A Review of Cervical Cancer: Incidence and

Disparities
Ama Buskwofie, M.D., Gizelka David-West, M.D., Camille A. Clare, M.D., M.P.H.

approximately 6.5% of women developing cervical cancer

Dr. Buskwofie and Dr. David-West are Assistant Professors of Obstetrics and Gy- before age 75 years. China and India together contributed
necology, NYMC.
to more than a third of the global cervical cancer burden
Dr. Clare is Associate Professor of Obstetrics and Gynecology, NYMC, Attending
Physician at NYC HþH/Metropolitan, & Associate Dean of Diversity and Inclusion,
with 106,000 cases and 48,000 deaths in China, and
NYMC 97,000 cases and 60,000 deaths in India. Globally, the
Abstract: Background: Cervical cancer is the fourth most common cancer
average age at diagnosis of cervical cancer was 53 years,
amongst women worldwide. In the United States, its incidence and mortality and the global average age at death was 59 years.1
have been declining due to the wide scale implementation of cytological
screening programs. However, there have been geographic disparities in While cancer incidence has been declining in Western,
cervical cancer, particularly in the US. developed countries, mainly as a result of lifestyle modi-
Objective: This review will outline the overall incidence of cervical cancer and
discuss the causes for disparities in its incidence and mortality rates.
fications, such as smoking cessation and improvements in
Methods: A literature review was performed from 1999 to 2020 of English
screening and treatment modalities, low income and
language manuscripts on the incidence and reasons for disparities in mortality developing countries have experienced increasing overall
rates of cervical cancer.

Results: Racial and ethnic minorities, socioeconomically disenfranchised, and

cancer incidence and mortality.2 Developing countries are
those in rural areas have disparate rates of vaccination, screening and disproportionately affected by infectious agents, such as
treatment of cervical cancer, leading to worse outcomes.
human papillomavirus (HPV), H. pylori and hepatitis B
Conclusions: By addressing these disparities via increased education, access to
care, and the expansion of screening and vaccination programs, reductions in and C viruses, and tend to have decreased structural and
cervical cancer incidence and mortality may be achieved. financial resources to support robust screening programs.2
Keywords: Cervical cancer-Incidence-Mortality-Disparities According to the 2002e2003 World Health Survey, which
evaluated the impact of income inequality on cervical
cancer screening in countries, the most significant factors
Author affiliations: Ama Buskwofie, New York Medical College, Department of Obstetrics
and Gynecology, Valhalla, NY, USA; Westchester Medical Center, Division of determining the rates of cervical cancer screening, inde-
Gynecological Oncology, Valhalla, NY, USA; Gizelka David-West, New York Medical
College, Department of Obstetrics and Gynecology, Valhalla, NY, USA; Westchester
pendent of individual demographic characteristics,
Medical Center, Division of Gynecological Oncology, Valhalla, NY, USA; Camille A. Clare, included having the poorest socioeconomic status, living
New York Medical College, Department of Obstetrics and Gynecology, Valhalla, NY, USA;
New York Medical College, School of Medicine, Office of Diversity and Inclusion, Valhalla, in a rural community and visiting a non-governmental
NY, USA; New York City Health þ Hospitals/Metropolitan, Department of Obstetrics and organization (as opposed to a private clinic or govern-
Gynecology, New York, NY, USA
ment agency).2
Correspondence: Dr. Camille A. Clare, M.D., M.P.H., New York Medical College,
Department of Obstetrics and Gynecology, USA., email: [email protected] In the United States, the incidence and mortality asso-
ª 2020 by the National Medical Association. Published by Elsevier Inc. All rights reserved. ciated with cervical cancer have steadily declined since the
https://doi.org/10.1016/j.jnma.2020.03.002 1970s, mainly as a result of wide-scale implementation of
cytological screening programs utilizing the Papanicolaou
test.3 However, despite significant improvements, in 2020,

