When Eleonora Teplinsky, MD, learns that a woman in her forties is getting her first Pap smear, she sees a string of lost opportunities: years of missed screenings, leaving potentially precancerous cervical lesions undetected and untreated.

A new analysis published in JAMA Network Open found about 15.4 million women between ages 21 and 65 had never been screened for cervical cancer.

“Without screening, precancerous changes can go undetected and a cancer may not be diagnosed until a patient develops symptoms,” said Teplinsky, a medical oncologist at Valley Health System in Paramus, New Jersey, and a spokesperson on gynecologic cancers for the American Society of Clinical Oncology.

The American College of Obstetrics and Gynecology recommends cervical cancer screening every 3 years beginning at age 21. At age 30, women should receive testing for human papillomavirus (HPV) every 5 years, even if they have been vaccinated.

However, a growing number of women report never having been screened.

The analysis found the proportion of women aged 21-29 years who had never undergone screening increased every year by 5.2%, from 12.5% in 2005 to 31.9% in 2023. The study analyzed nine cycles of data from the National Health Interview Survey.

Among women aged 30-65 years, the rate went from 5.3% to 14.8%, an average annual increase of 6.8%.

Who Is Missed?

Lower rates of screening are expected among women who recently turned 21 as they are newly eligible. But the results among this younger population are concerning because early engagement with preventive care can establish lifelong screening patterns, according to Kalyani Sonawane, PhD, a public health researcher at the Medical University of South Carolina in Charleston, South Carolina, who led the study.

“The transition into adulthood is a critical window for establishing preventive health behaviors, and our findings suggest that many young women may be missing that opportunity,” Sonawane said.

Young adults may experience disruptions in insurance coverage and fewer routine healthcare visits than older adults. Some may not know when they should start getting Pap smears or may not consider screening a priority because they feel healthy, Sonawane said.

Another complication may have inhibited people from getting screened: recommendations have changed.

Women no longer need the annual Pap tests that were once routine, with screening intervals now varying by age and testing approach, said Eve Espey, MD, distinguished professor in the Department of Obstetrics and Gynecology at the University of New Mexico in Albuquerque, New Mexico.

“It may be more difficult to remember when it’s time to get a Pap smear,” she said.

Some younger women may also believe HPV vaccination eliminates the need for screening. The first vaccine for HPV, Gardasil, was approved in 2006, meaning some adults have grown up with the vaccination as part of routine preventive care.

Older patients may also be more reluctant to undergo pelvic examinations, particularly if they have had painful or uncomfortable experiences with other medical procedures, Espey said.

“Distrust in physicians — who arguably took a long time to acknowledge that discomfort — may be a barrier to care,” Espey said.

Some races also showed lower screening rates.

After adjustment for sociodemographic characteristics, Asian women aged 30-65 years had a prevalence ratio of 2.27 (95% CI, 2.13-2.30) for never having been screened compared with White women. Among younger women, the prevalence ratio was 1.48 (95% CI, 1.23-1.49). Black and Latino women also had lower rates of screening than White women.

“That was one of the most striking findings in our study,” Sonawane said.

Previous research suggests that limited access to care, language challenges, lower awareness of screening recommendations, cultural norms on preventive and gynecologic care, and concerns about stigma may contribute to the lower rates.

The same combination of factors may help explain other disparities. Women without insurance and those with less than a high school education had lower rates of screening than those with private insurance or more education.

“Access to care is fundamental because cervical cancer screening generally requires interaction with the healthcare system, insurance coverage, and access to a clinical provider,” Sonawane said. “At the same time, access alone does not fully explain the disparities we observed.”

Espey also pointed to fragmentation within the healthcare system. A woman may see a primary care clinician regularly who does not provide Pap smears and need a referral for a pelvic exam.

“It’s important not to frame lack of screening simply as an individual choice but to discuss it on a system-wide level,” Teplinsky said.

Women with disabilities are also among those who are missing getting screened, according to a recent separate study by the American Cancer Society.

Those with self-care, vision, mobility, cognition, and communication related disabilities had lower rates of screening. Cervical cancer screening prevalence was 53% lower among those with substantial self-care difficulty than among those without such difficulty. Women with substantial communication difficulties also had a 35% lower screening prevalence. The researchers adjusted for health insurance type, geographic region, and education, among others.

“That means the disparity is largely independent of healthcare access differences, pointing to barriers related to having the disability itself, including those in the clinical setting,” said Priti Bandi, PhD, scientific director of Cancer Risk Factors and Screening Surveillance Research at the American Cancer Society and senior author of the disability study.

The Concern About Later-Stage Disease

The rise in never-screened women is occurring alongside increases in some forms of later-stage cervical cancer.

Among women aged 30-64 years, incidence of cervical cancer that has spread beyond the cervix to nearby tissues or lymph nodes increased 2.3% annually from 2017 through 2023. Distant-stage incidence increased 0.4% annually from 2001 through 2023. Among women 65 years or older, distant-stage incidence increased 2.6% annually from 2018 through 2023.

“The rise in regional stage and distant stage incidence may be due to the increase in women who have not been screened for cervical cancer,” Teplinsky said. “Missed or delayed screening could contribute to later-stage diagnoses because screening gives us the opportunity to identify precancerous changes or cancer earlier.”

However, Sonawane cautioned that their analysis was not designed to establish a causal relationship between never screening and cervical cancer incidence.

Bringing Screenings to Women

To increase screening rates, Espey said residency programs could better train primary care clinicians to perform Pap tests, likely reducing the need to refer patients to an ob/gyn.

HPV self-collection could also offer another way around some of those barriers.

In the disability study, stool-based cervical cancer testing was more common among people with greater levels of disability. The method can remove some of the logistical barriers associated with a clinic visit. The Teal Wand at-home kit is currently the only at-home self-collection device approved by the FDA.

Espey said of HPV self-collection, “100% — this could be a game changer.” “But there may still be meaningful challenges even with self-collection, such as performing self-collection for those with self-care disabilities or understanding multistep instructions in those with cognitive difficulties.”

And a screening test is only the first step. A positive result requires follow-up testing and when indicated, diagnosis, and treatment.

For clinicians, closing the gap entails asking a simple question at every opportunity: Has this patient ever been screened? And when the answer is no, the next step may be equally simple.

“Offer it today,” Espey said.

Sonawane, Espey, Teplinsky, and Bandi reported having no relevant disclosures.

Lara Salahi is a health journalist based in Boston.