One-third of women with inflammatory bowel disease don't undergo screening for cervical dysplasia or cancer as recommended, according to Dr. Millie D. Long and her colleagues.
This is particularly alarming because many of these women appear to be at increased risk for abnormal cervical cytology because they take immunosuppressants to control the inflammatory bowel disease (IBD), wrote Dr. Long and her associates at the University of North Carolina, Chapel Hill.
The investigators assessed rates of cervical screening because two recent studies suggested that women with IBD are at increased risk for abnormal results on Pap smears. The authors used a database of insurance claims from patients enrolled in 87 health plans in 33 states. The large, diverse study population was representative of the entire U. S. population. The study was published in Clinical Gastroenterology and Hepatology ahead of print (doi:10.1016/j.cgh.2009.03.01).
Among all female patients aged 20–64 years in the database, the researchers identified 9,356 who had Crohn's disease or ulcerative colitis. Another 25,849 women without IBD who were matched for age, health plan, and geographic region served as control subjects. The mean subject age was 44 years.
Only 70% of the women with IBD and 65% of the control subjects underwent Pap smear screening during a 3-year observation period. Such screening is recommended for this age group in several sets of treatment guidelines, including those of the American College of Obstetricians and Gynecologists, the American Cancer Society, and the U.S. Preventive Services Task Force, they noted.
When the data were categorized by type of IBD, the results did not differ: Approximately one-third of the women with ulcerative colitis and one-third of those with Crohn's disease failed to undergo cervical screening.
A subgroup of 7,415 IBD patients filled two or more prescriptions for immunosuppressant medications during the study. These included prednisone, azathioprine, 6-mercaptopurine, methotrexate, infliximab, and adalimumab.
Only half of this subgroup of women taking immunosuppressants underwent Pap screening during a 15-month period, a finding the investigators termed “quite concerning.”
If studies in the literature are correct that the use of immunosuppressants raises the risk for cervical abnormalities, “then it appears that the women at highest risk for cervical pathology are the ones who, paradoxically, are the least likely to be screened,” said Dr. Long.
The investigators also found that women who saw primary care providers were more than twice as likely to receive Pap smears as were those who did not see primary care providers. This finding “suggests that women with IBD ought to be co-managed by a primary care provider along with a gastroenterologist,” they added.
Women who had Medicaid coverage, a proxy measure for low socioeconomic status, were the least likely of all to receive a Pap smear, at 44%, compared with 71% of women covered by commercial insurance. This finding “highlights the fact that our health system must strive for more equitable care, even among IBD patients,” the investigators said.
Older women also were less likely than were younger women to undergo cervical screening. This pattern has been observed in the general population.
“This suboptimal preventive care is particularly alarming, given the abundant evidence that Pap smear screening can reduce the incidence of and mortality from cervical cancer.”
“Indeed, although this malignancy is largely preventable with proper screening, it is estimated that 50% of women who receive diagnoses of cervical cancer have never been screened,” they wrote.
This study was supported in part by the National Institutes of Health's digestive disease epidemiology training program and the Center for Gastrointestinal Biology and Disease, a part of the National Institute of Diabetes and Digestive and Kidney Diseases.