G
lobally, cervical cancer is the fourth most common
cancer amongst women, ranking only after breast it is estimated that 13,800 women will be newly diagnosed
cancer (2.1 million cases), colorectal cancer (0.8 with cervical cancer in the US, and an estimated 4290
million) and lung cancer (0.7 million).1 In 2018, there women will die as a result of their disease.4 In the US, the
were approximately 570,000 cases of cervical cancer and largest geographic differences in cancer rates are seen for
311,000 deaths.1 The estimated age-related incidence of the most preventable types, including cervical cancer.4
cervical cancer was 13.1 per 100,000 women globally and This disparity was described from 2012 to 2016, when
varied widely among countries. In Eastern, Western, the incidence rates for cancers of the cervix in the US was
Middle, and Southern Africa, cervical cancer was the 7.6 per 100,000 population overall, and varied from the
leading cause of cancer-related deaths in women in 2018. highest of 9.8 per 100,000 population in Arkansas
The highest incidence was estimated in Eswatini, with compared to 4.1 per 100,000 population in Vermont.4 It is

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INCIDENCE AND DISPARITIES IN CERVICAL CANCER

predicted that these geographic differences will persist, year relative survival for all stages of cervical cancer,
and new cervical cancer cases in 2020 are estimated to be compared to 71% for white women. The World Health
among the highest in California (1,630), Texas (1,410), Organization’s (WHO) global strategy for the elimination
Florida (1,130) and New York (930).4 These disparities by of cervical cancer by 2030 outlines the three main pillars
states may be explained by differences in the uptake of the for the elimination of cervical cancer, which are preven-
HPV vaccination and Medicaid expansion, further tion, screening, and treatment. The WHO recommends that
expounding geographic differences. in order to meet elimination global targets by this time,
In women ages 20e39 years, cervical cancer continues every country must achieve 90% coverage of HPV
to be the second leading cause of mortality from cancer, vaccination of girls (by 15 years of age); 70% coverage of
causing 10 premature deaths per week in this age group.5 screening and 90% treatment of precancerous lesions; and
Increasing trends in late stage diagnoses and cervical management of 90% of invasive cancer cases.11 Dispar-
adenocarcinoma, which is often not detected by cytology, ities exist in each of these areas, which have the potential
point to a consideration for increasing HPV vaccination to threaten the achievement of these goals, and thus, must
rates and possible pap smear and HPV co-testing algo- be addressed.
rithms. These preventative and screening measures are the Vaccination and screening mark the first opportunities
cornerstone to eradicating cervical cancer, given the well- for the prevention of and/or intervention prior to the
established and researched link between HPV and cervical development of cervical cancer. The vaccine for the pre-
cancer.5 For over 30 years, the oncogenesis of HPV has vention of cervical cancer-causing strains of HPV has been
been investigated, and several low and high-risk strains commercially available since 2006, however, in the United
have been identified and linked to the most common types States, vaccine uptake has been slow, and varies widely
of cervical cancer.5,6 The most high-risk HPV strains, ac- among different geographic and racial/ethnic pop-
counting for more than 70% of cervical cancers, are HPV ulations.12 Overall in 2017, 48.6% of adolescents aged
16 and 18.7 To date, there are a total of 15 high-risk strains 13e17 were up to date with their HPV vaccination se-
of HPV identified, and seven of those strains (HPV 16, 18, ries.13 Initially, lower vaccination uptake among blacks,
31, 33, 45, 52, 58) are covered by the commercially Asians, and Latinas compared to whites in the United
available HPV vaccine, Gardasil-9.7,8 The randomized States has been reported.14,15 However, more recent data
trial, which led to FDA approval of the vaccine, demon- has shown a steeper increase in vaccine uptake amongst
strated that the vaccine was 97% effective against these racial and ethnic minority adolescents, resulting in higher
high-risk strains.8 Additionally, several safety studies were coverage comparatively amongst these groups in com-
conducted prior to its approval, and ongoing safety parison to their white counterparts.13,16 Estimated HPV
monitoring systems continue to confirm that the vaccine is vaccination rates amongst adolescents in 2017 was 44.7%
safe.9 The HPV vaccine is recommended for routine for whites, 50.2% for blacks, 56.4% for Hispanics, and
vaccination of adolescent children ages 11 or 12, with 52.5% for Asians.13
catch-up vaccinations through the age of 26 for those not Vaccination coverage trends vary wildly geographically
vaccinated, and shared decision making for those 27e45 and tend to be lower in non-metropolitan areas and
years.9 Despite these advances in screening and preven- amongst women without health insurance. In 2018, among
tion, the US population at risk for cervical cancer adolescents aged 13e17 years, HPV vaccination rates
continues to lag behind other developed countries with ranged from 38% in Kansas and Mississippi to >70% in
only approximately one-half of adolescent girls being Washington, DC and Rhode Island among girls, and from
fully vaccinated, and only 43% of women in their 30s 27% in Mississippi to >70% in Massachusetts and Rhode
receiving recent Papanicolaou/HPV DNA screening tests Island among boys.4 Increased vaccination uptake among
in 2015.4 minority populations over time is thought to be secondary
Although there has been an overall decrease in inci- to strong provider recommendations and increased patient
dence and mortality associated with cervical cancer, awareness and understanding of HPV.16 Knowledge of
marked disparities in vaccination, screening, treatment, HPV and strong provider recommendations have had an
and overall mortality exist amongst the most vulnerable important impact on the initiation of HPV vaccination and
populations, including racial and ethnic minorities, the could be instrumental in increasing uptake and decreasing
socioeconomically disadvantaged, and women residing in disparities geographically.
rural and isolated areas.3,10 According to the SEER data- Variation in cervical cancer screening rates represents
base, between 2012 and 2016, the mortality rate for black an additional cause and potential exacerbating factor in
women was 3.5 per 100,000 versus 2.2 per 100,000 for disparate cervical cancer incidence and mortality.
white women. Additionally, black women had a 58% five- Although the overall cervical cancer screening rates in the

