The Role of Reproductive Health: Racial Disparities in Cervical Cancer

HPV is not the only factor

By Haider Mahdi, MD, MPH

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Although 80 percent of women will be infected with HPV in their lifetime, only a small proportion will develop cervical cancer, suggesting there are other cofactors in the progression to cervical cancer.

Given the infectious etiology of cervical cancer, other contributing reproductive health factors have been described. As expected, the number of sexual partners correlates with HPV infection. Younger age at first intercourse has been linked to development of cervical neoplasia, consistent with persistent infection leading to neoplasia.

Primary care physicians should provide timely and comprehensive sexual education, including information on safe sexual practices and pregnancy prevention.

Human immunodeficiency virus

In 2010, the estimated rate of new human immunodeficiency virus (HIV) infections in African American women was nearly 20 times greater than in white women. Previous studies have shown a clear relationship between HIV and HPV-associated cancers, including cervical neoplasia and invasive cervical cancer.

Women with HIV should receive screening for cervical cancer at the time of diagnosis, six months after the initial diagnosis and annually thereafter.

Conflicting evidence exists regarding the effect of highly active antiretroviral therapy on the incidence of HPV-related disease, so aggressive screening and management of cervical neoplasia is recommended for women with HIV, regardless of CD4+ levels or viral load.

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Additional infectious culprits

Coinfection with other sexually transmitted infections, specifically Chlamydia, herpes, and HIV, has been associated with cervical neoplasia and invasive cervical cancer. A positive linear association exists between the number of sexually transmitted infections and cervical neoplasia.

C trachomatis is the most common sexually transmitted infection in the United States, with a six-times higher rate in African American women. Women who are seropositive for C trachomatis are at twofold higher risk of developing squamous cell cervical cancer. Women who are seropositive for Chlamydia infection, herpes virus 2, or HPV are at markedly increased risk of invasive cervical cancer.

Tobacco use

The negative impact of smoking on numerous other cancers resulted in investigation of its role in cervical cancer.

Early case-control studies found an association between cervical cancer and smoking, but because these studies did not account for HPV infection status, they could not establish causality. Subsequently, several studies did control for HPV infection; the risk of squamous cervical cancer was twice as high in women who had ever smoked. Furthermore, the more cigarettes smoked per day, the higher the risk of cervical neoplasia.

According to the US Centers for Disease Control and Prevention in 2014, the highest prevalence of smoking was among American Indian and Alaskan Native women, 32.5 percent of whom said they smoked every day, compared with 17.2 percent of white women and 13.7 percent of African American women.

How can primary care physicians close the gap?

Primary care physicians are the first point of contact for patients of all ages and so can help minimize such disparities. They can tackle two important cervical cancer prevention interventions first-hand: vaccination and screening, including follow-up of abnormal screening results.

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By promoting HPV vaccination to children and young adults, primary care physicians can help prevent cervical cancer. Moreover, primary care physicians will see most adolescents for a nonpreventive health visit, an optimal opportunity to discuss sexual activity practices and HPV vaccination. Including the HPV vaccine as routine with other vaccinations can close the gap.

Screening and treatment of sexually transmitted infection during these visits can affect the risk that future HPV infection will progress to neoplasia or cancer. Persistent lifestyle modification counseling, especially smoking cessation through motivational interviewing, can lessen the risk of cervical cancer neoplasia progression.

Additionally, in light of recent changes in cervical cancer screening guidelines, the primary care physician’s role as educator is of utmost importance. In one study, although 99 percent of women had received a Pap test, 87 percent could not identify the purpose of the Pap test. The primary care physician’s role is perhaps the most influential in preventing disease and, as such, has the greatest impact on a patient’s disease process.

Dr. Mahdi is a gynecologic oncologist at Cleveland Clinic.

This is an abridged excerpt from an article previously printed in Cleveland Clinic Journal of Medicine. For full article, author and reference lists, click here.