By Dr. Anisa Shomo, Director of Family Medicine Scholars at the University of Cincinnati in Cincinnati, Ohio and Health Columnist for the NNPA.
Many people may believe that cervical cancer is a problem of the past. Prior to the 1940s, it was a major cause of death of women of childbearing age. According to the National Institute of Health, invasive cervical cancer is now considered to be the 14th cause of cancer deaths in women in the US. That accounts for approximately 4,000 deaths of women each year.
African American women are twice as likely as Caucasian women to be diagnosed with invasive cervical cancer and 2-3 times more likely to die from this diagnosis. Before we examine why this health disparity exists, let’s explore the historical gains that lead to the reduction of invasive cervical cancer diagnosis and deaths.
Before the 1940s, it was difficult to diagnose cervical cancer unless accompanied by significant symptoms such as bleeding, pain, and nausea were occurring, which caused women to present in the later stages. In 1943, Dr. George Papanicolau published a paper on his work to identify cervical changes as normal or cancerous via a microscope before invasive cancer occurred in an article titled “Diagnosis of Uterine Cancer on Vaginal Smear.”
In 1954, Dr. Papanicolau published his atlas for labs to learn how to identify cervical cancer using his method and this is now called a Papanicolau test or “Pap” smear. We now use this to screen for cervical cancer and catch it in its early stages. Cervical cancer caught in the early stages can be removed with very minor surgeries and in many cases, hysterectomy can be avoided.
In the 1970s, the HPV virus was being extensively researched as a possible link to cervical cancer. In 1984 Dr. Harald zur Hausen discovered that HPV 16 and 18 were major causes of cervical cancer. He later won a Nobel Prize in Science for this discovery. In the 1990s, Dr. Lowy and Schiller began working to create an HPV vaccine that could help prevent cervical cancer altogether. In 2006 the FDA approved the first HPV vaccines.
We now use the HPV vaccine to help prevent cervical cancer in the first place. This is especially important internationally since currently 500,000 women are diagnosed with cervical cancer each year and 275,000 of them will die of their disease due to low access to screening and treatment.
Cervical cancer has had such great advancements in treatment and diagnosis in the United States that even one death from this disease could be considered a failure of the system. But an estimated 700 African American women still die of cervical cancer each year. The three main reasons are: later stage at diagnosis, less aggressive treatment, and more barriers to care once diagnosed.
One reason cited for lack of timely screening is confusion of Pap smear with a pelvic exam causing a person to think that they have already been screened, although they may have had this exam for a different reason. Many African American women do not receive treatment due to comorbid conditions, advanced cancer, or refusal to be treated. In 2016, Nardi et al detailed some of the findings of multiple studies that indicate that lack of knowledge about cervical cancer may be the largest barrier to screening and treatment of cervical cancer in African American women.
Many women do not know that a Pap smear is a cervical cancer screening and do not realize that HPV is a known risk factor. They also may believe that if they are no longer sexually active, they no longer need to be screened which may contribute to presenting with cervical cancer in the later stage. There was also discussion that women feared hysterectomy would be needed and they did not desire to have this performed so they avoided screening.
In 2012, the American College of Obstetricians and Gynecology drastically changed the guidelines for cervical cancer screening. As of September 2017, the guidelines are:
Screening starting at age 21 with a Pap smear
Screening is now every 3-5 years with a Pap Smear and depending on age, HPV testing
HPV testing is recommended to start at age 30 but many physicians perform it at ages 21-29 with Pap smear
These changes have caused further confusion about the importance of cervical cancer and when a person’s next pap smear is due. This change occurred due to research demonstrating that yearly Pap smears were not better at decreasing cancer rates than when performed every 3 years. There was also concern about damaging the cervix with unnecessary procedures if screening too often.
The HPV vaccine has been FDA approved since 2006. It is currently recommended for use in all genders aged 11-26 and it was most recently approved to be extended for use up to age 45. The vaccine has been shown to be effective in preventing an estimated 90% of HPV related cancers. In 2015, the CDC studied the percent of women aged 19-26 who received at least 1 dose of the vaccine and it was found that African American women were 10% less likely to have started that vaccine.
Despite the many advances in cervical cancer screening, treatment, and prevention, African Americans women are more likely to be diagnosed with invasive cervical cancer and death as a result of late diagnosis. Increased knowledge about the purpose of a Pap smear and how often it is needed, the new treatments available that may prevent need for hysterectomy, and the purpose of the HPV vaccine may help reduce this health disparity in the future.
For Black American women receiving updated information about how to prevent cervical cancer is a matter of life or death. If our Black families and communities are made more aware of the advantages of early detection and diagnosis concerning cervical cancer, the current disproportionate mortality rates for Black women with this health problem in America will be dramatically reduced.
Dr. Anisa Shomo is the Director of Family Medicine Scholars at the University of Cincinnati in Cincinnati, Ohio and is a health columnist for the NNPA. She can be reached at firstname.lastname@example.org