1081–1090

123

recommend screening for women who have had a complete

hysterectomy for benign disease [2], and these women are

not eligible for cervical cancer screening through the

NBCCEDP. Because the CPS ASEC does not include

questions concerning cancer or whether a woman has had a

hysterectomy, we used additional data sources. These

auxiliary data are described below.

NHIS

The National Health Interview Survey (NHIS) is a multi-

purpose health survey conducted annually by the National

Center for Health Statistics (NCHS), Centers for Disease

Control and Prevention. NHIS collects health information

during in-person interviews of a nationally representative

sample of the civilian, non-institutionalized US population.

From each selected family, information is collected using a

core questionnaire for one randomly selected adult. The

core questionnaire has remained nearly the same from year

to year, with revisions approximately every decade. Each

year, one or more supplements are included in the NHIS

that focus on specific health topics. In 2005, a supplement

on cancer control was administered to each sample adult to

collect detailed information on cancer screening. Data for

the NHIS are obtained from a multistage sample design

involving stratification, clustering, and oversampling. A

full description of the 2005 NHIS and these methods are

available online [14]. We used the 2005 NHIS data to

estimate the proportion of the population that were NBC-

CEDP-eligible based on the criterion of not having had a

hysterectomy. Because of the small numbers of women in

many of the race and ethnicity categories, we used the

percentages of all women in those race and ethnicity cate-

gories who were 18–64 years of age and who had had a

hysterectomy, irrespective of income and insurance status.

For age-only categories (18–39 and 40–64), we used the

percentages of all women who had had a hysterectomy in

that age category. For instance, the NHIS hysterectomy rate

for low-income, uninsured, Hispanic women 18–64 years of

age is identical to the estimated hysterectomy rate of

Hispanic women 18–64 years of age. Similarly, the NHIS

hysterectomy rate for low-income, uninsured women

40–64 years of age is identical to the hysterectomy rate of

women 40–64 years of age. We also used the 2005 NHIS to

calculate the percentage of low-income and uninsured

women, 18–64 years of age, who had not undergone a hys-

terectomy and had received a Pap test within the past 3 years.

BRFSS

Because NHIS does not provide state-level information, we

used the Behavioral Risk Factor Surveillance System

(BRFSS) to obtain state-level prevalence information on

hysterectomy status. The BRFSS, a state-based telephone

survey of the civilian, non-institutionalized adult popula-

tion, collects information on health practices and risk

behaviors [15]. Because of the small numbers of women in

many age, race, and ethnicity categories, we used the per-

centages of women who had had a hysterectomy for each age

category, irrespective of income and insurance status. For

instance, the BRFSS hysterectomy rate for low-income,

uninsured women 18–64 years of age is similar to the esti-

mated hysterectomy rate of all women 18–64 years of age.

NBCCEDP

We obtained data on the number of women screened during

the three-year period from January 2004 through December

2006 from NBCCEDP service records. We used data from

a 3-year period because the USPSTF recommends that

women initiate screening for cervical cancer within 3 years

of onset of sexual activity or at age 21 (whichever comes

first) and receive screening at least every 3 years [2].

NBCCEDP grantees routinely collect information on

income, family size, and insurance to determine eligibility.

Grantees also compile screening information on each

woman participating in NBCCEDP [7], including screen-

ing location, demographic characteristics, service dates,

and outcomes. For the purposes of our study, these data

represent counts of women who had at least one NBC-

CEDP-related screening service. Women were counted

based on their state of residency within the 50 states and

DC. Demographic data are self-reported, and reporting of

race and Hispanic origin is optional. Race/ethnicity data

was unavailable for 1.8% of the women who received

NBCCEDP-funded Pap tests. We classified women who

received at least one NBCCEDP-funded Pap test during

2004–2006 into age, race, and Hispanic-origin groups. The

structure of NBCCEDP and methods for collecting and

reporting NBCCEDP data have been described on

NBCCEDP’s website [8].

We categorized age as either 18–64, 18–39, or

40–64 years of age. Race and ethnicity were categorized

the same way in all of the datasets used in this research:

Hispanic, non-Hispanic white alone, non-Hispanic black

alone, non-Hispanic American Indian and Alaska Native

alone (AIAN), non-Hispanic Asian and Native Hawaiian

and other Pacific Islander (ANHOPI), and non-Hispanic

race combinations. Our non-Hispanic ANHOPI race

category includes those who reported that they were only

Asian or only Native Hawaiian or other Pacific Islander, as

well as those who reported that they were Asian combined

with Native Hawaiian or other Pacific Islander. The non-

Hispanic race combinations category includes those who

reported more than one race, with the exception of those

included in our ANHOPI group.

