E84: The Financial Domain of Pap Smears

Kirtly: Welcome back to the "7 Domains of Women's Health" and our effort to understand the Pap smear, that universal experience for women. Well, almost universal experience.

I'm Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah. And although I'm a reproductive endocrinologist doing infertility, women's hormones, menopause, that kind of stuff, I've been involved in providing reproductive healthcare for underserved women and in the public health issues for women all my professional life.

And with me is my colleague in Pap smears and helping women avoid cervical cancer, Dr. Katie Ward. Katie has a Doctorate in Nursing Practice and is a women's health nurse practitioner.

We're going to talk about the financial domain of Pap smears and cervical cancer screening.

The Pap smear, and now the development of HPV screening, looking for the presence of the human papillomavirus strains that can cause cervical cancer, is the number one success story for cancer screenings.

And I'm going to remind you if you didn't listen to this already, but it's important to know because we have many screening tests in our healthcare system, that a screening test should be good at finding what it's looking for.

In the case of a Pap smear or HPV test, it is very good at looking for pre-cancerous conditions and cancer. And the HPV test is good at finding the troublesome viruses that cause cervical cancer and pre-cancerous conditions. They are good tests if people know how to do them, and they're easy to teach and easily done right.

The screening tests, again, shouldn't say that there's a problem when there isn't one. The test shouldn't be risky to the person being tested. It shouldn't have a lot of risks or side effects. And these tests don't.

Even though women don't like to have them and they can be a little embarrassing to have done and a little uncomfortable, as far as I'm concerned, these tests are more reliable and less uncomfortable than mammograms. That's just me.

Katie: For sure.

Kirtly: And the test should be inexpensive and universally available. And this is true for Pap tests and HPV tests. They are very cheap, they're covered by every insurance policy under the Affordable Care Act, and they're often free in almost every county in the country through screening clinics.

Katie: The introduction of the Pap smear reduced cervical cancer by 70% when it became available. So when you say it's sort of the model test, it really changed that whole world for women.

But even though in theory they're free and available, the women who are most likely to be diagnosed with cervical cancer are women who've not been getting Pap tests.

It's interesting because cervical cancer doesn't just go from not there to there the next day. It has a very long period of slow-growing change, when if we can catch it in that space, it never becomes cancer. And so that's the beauty of the Pap test, is it's really picking up those pre-cancerous changes. The issue is often that women, in spite of it being available, are not getting the test.

And if you look at a map of the United States, you can really sort of see it's a corridor of poor health outcomes, including cervical cancer. So, for our purposes today, we can call this the cervical cancer corridor. And this is a space across primarily the Southern United States where you have more poverty, more rural areas, and places with limited access to healthcare and healthcare providers. You just have a less per capita healthcare provider penetration there.

So when we look at mortality rates, the people who live in those areas, we see a higher rate for Black women. Black women die from cervical cancer at twice the rate of White women. And Hispanic women have the highest incidence of getting cervical cancer.

These disparities are not about biology. They're reflecting a systematic inequality in healthcare access.

So the financial domain isn't just about individual costs, but it's about how we allocate resources as a healthcare system and as a society. And when we underfund preventive care in marginalized communities, we end up with these disparities that cost lives.

We talked about the HPV self-collection in the emotional domain, and I'm really excited about the potential to reach women in rural areas through programs that mail self-collection kits to people's homes so they don't have to travel to see a healthcare provider when that may be quite an obstacle.

And I think the future of cervical cancer screening is going to be kind of a hybrid where people can self-collect the HPV for initial screening, and then if that comes back positive, then that's when they will need a clinic visit for either a colposcopy or a Pap test at that point.

But the Pap is going to maybe stop being the first test you get, and it will be used to help us sort out which HPV we need to follow up on and which one we don't.

Kirtly: Well, I did my poop test. So I got screened for colon cancer instead of having a colonoscopy, which I had had once and does not meet the screening criteria because it's inordinately expensive as a screening test. But I got my poop test mailed to me at home. It's not cheap, but my insurance paid for it, and I got to do it in the privacy of my home. I was thrilled. It was a little complicated, the instructions, but I watched the video and I figured how to do it. So getting people screened at home, it works. At least it worked for me.

Katie: It's exciting.

Kirtly: Anyway, back to the financial domain. If Paps and HPV tests are covered by all health insurances and Medicare and there are many free screening programs for women without health insurance, why are we even talking about the financial domain?

Well, the problem is that for many reasons, women don't get this cheap and easy screening test, as Katie said. And the next problem is that the next step, if a woman has an abnormal Pap that suggests a precancerous condition and a risky HPV virus, is a colposcopy.