230 VOL. 112, NO 2, APRIL 2020 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
 INCIDENCE AND DISPARITIES IN CERVICAL CANCER

United States is relatively high at 81%, this has fallen short to their white counterparts.22 However, more recent data
of the Healthy People 2020 goal of 93%.17 Additionally, showing mortality rates corrected for rates of hysterectomy
there has been a significant decline in screening with pap have demonstrated that the reported disparity in mortality
smear testing between 2000 and 2015 (5.8%) among between black and white women may have been under-
women aged 21e65 years.18 Given the correlation be- estimated by 44%.23 For black women, the corrected
tween inadequate screening and increased risk of cervical mortality rate was 10.1 per 100,000 (uncorrected 5.7 per
cancer, this fact is extremely concerning. Women who are 100,000) versus 4.7 per 100,000 (uncorrected 3.2 per
uninsured, are immigrants, have low educational attain- 100,000). Additionally, the corrected mortality rates
ment, and/or do not have an established health care pro- among black women became even more dramatic with
vider, tend to report the lowest rates of cervical cancer increased age, that is, 29.7 per 100,000 among those
screening. Asian (75.8%) and Hispanic women (78.6%) 75e79 years old, 33.4 among those 80e84 years old, and
reported lower screening rates than non-Hispanic whites 37.2 among those 85þ years old.23
(83.7%) and blacks (85.3%). Cervical cancer screening Racial and ethnic disparities in morbidity have been
was lowest amongst women without a usual source of linked to differences in treatment adherence and access to
health care (65.1%) and women who were uninsured care. Recent studies have shown that disparities in stan-
(63.8%).19 dard of care therapy for women with early stage disease
Additionally, geographic location has been implicated (IA1-IIA) has abated in recent years as black women have
as a point of variation in cervical cancer screening with received the indicated surgery or chemo-radiotherapy.
women living in rural areas being less likely to undergo However, for later stage disease (stage IIB-IVA), black
screening than women living in urban or suburban areas.20 women were less likely to receive chemo-radiotherapy
Additionally, in the United States, southern states have than other women (75.6% versus 80.4%). Although the
reported significantly higher proportions of women who magnitude of the disparity has decreased over time, the
have not been screened for cervical cancer in the past five odds of receiving chemo-radiotherapy were 35% lower
years. This was unfortunately correlated with the fact that among black women after adjustment for known cova-
compared to other census regions, the South had the riates.24 Studies regarding access to care, contributing to
highest incidence rate of newly diagnosed cervical cancers disparity in outcomes, have been mixed. A recent National
(8.5 per 100,000) and the highest death rate (2.7 per Cancer Data Base (NCDB) study of stage IB2-IVA cer-
100,000).21 These disparities in screening geographically vical cancer patients reported that disparities in guideline-
are thought to be linked to a decreased number of pro- based care were highest at high-volume hospitals, sug-
viders in rural areas and an increased uninsured gesting that access was not the main issue.25 However,
population. other studies have shown that equal access to care has
Barriers to cervical cancer screening can be both per- resulted in similar survival rates.26
sonal as well as secondary to structural obstacles in In conclusion, cervical cancer remains the fourth most
accessing care. Personal factors, such as lack of education common cancer amongst women globally and a continues
regarding screening and risk factors, fear of being diag- to remain a significant source of morbidity and mortality in
nosed with cancer, embarrassment, and distrust of the the United States. The most vulnerable populations,
medical system have been identified as barriers to including racial and ethnic minorities, the socioeconomi-
screening.20 Additionally, structural hindrances, for cally disenfranchised, and those living in rural or remote
example, transportation, cost, time off work, language areas, continue to have disparate rates of vaccination,
barriers, and lack of physician access or recommendation screening, treatment, and consequently, worse outcomes.
have been associated with inadequate screening amongst The WHO has outlined a strategy for elimination of cer-
our most vulnerable populations.20 vical cancer by 2030 through tackling each of these areas.
Missed opportunities for prevention through vaccina- Increasing education, access to care, and the expansion of
tion and screening are directly correlated to the develop- screening and vaccination programs both here and globally
ment of cervical cancer. However, not only are there will bring us closer to this goal.
disparities in the opportunities for prevention of cervical
cancer, but also once a diagnosis of cervical cancer has
occurred, there are also disparities in treatment and mor- REFERENCES
tality associated with that diagnosis for the most vulner- 1. Arbyn, M., Weiderpass, E., Bruni, L., et al. (2020). Estimates of
able populations. Black women after controlling for age, incidence and mortality of cervical cancer in 2018: a world-
stage, histology, and initial treatment type, remained at a wide analysis. Lancet Global Health, 8(2). https://doi.org/10.
19% increased risk of dying from their disease compared 1016/s2214-109x(19)30482-6.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL 112, NO 2, APRIL 2020 231
INCIDENCE AND DISPARITIES IN CERVICAL CANCER