Cancer Causes Control (2010) 21:1081–1090 1083

123

Data analysis

Using CPS ASEC estimates of the number of women who

were uninsured and who had low income (low income being

defined by the state’s threshold), we estimated the number

of women eligible for NBCCEDP. Using the hysterectomy

rates from NHIS (at the national level) and BRFSS (at the

state level), we then adjusted the low-income, uninsured

estimates to account for the prevalence of hysterectomies

and obtain an estimate of the number of women eligible for

NBCCEDP-funded Pap tests. Specifically, we calculated

the number of eligible women as a percentage of those who

have not had a hysterectomy multiplied by the total number

of low-income, uninsured women. The number of eligible

women based on the auxiliary data from the NHIS differed

from the estimated number of eligible women from the

BRFSS; because the surveys differ, we expected a small

difference. For consistency across estimates, we calibrated

the aggregated number of NBCCEDP-eligible women as

defined by the BRFSS to equal the national number of eli-

gible women as defined by the NHIS.

Based on the number of women screened and estimates

of the numbers of women 18–64, 18–39, and 40–64 years

of age for both the US population and NBCCEDP-eligible

population, we estimated the percentage of all US women

and NBCCEDP-eligible women who received a NBC-

CEDP-funded Pap test at least once in 2004, 2005, or 2006.

We examined the distribution of cervical cancer screening

among women from different racial and ethnic back-

grounds at the national level, as well as screening rates at

the state level for women 18–64 years of age. Using our

estimates of the number of women eligible for NBCCEDP-

funded Pap tests, the percentage of eligible women

screened nationally according to our 2005 NHIS analyses

and the percentage screened via the NBCCEDP, we esti-

mated the percentage of NBCCEDP-eligible women

screened outside the program and the percentage not

screened within 3 years. All comparative statements in this

study have undergone statistical testing (mean and mean

difference hypothesis testing) and are significant at the

90% confidence level unless otherwise noted [16]. We

reported the 90% confidence interval to be in accord with

the US Census Bureau’s Standard [16].

Results

National results

Number and percent eligible

Unless otherwise stated, all of the statistics and compari-

sons of statistics are significant at the 99% level (or a

p-value less than 0.01). Table 1 shows that during 2004–

2006, approximately 93 million women 18–64 years of age

resided in the United States. Of those women, approxi-

mately 8.9 million or 9.5% were eligible for a NBCCEDP-

funded Pap test. Women 18–39 years of age have a lower

hysterectomy rate than women 40 years and older [17]; this

younger group accounted for the highest number of

NBCCEDP-eligible women (6 million) within the 18–64

age group. Although the number of non-Hispanic women

(5.9 million) is larger than the number of Hispanic women

(3 million), the percentage of Hispanic women who were

eligible for NBCCEDP (23.8%) was significantly larger

than that of non-Hispanic women (7.3%). At 3.7 million,

non-Hispanic white women constituted the largest group of

non-Hispanic women eligible for NBCCEDP. However,

the percentage of non-Hispanic white women who were

eligible for NBCCEDP (5.9%) was smaller than that of

non-Hispanic black women (13.2%). Among non-Hispanic

women, the percent of AIAN who were eligible (20.4%)

was statistically higher than the percent of eligible women

in the other race groups.

Number and percent screened

During 2004–2006, 775,312 women 18–64 years of age

received at least one Pap test through NBCCEDP, among

whom 639,508 (82.5%) were women 40–64 years of age

(Table 2). NBCCEDP provided cervical cancer screening

to approximately 0.8% of all women 18–64 years of age in

the United States. The rates of screening with Pap tests

during the three-year period 2004–2006 (referred to

henceforth as screening rates) varied substantially by age

group, race, and ethnicity. Approximately, 0.3 and 1.3% of

all US women 18–39 and 40–64 years of age, respectively,

were screened through NBCCEDP. In terms of race and

ethnicity, about 1.7% of Hispanic women and 0.7% of non-

Hispanic women received a Pap test through the program.

Among non-Hispanic women, about 0.6% of white women

and 0.9% of black women were screened through

NBCCEDP.

Among all women eligible for NBCCEDP, approxi-

mately 8.7% were screened one or more times (Table 2).

The percentage of all eligible women who were screened

in NBCCEDP varied by age group, race, and ethnicity.