So that's a procedure. The word colposcopy means looking, that's the "scopy" part, at the upper vagina, that's the "colpo" part, specifically the cervix. And colposcopies with biopsies, taking a tiny bit of tissue the size of a hangnail, are very good at detecting the presence of precancerous conditions.

But they are not widely available, and they're not inexpensive. Katie, you've been out there doing colposcopies for a long time.

Katie: I have. I have been a certified colposcopist, there's a mouthful, for more than 20 years now. I probably do 150 colposcopies a year. For 20 years, I did the math, that's a lot of colposcopies.

But yeah, it's a big, scary word, and it sounds sort of like colonoscopy, so people may be worried they're getting a poop test.

Kirtly: Right. No, if you put a colposcopy into your search engines, colonoscopy keeps coming up. No, that's not what I wrote. I wrote colposcopy.

Katie: So colposcopy, yes, it's a specialized follow-up test and you only get this if you've had an abnormal Pap with a positive HPV that meets certain criteria. It does require specialized training beyond what many primary care providers, nurse practitioners, nurse midwives, PAs get in their training program. And so that's . . .

Kirtly: And physicians. Most physicians don't get it either.

Katie: Yeah. So I think that's one of the problems with the issue of disparities in care, is in rural communities, they're often being served by primary care providers who don't specialize in OB-GYN and would not have had this training. And so the travel to somebody with this specialty becomes an obstacle.

But assuming you can find somebody that performs a colposcopy, and your healthcare provider will help you with that, it is a more detailed examination.

Often, the way I explain it to my patients is with a Pap, we're really getting cells that were falling off anyway. And with the colposcopy, we're going to look at the cervix under magnification, figure out what areas might contain those abnormal cells, and then specifically take the biopsy from the area that looks like it's got abnormal cells in it.

It's a procedure that takes about 15 to 20 minutes. It's performed in an exam room similar to where you'd get a Pap smear. It's not done under anesthesia. You'll be able to drive yourself home.

You'll be positioned on an exam table with your feet in stirrups, just like a regular pelvic exam. And the provider inserts a speculum to view the cervix, same as we do with a Pap test.

What is different is what happens next. We pull around this big colposcope. It's really a microscope on a stand with a bright light. It allows us to see the cervix under magnification. So we're looking through this fancy pair of binoculars.

And then we apply some kind of solution. Usually it's a vinegar, and sometimes it's iodine. Those solutions temporarily highlight the areas where the abnormal cells are by kind of changing their color and appearance. That part is totally painless. So all of the looking at the cervix is a painless procedure.

Once we identify areas where there might be abnormal cells, then that's when we'll take a biopsy. And that gives women a quick little cramp, but it's not a pain that lingers, and the cervix really doesn't have a lot of nerve endings.

We can provide some anesthesia if people are particularly anxious or if it's really uncomfortable, but generally it's a very brief cramp.

Afterwards, though, women will have some bleeding or spotting, and so we recommend avoiding tampons, intercourse, douching, menstrual cups for a week to just make sure that those sites heal and you don't start up any additional bleeding.

And then most people will get their biopsy results. They're sent to a pathology lab, and they come back in a week or two. And that really gives us definitive information about whether or not there are pre-cancerous cells.

In most cases, the Pap is showing us something mildly abnormal, and the colposcopy is a backup test to make sure the Pap didn't miss anything worse.

And more often than not, with the new guidelines that we were talking about earlier, the recommendation is to watch closely. And so we'll see people back every 12 months instead of every 5 years.

Routine Pap screening now is every five years. And if you're in that process where we're following up an abnormal, then we may be asking you to come in every 12 months and just continue to watch that.

Sometimes I have patients that get two or three colposcopies every other year, but we're able to watch them and reassure them that things are not getting worse and that it's safe to not do any treatment at this time.

So that can be the really reassuring thing about going through the colposcopy, is that you know that you don't need to get any more aggressive treatment.

Kirtly: So Pap smears are cancer screening and are covered by all insurances under the Affordable Care Act, and are free in many places. Colposcopies are diagnostic procedures, and that's important. You have a mammogram that's slightly abnormal, and then you need a diagnostic test. Diagnostic procedures are not always fully covered and may have significant copays. Most colposcopies have biopsies performed, and that's an additional cost because that's a medical test.

So if you ask me what a colposcopy costs, I would say it depends. Don't you hate that? I hate that. Depends on what? Well, healthcare costs vary widely across the country, and the average cost of a colposcopy and biopsy might be $400 in some states and $1,000 in another state.

And it depends on the clinic you're attending. Some have sliding fee scales based on your ability to pay. Some charge your insurance a smaller amount than what you might have to pay if you don't have insurance. That always gripes me a lot.

