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Beyond September: Hidden Populations in Cervical Cancer Screening | Keisha Mulugeta-Gordon, MD

DiversityHealth DisparitiesInclusion & Health EquityVoices
Nov 10, 2021

Keisha Mulugeta-Gordon, MD

As an OB/Gyn resident training at a high volume, urban, academic institution, resources are vast, but that does not mean adequate gynecologic care is reaching every woman. Too often, I am struck by the women diagnosed with advanced cervical cancer despite hearing headlines saying cervical cancer is declining in the United States.

From the 1960s to the mid-2000s, cervical cancer incidence and mortality have declined significantly with the adoption of cervical cancer screening and public health programs utilizing cytology, HPV testing, and vaccinations. However, even with this impressive overall decrease, there are still certain groups of women that have an increased risk of cervical cancer. Disparities in incidence and mortality in specific populations are striking when looking at race and ethnicity and in those with specific barriers to adequate health care.

Immigrants, refugees, incarcerated women, and women living in rural areas are all at an increased risk. What do these women all have in common? Multifactorial structural, social, economic, and psychological barriers to access appropriate and adequate health care, ultimately leading to poorer health outcomes as a result.

According to Albi et al., for immigrant and refugee women, barriers to screening were attributed to psychosocial aspects (concern over body image and embarrassment to have a gynecologic exam), communication (non-native English speaker), and access to a health care provider (no access to clinics or a provider).1,2 The CDC reports when immigrants arrive in the United States, there is a new-arrival medical screening exam which includes recommendations for a pelvic exam in women.3 However, it is worth considering immigrant women’s comfort level in receiving a pelvic exam upon arrival in a foreign country. It is also important to consider that a high percentage of these women have experienced sexual assault or other trauma, which can ultimately make planning and receiving a pelvic exam more traumatic. Unfortunately, some of these concerns are not unique to just the immigrant and refugee population. We see similar patterns in the incarcerated female population.

According to Binswagner et.al, incarcerated women are 4-5x more likely to receive a diagnosis of cervical cancer.4 These women often come from lower socioeconomic backgrounds and have attained lower levels of education and therefore lower overall health literacy. 5-6

Furthermore, these individuals are more likely to have a history of abuse and may suffer from psychological disorders.7 All of these factors mentioned are considered barriers to receiving gynecologic care and, ultimately, cervical cancer screening. Unsurprisingly, these risk factors also lead to a greater health disparity. Additionally, when we take this one step further and consider the HPV vaccine as a preventative measures, incarcerated women or those who have a history of being incarcerated are less likely to complete the HPV vaccination series.5-6,8 While it may now seem obvious after discussion that immigrant, refugee, and incarcerated women are disproportionately at risk, women living in rural areas may come as more of a surprise to some.9

In 2014, ACOG published a committee opinion highlighting the lack of obstetrician-gynecologist providers in rural areas.10 From an obstetrical standpoint, these women are less likely to receive prenatal care and access to maternal-fetal medicine specialists, if necessary. From a gynecologic standpoint, these women are less likely to receive routine cervical cancer screening. Twenty percent of the United States’ population live in rural areas – this means 1 in 5 women are not getting screened for this preventable disease.

As a trainee, I am left with more questions than answers…

What can we do as gynecology care providers at the community level, provider level, and systemically to address these barriers?

For the residents in a continuity clinic, what are the follow-up care and navigation processes for patients? Who is going to follow up on the pap smear results for patients presenting to your free clinic?

For the gynecologic oncology fellows, how can you bring awareness to the importance of screening and increase HPV vaccination uptake at your institution?

For the gynecologic oncology attendings, how can you incorporate advocacy into your practice and inspire your trainees to do the same?

Although pap smears are often performed by general OB/Gyns and primary care providers, any women’s healthcare provider can speak up for change. For our future direction, we need to develop attainable and sustainable programs for women that fall in the hidden populations, as their access to screening is equally important.



  1. Abdi HI, Hoover E, Fagan SE, Adsul P. Cervical Cancer Screening Among Immigrant and Refugee Women: Scoping-Review and Directions for Future Research. J Immigr Minor Health. 2020 Dec;22(6):1304-1319.
  2. Goel MS, Wee CC, McCarthy EP, Davis RB, Ngo-Metzger Q, Phillips RS. Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care. J Gen Intern Med. 2003 Dec;18(12):1028-35.
  3. Center for Disease Control – Cancer Screening. Mar. 2021.
  4. Binswanger, I. A., Krueger, P. M., & Steiner, J. F. (November 2009). Prevalence of chronic medical conditions AMONG jail and prison inmates in the USA compared with the general population. Journal of Epidemiology & Community Health, 63(11), 912–919.
  5. Pankey T, Ramaswamy M. Incarcerated women’s HPV awareness, beliefs, and experiences. (May 2015) Int J Prison Health. 2015;11(1):49-58.
  6. Singh GK, Miller BA, Hankey BF, Edwards BK. Persistent area socioeconomic disparities in U.S. incidence of cervical cancer, mortality, stage, and survival, 1975-2000. Cancer. 2004 Sep 1;101(5):1051-7.
  7. Brousseau EC, Ahn S, Matteson KA. Cervical Cancer Screening Access, Outcomes, and Prevalence of Dysplasia in Correctional Facilities: A Systematic Review. (December 2019). J Womens Health (Larchmt), 28(12):1661-1669.
  8. Kelly PJ, Allison M, Ramaswamy M. (July 2018). Cervical cancer screening among incarcerated women. PLoS One, 13(6).
  9. Buskwofie A, David-West G, Clare CA. A Review of Cervical Cancer: Incidence and Disparities. J Natl Med Assoc. 2020 Apr;112(2):229-232. doi: 10.1016/j.jnma.2020.03.002. Epub 2020 Apr 8. PMID: 32278478.
  10. ACOG Committee Opinion No. 586: Health disparities in rural women. Obstet Gynecol. 2014 Feb;123(2 Pt 1):384-388. doi: 10.1097/01.AOG.0000443278.06393.d6. PMID: 24451676.

Keisha Mulugeta-Gordon, MD, Postgraduate Year 3 in Obstetrics & Gynecology at The Hospital of the University of Pennsylvania.

This column is sponsored by an unrestricted grant from GSK. Sponsorship excludes editorial input. Content developed by the SGO Diversity, Inclusion & Health Equity Committee.