NBCCEDP-eligible women 40–64 years of age had a

higher screening rate (22.6%) than eligible women

18–39 years of age (2.3%). Non-Hispanic women had a

higher screening rate (9.3%) than Hispanic women (7.3%).

Among non-Hispanics, the screening rate was highest

among AIAN women (36.1%) and lowest for multiracial

women (4.6%), with intermediate rates for white women

(9.7%), ANHOPI women (9.0%), and black women

(6.5%). Differences among rates for non-Hispanic women,

1084 Cancer Causes Control (2010) 21:1081–1090

123

non-Hispanic white women, and non-Hispanic ANHOPI

women were not statistically significant at the 90% level.

State-level results

Number and percent eligible

Table 3 shows state-specific income-to-poverty guidelines

used as eligibility criteria and the estimated number and

percentage of NBCCEDP-eligible women in each state.

The numbers of eligible women were highest in heavily

populated states such as California, Texas, New York,

and Florida. The percentage of women eligible for

NBCCEDP was highest in states such as New Mexico

(17%), although this percentage was not statistically

distinguishable (at the 90% level) from the percentages

for Arizona, Arkansas, Louisiana, Mississippi, Montana,

Oregon, and Texas. Similarly, although Minnesota’s

percentage of eligible women was among the lowest

(5%), it was not statistically distinguishable (at the 90%

level) from the percentage in Connecticut, Hawaii, and

16 other states.

Number and percent screened

The percentages of eligible women who were screened

through NBCCEDP varied greatly across states (Fig. 1).

The state-level percentage of eligible women screened

ranged from about 2 to 38.4%. The twenty-fifth state per-

centage of eligible women screened was 10.7%. The tenth

lowest percentage estimate was 5.8%, and the tenth highest

percentage estimate was 19.4%.

Percent screened from other sources

According to our analysis of the 2005 NHIS, 65.3% of

NBCCEDP-eligible women had a Pap test during the pre-

vious 3 years. We estimated that the NBCCEDP screened

9% of its eligible population. Consequently, using the

NHIS analysis, we estimated that approximately 56.2% of

NBCCEDP-eligible women received a Pap test from other

sources, and 34.8% received no Pap test from any source.

A large number of federally funded community health cen-

ters, hospitals, clinics, and voluntary associations provide

cervical cancer screening services to underserved women

outside of NBCCEDP.

Table 1 Estimated number and percentage of US women eligible for National Breast and Cervical Cancer Early Detection Program

(NBCCEDP)-funded Pap tests, 2004–2006

Characteristics General population Women eligible for NBCCEDP Pap testa

Number

(in thousands)

Percent

distributionbNumber

(in thousands)

90% Confidence

interval

Percentc 90% Confidence

interval

Age

18–64 93,272 100 8,863 8,622–9,103 9.5 9.2–9.8

18–39 44,083 47.3 6,034 5,822–6,247 13.7 13.2–14.2

40–64 49,189 52.7 2,828 2,694–2,962 5.7 5.4–6.0

Race and ethnicity

Hispanic 12,485 13.4 2,967 2,818–3,116 23.8 22.6–25.0

Non-Hispanic 80,787 86.6 5,896 5,698–6,094 7.3 7.1–7.5

White, non-Hispanic 62,649 67.2 3,714 3,563–3,865 5.9 5.7–6.1

Black, non-Hispanic 11,866 12.7 1,561 1,460–1,663 13.2 12.3–14.1

Non-Hispanic AIAN 561 0.6 115 87–143 20.4 15.4–25.4

Non-Hispanic ANHOPI 4,660 5.0 412 358–467 8.9 7.7–10.1

Non-Hispanic race combinations 1,051 1.1 93 68–118 8.9 6.5–11.3

a Women eligible for NBBCCEDP-funded Pap tests include those 18–64 years of age who have a cervix, are uninsured, and have low-income

(as defined by the state’s low-income criteria) aggregated to the nation. The number of eligible women could be underestimated because it

excludes those who have health insurance but whose insurance does not cover cervical cancer screening and those who are uninsured for less than

1 year. See Sect. ‘‘Methods’’ for detailsb Percent of all US women 18–64 years of agec Percent of all US women 18–64 years of age in a given age, racial, and ethnic groups who were eligible for NBCCEDP-funded Pap tests

Source Authors’ tabulations of modified data from the US Census Bureau, Current Population Survey, 2004–2006 Annual Social and Economic

Supplements. The modification of the data was the authors’ tabulations of data from the 2005 National Health Interview Survey

Note AIAN American Indian/Alaska Native; ANHOPI Asian American, Native Hawaiian, and Pacific Islander

