Inadequacy of cervical cancer screening among urban recent immigrants: A population-based study of physician and laboratory claims in Toronto, Canada
Introduction
Routine Papanicolau (Pap) smear screening can prevent up to 90% of invasive cervical cancers (Miller et al., 1991). Spontaneous screening has been a success story in Canada, with average annual reductions in incidence and mortality of invasive cervical cancer of 2.1% and 1.9% from 1992 to 2001, respectively. The incidence of invasive cervical cancer is 7.5 cases per 100,000 women in Canada, similar to that in the United States (National Cancer Institute of Canada, 2006, National Center for Health Statistics, 2005). Despite low cancer rates and universal health coverage, socioeconomic differences in incidence persist (Mackillop et al., 2000). Most new cases of invasive cervical cancer in Canada occur among women who have either been under-screened or never been screened (Duarte-Franco and Franco, 2004, Stuart et al., 2004).
Minority women in Canada have previously been identified as less likely to be screened for cervical cancer (Hyman et al., 2002, Johnston et al., 2004), and national surveys have demonstrated that women with lower income, lower education, foreign language, and who are not Canadian-born are less likely to report screening (Grunfeld, 1997, Finkelstein, 2002, Maxwell et al., 2001, Lee et al., 1998, Snider et al., 1996). Self-report of Pap smears, however, is subject to recall and social desirability biases (Tremblay, 2004) and no previous study of actual screening (Finkelstein, 2002, Colgan et al., 2002) has examined immigrant or minority women.
The Toronto area receives almost half of all new immigrants to Canada and is now one of the most diverse urban areas in the world (Citizenship and Immigration Canada, 2003). Many regions of origin for Toronto’s immigrants, including south Asia and eastern Europe, have very high cervical cancer incidence (Citizenship and Immigration Canada, 2003, National Cancer Institute of Canada, 2004) and those same regions also have low screening rates. Our setting, therefore, has many women potentially at high risk for cervical cancer due to a history of insufficient screening but whose actual use of Pap smears once in Canada is not known. The aim of this study was to investigate the utilization of cervical cancer screening among recent immigrants and socioeconomically disadvantaged women in one of the highest immigration areas in the world.
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Methods
According to the 2001 Canadian census, there were 2,481,494 people living in Toronto, on a land area of 629.9 km2, making it Canada’s largest city. In 2001, Toronto contained 525 census tracts (CTs), 520 of which had socioeconomic information available from the census.
We accessed information about Toronto’s population eligible for health services and women receiving Pap smears through a comprehensive research agreement with Ontario’s Ministry of Health and Long-Term Care. All personal
Results
Characteristics of the study area are summarized in Table 1 and are compared to those for the province and for the country. Toronto has much higher rates of immigration and visible minorities than Ontario or Canada as a whole.
The proportion of eligible women having at least one Pap smear from 2000 to 2002 was 55% in both age groups. Variation in Pap smear rates over the CTs analyzed was large, with a range of 37–75% for those 18–41 and 40–73% for those 42–66 years of age. Interquintile analysis
Discussion
Rates of cervical cancer screening appear to be quite low in Toronto for all women, with consistent, significantly lower rates in areas with high levels of recent immigration, non-official home language, and visible minorities. Especially low rates were found among a group of mostly immigrant women who recently registered for health care coverage in Ontario. Low income and low education were also associated with lower Pap smear rates. Although recent immigrants tend to settle in low income
Conclusions
Rates of cervical cancer screening in Toronto are well below those dictated by evidence-based practice. Efforts to improve coverage of cervical cancer screening need to be directed to all women, their providers, and the health system, but with emphasis on addressing barriers for women who recently arrived in Ontario and those with socioeconomic disadvantage.
Acknowledgments
Supported by the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada, and the Ontario Ministry of Health and Long-Term Care. The opinions, results, and conclusions are those of the authors and no endorsement by the Ministry is intended or should be inferred. The authors would like to thank Piotr Gozdyra for creating the maps presented in this paper. This work was funded by the Canadian Institutes of Health Research. From the Centre for Research on Inner City Health, The Keenan
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