2. Akinyemiju, T. F. (2012). Socio-economic and health access 15. Daniel-Ulloa, J., Gilbert, P. A., & Parker, E. A. (2016). Human
determinants of breast and cervical cancer screening in low- papillomavirus vaccination in the United States: uneven up-
income countries: analysis of the World health Survey. PLoS take by gender, race/ethnicity, and sexual orientation. Am J
ONE, 7(11). https://doi.org/10.1371/journal.pone.0048834. Publ Health, 106(4), 746e747. https://doi.org/10.2105/ajph.
2015.303039.
3. Collins, Y., Holcomb, K., Chapman-Davis, E., Khabele, D., &
Farley, J. H. (2014). Gynecologic cancer disparities: a report 16. Burdette, A. M., Webb, N. S., Hill, T. D., & Jokinen-Gordon, H. (2017).
from the health disparities taskforce of the society of gyneco- Race-specific trends in HPV vaccinations and provider recom-
logic oncology. Gynecol Oncol, 133(2), 353e361. https://doi. mendations: persistent disparities or social progress? Publ Health,
org/10.1016/j.ygyno.2013.12.039. 142, 167e176. https://doi.org/10.1016/j.puhe.2016.07.009.

4. Siegel, R. L., Miller, K. D., & Jemal, A. (2020). Cancer statistics, 17. Hall, I. J., Tangka, F. K., Sabatino, S. A., Thompson, T. D., Grau-
2020. CA A Cancer J Clin, 70(1), 7e30. https://doi.org/10.3322/ bard, B. I., & Breen, N. (2018). Patterns and trends in cancer
caac.21590. screening in the United States. Prev Chronic Dis, 15. https://doi.
org/10.5888/pcd15.170465.
5. Hausen, H. Z. (2002). Papillomaviruses and cancer: from basic
studies to clinical application. Nat Rev Canc, 2(5), 342e350. 18. Watson, M., Benard, V., King, J., Crawford, A., & Saraiya, M. (2017).
https://doi.org/10.1038/nrc798. National assessment of HPV and pap tests: changes in cervical
cancer screening, national health interview Survey. Prev Med, 100,
6. Erickson, B. K., Alvarez, R. D., & Huh, W. K. (2013). Human
243e247. https://doi.org/10.1016/j.ypmed.2017.05.004.
papillomavirus: what every provider should know. Am J Obstet
Gynecol, 208(3), 169e175. https://doi.org/10.1016/j.ajog.2012. 19. White, A., Thompson, T. D., White, M. C., et al. (2017). Cancer
09.007. screening test use d United States, 2015. MMWR Morb Mortal Wkly
7. Muñoz, N., Bosch, F. X., Sanjosé, S. D., et al. (2003). Epidemio- Rep, 66(8), 201e206. https://doi.org/10.15585/mmwr.mm6608a1.
logic classification of human papillomavirus types associated 20. Akinlotan, M., Bolin, J. N., Helduser, J., Ojinnaka, C., Lichorad,
with cervical cancer. N Engl J Med, 348(6), 518e527. https:// A., & Mcclellan, D. (2017). Cervical cancer screening barriers
doi.org/10.1056/nejmoa021641. and risk factor knowledge among uninsured women.
8. Printz, C. (2015). FDA approves Gardasil 9 for more types of J Community Health, 42(4), 770e778. https://doi.org/10.1007/
HPV. Cancer, 121(8), 1156e1157. https://doi.org/10.1002/cncr. s10900-017-0316-9.
