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No woman should ever die of a highly preventable and treatable disease like cervical cancer. Yet, Black women are more likely to die from the disease than any other racial or ethnic group. In fact, they are twice as likely to die from cervical cancer compared to white women in the US.1 Despite advancements in cervical cancer screening and vaccination against high-risk human papilloma virus (HPV) that have contributed to an overall disease reduction, long-time racial, ethnic, and socioeconomic disparities are still prevalent within health care, specifically cervical cancer, and have not yet been addressed.2,3 Of concern, the American Cancer Society (ACS) recently released new cervical cancer screening guidelines that openly acknowledge Black and Latinx women have higher rates of cervical cancer, yet these guidelines will limit screening options and potentially cause the racial disparity gap to grow even further.4 It is imperative for the OB/GYN community to fully acknowledge this gap and work together to advance healthcare equity for all women.
Racial, Ethnic, and Socioeconomic Cervical Cancer Disparities are Prevalent
Cervical cancer incidence and mortality rates demonstrate troubling disparities when analyzed by race and ethnicity. In 2017, the cervical cancer incidence rate per 100,000 US women was:
The age-adjusted cervical cancer mortality rate per 100,000 US women also demonstrated increased mortality among Black and Hispanic women when compared to white women.6
These disparities are the result of significant socioeconomic barriers that lead to differences in screening rates.2,7-10 Studies show that both Black and Hispanic women are diagnosed at a later stage and have higher resultant mortality.11,12 Black women with cervical cancer also receive less aggressive treatment and have less access to health care.12-14 A substantial widening of the racial disparities in incidence and mortality occurs with advancing age, particularly in Black women.15
The incidence of cervical cancer also is higher in rural versus metropolitan communities in the US, which may reflect differences in screening rates, socioeconomic status, and access to quality health care.2,3 In fact, more than 60% of US cases occur in areas of underserved and under screened women, many of which are rural settings.16 These screening disparities in rural communities show up at a particularly high rate in the southern region of the US,3,17 where many women lack adequate health insurance.3
Although the lack of health insurance in the US is a socioeconomic barrier contributing to inadequate access to routine cervical cancer screening,11 a study showed that more than half of women (56%) with long-term health insurance and access to health care were not screened for at least three years prior to their cervical cancer diagnosis.18 Additionally, there was failure to follow up on the testing results in an additional 13%.18 Poor screening frequency due to access issues was the primary factor for development of cervical cancer in a meta-analysis of 42 studies. Approximately 54% of the women with cervical cancer had inadequate screening histories and 42% had never been screened prior to their diagnosis.19 The main factors for explaining racial, ethnic, and socioeconomic disparities include: lack of screening, access to screening services, and follow-up of abnormal tests which can affect the overall cervical cancer incidence and stage at diagnosis.2
Along with imbalances in cervical cancer screening rates, disparities in the uptake of the HPV vaccine and completion of the vaccine series by geographic region and by race or ethnicity may also contribute to continued health disparities within cervical cancer.20 The CDC found that less than half of adolescents in the US have completed the HPV vaccination series, including only 53% of Black adolescents and 57% of Hispanic adolescents. The HPV vaccination rates in high-risk adolescent populations need to improve to prevent a greater future increase in cervical cancer disparities.21 A blanket assumption of vaccine uptake across the US is detrimental to ensuring prevention and should not lead to decisions of limiting cervical cancer screening choices for women, especially in at-risk populations.
Recent Cervical Cancer Screening Guidelines May Widen the Disparities Gap
The American Cancer Society recently updated their cervical cancer screening guidelines for women at average risk.4 Among the notable changes was the recommendation to begin screening at 25 years of age rather than 21 years, as well as to remove the proven Pap test from frontline screening and rely on HPV-alone screening.