Details may not sum to totals because of rounding

Cancer Causes Control (2010) 21:1081–1090 1085

123

Discussion

We estimated the number of women eligible for cervical

cancer screening services through the only national orga-

nized screening program in the US, NBCCEDP, the per-

centage screened within and outside the program, and the

percentage not screened through any source. Overall, the

program was successful in screening more than 775,000

women between 2004 and 2006. However, fewer than 10%

of the eligible population received NBCCEDP-funded Pap

tests. An earlier study found that during 1994–1996,

NBCCEDP provided either breast or cervical cancer

screening services to about 12–15% of eligible women

50–64 years of age but that research did not estimate the

proportion of women who were provided Pap tests spe-

cifically nor did it provide estimates by race/ethnicity,

state, or for the 18–49 age group [9]. The numbers and

percentages of eligible women who were screened varied

widely by age, race/ethnicity, and state of residence. The

program was most successful in meeting the needs of

women in the 40–64 age group, although eligibility rates

for services are higher in the 18–39 age group. Nineteen

programs offer no cervical cancer screening services to

women under the age of 40. More than half of the eligible

women screened were racial and ethnic minorities. These

findings are consistent with the program’s focus on

screening women 40 years and older and women from

racial and ethnic minority populations [18].

The percentage of the eligible women screened by the

NBCCEDP is small. Although program-eligible women,

particularly those 18–39 years of age, receive cervical

screening services from other providers such as family

planning clinics, the finding that nearly 35% of program-

eligible women did not receive screening from any source

highlights the importance of the program. Possible reasons

why more program-eligible women do not receive cervical

cancer screening through the program include fear of

painful procedures, fear of having cancer, lack of knowl-

edge about need for screening or recommended screening

intervals, inadequate provider capacity, and lack of

accessibility to services in geographically isolated areas

[19]. It is conceivable that factors such as low literacy, non-

English language preference, transportation or dependent

care issues, which are likely correlated with low-income

Table 2 Number and percentage of women eligible for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and US

women provided with at least one Pap test through NBCCEDP, between 2004 and 2006

Characteristics Number of

women screened

Percentage of US

women screenedaPercentage of NBCCEDP-eligible women screenedb

Percent 90% Confidence interval

Agec

18–64 775,312 0.8 8.7 8.5–9.0

18–39 138,827 0.3 2.3 2.2–2.4

40–64 639,508 1.3 22.6 21.5–23.7

Race and ethnicity

Hispanic 215,528 1.7 7.3 6.9–7.6

Non-Hispanic 545,701 0.7 9.3 8.9–9.6

White, non-Hispanic 360,957 0.6 9.7 9.3–10.1

Black, non-Hispanic 101,850 0.9 6.5 6.1–6.9

Non-Hispanic AIAN 41,462 7.4 36.1 27.3–44.9

Non-Hispanic ANHOPI 37,147 0.8 9.0 7.8–10.2

Non-Hispanic race combinations 4,285 0.4 4.6 3.4–5.8

Unknown race and ethnicity 14,083 – – –

Women eligible for NBCCEDP-funded Pap tests include women ages 18–64 years who have a cervix, are uninsured, and have low-income

(as defined by the state’s low-income criteria) aggregated to the nationa Percent of all US women in a given age, racial, and ethnic group who were provided Pap tests funded by NBCCEDPb Percent of all US women 18–64 years of age in a given age, racial and ethnic groups who are eligible and who were provided with NBCCEDP-

funded Pap testsc Numbers of women screened at ages 18–39 and 40–64 do not sum to the numbers for 18–64 because age groups are not mutually exclusive

over the 3-year period

Source Authors’ tabulations of modified data from the US Census Bureau, Current Population Survey, 2004–2006 Annual Social and Economic

Supplements, and from NBCCEDP April 2008 data. The modification of the data was the authors’ tabulations of data from the 2005 National

Health Interview Survey

Note AIAN American Indian/Alaska Native; ANHOPI Asian American, Native Hawaiian, and Pacific Islander

1086 Cancer Causes Control (2010) 21:1081–1090

123

Table 3 Number of women 18–64 years of age and number of women eligible for the National Breast and Cervical Cancer Early Detection

Program (NBCCEDP), cervical cancer screening, by state: 3-year averages for 2004–2006

US Population Eligible womena

Number (in thousands) Poverty criterionb Number

(in thousands)

90% CI

(in thousands)

% of totalc 90% CI (%)

