Evaluation of Cervical Cancer Screening Uptake and Adherence Among Women Without Human Papillomavirus Vaccination in the US

Human papillomavirus (HPV) vaccination and cervical cancer screening are the cornerstone interventions to achieve cervical cancer elimination.¹ Given that 46% of adolescent and 65% of young women are not up to date on the HPV vaccination series in the US, screening is an indispensable measure for cervical cancer elimination.^1,2 However, a sharp decline in cervical cancer screening rates among young women has occurred in recent years.³ Unvaccinated women who have not had a screening may remain susceptible to cervical cancer. Herein, we examined cervical cancer screening uptake and adherence among women in the US in 2019 stratified by HPV vaccination status.

This cross-sectional study analyzed National Health Interview Survey data from 2019. The survey participants self-reported sociodemographic information; however, race and ethnicity information was selected according to defined categories in the National Health Interview Survey, including Hispanic, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White, and other (non-Hispanic American Indian/American Natives only, non-Hispanic American Indian/American Natives and any other group, other single race and multiple races). The study population included women who were ever eligible to receive the HPV vaccine (ie, those aged 9-26 years between the vaccine’s licensure from 2006 to 2019) and were eligible for cervical cancer screening on the basis of age (ie, those aged 21-39 years for the purposes of this study). We excluded women who underwent a hysterectomy and those with missing information on HPV vaccination and cervical cancer screening. The outcomes of interest were (1) ever screened for cervical cancer and (2) up to date on screening on the basis of the US Preventive Services Task Force recommendations.⁴ A survey design–adjusted Wald F test was used to compare cervical cancer screening uptake and up-to-date status stratified by HPV vaccination status. We estimated the odds ratio for screening uptake and up-to-date status among unvaccinated women using multivariable logistic regression models. Statistical significance was tested at 2-sided P = .05. All analyses were performed with SAS software, version 9.4 (SAS Institute) using SAS PROC SURVEY procedures and adjusting for the complex survey design and sampling weights. The institutional review board of the University of Texas Health Science Center deemed this study exempt from review and waived the requirement for informed consent owing to the use of publicly available data. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

The National Health Interview Survey from 2019 included data for 1872 women aged 21 to 29 years (mean [SE] age, 25.1 [0.1] years) who were predominately White individuals (54.1%) with some college education (35.8%), private insurance (62.4%), and urban status (89.3%) living in the South (40.1%). Of these women, 24.6% never underwent cervical cancer screening, and 29.1% did not adhere to screening recommendations. Among 2637 women aged 31 to 39 years (mean [SE] age, 34.5 [.01] years) (most were White individuals [54.2%] with some college education [29.5%], private insurance [65.2%], and urban status [87.4%] who were living in the South [37.8%]), 11.5% never underwent cervical cancer screening, and 17.5% did not adhere to screening recommendations.

Among women aged 21 to 29 years who were not vaccinated for HPV, a higher proportion reported never receiving cervical cancer screening compared with vaccinated women (32.2% vs 17.9%; P < .001) (Table 1). Similarly, a greater proportion of unvaccinated women were not up to date on cervical cancer screening recommendations compared with their vaccinated counterparts (37.4% vs 21.6%; P < .001). Findings were similar for women aged 30 to 39 years; a higher proportion of unvaccinated women vs vaccinated women were never screened (13.5% vs 5.0%; P < .001) and did not adhere to screening recommendations (19.9% vs 9.3%; P < .001).

Among women aged 21 to 29 years who were not vaccinated for HPV, the likelihood of never receiving cervical cancer screening was higher for non-Hispanic Asian women (adjusted odds ratio [AOR], 2.07; 95% CI, 1.03-4.16) and women with an educational level up to a high school diploma (AOR, 2.33; 95% CI, 1.07-5.12) (Table 2). Among women aged 30 to 39 years, the likelihood of never receiving a cervical cancer screening was higher for Hispanic (AOR, 2.77; 95% CI, 1.71-4.51), non-Hispanic Asian (AOR, 3.03; 95% CI, 1.70-5.40), and non-Hispanic Black women (AOR, 2.25; 95% CI, 1.37-3.69) as well as those with educational attainment up to a high school diploma (AOR, 1.89; 95% CI, 1.11-3.21) and those who were uninsured (AOR, 2.46; 95% CI, 1.56-3.88). Findings were similar for women who were not up to date on screening recommendations.

A substantial proportion of women who were not vaccinated for HPV never received cervical cancer screening or were not up to date on screening recommendations in 2019. These findings are particularly important in the context of declining cervical cancer screening uptake, recent stabilization in cervical cancer incidence, and the COVID-19 pandemic, which has further exacerbated HPV vaccination and cervical cancer screening rates.^5,6 For instance, a more than 75% decrease in screening rates occurred among women aged 21 to 29 years during the stay-at-home order in Southern California.⁶ Findings of the present study also suggest that non-Hispanic Asian women, those with educational attainment up to a high school diploma, and those who are uninsured are less likely to undergo or adhere to screening recommendations, implying a need for targeted prevention in these groups. The study limitations include the cross-sectional survey design and the self-reported nature of the data.

Poor cervical cancer screening uptake among US women who are not vaccinated for HPV is a major public health concern. Vigorous efforts are needed to reduce existing screening disparities.

Accepted for Publication: August 21, 2021.

Published: October 26, 2021. doi:10.1001/jamanetworkopen.2021.31129

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Sonawane K et al. JAMA Network Open.

Corresponding Author: Ashish A. Deshmukh, PhD, MPH, Center for Health Services Research, Department of Management, Policy & Community Health, UTHealth School of Public Health, 1200 Pressler St, RAS-E 329, Houston, TX 77030 (ashish.a.deshmukh@uth.tmc.edu).

Author Contributions: Dr Deshmukh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Sonawane and Suk served as co–first authors and contributed equally to the work.

Concept and design: Sonawane, Suk, Schmeler, Fernandez, Deshmukh.

Acquisition, analysis, or interpretation of data: Sonawane, Suk, Chiao, Montealegre, Fernandez, Deshmukh.

Drafting of the manuscript: Sonawane, Suk, Deshmukh.

Critical revision of the manuscript for important intellectual content: Sonawane, Chiao, Schmeler, Montealegre, Fernandez, Deshmukh.

Statistical analysis: Sonawane, Suk, Deshmukh.

Obtained funding: Sonawane, Montealegre, Deshmukh.

Administrative, technical, or material support: Schmeler, Fernandez, Deshmukh.

Supervision: Sonawane, Chiao, Fernandez, Deshmukh.

Conflict of Interest Disclosures: Dr Chiao reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Schmeler reported receiving grants from the National Cancer Institute, US Agency for International Development, Cancer Prevention and Research Institute of Texas, and The Raul Tijerina Jr. Foundation outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by grants from the National Cancer Institute of the National Institutes of Health (R01CA232888, Dr Deshmukh) and the National Institute on Minority Health and Health Disparities (R01MD013715, Dr Montealegre; and K01MD016440, Dr Sonawane).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Additional Contributions: We acknowledge the National Center for Health Statistics of the Centers for Disease Control and Prevention for making the National Health Interview Survey publicly available and the women who participated in the survey.