If you have insurance, it's important to know if the clinic or clinician providing the colposcopy service is in your network, as out-of-network colposcopies copays can be as high as 50%. Fifty percent of a $1,000 is $500. Now, this is basic math, and I'm doing it for you, but that's a lot of money.

And of course, the cost of a medical procedure for women's health goes far beyond the medical billing for women in rural areas. There may be significant travel, hundreds of miles. There are childcare costs, out-of-work costs. All of these things figure into whether a woman will be able to get a colposcopy and the next step of treatment, if there's evidence of a pre-cancerous area on the cervix.

The cost of treating a pre-cancerous area might be several hundred dollars, but that is much, much less than having the cells progress to cancer.

But poverty, lack of information, and lack of resources all lead to denial. And putting things off when there are so many other pressures at home that seem to be more pressing is a really natural thing. Women in rural areas only follow through with their colposcopies maybe 75% of the time, and 25% of women from rural areas slip through the cracks.

Katie: Yeah, and I think that's why we see those disparities in care. At the same time, those are the places that are hardest to staff with specialty providers. So it is really a distribution of healthcare provider problem as well.

So let's talk about some places you can get a colposcopy if you don't have insurance or it's a challenge.

This is a little bit specific to Utah, but as of the recording date in March 2025, the Utah Breast and Cervical Cancer Screening Program, run by the Utah Department of Health, provides cancer screenings to those who qualify. There's an 800 number, 800-717-1811, or there's an online portal through the Utah Department of Health.

And so that program can be a lifeline for many women in our state who might otherwise not have access to cancer screening or other preventive care.

Other counties have their own specific programs. So wherever you're listening, you can check with your county health department or your state health department, and usually be able to look up what their breast and cervical cancer screening program is.

Most areas have community clinics. These are typically run by some of the larger healthcare systems in our state. The University of Utah and Intermountain Healthcare both run community clinics that offer sliding fee scales.

And then throughout the country, actually, there are currently some innovative student-led clinics. There's one here in Rose Park and one in the Maliheh Free Clinic in the Salt Lake Valley.

And then the other thing I know about, at least in the Salt Lake area, is once a year, the Junior League puts on a health fair over a couple of days. It's called the Care Fair. It usually happens in July, and it screens all kinds of people for all kinds of things, but they do offer an area where women can get a Pap and a breast cancer screening.

That's kind of a joint venture between a lot of healthcare providers, and then a different healthcare system that helps with the follow-up. As we've been talking about, the Pap is the easy part, but kind of helping navigate the follow-up can be the challenging thing.

So for younger women and girls, the Utah immunization program Vaccines for Children provides low-cost HPV vaccines, and those are available for females ages 9 to 18 who meet certain income guidelines. The vaccine is probably the best cervical cancer prevention, the best investment in that that we can apply.

So for women who have had an abnormal Pap . . . Say you got one at the Care Fair or community clinic, and then you need that additional colposcopy. There is a program called the Utah Cancer Control Program, and that does help people access colposcopy and treatment by funneling them into Medicaid. And even if people don't otherwise qualify for Medicaid, they're able to access funds just for this one targeted treatment.

I've done some work over the years with Utah Cancer Control. So that is a program that's available if you don't have insurance and you're looking at a large bill for a colposcopy.

Again, the same site for accessing the Utah Cancer Control program is that Utah Department of Health number. I'll give it to you one more time, 800-717-1811. And you can also find their website at the Utah Department of Health.

But yeah, as Kirtly was saying before, the most expensive healthcare is the healthcare you don't get when you need it. So if financial concerns are keeping you from getting screened or following up on those abnormal results, please reach out to your provider or your local health department. There are resources to help people. It doesn't help with the time off of work, but the resources are there.

Kirtly: Or the childcare or the travel. Well, the financial truth is that the cost of public health and prevention of cervical cancer screening and early detection and treatment and vaccines to prevent women and men from acquiring the cervical cancer virus and transmitting it, these costs are much less expensive in the long run than the treatment of cervical cancer and the cost of lives lost.

That's one of the other measures of a good screening test. It has to be worth it, and the Pap smear and HPV test and the vaccines certainly are.

Thanks for joining us on our Pap smear journey through the "7 Domains." And if this has been helpful to you or helps spark a conversation with friends and family, please share and join us with our other Domains of Pap Smears and our other Domains of Women's Health.

You can find our podcasts on the 7 Domains of Paps, and Adventuring, and Grieving, and Caffeine, all of those, wherever you get your podcasts, or at womens7.com.

Thanks for listening, and may you always get a Pap smear and it always be normal.