Disparities in Cervical Cancer Mortality Rates Highlight Need for Specialized Treatment

Anne Rositch, PhD

A recent study published in Cancer has shown that hysterectomy-corrected mortality rates in cervical cancer reveal a significantly large racial disparity in the United States.

To examine cervical cancer mortality rates from 2002 to 2012 in the United States, Anne Rositch, PhD, and her colleagues obtained estimates from the National Center for Health Statistics and the NCI Surveillance, Epidemiology, and End Results Mortality Database.

The researchers found that, overall, cervical cancer mortality rates are much higher than previously thought, and there is a drastic difference between the mortality rates in black and white women. Black women in the United States are dying of cervical cancer at a rate 77% higher than previously thought. In contrast, white women are dying at a rate 47% higher than prior estimates.

Specifically, the corrected mortality rate in black women was 10.1 per 100,000 women, compared with 5.7 per 100,000 uncorrected. The corrected rate in white women was 4.7 per 100,000 compared with 3.2 per 100,000 uncorrected.

“Although trends over time show that the racial disparity in cervical cancer mortality is closing, these data emphasize that it should remain a priority area,” lead study author Anne Rositch, PhD, an assistant professor at the Johns Hopkins Bloomberg School of Public Health, said in a statement.

OncLive: Please provide some background on the rationale for conducting this study.

In an interview with OncLive, Rositch discussed the important takeaways from her study and the significance of cervical cancer screening.Rositch: This study on mortality is a follow-up to an identical study that we did in 2014, where we were looking at incidence rates. So putting the 2 pieces together, which include both the corrected incidence rates and the corrected mortality rates, gives us a picture of what’s happening with cervical cancer in the subset of our population that we target for screening and prevention—women over the age of 20 and who have an intact cervix.

How was this study designed?

What were the most noteworthy findings that you hope oncologists took away from the study?

The current study focused on mortality and was really motivated by just wanting to complete the picture with regard to cervical cancer. We originally undertook the full study—the 2 pieces sort of combined—because we realized, through the course of some of our other work, that a large proportion of women had a hysterectomy. This wasn’t taken into account, so it made us wonder, “What impact would this have, particularly by age?” Our original motivation was to better understand age-specific cervical cancer trends and tease out if this was truly a disease that older women were not at risk of developing. Of course, in doing so, and in looking at the patterns of hysterectomies, we realized that black women are more likely to have a hysterectomy, and that’s also why you see a profound effect in black women. Older women and black women are more likely to have a hysterectomy. So those are the subgroups of the population that are most affected by our recalculation.We mainly brought together 2 data sources, including national mortality statistics. We obtained national data on the number of women who had died due to cervical cancer. Also, there is an annual survey that is conducted by the Centers for Disease Control and Prevention, which is called the Behavioral Risk Factor Surveillance System. In those national surveys, they ask women if they have had a hysterectomy. From that national survey, we obtained an estimate of what fraction of women, by age, race, state, and time, had had a hysterectomy and were thus no longer at risk for cervical cancer. We applied those estimates to the calculation of cervical cancer mortality that we obtained from the national death index and our cancer surveillance program.The trends in the study show high mortality among our older women and our black women. For oncologists, in particular, that is proof of individuals who are seeing these patients who now have cancer, and who play a really significant role in preventing death due to that cancer. It’s really reaffirming and re-recognizing the importance of their role in providing equal, effective treatment by age and by race, to all women.

Are there any next steps planned following this study, perhaps to find some of those factors that contribute to these differences in mortality?

Our study, unfortunately, does not help us really understand what factors are contributing to the higher than previously recognized mortality rates. That could be the sort of primary care and gynecologist side of it, related to screening and follow-up of abnormal screenings. Or, it could be on the care and treatment side among women who are diagnosed, and that really speaks to our oncologists, particularly because we know that individuals who receive care from a specialized oncologist (in this case, a gynecologic oncologist) have better outcomes than those who don’t. It speaks to their role in preventing these deaths through equal and effective treatment, and the collaboration of medical specialties and systems working together to get our patients from primary care, or wherever they’re obtaining screening and follow-up, into specialty care through our oncology department.I think it’s going to be a two-fold approach. We know there are only a variety of reasons to explain these results: lower screening rates, lower or differential follow-up, abnormal screening, or differences in care. I think, while those can all be directly targeted, all good can come from ensuring equal and sufficient access along that whole care continuum, so certainly reaching out to our care partners to ensure that.

Then, from a research perspective, we need to really understand the extent to which those different sources are contributing to mortality. What are the provider and healthcare barriers along that continuum to getting women into equal and effective care? And from the patient perspective, we need to better understand barriers that they face in getting screening and obtaining adequate follow-up for cancer care.

What are your concerns going forward in this new political climate, in which parts of the Affordable Care Act could potentially be repealed, thus affecting screening and treatment for some patients with cervical cancer?

So that’s going to be the two-fold approach, and that’s why having our healthcare providers see the findings and reaffirm their very important role on that continuum is important coming out of this research.Between our prior paper showing higher than previously recognized incidence rates, and now this paper showing that it is also related to higher mortality rates, I think it really speaks to the importance of obtaining women’s care and preventive care—2 things that we certainly need to be very cognizant of in this current political climate.

Prevention for cervical cancer is the best mechanism. We have a lot of ways in which we can prevent the development, and thus the mortality, of cervical cancer, and that’s through our routine, adequate, and equal screening. Anything that puts that on the line, or calls those into jeopardy, is going to be really important. And we know that the Affordable Care Act enabled better access and more quality to screening, and similarly, we know that a large fraction of women are able to obtain preventive care through Planned Parenthood.

What are some of the other major challenges that remain in cervical cancer, and how can they be addressed?

As we move forward into a different era, we’re going to have to really think about how we can still provide adequate and equal preventive care to women who are at risk of cervical cancer, and of course, lots of other preventive health conditions in our female populations, and those who are traditionally underserved and thus at risk of not obtaining the care they need in the incoming political climate.I think any conversation about cervical cancer that doesn’t touch on our other mode of prevention, which is HPV vaccination, would just be amiss. I would say that these data, if anything, reaffirm or refocus our efforts to increase our vaccination rates here in the United States among our current young people. We know that that’s an extremely viable option to get widespread reductions in cervical cancer incidences, and we do have suboptimal rates that I hope these data highlight. Our current generation of adolescents needs to know that they can benefit from HPV vaccination. I would certainly think that, looking forward, that’s a really important avenue to focus on in the fight against cervical cancer.

Beavis AL, Gravitt PE, and Rositch AF. Hysterectomy-corrected cervical cancer mortality rates reveal a larger racial disparity in the United States [published online January 23, 2017]. Cancer. 2017. doi:10.1002/cncr.30507.