Cervical Cancer Screening Access, Outcomes, and Prevalence of Dysplasia in Correctional Facilities: A Systematic Review

Abstract

Background: Incarcerated women often access health care primarily through contact with correctional systems. Cervical cancer screening within the correctional system can address the preventable outcome of cervical dysplasia and cancer in this high-risk population.

Materials and Methods: A search of PubMed, EMBASE, CINAHL, and ClinicalTrials.gov was conducted for articles published between January, 1966 and December, 2018. All studies on a population of jailed or incarcerated females and at least one of the following outcomes: cervical cancer or dysplasia, pap smear screening, knowledge about screening, treatment of cervical dysplasia, and compliance with follow-up were analyzed.

Results: Forty-two studies met inclusion criteria. All 21 studies with prevalence outcomes described a higher prevalence of cervical dysplasia and cancer in the women involved with corrections, compared to a variety of different sources that served as community control groups. The data on screening outcomes were inconsistent. Follow-up compliance for abnormal results was poor, with a study finding that only 21% of women were rescreened within 6 months of the recommended time period. Knowledge about cervical cancer and screening was evaluated in eight studies and was poor across all studies.

Conclusion: Women involved in correctional systems have a higher prevalence of cervical dysplasia and cancer than women in the general population. Acceptance of screening varies, and no published interventions have been shown to improve screening within the prison system. Treatment and compliance with follow-up recommendations are extremely poor and should be a focus of future research.

Introduction

Cervical cancer is a highly preventable cancer. Effective screening has greatly reduced the incidence of cervical cancer in developed countries. In the United States, it is estimated that 13,240 women will be diagnosed with cervical cancer in 2018.¹ Certain populations of women are at higher risk for cervical cancer. As early as the 1960s, published literature noted that women in correctional facilities had a higher prevalence of cervical cancer compared to women in the general population.^2,3

Correctional facilities house women who are in prison or jail, and the term “incarcerated” can be used to refer to either prison or jail. Typically, prisons house women who are sentenced to incarcerations of greater than 1 year, and jails house women who are awaiting trial or sentenced to shorter periods of time. Both populations of women are included in the body of literature describing the increased risk of cervical dysplasia and cancer in correctional facilities.

Risk factors for cervical cancer such as multiple sexual partners, HIV infection, and tobacco use are present in a high percentage of women involved in the correctional system.^4,5 Women in correctional facilities also report poor access to preventive health care before incarceration.⁶ The increased risk of disease, coupled with the decreased access to care, make incarcerated women an ideal population to target for cervical cancer screening to reduce the health disparities associated with this cancer.

There are systematic barriers to cervical cancer screening within the correctional system. Access to gynecologic care can be limited, and women who are briefly jailed and released may never have the opportunity for screening. Qualitative data suggest that many incarcerated women do not trust the medical system within the prisons.⁷ A high proportion of women in prison have been subject to physical, emotional, and sexual abuse, and this history of victimization may also reduce willingness to access gynecologic care in the setting of incarceration.⁸

To address the disparities in cervical cancer diagnosis in this population of women who are involved in the criminal justice system, it is important that we understand the prevalence of dysplasia and the processes for screening that exist in the correctional system. We analyzed the literature with a broad perspective and explored outcomes of screening, treatment, compliance, knowledge, and experiences. We conducted this systematic review with the objective to address the following questions: (1) What is the prevalence of cervical dysplasia and cervical cancer among women involved in the correctional system? (2) What interventions have been assessed for optimizing cervical cancer screening among women involved in the correctional system? (3) What is the reported compliance with recommended treatments and follow-up for abnormal screening among this population of women? and (4) Among incarcerated women, what is the knowledge about cervical cancer screening and what experiences have been reported in relation to screening and correctional facilities?

Materials and Methods

Information sources and search strategy

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations for reporting on systematic reviews⁹ (see Supplementary Data).

PubMed, EMBASE, CINAHL, and ClinicalTrials.gov were queried. In addition, we manually reviewed the list of references for each article that met criteria for population and outcome. We searched a period spanning January 1, 1966 through December 31, 2018. The search strategy incorporated a comprehensive search of terms that could be used to identify the population and cross-matched these results with all identifiable terms that could be used to refer to each outcome of interest. The search strategy for the PubMed search is included in a Supplementary Appendix S1.

