Study Indicates That Immigrant Women in Ontario Shun Cervical Cancer Screening

New data suggest that immigration status may help explain why some women decide to be screened for cervical cancer and others do not. The study by Canadian researchers additionally indicates that age and income may also affect screening rates.

Aisha K. Lofters, MD, with St. Michael’s Hospital in Toronto, Ontario, Canada, and associates examined the medical billing records of 2.9 million women aged 18 to 69 years who were living in urban areas of Ontario between 2006 and 2008.

The study aimed to compare the prevalence of appropriate cervical cancer screening in Ontario among major geographic regions of the world and Canadian-born women. Canadian guidelines advise women who are at low risk for cervical cancer to have a Pap test every 3 years. Overall, nearly 1.8 million (61.3%) women had had a recent screening per recommended guidelines during the study period.

Older, poorer women born in South Asia had the lowest screening rates. In fact, only 21.9% of South Asian immigrants who were aged >50 years, were living in a low-income neighborhood, and did not have a primary care doctor had had a recent Pap test compared with 79% of native women residing in the highestincome neighborhoods who had a primary care physician.

Lofters and colleagues said that the observation that screening inequities were most pronounced in women from South Asia, especially in those aged >50 years, is especially worrisome. First, India is the primary source country for Ontario’s immigrants, and, secondly, South Asians are among the fastestgrowing minority groups in Canada. Further analysis revealed that immigrant women who had lived in Canada for more than 10 years still had significantly lower screening rates, thereby suggesting that a longer time spent in Canada does not eradicate screening barriers.

Lofters and associates suggested that cultural barriers and women’s prior experience in their country of origin may contribute to low screening rates in immigrant women. Future research is needed to examine the role of such factors and other potential barriers, such as provider gender and ethnicity.

The investigators emphasized that their study is large and population-based with broad inclusion criteria. Multiple subgroup and sensitivity analyses were done to corroborate the robustness of the findings. They cautioned, however, that they are not sure whether their results can be extrapolated to other settings, although Canada’s immigration patterns are known to be similar to global patterns.

The findings suggest that primary care providers should pay closer attention to risk factors for low screening, such as immigration status, age, and income when women present who are eligible for cervical cancer screening. The data also mean that policy makers may consider targeting particular subgroups of women for culturally appropriate screening campaigns.

Cervical cancer is the second most common cancer in women worldwide, with incidence rates in less developed countries nearly double those in developed countries. The significantly higher incidence rates are thought to be primarily due to routine and widespread Pap test-based screening programs in developed countries.

Lofters AK, Hwang SW, Moineddin R, Glazier RH. Cervical cancer screening among urban immigrants by region of origin: a population-based cohort study. Prev Med. 2010. Dec;51(6):509-16 [Epub ahead of print October 7, 2010].