They found that states that experienced clinic closures also saw a 2% drop in cervical cancer screenings, relative to states without clinic closures, with the greatest declines in screening for patients without insurance (-6.18 percentage points (PP), p=0.01), Hispanic women (-5.32 PP, p<0.01), women ages 21 to 34 (-4.81 PP, p<0.01and unmarried women (-4.37 PP, p<0.01).

Overall, cervical cancer survival rates improved in states without clinic closures but dropped in those with a reduction in the number of clinics. There was a significant increase in the risk of dying from cervical cancer (HR 1.36, 95% CI 1.02-1.83, p=0.04) in states where clinics were closing, especially among residents in urban areas (HR 1.40, 95% CI 1.04- 1.90, p=0.03).


Researchers also found an increase in early-stage diagnoses among 18-34-year-old women in states in which no clinics had closed, but a decrease in early-stage diagnoses for this same age group in states in which clinics had closed. In those states, 13% fewer women were diagnosed in the early stages of cervical cancer than in states without closures. Correspondingly, there was a trend toward increased late-stage diagnoses in this age group women, with 8% more women being diagnosed with late-stage disease in states with clinic closures (p=0.14). Patients diagnosed with later stages of cancer generally face worse prognoses and must undergo more aggressive treatment.

“At first we thought it sounded good that there were fewer early-stage diagnoses,” said Dr. Srivastava. “But then we saw the trend toward later-stage diagnoses, for which patients need more invasive treatments, all of which have side effects. Even more concerning, we saw a higher risk of mortality in states with decreasing numbers of clinics. A story started to come together looking at these two sets of data, of this association between clinics closing and fewer women undergoing screening and an association between clinics closing and more women dying from cervical cancer.”

The findings, were startling, said Dr. Srivastava, because of the short period of time it took for serious adverse effects to occur.

“In order to see a difference in cancer survival rates, you usually need very mature, long-term follow-up data,” he said. “It can be 15-20 years in some cases. What is surprising about this study is that even though these closures occurred just a few years ago, we are already seeing clear differences in death versus survival from cervical cancer. That was both surprising and scary.”

While the correlational study cannot confirm a causal relationship between the health clinic closures and an increase in adverse health impacts for women, the findings should raise serious flags, said Dr. Srivastava.

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