Study selection

We assessed all studies that evaluated any aspect of cervical cancer screening in correctional systems. We included studies if the population included women in corrections and evaluated any of the following topics: prevalence of cervical cancer or dysplasia, adherence to screening, compliance with follow-up, experience associated with cervical cancer screening in prison, and knowledge of the inmates about cervical cancer and human papillomavirus (HPV). We defined women in corrections as those women who were in prison or jailed. We deleted duplicate studies and excluded publications that were not in English. Potentially eligible articles were screened by title and abstract by E.C.B. Then a final selection was made by E.C.B. and S.A. after reading the full text articles.

Data extraction

Studies were independently assessed by two reviewers [E.C.B., S.A.].

Data were extracted on study design, study population and characteristics, and outcomes. IRB approval was not necessary for this review.

Risk of bias assessment

The quality of each study was assessed independently by two reviewers [E.C.B., S.A.], with a third reviewer [K.A.M.] utilized in the cases of any disagreement. Reviewers used a tool adapted from the National Institute of Health-National Heart, Lung, and Blood Institute assessment tool for observational cohort and cross-sectional studies.¹⁰ There were no randomized controlled trials and only a single intervention study design. Quality assessment measures included evaluation of selection of cohorts, assessment of exposure and outcome, and consideration of confounding variables. Study quality was graded as Good, Fair, or Poor.

Summary measures

The outcomes measured varied across the studies, and many studies did not produce a measure such as risk ratio, odds ratio, or difference in the means. Prevalence of dysplasia within the incarcerated populations was the most common outcome across studies, although it was measured in different ways.

Results

Two hundred sixty-four studies were identified with the initial search. Thirteen articles were duplicates. After the initial screening, 185 records were excluded: 96 were the wrong population, 82 did not have any outcomes of interest, and 7 were not in English. Forty-two articles met the inclusion criteria for analysis. Figure 1 details the selection process. The following results are presented by outcome category.

FIG. 1.

Flow Diagram for Study Selection.

Prevalence of cervical cancer and cervical dysplasia

Twenty-one studies (16 rated as fair quality and 5 rated as good quality observational studies) presented data on the prevalence of cervical dysplasia, cervical cancer, or presence of HPV in jailed or incarcerated women. Studies were conducted in a range of countries; eight in the United States,^2,11–17 four in Canada,^18–21 four in England,^3,22–24 two from Brazil,^25,26 and one each in Taiwan,²⁷ Scotland,²⁸ and Spain.²⁹ The majority of studies were retrospective cohorts (12) or cross-sectional (5), and four studies were prospective cohorts.

Although all the study populations included either jailed or incarcerated women or both, the comparison populations differed between studies. Four studies compared cervical dysplasia and cancer prevalence data among incarcerated women to women in the general community population.^13,16,19,21 Three studies compared incarcerated women to a registry or database, such as a Canadian cytology registry, employer database, and Surveillance, Epidemiology, and End Result Program.^12,18,20 Inmate cytology results were compared to cytology results among women who received sexually transmitted infection testing at a geographically nearby outpatient clinic in one study¹⁴ and compared to cytology results among women who received testing at a Planned Parenthood Clinic in another study.² Ten studies provided prevalence results from within a correctional facility without any comparison data.^{3,11,15,21,24,26,28–30,31} Two studies compared cervical dysplasia rates between incarcerated women with and without HIV.^17,27

The specific cervical cancer and dysplasia outcomes also varied between the studies. (Table 1) Pap test or cytology results were the most commonly reported outcome. Other outcomes reported across studies included prevalence of HPV infection, carcinoma-in-situ (CIS), or cervical cancer. Three studies reported histologically diagnosed dysplasia (CIN on biopsy or cone procedure).

Table 1.

