Four in Five Mentally Ill Women on California Medicaid Not Screened for Cervical Cancer

A new study has found some concerning gaps in cervical cancer screening among a vulnerable population: women with severe mental illness enrolled in a state Medicaid program.

The research, published in Psychiatric Services, looked at the rates of cervical cancer screening among over 31,000 female enrollees in California’s Medicaid program, called Medi-Cal, who had gotten care from a specialty mental health clinic. The study authors aimed to clarify whether this population is indeed less likely to be screened for cervical cancer, as prior research on severely mentally ill women in the general population has yielded conflicting results.

Using Medi-Cal claims data, the researchers estimated cervical cancer screening rates among the study cohort as indicated by codes for Pap smear screening. Statistical analyses, conducted as part of the study, estimated the effects of several possible predictors of screening, including age, race/ethnicity, drug or alcohol use, urban or rural residence, severe mental illness diagnosis, and healthcare utilization history.

Only about 20% of the women in the study cohort received screening for cervical cancer over the 1-year study period, which is less than half the rate of 42.3% within California overall. Asian women in the study had the highest screening rates; screening was slightly but significantly more likely for Asian, black, or Hispanic women than for white women. Women aged 18 to 27 years were less likely to have received screening than those aged 28 to 47.

The strongest predictor of cervical cancer screening was prior primary care utilization, as the three-quarters of women in the study who had claims indicating a primary care visit were over 3 times more likely to have received screening than those who did not. Finally, the researchers found that when controlling for history of drug or alcohol use, women with a diagnosis of schizophrenia were significantly less likely to have been screened compared with those diagnosed with bipolar disorder, major depressive disorder, or generalized anxiety disorder.

"The women were receiving services in a public health setting, but were not receiving preventive services as often as women in the general population," senior study author Christina Mangurian, MD, MAS, summarized in a press release from the University of California, San Francisco. "The results of this very large study indicate that we need to better prioritize cervical cancer screening for these high-risk women with severe mental illnesses."

The researchers identified some potential solutions, like bringing screening services to where these women already receive care by periodically holding a "women’s mini-clinic" at the specialty mental health facilities they visit. They also focused on the importance of primary care as a predictor for cervical cancer screening.

“Although improving access may seem straightforward, more work is needed to address previously identified barriers to use of primary care for this population, including difficulties with transport and access, adverse experiences, fear of mistreatment, embarrassment, and history of sexual assault,” they wrote.

Future work to remedy the disparities in cancer screening for mentally ill women enrolled in Medicare could have the effect of expanding access to care while also improving cancer mortality outcomes for this at-risk population, the study authors concluded.