Patients at community health centers in Washington and Idaho received meaningfully different types of cervical cancer screening depending on which clinic system they visited, according to an analysis published in BMC Primary Care. Patients living in rural areas, patients without insurance, and patients with fewer primary care visits were significantly less likely to receive the more comprehensive test.
The finding, reported by the University of Minnesota's Center for Infectious Disease Research and Policy, examined three primary care systems operated by federally qualified health centers. These nonprofits receive federal grants to provide medical services in underserved communities regardless of a patient's ability to pay.
The practical question for a patient is not abstract. Cervical cancer is one of the few cancers that can be prevented at multiple stages, through HPV vaccination and through screening that catches precancerous changes before they become cancer. Which test a patient receives affects how much reassurance a normal result actually provides and how long they can safely wait before the next screening.
The Clinical Difference Between the Tests
A Pap smear, also called cytology, collects cells from the cervix with a small brush and examines them under a microscope for abnormal or precancerous changes. It detects cellular changes that have already begun.
HPV testing looks for the high-risk strains of human papillomavirus that cause nearly all cervical cancers. It identifies risk earlier, before cells have visibly changed. Co-testing performs both.
Current U.S. Preventive Services Task Force recommendations call for cytology alone every three years for women aged 21 to 29, and for women aged 30 to 65, either high-risk HPV testing alone every five years, cytology alone every three years, or co-testing every five years. That interval difference is the practical consequence: a normal HPV based result generally supports a longer safe gap before the next screening than a normal Pap alone.
Professional guidance has been moving further toward HPV based screening. The American Cancer Society updated its guideline in December 2025 to recommend primary HPV testing every five years beginning at age 25, with self-collected vaginal samples acceptable when clinician-collected samples are not used.
That does not mean more testing is always better. A March 2026 paper in JAMA Network Open concluded that after an initial negative HPV test, continued co-testing may yield limited additional benefit while increasing costs. The debate among researchers is about where the added value stops, not about whether HPV based screening is superior to cytology alone.
Adoption Rates Diverged Sharply Across Three Systems
In 2012, Pap smears were used almost exclusively for a patient's first routine cervical cancer screening across all three systems. Over the following decade, all three began offering co-testing, but they adopted it at very different rates.
By 2022, co-testing accounted for 76.8% of first routine screenings at the system the researchers labeled FQHC C, which had the lowest share of patients publicly insured through programs like Medicaid and Medicare. At FQHC A, the only system serving rural communities, the figure was 58.8%.
The third system moved in the opposite direction. FQHC B provided co-testing for 63.8% of first routine screenings in 2019, then reverted to providing almost exclusively Pap smears by 2022. The analysis does not establish why that reversal occurred.
The patient-level pattern was consistent. Rural residence, lack of insurance, and fewer primary care visits were each associated with a lower likelihood of receiving co-testing. "These patterns suggest that access to care, visit frequency, and continuity of care may influence whether patients are offered or receive HPV-based screening," the study authors wrote.
The Limits of What This Study Shows
This is an observational analysis of practice patterns, not a study of health outcomes. It measured which tests patients received. It did not measure cancer incidence, cancer stage at diagnosis, or mortality, and it cannot establish that patients who received cytology alone experienced worse results.
The scope is also narrow. Three health center systems in two states cannot be assumed to represent the more than 1,300 federally qualified health centers nationally. The researchers examined only the first routine screening, not subsequent screening or follow-up after an abnormal result.
The authors did flag a broader concern. Potential barriers to HPV based screening in rural communities are concerning, they wrote, given that rural populations already experience lower cervical cancer screening rates and that rural and urban disparities may have widened following the COVID-19 pandemic.
Context from a separate national analysis supports that concern. Research led by the Medical University of South Carolina's Hollings Cancer Center found that only about 55% of women seen at these health centers were up to date on cervical cancer screening, compared with 74% nationally and a Healthy People 2030 goal of 79%.
Practical Steps for Patients
Anyone due for cervical cancer screening can ask a direct question at the appointment: which test is being performed, and when is the next one due based on that result. Those two answers determine the screening schedule, and patients are entitled to know both.
Patients aged 30 and older who receive cytology alone can ask whether HPV testing is available at that clinic and, if not, whether a referral is possible. Cost is a common barrier, and most insurance plans cover preventive cervical cancer screening without cost sharing. Community health centers provide screening on a sliding fee scale regardless of insurance status.
Self-collection for HPV testing has also become available in some settings, which removes the need for a clinician-collected sample and may help patients who have delayed screening because of discomfort or scheduling difficulty. MedicalDaily has previously covered FDA authorization of a self-collection device.
Financial pressure on community health centers is intensifying as the uninsured population grows, and decisions about when and how often to offer co-testing may become more consequential. Patients cannot control those institutional choices, but they can ask what test they received and what interval it supports.
Key Questions Answered
What is the difference between a Pap smear and HPV testing? A Pap smear examines cervical cells for abnormal changes that have already begun. HPV testing looks for the high-risk virus strains that cause nearly all cervical cancers, identifying risk earlier. Co-testing does both.
What did the analysis find? Across three community health center systems in Washington and Idaho, co-testing rates for a first routine screening in 2022 ranged from almost none at one system to 76.8% at another. Rural, uninsured, and less frequently seen patients were less likely to receive co-testing.
Does this mean some patients got worse care? The study did not measure outcomes. It measured which tests were used. Cytology alone remains a recommended option for certain ages and intervals under current guidelines.
What are the current screening recommendations? Under the Task Force recommendation, cytology every three years for ages 21 to 29. For ages 30 to 65, HPV testing alone or co-testing every five years, or cytology alone every three years. The American Cancer Society now recommends primary HPV testing every five years starting at 25.
What should a patient ask at their appointment? Which test is being done, and when the next screening is due based on that result. Patients aged 30 and older can ask whether HPV testing is available.
Is screening affordable without insurance? Community health centers provide screening on a sliding fee scale regardless of insurance status, and most insurance plans cover preventive cervical cancer screening without cost sharing.
Does HPV vaccination replace screening? No. Vaccination prevents most infections that lead to cervical cancer, but screening remains recommended for vaccinated people.