Studies with Prevalence Outcomes

Study	Study design	Study location	Quality	Prison pop. (N)	Control pop. (N)	Primary outcome	Outcome measured favoring prison pop.
Mathew et al.12	Retrospective cohort	United States	Fair	196	SEER data- unkn N	Cervical cancer	Percent of female cancer diagnoses that are cervix, 31.6% compared to 12.2%
Audet-Lapointe20	Retrospective cohort	Canada	Fair	337	Employee data, Bell Telephone- unkn N	Cervical cancer/CIS	CIS, cervical cancer CIS 1.8% compared to 0.50% Cervical cancer 2.97% in inmates
Davies et al.23	Retrospective cohort	England	Fair	102	Thames Cancer Registry- unkn N	Cervical cancer/CIS	Cervical cancer and cervical carcinoma in situ in prisoners with cancer, 83.3% of female cancer was CIS, 3% was invasive cx cancer
Moghissi and Mack2	Prospective cohort	United States	Fair	460	460	CIS	CIS, 3.9% compared to 1.1%, OR = 3.71 (1.36–10.07)
Singer24	Prospective cohort	England	Fair	768	None	Colposcopic examination and biopsy	48% of colposcopies were abnormal and 8.6% of abnl colpo had mod-severe dysplasia on biopsy
Keighley3	Prospective cohort	England	Fair	185	None	Pap and path results	Cervical dysplasia on pap 10.3% Invasive cancer on cone 8.6%
Clarke et al.11	Retrospective cohort	United States	Fair	785	None	Pap results	Pap smear results, 24.8% abnormal, 13% of the abnormalities were high grade
Cu-Uvin et al.17	Retrospective cohort	United States	Good	191	None	Pap results	Pap smear results, 3.14% were HGSIL, overall dysplasia rates did not differ between HIV±
Downey et al.22	Retrospective cohort	England	Fair	5081	General population- 49,121	Pap results	Pap smear results, CIN II 3.1% compared to 0.9%, CIN III 1.8% compared to 0.8%, invasive squamous carcinoma 0.4%–0.1%
Karsai et al.19	Retrospective cohort	Canada	Fair	2440	Expected value from general pop data- 2440	Pap results	CIN III on cervical smear, 6.4% compared to 2.2%
Lessa et al.25	Retrospective cohort	Brazil	Fair	561	1570	Pap results	Cervical dysplasia on pap High grade dysplasia, 3.2% compared to 0.9%
Logrono and Wong16	Retrospective cohort	United States	Fair	25,522	6883 (private) 56,178 (clinic)	Pap results	Pap smear results, HGSIL 2.54% compared to 0.61% private office, 2.20% university clinic
Martin18	Retrospective cohort	Canada	Fair	93	Canadian registry- 4730	Pap results	High-grade pap result, 32.2% compared to 5.6%, p < 0.0001
Proca et al.13	Retrospective cohort	United States	Good	1024	General population- 40,993	Pap results	Pap smear results, HGSIL 1.3% compared to 0.6%. LGSIL, ASCUS, AGUS no significant difference
Martin and Much14	Retrospective cohort	United States	Fair	81	STD clinic, n = 491	Pap results	Cervical dysplasia on pap 10% in prison compared to 1.2%
Besney et al.21	Retrospective cohort	Canada	Fair	94	None	Pap results	3% of paps were reported as abnormal
Will and Moffett 28	Prospective cohort	Scotland	Good	229	None	Pap results	Cervical dysplasia in 1.7% of paps, with 0.5% noted to be malignant
da Silva et al. 26	Cross-sectional	Brazil	Fair	110	None	Pap results	5.5% noted with dysplasia, 3% ASCUS, 2% LGSIL, 1% ASCUS-H
González et al.29	Cross-sectional	Spain	Good	219	None	Pap and HPV results	Cervical dysplasia on pap and HPV 8.2% LGSIL, 2% HGSIL, 27% HRHPV
Chu et al.27	Cross-sectional	Taiwan	Good	148	None	Pap and HPV results	Pap smear results, 10.81% rate of abnormalities, 35.14% HR HPV positive
Bickell et al.15	Cross-sectional	United States	Fair	114	None	Pap and HPV results	Cervical dysplasia on pap, HPV by cervicovaginal lavage, 9% abnormal pap, 35% HPV

HPV, human papillomavirus; SEER, Surveillance, Epidemiology, and End Result Program; CIS, carcinoma-in-situ; AGUS, atypical glandular cells; LGSIL, low grade squamous intraepithelial lesion; HGSIL, high grade squamous intraepithelial lesion; ASCUS, atypical squamous cells of undetermined significance; STD, sexually transmitted disease; HRHPV, high risk human papillomavirus.