US 93,272 185/200/225/

250 8,863

8,622–

9,103 9.5

9.2–9.8

Alabama 1,477 200 129 102–155 8.7 6.9–10.5

Alaska 210 250 21 9–32 9.9 4.5–15.3

Arizona 1,825 250 261 221–301 14.3 12.1–16.5

Arkansas 873 200 108 83–132 12.3 9.5–15.1

California 11,193 200 1,198 1,109–1,287 10.7 9.9–11.5

Colorado 1,495 250 154 123–185 10.3 8.2–12.4

Connecticut 1,118 200 60 40–80 5.3 3.5–7.1

Delaware 274 250 20 9–31 7.2 3.1–11.3

District of Columbia 197 250 13 4–23 6.7 1.9–11.5

Florida 5,516 200 581 521–641 10.5 9.4–11.6

Georgia 3,000 200 286 245–327 9.5 8.1–10.9

Hawaii 391 250 21 9–33 5.5 2.4–8.6

Idaho 442 200 37 22–51 8.3 5.0–11.6

Illinois 3,963 200 309 265–354 7.8 6.7–8.9

Indiana 1,990 200 151 121–181 7.6 6.1–9.1

Iowa 927 250 66 45–86 7.1 4.9–9.3

Kansas 826 250 69 49–89 8.3 5.9–10.7

Kentucky 1,333 250 139 111–167 10.4 8.3–12.5

Louisiana 1,349 250 213 179–248 15.8 13.2–18.4

Maine 424 250 25 12–37 5.8 2.9–8.7

Maryland 1,818 250 150 119–181 8.3 6.6–10.0

Massachusetts 2,086 250 122 93–150 5.8 4.4–7.2

Michigan 3,188 250 248 209–287 7.8 6.6–9.0

Minnesota 1,623 250 81 58–104 5.0 3.6–6.4

Mississippi 907 250 118 92–143 13.0 10.2–15.8

Missouri 1,841 200 151 120–181 8.2 6.5–9.9

Montana 292 200 35 21–49 12.0 7.1–16.9

Nebraska 537 225 38 23–53 7.1 4.3–9.9

Nevada 744 250 88 64–111 11.8 8.7–14.9

New Hampshire 417 250 25 12–38 6.0 2.9–9.1

New Jersey 2,745 250 248 207–289 9.0 7.5–10.5

New Mexico 598 250 102 77–127 17.0 12.8–21.2

New York 6,158 250 581 519–643 9.4 8.4–10.4

North Carolina 2,763 200 275 235–316 10.0 8.5–11.5

North Dakota 198 200 11 3–19 5.6 1.4–9.8

Ohio 3,677 200 219 182–256 6.0 5.0–7.0

Oklahoma 1,070 185 119 93–145 11.1 8.7–13.5

Oregon 1,154 250 145 115–175 12.6 10.0–15.2

Pennsylvania 3,878 250 269 227–310 6.9 5.8–8.0

Rhode Island 350 250 21 9–33 6.0 2.6–9.4

South Carolina 1,348 200 119 92–145 8.8 6.9–10.7

South Dakota 235 200 17 7–28 7.3 2.9–11.7

Tennessee 1,875 250 160 129–190 8.5 6.9–10.1

Texas 7,056 200 1,065 984–1,147 15.1 13.9–16.3

Cancer Causes Control (2010) 21:1081–1090 1087

123

and being un- or underinsured, may persist as barriers to

accessing the program. Evidence suggest that among

women using the NBCCEDP services, low education level

and foreign-born status were associated with not returning

for repeat screening within the program, suggesting that

low education and factors associated with foreign-born

status may remain as barriers to use of the program [20].

Others have found a strong association between physician

recommendation and having had a recent Pap smear [4,

21]. Underserved women do not have usual source of care,

thus are less likely to be screened. Another reason why

eligible women do not receive cancer screening services

through the NBCCEDP is lack of knowledge and aware-

ness of the program [22].

The percentage of eligible women screened in each state

ranged from 2 to 38.4%.

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

NBCCEDPUS States and District of Columbia - ordered by participation rates

Fig. 1 Percent of NBCCEDP-eligible women screened by State and

District of Columbia, compared to the national average, 2004–2006.

Note The boxes show the percentage of eligible women screened by

each state and District of Columbia. One state that uses different

eligibility criteria is not included. The whiskers in each box show the

variation in the screening rate (upper and lower 90% confidence

intervals). NBCCEDP the National Breast and Cervical Cancer Early

Detection Program. * Sorted by percentage of eligible women

screened. Source Authors’ tabulations of modified data from the US

Census Bureau, Current Population Survey, 2004–2006 Annual Social

and Economic Supplements, and from NBCCEDP April 2008 data.

