One key contributor to the high rates of ICC incidence and mortality in Appalachian Kentucky is the suboptimal use of Pap tests. Inadequate Pap screening, including lack of and lapses in screening, likely contributes to the elevated ICC rates among middle-aged and older Appalachian women. Recent data reveal that in 2002, nearly one-third of Kentucky women aged 50 and over had not had a Pap test
within the prior 3 years [14].