All studies that compared prevalence of dysplasia or cancer between incarcerated or jailed women and nonincarcerated women showed an increased risk for high-grade cervical dysplasia or cervical cancer among the incarcerated population. A study in England compared a sample of 5081 inmate pap tests to controls from general practice in the same geographic area, and invasive cancer was diagnosed in 0.4% of the inmates compared to 0.1% of the general population.²² A Canadian study noted cervical cancer diagnosis in 10 of a sample of 337 inmate pap smears, an almost 3% rate of cancer in their sample population.²⁰

High-grade cervical dysplasia was also more prevalent among populations of women involved in the correctional system compared to a variety of different control populations. Three studies of incarcerated populations (in Rhode Island,¹¹ Texas,¹⁶ and Spain²⁹) reported higher rates of percentage high grade squamous intraepithelial lesion (HGSIL) (2–3.1% of pap tests) compared to the rates shown in other screened populations.³⁰ Pap smear results from an Ohio prison reported a rate of HGSIL of 1.3% in a sample population of more than a thousand inmates. This is significantly higher than the general population in Ohio which reported a rate of HGSIL of 0.6% in more than 40,000 pap smears, p < 0.01.¹³ Similar results were reported in Brazil where in 561 pap smears from the prison records, 3.2% were high-grade abnormalities compared to 0.3%–0.9% of the local general population statistics.²⁵ Comparable results in Canada comparing the pap smear results from women in their prison system to the large Registry of the general population reported significantly higher rates of high-grade abnormalities in the prison population across all age groups, p < 0.0001.¹⁸

In 1968, Moghissi and Mack compared pap smear results from women in a Detroit prison to results from patients at a nearby Planned Parenthood matched for age, race, and parity and reported a 3.71 increased odds of CIS among the prison pap smears (95% confidence interval [CI] 1.36–10.07).² Almost three decades later, a study in England supported this finding and noted an almost threefold increased risk for a cytologic result of CIN 2 or greater (odds ratio [OR] 2.98, 95%CI 2.60–3.43) in the prison population compared to the general population.²² A Canadian study reported an increased odds of CIN 3 among prisoners compared to the general population over the period 1970–1984 (OR = 2.82, 95%CI 2.46–3.28).¹⁹

Looking at the proportion of pap smear or cytologic abnormalities among all women screened, results from incarcerated and jailed women were consistently more likely to be abnormal. Pap smear results from a prison in Pennsylvania were compared to a local clinic and reported a significantly higher rate of dysplasia among the prisoners compared to the clinic (10% compared to 1.2%, p-value <0.001).¹⁴ Eight other studies reported on the percentage of pap smears in the incarcerated population that were abnormal, and this ranged from 2% to 24.8%.^{11,14–16,21,26–28} Information available to estimate the risk for having an abnormal pap screening in a nonincarcerated population is drawn from a large cohort of women in the Kaiser Permanente Northwest system that reported that only 5% of women had abnormal screening results.³⁰ In most studies reviewed, the risk for abnormal cytology in the incarcerated population is at least twice that of a general population.

Screening for cervical cancer in incarcerated populations

Thirteen studies (six fair quality, six good quality, and one poor quality) reported on prevalence of cervical cancer screening, both during and before that incarceration, in a population of inmates. Five studies were conducted in the United States,^8,31–34 four in Canada,^18,21,35,36 two in Brazil,^26,37 and one each in Australia³⁸ and England.³⁹ Eight of the studies were cross-sectional designs, with three retrospective cohorts and two prospective intervention studies aimed at improving screening within a facility.

Nine studies reported on prevalence of cervical cancer screening before incarceration among populations of jailed and incarcerated women. One study of more than 200 women in a U.S. jail reported that 84% stated that they had been screened for cervical cancer within the previous 3 years.⁸ In Australia, a survey showed a greater compliance with cervical cancer screening among incarcerated women compared to the general population. Prisoners were significantly more likely to report having had a pap smear in the previous 2 years (74.30% compared to 61.8%, p < 0.001) and more likely to have ever had a pap smear (90.6% compared to 84.0%, p = 0.001).³⁸

Conversely, a study in England showed that women surveyed in prison were less likely to report having had a pap within the previous 5 years compared to national data (69% compared to 82%).³⁹ In Rhode Island, 67% of women surveyed in prison had a pap smear within the past year, and 58% reported having had a pap within the prison system.³¹ In the most recent surveys of incarcerated women in the United States, 66%–77% of women reported having had a pap smear within the previous 3 years.^33,34

Three studies directly asked incarcerated women if they would desire and accept pap smear screening for cervical cancer while in prison.^31,32,35 Reported willingness to have cervical cancer screening in prison was high across studies, 71%, 75%, and 94%. Finally, a prospective cohort study evaluating a nurse-led intervention to improve screening in a Canadian prison was ineffective in significantly increasing the proportion of women who received cervical cancer screening. The odds of inmates receiving cervical cancer screening postintervention were not significantly increased over the preintervention period (OR = 1.38, 95%CI 0.98–1.94).⁴⁰