The modification of the data was the authors’ tabulations of data from

the 2004–2006 Behavioral Risk Factor Surveillance System

Table 3 continued

US Population Eligible womena

Number (in thousands) Poverty criterionb Number

(in thousands)

90% CI

(in thousands)

% of totalc 90% CI (%)

Utah 747 250 78 56–100 10.5 7.6–13.4

Vermont 207 250 12 3–21 5.8 1.5–10.1

Virginia 2,452 200 172 139–205 7.0 5.7–8.3

Washington 2,004 250 147 117–178 7.4 5.9–8.9

West Virginia 580 200 61 42–80 10.5 7.2–13.8

Wisconsin 1,742 250 111 84–137 6.4 4.9–7.9

Wyoming 157 250 15 6–24 9.5 3.6–15.4

a Women eligible for NBCCEDP-funded Pap tests include women 18–64 years of age who have a cervix, are uninsured, and have low-income

(as defined by the state’s low-income criteria)b 30 states and District of Columbia set income eligibility at 250% of poverty, 19 states at 200% of poverty, 1 state at 225%, and 1 state at 185%

of poverty. The estimated number of eligible women for the United States is based on the eligibility criteria used in each statec Eligible women as percentage of all women 18–64 years of age in that state

Source Authors’ tabulations of modified data from the US Census Bureau, Current Population Survey, 2004–2006 Annual Social and Economic

Supplements. The modification of the data was the authors’ tabulations of data from the 2004–2006 Behavioral Risk Factor Surveillance System

Details may not sum to totals because of rounding

1088 Cancer Causes Control (2010) 21:1081–1090

123

Variation in screening rates across states could be

explained by differences in amount of funding from CDC

and other sources; clinical costs; program infrastructure for

management and service delivery; and the number of eli-

gible women. Programs receive varying levels of funding

from the CDC, state government and other sources, which

directly influence the number of women served. Clinical

cost also varies by state, tribe, and territory. Within

national guidelines for program eligibility, each program

implements strategies to recruit underserved women. For

example, states use different income eligibility criteria.

Thirty states and the District of Columbia set income eli-

gibility at 250% of poverty, 19 states at 200% of poverty, 1

state at 225%, and 1 state at 185% of poverty. The esti-

mated number of eligible women for the NBCCEDP is

based on the eligibility criteria used in each state [23].

Following the passage of the Breast and Cervical Cancer

Prevention and Treatment Act in 2000, women diagnosed

with breast and cervical cancer through the NBCCEDP

have access to treatment via Medicaid [24]. In the event

that the woman is not Medicaid-eligible (i.e., non-citizen),

the program identifies other treatment resources. However,

few statewide alternatives to Medicaid coverage are

available to NBCCEDP-eligible women who are ineligible

for Medicaid. According to the US Government Account-

ability Office (GAO) May 2009 report, only four states

have a statewide program that pays for cancer treatment or

provides broader health insurance or free or reduced-fee

care. Most states identify other local resources as alterna-

tives such as donated care, funding from charity organi-

zations, reduced-fee care from charity hospital system, and

county assistance. In fourteen states, physicians donate

health care services to eligible residents in local areas [19].

Through the GAO survey, twenty states reported having

charity funds available to pay for cancer treatment; eleven

states reported having county indigent funds, public assis-

tance programs, and county hospitals paying for cancer

screening, diagnostic services, and treatment for low-

income, uninsured women [19].

Our study is subject to a number of limitations. First, the

CPS ASEC may underestimate the number of NBCCEDP-

eligible women because women who are underinsured

(those whose insurance does not cover preventive services)

are eligible for NBCCEDP but are not included in the CPS

ASEC uninsured estimates and thus are not included in the

denominators of our screening percentages. No general

definition of being underinsured exists, and the number of

low-income, underinsured women in the population is

unknown. On the other hand, health insurance coverage

could be underreported due to recall bias in the CPS ASEC:

