Following the closure of nearly 100 women’s health clinics across the United States from 2010 to 2013, fewer women were screened for cervical cancer; more women were diagnosed with advanced stages of the disease; and disease mortality rates rose. Findings from a new analysis combining several nationwide data sets were presented by Srivastava et al at the 61st Annual Meeting of the American Society for Radiation Oncology (ASTRO) and simultaneously published in the International Journal of Radiation Oncology · Biology · Physics.

“The data are troubling,” said lead analysis author Amar Srivastava, MD, MPH, of Washington University School of Medicine in St. Louis, in a press release. “Reducing the availability of cervical cancer screening has very real, negative consequences for women. Cervical cancer is largely preventable because of the wide availability of the human papillomavirus vaccine and screening that can detect precancerous lesions. The pressing issue now is to ensure that all women have access to screening.”

Each year, there are more than 13,000 cervical cancer diagnoses and 4,250 deaths from the disease in the United States.

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Nearly 100 comprehensive women's clinics closed between 2010 and 2013, due primarily to changes in funding structures (eg, regulations for Title X funding) and the passage of laws that regulated standards at these clinics. “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 of cervical cancer,” said Dr. Srivastava.

Methods

In the analysis, Dr. Srivastava and his team grouped the 50 U.S. states into two cohorts: those that experienced a decrease in the number of women’s health clinics providing abortion per capita from 2010–2013 (n = 37) and those with either no decrease in the number of clinics or an increase in the number of women’s health clinics providing abortion per capita (n = 13). The researchers relied on data for nearly 200,000 women in the Behavioral Risk Factors Surveillance Study (BRFSS) to evaluate screening utilization and data for more than 10,000 women in the Surveillance, Epidemiology, and End Results Registry (SEER) to evaluate cancer stage at diagnosis and mortality. For each cohort of states, the analyses compared data for women in both data sets from 2008 to 2009 with outcomes from 2014 to 2015.

A total of 197,143 cases from the BRFSS and 10,652 patients from SEER were eligible for inclusion. Population characteristics differed by race/ethnicity, metropolitan residence, county income and education, and insurance status between states with decreases in clinics vs no decreases in clinics in both BRFSS and SEER patients in both time periods.

Results

After difference-in-difference analysis with adjustment, researchers found that states that experienced clinic closures also saw a 2% drop in cervical cancer screenings, relative to states without clinic closures, with the greatest declines in screening for patients without insurance (–6.18 percentage points [PP], P = .01), Hispanic women (–5.32 PP, P < .01), women aged 21 to 34 years old (–4.81 PP, P < .01), and unmarried women (–4.37 PP, P < .01).

There was a significant increase in the risk of dying of cervical cancer (hazard ratio [HR] = 1.36, 95% confidence interval [CI] = 1.02–1.83, P = .04) in states with a decrease in women’s health clinics, especially among residents living in metropolitan areas (HR = 1.40, 95% CI = 1.04–1.90, P = .03).

Researchers also found an increase in early-stage cervical cancer diagnoses among women aged 18 to 34 in states in which no clinics had closed but a decrease in early-stage diagnoses for this same age group in states in which clinics had closed. In those states, 13% fewer women were diagnosed with early-stage cervical cancer. Correspondingly, there was a trend toward increased late-stage diagnoses in this age group, with 8% more women being diagnosed with late-stage disease in states with clinic closures (P = .14).

“At first, we thought it sounded good that there were fewer early-stage diagnoses,” said Dr. 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, of this association between clinics closing and fewer women undergoing screening and an association between clinics closing and more women dying of cervical cancer.”

The findings were startling, said Dr. Srivastava, because of the short period it took for serious adverse effects to occur. “To see a difference in cancer survival rates, you usually need very mature, long-term follow-up data,” he said. “…What is surprising about this study is that even though these closures occurred just a few years ago, we are already seeing clear differences in death vs survival from cervical cancer. That was both surprising and scary.”

The study authors concluded, “The passage of laws resulting in the closure of women’s health clinics between 2010 and 2013 was associated with adverse effects on women’s health, including decreased screening, increased stage at presentation, and also higher mortality from cervical cancer, even in the short term. Though causality cannot be confirmed, these findings warrant further evaluation, particularly in the context of ongoing legal battles related to these laws.”

Disclosure: For full disclosures of the study authors, visit redjournal.org.