Previous abnormalities on cervical cancer screening tests

A high percentage of women in correctional facilities reported having a history of an abnormal pap. Seven studies (three Fair quality, four Good quality) remark on inmates stating a personal history of abnormal cervical cancer screening. In a survey of 100 women in Canada, 28% reported that they had a history of an abnormal pap, while 11% stated that they had undergone colposcopy testing.³⁵ Five other studies documented that more than 40% of the incarcerated or jailed women surveyed reported a history of an abnormal pap.^5,8,31,33,34 In a survey by Ramaswamy et al., 11% of jailed women in Kansas City reported a history of cervical cancer.⁸ Conversely, in a small retrospective study of 109 inmates in Canada, only 12% reported a history of an abnormal pap.²¹

Experience with cervical cancer screening

Two studies (both Good quality) focused on the women's reported experiences with pelvic examinations and cervical cancer screening within the correctional system. Both studies were conducted in the United States and used qualitative interviews to evaluate reported experiences with cervical cancer screening, both within the correctional facility and before incarceration.^39,41

One study focused on experiences within the correctional facility, specifically the adequacy of the facilities and equipment, contact with the provider, and prison infrastructure. Complaints about the experience included the following: examination was uncomfortable, lack of privacy, poorly kept facilities, inappropriately sized speculums, and rough manner of the provider. The prison infrastructure was cited as problematic with no standard process for scheduling, long delays, inconsistency with cost to inmate, and lacking a process for providing results.⁴²

Follow-up

Five studies (three Fair quality, two Good quality) provided information on follow-up of abnormal pap testing, including colposcopy and surveillance with repeat pap testing. Two studies were conducted in the United States,^11,13 two in Canada,^20,43 and one in England.²² The outcomes examined included time to colposcopy, colposcopy results, and follow-up surveillance with pap smear testing. Time to colposcopy was defined as the number of days between obtaining the abnormal pap and receiving colposcopy. In Clarke et al.'s study, “conducted in Rhode Island, the mean days to colposcopy differed by the degree of the abnormality and the availability of on-site colposcopy. Before the availability of on-site colposcopy, the average number of days to colposcopy was 65.5 days for atypical glandular cells (AGUS), HGSIL, and low grade squamous intraepithelial lesion (LGSIL) pap results and 84 days for atypical squamous cells of undetermined significance (ASCUS). This decreased after the availability of on-site colposcopy, which resulted in 42.5 days to colposcopy for AGUS, HGSIL, and LGSIL and 75 days to colposcopy for ASCUS. Of the 195 women in this study with abnormal pap results, 93 (47.7%) received colposcopy in the prison.¹¹

Two studies conducted in Canada evaluated the clinical outcomes of women who had pap smears in prison. One study utilized Pap screening data from a centralized cytology database registry to follow the adherence to repeat pap recommendations over a 3-year period, after screening in prison. Only half of the women screened in the prison were known to receive any pap testing within the following 3 years.⁴²

A study designed to evaluate the prevalence of cervical dysplasia in prisoners also followed the outcomes for the women who had abnormal screening. Of 17 women who had abnormal pap smears, 11 women were noncompliant with follow-up. Of 10 women who were diagnosed with cervical cancer, 6 were lost to follow-up, 1 refused treatment and died, and 3 continued to follow-up in the clinic for surveillance.²⁰

Another study in England followed 270 incarcerated women who had abnormal results on cervical cancer screening and were referred for colposcopy. Sixty-four women were released before they received colposcopy. Two hundred six women were seen by the gynecologist and received colposcopy, and only 49 women (23.8%) were known to be completely compliant with the advised treatments.²²

In a study from a correctional center in Ohio, over a 12-month period, 169 of 1024 pap smears were abnormal. Seventy-five pathology specimens were obtained as follow-up, representing 24.4% of the abnormal cytologic results. Only 61.5% of the HGSIL cytology results were subsequently followed by tissue specimens. Fifty-two percent of the follow-up pathology specimens were diagnosed as CIN II/III.¹³

Knowledge about cervical cancer screening and cervical cancer

Eight articles (from six separate studies rated Fair quality) explored the basic knowledge about cervical cancer screening and HPV in sample populations of women in prison. Three U.S. studies used qualitative focus groups to explore knowledge and beliefs about pap testing, cervical cancer, and HPV.^7,33,41 Discussions revealed general confusion over the purpose of a pap smear and the etiology of cervical cancer. Women noted that poverty, transportation, addiction, and fear of arrest were other common reasons they avoided the health care system.⁷

