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Commentary & Opinion

Sean Philpott-Jones: A Public Cervix Announcement

On Monday, just days after millions of women (and their allies) marched in political demonstrations, researchers reported a disturbing new finding that could affect the health and wellbeing of these protestors. In a study published in this month’s issue of the journal Cancer, scientists found that a woman’s risk of dying from cervical cancer was much higher than originally suspected.

Cervical cancer is the fourth most common cancer in women worldwide. It also has the fourth highest mortality rate. Approximately 13,000 cases of invasive cervical cancer are diagnosed annually among American women. The number of women diagnosed with cervical cancer has decreased significantly over the past 40 years, largely due to widespread use of the Pap test (or smear) to screen for the presence of precancerous lesions on the cervix, but over 4,000 women still succumb to the disease every year.

Previously, health experts had used those numbers to estimate that cervical cancer killed approximately 5.7 of 100,000 black women and 3.2 of 100,000 white women in the US. That racial disparity in death rates is pretty stark, particularly when you consider rates of cervical cancer incidence and mortality among other racial and ethnic groups. For example, Latinas have even higher incidence rates than black women -- Hispanic women in the US are more likely to be diagnosed with cervical cancer -- but in recent years the death rate in this group has fallen to the point where it is similar to that of white women.

What is particularly disturbing is we now know that those death rates are wrong, and that the racial disparity is much more worse than we assumed. Previous estimates of cervical cancer mortality failed to account for women who had undergone a hysterectomy to treat other conditions like endometriosis, fibroids, pelvic inflammatory disease, or ovarian and uterine cancer; almost one-third of American women will undergo a hysterectomy by the time they are 60. Because a hysterectomy almost always involves the removal of the cervix, which eliminates a woman’s cervical cancer risk, failing to exclude these individuals leads to a significant underestimate of the true rate of cervical cancer death.

When researchers adjusted these estimates to exclude women who had had hysterectomies, the results were startling. In fact, the actual cervical cancer death rate is 4.7 per 100,000 white women and 10.1 per 100,000 black women. Those are rates that are 47% and 77% higher than previously calculated. Moreover, despite the fact that Hispanic women were not included in this study, the racial disparity in cervical cancer death rates is much wider than originally thought.  Black women in the US are dying of cervical cancer at the same rate as women living in less developed countries in Africa, Asia and Latin America.

This is particularly troubling for a number of reasons, most notably because cervical cancer is largely preventable.  

First, almost all cases of cervical cancer are caused by the human papilloma virus (HPV). HPV is a sexually transmitted disease believed to infect nearly 80% of the adult population.  Luckily, there are now vaccines on the market that protect against the types of HPV that cause 70% of cervical cancers in women. Studies suggest that these vaccines, if given before a woman becomes sexually active, are likely to be highly effective in preventing cervical cancer. Widespread vaccination of adolescents against HPV would largely eliminate this deadly disease.

Second, for those already infected with HPV, regular Pap smears (or more modern and less invasive tests) can be used to identify precancerous cervical lesions early. The potentially cancerous cells can then be excised, frozen or destroyed by using a laser. Without treatment, these precancerous lesions will progress to invasive cancer in about 30 to 50% of cases. With treatment, less than 1% of them do.

So, the fact that so many women still die of cervical cancer, and the fact that black women die at significantly higher rates than white women, raises serious questions about their access to the HPV vaccine and to cervical cancer screening and treatment programs. For example, only 40% of American girls aged 13 to 17 have been fully vaccinated against HPV, and geographic, socioeconomic and racial disparities persist. Similarly, despite expert recommendations, only about half of American women undergo regular Pap smear screening. Oddly enough, rates of Pap smear testing are remarkably similar between black and white women, suggesting that the difference in death rates may be a result of disparate access to treatment and care rather than to the screening programs themselves.

Whatever the reason for the difference, these new findings – particularly the observation that black women in the US are dying from cervical cancer at the same rate as their counterparts in far less economically developed countries – suggest that our current prevention, screening and treatment programs are insufficient.

Sadly, given the political winds currently blowing in Washington and various state capitals, we probably won’t see any improvements soon. When a prominent anti-vaxxer is tapped to chair an important vaccine panel, when a vocal opponents of Planned Parenthood is nominated to head the Department of Health and Human Services, and when the first goal of the new Administration is to repeal a program that provides preventative health care to millions, a new and concerted push to promote cervical cancer prevention and treatment programs is unlikely occur. 

A public health researcher and ethicist by training, Dr. Sean Philpott-Jones is Director of Research Ethics for the Bioethics Program of Clarkson University-Icahn School of Medicine at Mount Sinai in Schenectady, New York. He is also Acting Director of the Center for Bioethics and Clinical Leadership, and Project Director of its Advanced Certificate Program for Research Ethics in Central and Eastern Europe.

The views expressed by commentators are solely those of the authors. They do not necessarily reflect the views of this station or its management.

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