the survey uses annual retrospective questions, and

respondents may have difficulty recalling the information

[25]. Analyses that further stratify the data (by age group at

the state level and by age group for individual race/ethnic

groups) were not possible due to small sample size. Sec-

ond, we used BRFFS and NHIS data to adjust the estimates

of the eligible population derived from the CPS ASEC data

on hysterectomy status. Using data from different sources

may introduce some errors in the estimates because the

questionnaires, data collection methods, and sampling

methods are different. Third, because BRFSS collects data

through telephone-based surveys, less affluent groups, such

as low-income uninsured women, may be underrepresented

because they are less likely to have a telephone [26]. In

contrast, NHIS is conducted by in-person interview. This

survey provides a nationally representative sample of the

civilian, non-institutionalized US population and allows

researchers to produce national estimates using sample

weights which reflect probabilities of selection, along with

adjustments for non-response and post-stratification by age,

sex, and race/ethnicity [14]. Although income and insur-

ance coverage are not specifically included in these

adjustments, NHIS data are frequently used to provide

national estimates of being uninsured and of having various

types of insurance coverage [27], which has included

estimates of uninsured persons with low family income

[28]. Last, a small percentage of women were excluded

from eligibility because they were thought to have had a

total hysterectomy, but actually had partial hysterectomies

[29] and therefore are eligible for cervical cancer screening

through NBCCEDP.

In 2000, when Healthy People 2010 first set out its

objectives of eliminating health disparities and increasing

to 97% the proportion of women 18 years of age and older

who had received a Pap test within a three-year period [10],

the greatest disparities in cervical cancer screening were

among women who had no health insurance, those who had

no usual source of care, and recent immigrants [4].

Although progress has been made since 1987 in increasing

cervical cancer screening among low-income and unin-

sured women, screening rates among low-income women

have increased more slowly than those among higher-

income women, and screening rates among the uninsured

still lag far behind those among women with private or

public health insurance [4]. CDC, through the NBCCEDP,

funds programs to recruit women and improve access to

screening and diagnostic services. Since the program

reaches underserved women, the program provides a

unique opportunity to reduce disparities in cervical cancer

screening and increase screening rates among the under-

served population. For the first time since its establishment

in 1990, this report provides estimates of the number of

women eligible for the NBCCEDP-funded Pap tests and

the percentage screened at both national and state levels,

and by age groups and race/ethnicity. Such information is

vital for planning, monitoring, and evaluating the only

Cancer Causes Control (2010) 21:1081–1090 1089

123

national organized screening program in the United States.

Furthermore, the findings indicate groups of eligible

women that have benefited relatively more from Program

screening services and groups for whom efforts to increase

awareness of Program availability or recruitment may be

particularly helpful.

References

1. US Cancer Statistics Working Group (2009) United States cancer

statistics: 1999–2005 incidence and mortality web-based report.

US Department of Health and Human Services, Centers for

Disease Control and Prevention and National Cancer Institute,

Atlanta. Available at: http://www.cdc.gov/uscs

2. US Preventive Services Task Force (2003) Screening for cervical

cancer. In: Guide to preventive clinical services. 3rd ed. Periodic

updates. AHRQ Publications Clearinghouse, Rockville (MD)

[cited 2008 Sep 29]. Publication No. APPIP02-0001. Available

from: http://www.ahrq.gov/clinic/3rduspstf/cervcan/cervcanrr.htm

3. Benard VB, Eheman CR, Lawson HW, Blackman DK, Anderson

C, Helsel W (2004) Cervical screening in the National Breast and

Cervical Cancer Early Detection Program, 1995–2001. Obstet

Gynecol 103(3):564–571

4. Swan J, Breen N, Graubard BI et al. (2010) Trends in cancer

screening practices in the United States: 1992–2005 National

Health Interview Surveys. Cancer (Forthcoming, Summer 2010)

5. US Department of Health and Human Services (2006) Healthy

people 2010 progress review [cited 2008 Sep 29]. Available from:

http://www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/

fa03-cancer2.htm

6. Tsui J, Saraiya M, Thompson T, Dey A, Richardson L (2007)

Cervical cancer among foreign-born women by birthplace and

duration in the United States. J Womens Health 16(10):1447–

1457

7. Tangka FK, Dalaker J, Chattopadhyay SK et al (2006) Meeting

the mammography screening needs of underserved women: the

performance of the National Breast and Cervical Cancer Early

Detection Program in 2002–2003 (United States). Cancer Causes

Control 17(9):1145–1154

8. Ryerson AB, Benard VB, Major AC (2005) National Breast and

Cervical Cancer Early Detection Program: 1991–2002 national

report. US Department of Health and Human Services, Atlanta

[cited 2008 Sep 29]. Available from: http://www.cdc.gov/cancer/

nbccedp/bccpdfs/national_report.pdf

9. Chattopadhyay SK, Hall HI, Wolf RB, Custer WS (1999) Sources

of health insurance in the US: analysis of state-level data and

implications for public health programs. J Public Health Manag

Pract 5:35–46

10. US Department of Health and Human Services (2003) Healthy

people 2010, 2nd edn. US Government Printing Office, Wash-

ington, DC

11. Swan J, Breen N, Coates RJ, Rimer BK, Lee NC (2003) Progress

in cancer screening practices in the United States: results from the

2000 National Health Interview Survey. Cancer 97(6):1528–1540

12. Blackman DK, Bennett EM, Miller DS (1999) Trends in self-

reported use of mammograms (1989–1997) and Papanicolaou

tests (1991–1997)—Behavioral Risk Factor Surveillance System.

