Disparities in Cervical Cancer Follow-Up and Screening in African American Women

By Haider Mahdi, MD, MPH

African American, Hispanic, American Indian and Alaskan Native women continue to be disproportionately affected by cervical cancer compared with white women. From 2006 to 2010, the incidence of cervical cancer in African American women was 10.3 per 100,000; in white women it was 7.2. The mortality rate from cervical cancer in African American women is twice that in white women.

As the first-line healthcare providers for many women, the primary care physician and the general obstetrician-gynecologist are optimally positioned to reduce these disparities.

Cervical cancer is the third most common gynecologic cancer, after uterine and ovarian cancer. Nearly 13,000 new cases are diagnosed each year in the United States, and more than 4,000 women die of it.

Why are black women more likely to die of cervical cancer?

• Later stage at diagnosis. African American women are more likely to present with advanced cervical cancer than non-Hispanic white women.
• Less-aggressive treatment. African American women are more likely to receive no treatment after a cancer diagnosis. Differences in treatment may be attributed to comorbid conditions, stage at cancer diagnosis and patient refusal.
• Less access to care. A study from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute looked at 7,267 women (4,431 non-Hispanic white women, 1,830 Hispanic white women and 1,006 non-Hispanic African American women) who were diagnosed with primary invasive cervical cancer from 1992 to 1996 and followed through 2000. African American women had a 19 percent higher mortality rate compared with non-Hispanic white women during follow-up despite adjusting for age, stage, histology and time of first treatment.

However, a later study from the same program found no such difference after 1995, when the data were adjusted for marital status, disease stage, age, treatment, grade and histology.

Equal access to healthcare may eliminate most of the disparity. A study in women with cervical cancer who sought treatment within the United States military healthcare system found no difference in treatment or five- and 10-year survival rates between African American and white women. Equal access to comprehensive healthcare eliminated any disparity once cervical cancer was diagnosed.

Cervical cancer screening: Who should be screened?

Previous recommendations called for women to undergo Pap testing when they first became sexually active and then every year. However, cervical lesions are likely to regress in young women. One study found that 28 percent of cervical intimal neoplasia (CIN) grade 2 and 3 lesions spontaneously regressed by 15 weeks, although lesions associated with HPV 16 infection were less likely to regress than with other HPV types.

To minimize unnecessary treatment of young women with dysplasia, the American Society for Colposcopy and Cervical Pathology in 2012 recommended cytologic screening for all women 21 years or older, regardless of age at first sexual encounter. Screening intervals were changed from every year to every three years until age 30, at which time cotesting with cytology and HPV testing is performed every five years. Routine cotesting is not recommended for women younger than 30, who have a high likelihood of HPV infection and spontaneous regression.

In 2014, the US Food and Drug Administration approved primary HPV screening (i.e., testing for HPV first, and then performing cytology in samples that test positive) for women age 25 and older.

Patients who need further evaluation and testing should be referred for colposcopy.

Are there disparities in screening and follow-up?

Disparities in screening and follow-up may exist, but the evidence is not clear-cut.

In a 2013 National Health Interview Survey report, the rates of cervical cancer screening with Pap tests did not differ between African American and white women. However, the information on Pap testing was based on a single question asking participants if they had had a Pap test in the last three years. In our experience, patients may confuse Pap tests with speculum examinations.

Once women are screened, adequate and timely follow-up of abnormal results is key.

In a study from the National Breast and Cervical Cancer Early Detection Program, African American women were the least likely to have a follow-up Pap smear compared with other racial groups.

On the other hand, there was no difference related to race in follow-up rates of abnormal Pap tests in women ages 47 to 64 in the South Carolina Breast and Cervical Cancer Early Detection Program.

In a study in an urban population (predominantly African African), the overall follow-up rate was only 26 percent at 12 months from an initial abnormal Pap smear. This study did not find any differences in follow-up according to race or ethnicity; however, it had insufficient power to detect a difference because only 15 percent of the study participants were white.

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.