A second article from the focus group study noted above explored knowledge and beliefs specific to HPV infection and vaccination. This study showed that incarcerated women with a self-reported history of an abnormal pap smear lacked information about HPV, the HPV vaccine, and the relationship between pap screening tests and the detection of cervical cancer, and the role of HPV vaccination in the prevention of cervical disease.⁴¹ A recent survey conducted in the Kansas jails reports that poor knowledge and access to HPV vaccination still exist. While 75% of women reported having heard of the vaccine, only 32% of women eligible for vaccination stated that a health care provider had recommended that they receive the vaccine.⁴⁴

To target some of these gaps in knowledge, an intervention study was conducted in a Midwestern U.S. prison to promote cervical health via the development of a jail-based educational program specifically targeting cervical health. A 1 week, five session educational intervention was tailored to the jail setting. The sessions were designed to address barriers to cervical cancer screening that have been described in other literature, specifically with the goal of improving knowledge and self-efficacy. One hundred eighty-eight women completed the intervention and did demonstrate a significant increase in cervical health literacy and self-efficacy.³⁴

Discussion

Our review provides a systematic summary of the existing literature on cervical dysplasia in jailed and imprisoned women. Results of our review suggest that women involved in the correctional system are at higher risk for abnormal cervical cancer screening, particularly of high grade abnormalities and even cancer. There are several possible reasons for this disparity. Women who become involved in the correctional system may have higher exposure to risk factors for cervical cancer such as: multiple sexual partners, selling sex for money, and smoking.^4,5 In addition, women who become involved in the correctional system report less access to preventive health care in the community before incarceration.⁶

Offering accessible and appropriate cervical cancer screening to women within the correctional facilities has the potential to address this disparity; some studies have suggested that women in and out of the correctional system may actually rely on the system for this preventive screening.^29,31,32 Although studies that assessed the proportions of women screened within the correctional system suggested a lack of consistency, many studies found that a high proportion of incarcerated women would be willing to accept screening within the correctional facilities.^31,32,35

This review suggests that screening in this population is particularly valid given the increased prevalence of cervical dysplasias in incarcerated women and is further emphasized by the data on the number of incarcerated women who report a prior history of an abnormal pap.^5,8,38,43 Although the extent of these women's cervical dysplasia and pap smear abnormalities was not reported, the implication is that many of these women have already experienced an abnormality and should be engaged with consistent routine screening because of their history of prior testing results.

Furthermore, this review suggests that follow-up for abnormal pap smear testing is poor in this population of women, both within the correctional facility and in the community postrelease. Longitudinal medical care for individuals within the correctional system is challenging because of the rapid turnover. Many women are incarcerated for only short periods of time. Given poor knowledge about cervical cancer and screening among incarcerated women, these women may not know to seek care for follow-up for abnormal cervical cancer screening tests postrelease.^35,41 In addition, a distrust of the medical system may contribute to poor compliance with screening and follow-up in women involved in the correctional system.^11,43 Systematic barriers such as transportation, insurance status, and poor mental health likely contribute to inadequate follow-up also and should be considered in future interventions and research.

The strength of this systematic review is that it represents a comprehensive summary of the literature on cervical dysplasia and cancer prevalence in incarcerated women. In addition, we systematically evaluated screening, follow-up, knowledge, and experiences associated with cervical cancer screening in incarcerated populations.

This systematic review of the literature also has several limitations. Because of the differences in the study populations, independent variables, and outcomes across studies, we were unable to perform meta-analyses to synthesize study results. In addition, over the years included in this review, there have been many changes in cervical cancer screening. Screening and treatment recommendations can also vary by country. Finally, the HPV vaccine has been available to women and girls ages 9–26 years since 2006 in many countries, and this protection could have an effect on prevalence of cervical cancer and dysplasia after 2006. We reviewed only published findings and did not search the gray literature or contact any experts in the field.

The published literature suggests that the prevalence of cervical dysplasia and cancer is higher among women involved in the correctional system compared to women in the general population. Screening within correctional facilities is inconsistent, but generally poor. Treatment or follow-up after abnormalities is insufficient to address the potential risk of dysplasia and cancer. Studies performed to date consist mostly of retrospective cohorts and cross-sectional data. Future research, focused on interventions to improve the screening and treatment of cervical cancer in correctional facilities, could be beneficial to this population of women that do not routinely access preventive health care in the community.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

Supplementary Data

Supplementary Appendix S1