29374. 21. Benard, V. B., & Thomas, C. C. (2014). Vital signs: cervical
9. Safety information for human papillomavirus (HPV) vaccine. cancer incidence, mortality, and screening d United States,
(December 3, 2019). Centers for Disease Control and Preven- 2007e2012. Morb Mortal Wkly Rep, 63, 1004e1009.
tion. https://www.cdc.gov/vaccinesafety/vaccines/hpv- 22. Carmen, M. G. D., Montz, F., Bristow, R. E., Bovicelli, A., Corne-
vaccine.html. Accessed February 18, 2020. lison, T., & Trimble, E. (1999). Ethnic differences in patterns of
10. Ginsburg, O., & Weiderpass, E. (2020). What will it take to care of stage 1A1 and stage 1A2 cervical cancer: a SEER
eliminate cervical cancer in the USA? Lancet Pub Health. database study. Gynecol Oncol, 75(1), 113e117. https://doi.
https://doi.org/10.1016/s2468-2667(20)30028-1. org/10.1006/gyno.1999.5543.

11. World Health Organization. (2020). In Draft: Global Strategy 23. Beavis, A. L., Gravitt, P. E., & Rositch, A. F. (2017). Hysterectomy-
towards the Elimination of Cervical Cancer as a Public Health corrected cervical cancer mortality rates reveal a larger racial
Problem. https://www.who.int/docs/default-source/documents/ disparity in the United States. Cancer, 123(6), 1044e1050.
cervical-cancer-elimination-draft-strategy.pdf Accessed 2020. https://doi.org/10.1002/cncr.30507.

12. Hirth, J. (2018). Disparities in HPV vaccination rates and HPV 24. Rauh-Hain, J. A., Melamed, A., Schaps, D., et al. (2018). Racial
prevalence in the United States: a review of the literature. Hum and ethnic disparities over time in the treatment and mortality
Vaccines Immunother, 15(1), 146e155. https://doi.org/10.1080/ of women with gynecological malignancies. Gynecol Oncol,
21645515.2018.1512453. 149(1), 4e11. https://doi.org/10.1016/j.ygyno.2017.12.006.

13. Walker, T. Y., Elam-Evans, L. D., Yankey, D., et al. (2018). Na- 25. Uppal, S., Chapman, C., Spencer, R. J., et al. (2017). Associa-
tional, regional, state, and selected local area vaccination tion of hospital volume with racial and ethnic disparities in
coverage among adolescents aged 13e17 Years d United locally advanced cervical cancer treatment. Obstet Gynecol,
States, 2017. MMWR Morb Mortal Wkly Rep, 67(33), 909e917. 129(2), 295e304. https://doi.org/10.1097/aog.0000000000
https://doi.org/10.15585/mmwr.mm6733a1. 001819.

14. Gelman, A., Miller, E., Schwarz, E. B., Akers, A. Y., Jeong, K., & 26. Farley, J. H., Hines, J. F., Taylor, R. R., et al. (2001). Equal care
Borrero, S. (2013). Racial disparities in human papillomavirus ensures equal survival for African-American women with cer-
vaccination: does access matter? J Adolesc Health, 53(6), vical carcinoma. Cancer, 91(4), 869e873. https://doi.org/10.
756e762. https://doi.org/10.1016/j.jadohealth.2013.07.002. 1002/1097-0142(20010215)91:43.0.co;2-d.

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