MMWR CDC Surveill Summ 48(6):1–22

13. DeNavas-Walt C, Proctor BD, Smith J (2007) Income, poverty,

and health insurance coverage in the United States: 2006. US

Census Bureau current population reports, P60-231. US Gov-

ernment Printing Office, Washington, DC

14. National Center for Health Statistics (2006) Data file documen-

tation, National Health Interview Survey, 2005 (Machine-read-

able data file and documentation). US Department of Health and

Human Services, Hyattsville, MD. Located at ftp://ftp.cdc.gov/

pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2005/

srvydesc.pdf. Accessed: December 30, 2009

15. Centers for Disease Control and Prevention; National Center for

Chronic Disease Prevention and Health Promotion (2008)

Behavioral risk factor surveillance system. [cited 2008 Sep 29].

Available from: http://www.cdc.gov/brfss/index.htm

16. US Census Bureau (2006) Source and accuracy of estimates for

income, poverty, and health insurance coverage in the United

States. [cited 2008 Sep 29]. Available from: http://www.census.

gov/hhes/www/p60_233sa.pdf

17. Merrill RM (2008) Hysterectomy Surveillance in the United

States, 1997 through 2005. Med Sci Monit 14(1):CR24–CR31

18. NBCCEDP Program Guidance Manual, Policies and Procedures,

August 2007

19. United States Government Accountability Office (2009) Report

to Congressional Requesters. MEDICAID. Source of Screening

Affect Women’s Eligibility for Coverage of Breast and Cervical

Cancer Treatment in Some States. GAO-09-384

20. Song L, Fletcher R (1998) Breast cancer rescreening in low-

income women. Am J Prev Med 15(2):128–133

21. Coughlin SS, Breslau ES, Thompson T, Benard VB (2005)

Physician recommendation for papanicolaou testing among U.S.

women, 2000. Cancer Epidemiol Biomarkers Prev 14(5):1143–

1148

22. Ingrid J, Hall1 C, Ashani T, Danielle B, Ngozi NK (2010)

Developing a community-based intervention to increase breast

cancer screening and early detection among low-income, Afri-

can-American women. [cited 2010 Jan 13]. Available from:

http://intl-preventionportal.aacrjournals.org/misc/07Disparities_

Poster_Session_B.pdf

23. Centers for Disease Control and Prevention (2010) National

Breast and Cervical Cancer Early Detection Program. Screening

Program Data. [cited 2010 Jan 4]. Available from: http://www.

cdc.gov/cancer/nbccedp/data/

24. Centers for Disease Control and Prevention (2010) National

Breast and Cervical Cancer Early Detection Program. [cited 2010

Jan 13]. Available from: http://www.cdc.gov/cancer/nbccedp/

about.htm

25. Ringel J, Klerman J (2005) Today or last year? How do inter-

viewees answer the CPS health insurance questions? RAND

Corporation Working Paper No 288. RAND Corporation Publi-

cations Department, Santa Monica, California

26. Ochner MH, Salvail FR, Ford ES, Ajani U (2008) Obesity and

self-reported general health, Hawaii BRFSS: are polynesians at

higher risk? Obesity 16(4):923–926

27. Centers for Disease Control and Prevention (2010) Publications

and information products. [cited 2010 Jan 27]. Available from:

http://www.cdc.gov/nchs/nhis/releases.htm

28. Cohen RA, Makuc DM (2008) State, regional, and national

estimates of health insurance coverage for people under 65 years

of age: National Health Interview Survey, 2004–2006. National

health statistics reports; no1. National Center for Health Statis-

tics, Hyattsville, MD. [cited 2010 Jan 27]. Available from:

http://www.cdc.gov/nchs/data/nhsr/nhsr001.pdf

29. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG (2007)

Hysterectomy rates in the United States, 2003. Obstet Gynecol

110(5):1091–1095

1090 Cancer Causes Control (2010) 21:1081–1090

123