These new guidelines represent a significant departure from current practice and have generated responses from several professional societies. The American College of Obstetrics and Gynecologists (ACOG) released a statement about the new guidelines and reinforced their position on cotesting. Several other groups also continue to support the use of cotesting and cytology for optimal cervical cancer screening including, The American Society of Cytopathology (ASC), the College of American Pathologists (CAP), and the American Society for Clinical Pathology (ASCP).22-25 The ASCP and ASC specifically warn that if Pap testing is no longer covered by insurance companies, existing screening disparities will increase further. Additionally, cases will be missed if only high-risk HPV tests are used for screening. Up to 10% of invasive cervical cancers test negative for HPV, and up to 14% may be negative for high-risk HPV types covered by the tests. Additionally, 8.3%-14% of high grade squamous intraepithelial lesion (HSIL) cases may also be negative for high-risk HPV.26,27 The CAP recommends cytology and cotesting be retained given that there is no longitudinal data applicable to US screening populations supporting the change.25
Advocacy groups and women’s health advocates are also concerned about the harmful implications of the new ACS guidelines. The Black Women’s Health Imperative released a statement saying that the new ACS guidelines “fail to preserve access to the most accurate and effective cervical cancer screening options and threatens to put lives at risk.”28 They emphasize that Black women are already more likely to be diagnosed with advanced cervical cancer and more likely to die from the disease. Additionally, there are concerns that adjusting the screening interval will make women visit their healthcare provider less frequently, thus missing opportunities to counsel patients on a variety of health issues. Limiting the screening options and testing fewer women at a decreased frequency will widen the disparity gaps even further.
It’s important to note that the ACS based their guidelines strategy on data modeling that is not representative of the US screening population. In fact, the guidelines acknowledge this limitation stating, “There is disparity in the cervical cancer disease burden in the United States, with higher rates of disease among Black and Hispanic women and women of lower socioeconomic status: populations not optimally represented in the RCTs.” While the ACS acknowledges that disparities exist, they seemingly do not adequately account for these concerns within their recommendations.
The ACS guidelines suggest that clinical evidence supports the effectiveness of HPV-alone screening, a claim that directly conflicts with findings from several studies reflecting real-world data.29-31 The national Quest Diagnostic database analysis confirmed the value of cotesting results. Their data retrospectively analyzed women over a nine-year period and found that cotesting identified cervical cancer and cervical precancers more often than cytology or HPV tests alone. HPV testing alone failed to detect twice as many cases of cervical cancer than co-testing; in fact, HPV alone missed 23% of all cervical cancer cases.29 Given the greater sensitivity associated with cotesting, women who receive a negative cotesting result are at lower risk for disease than women who receive a negative HPV test result.
We Must Reduce Screening Disparities by Protecting All Screening Options
Cervical cancer prevention relies heavily on adequate screening, but despite recommendations for regular cervical cancer screening, many women are inadequately screened or not screened at all. A significant driver in the disproportionate burden of cervical cancer among Black and Hispanic women is related to this lack of screening. Recommendations like those from the ACS that further limit screening options could inadvertently undermine efforts to promote preventive measures in already underserved populations. These health disparities within cervical cancer are briefly recognized but not adequately addressed in the new ACS guidelines. Their recommendations are not tailored to the current US health care system and could increase disparities rather than remove barriers to routine cervical cancer screening. Any new cervical cancer screening guidelines must adequately account for a diverse screening population and the wide range of recognized socioeconomic barriers. Additionally, the guidelines state that Pap testing is less effective in HPV-vaccinated populations; however, significant disparities in vaccine uptake also remain unaddressed. The ACS guidelines should be reconsidered for its lack of applicability to a diverse screening population and the unfortunate likelihood that they will expand pervasive cervical cancer health disparities among women across the US.
OB/GYNs and other healthcare providers must continue to advocate for all cervical cancer screening options to remain available for patients. Providing sufficient, regular preventive care is challenging enough. Any attempt to limit cervical cancer screening options will make it even more challenging to ensure women with different racial and socioeconomic backgrounds get the protection they need to prevent unnecessary disease.
Roland Matthews is professor and chairman of the Department of Obstetrics and Gynecology at the Morehouse School of Medicine, and a board-certified gynecologic oncologist and attending physician at Grady Memorial Hospital in Atlanta. He graduated from Columbia College, and earned his M.D. degree, with a distinction in research, from the State University of New York at Stony Brook. Dr. Matthews completed his residency in Obstetrics and Gynecology, then completed a fellowship in Gynecologic Oncology at the State University of New York, Downstate Medical Center. Dr. Matthews is a Georgia Cancer Coalition (GCC) Distinguished Cancer Scholar and is currently the Director of the Georgia Cancer Center for Excellence at Grady. He is Vice President of the Georgia Center for Oncology Research and Education (CORE) board, and serves on the executive committee of the Obstetrics and Gynecology Section of the National Medical Association. Throughout his career, Dr. Matthews’ research, education and clinical activities have focused on reducing disparities in underserved communities.