By Rebecca B. Perkins, MD, MSc
Professor, Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center
SYNOPSIS: The incidence of stage IV cervical cancer in the United States between 2001 and 2018 increased. Rates were highest among Black women, but the annual rate of increase was highest among white women in the South age 40-44 years.
SOURCE: Francoeur AA, Liao CI, Casear MA, et al. The increasing incidence of stage IV cervical cancer in the USA: What factors are related? Int J Gynecol Cancer 2022; Aug 18. doi: 10.1136/ijgc-2022-003728. [Online ahead of print].
Nearly all cervical cancers are preventable with vaccination and screening. The transformation from HPV infection to cervical precancer (cervical intraepithelial neoplasia) typically takes five to 10 years, and the progression from precancer to cancer can take decades. Because of this long pre-invasive period, cervical cancer screening has been extraordinarily effective at reducing rates of invasive cancer, as well as allowing cancer detection at early stages. Furthermore, HPV vaccination can prevent the oncogenic infections that lead to cancer. Francoeur et al examined the incidence of stage IV cervical cancers, cervical cancer screening, and HPV vaccination in the U.S. Cancer Statistics program using the Behavioral Risk Factor Surveillance System (BRFSS) and TeenVaxView databases. They found that between 2001 and 2018, rates of stage IV cervical cancer rose 1.3% annually. SEER*Stat data indicate overall cancer rates were highest among Black women (1.55/100,000 vs. 0.92/100,000 in white women), but the annual rate of increase was highest among white women in the South age 40-44 years. Data from BRFSS imply rising rates could be the result of a lack of screening. More Black women than white women reported they were up to date on cervical cancer screening (86% vs. 73%) in the BRFSS. TeenVaxView data indicated white teens were vaccinated at a lower HPV rate than teens of other races (66% vs. 75%).
COMMENTARY
This study indicates cervical cancer control in the United States remains inadequate. Data indicate HPV vaccination nearly eliminates cervical cancer, and that screening programs that use HPV testing and achieve high follow-up rates can nearly eliminate cervical cancer, even among unvaccinated populations.1,2 Therefore, the increase in stage IV diagnoses relates not to a lack of knowledge of how to prevent cervical cancer, but to a lack of ability to implement programs that reach all individuals with a cervix.
HPV vaccination rates are climbing each year, with the 2021 National Immunization Survey — Teen data indicating approximately 77% of teens have received at least one dose, although only 61% have completed the series.3 However, the number of HPV vaccine doses administered fell during the COVID-19 pandemic, and deficits remain. In addition, HPV vaccine uptake varies by demographic and geographic factors. People living in areas with high vaccination rates may benefit individually and from herd immunity, while low vaccination rates in other areas could exacerbate existing geographic disparities.4
Among adults born too late to benefit from vaccination, screening remains critical to cervical cancer prevention. Research consistently indicates screening prevents cancer incidence and cancer mortality.5,6 Screening with HPV testing (with or without concurrent Pap testing) has been shown to increase the detection of cervical precancer and dramatically decrease cancer risks, especially over repeated rounds of screening.7 Yet, among women diagnosed with cervical cancer, most were unscreened and also did not realize they were at risk for cervical cancer.8
Lack of knowledge and appreciation of the ability of vaccination and screening to mitigate risk appears to contribute to low utilization of both HPV vaccination and screening. The data from Francoeur et al indicate low vaccination rates and low screening uptake may co-occur, which could further affect cancer disparities in the future. Efforts should be made to ensure equitable access to vaccination and screening throughout the United States, and also to inform patients and providers about the effectiveness of measures to prevent cervical cancer.
REFERENCES
1. Lei J, Ploner A, Elfström KM, et al. HPV vaccination and the risk of invasive cervical cancer. N Engl J Med 2020;383:1340-1348.
2. Castle PE, Kinney WK, Cheung LC, et al. Why does cervical cancer occur in a state-of-the-art screening program? Gynecol Oncol 2017;146:546-553.
3. Pingali C, Yankey D, Elam-Evans LD, et al. National vaccination coverage among adolescents aged 13-17 years – National Immunization Survey-Teen, United States, 2021. MMWR Morb Mortal Wkly Rep 2022;71:1101-1108.
4. Brisson M, Bénard É, Drolet M, et al. Population-level impact, herd immunity, and elimination after human papillomavirus vaccination: A systematic review and meta-analysis of predictions from transmission-dynamic models. Lancet Public Health 2016;1:e8-e17.
5. Landy R, Pesola F, Castañón A, Sasieni P. Impact of cervical screening on cervical cancer mortality: Estimation using stage-specific results from a nested case-control study. Br J Cancer 2016;115:1140-1146.
6. Vicus D, Sutradhar R, Lu Y, et al. The association between cervical cancer screening and mortality from cervical cancer: A population based case-control study. Gynecol Oncol 2014;133:167-171.
7. Castle PE, Kinney WK, Xue X, et al. Effect of several negative rounds of human papillomavirus and cytology co-testing on safety against cervical cancer: An observational cohort study. Ann Intern Med 2018;168:20-29.
8. Senkomago V, Greek A, Jackson JE, et al. Learning from cervical cancer survivors: An examination of barriers and facilitators to cervical cancer screening among women in the United States. J Prim Care Community Health 2021;12:21501327211041862.
The incidence of stage IV cervical cancer in the United States between 2001 and 2018 increased. Rates were highest among Black women, but the annual rate of increase was highest among white women in the South age 40-44 years.
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