It’s easy to think cervical cancer could be 100% preventable. Along with lung, breast, and colorectal cancer, it has screening tests to find precancerous changes that can be treated before full-blown cancer develops. Even more, there is a highly effective vaccine against HPV, the virus that causes most cervical cancer diagnoses.
Still, those two forms of prevention are not enough if people aren’t getting them, a research letter published Monday in JAMA Network Open reports. The cross-sectional study found incidence and mortality rates have been climbing in rural counties in the United States since 2012, going in the wrong direction after declining since 2001. Cases were 25% higher and deaths were 42% higher in rural counties compared to urban counties through 2019.
Researchers said those jumps in incidence and mortality showing up in rural areas may be a result of lower screening, diagnosis, and treatment rates, all an offshoot of reduced options for care outside cities.
There was also a trend toward higher incidence among Black women starting in 2017, but that rise was not statistically significant. Other research, from the American Cancer Society, has concluded the mortality rate for Black women is roughly 65% higher than the rate for white women.
“The fact that we’re finding higher incidence and higher mortality, that’s very concerning from a cancer that is mostly preventable,” Trisha Amboree, assistant professor of public health sciences at the Medical University of South Carolina and lead author of the study, told STAT.
Her team’s data follow encouraging news released last week by the Centers for Disease Control and Prevention on the impact of the HPV vaccine. Looking at women 20 to 24 years old, researchers found that rates for precancerous lesions plummeted by about 80% among women screened for cervical cancer. That result squares with the agency’s 2006 recommendation that the vaccine be given to girls at age 11 or 12 followed by 2011 guidance for boys the same age.
With vaccination rates falling in the U.S. for everything from childhood immunizations to flu shots, concern is growing that low rates of HPV vaccination compared to other countries’ levels may fall ever farther, far below a WHO goal to vaccinate 90% of girls by 2030.
The new study looked at cervical cancer at all ages, focusing on where women live and underlying health disparities revealed by the urban-rural divide. Overall incidence was declining until it began to plateau in 2013. Amboree said other studies have shown that from 2005 to 2019, there was about a 9 percentage point drop in screening rates across the nation.
“We’ve seen this decline in screening uptake over the last 20 years or so, and I think what we’re starting to see is we’re having more advanced stage disease now. We’re having higher mortality now,” she said. “As far as why incidence may be climbing up, I’m not fully sure why that might be.”
Alex Francoeur, a fellow in obstetrics and gynecology at the University of California, Irvine, who has studied the increase in late-stage cervical cancers, said different obstacles affect incidence and mortality. For incidence, poor access to vaccination and screening are what matters. Most women who are diagnosed at an advanced stage have never been screened.
“Higher-stage disease could probably be explained by both barriers to screening, vaccination, and then treatment,” Francoeur said. She was not involved in the new study. “This study is definitely something that highlights disparities and how they are disparate in different areas in our country.”
For mortality and disparities, barriers to treatment make the difference.
Treatment is not easy. Women with late-stage or even locally advanced cervical cancer undergo intensive chemotherapy and radiation daily for five weeks.
“As you can imagine, patients living in rural areas, where they’re driving several hours daily to get these treatments, probably face much, much more significant barriers in rural regions to treatment, which probably plays out in the mortality gap we’re seeing,” Francoeur said. “I practice in Orange County, and we have patients who get referred to us from San Bernardino, Riverside, drive over two hours to come get care. And this is within a relatively urban area. Those are going to be much more pronounced in these rural regions of the United States.”
Both HPV vaccination and screening are lower in rural countries compared to urban counties, study author Amboree said. Then there are difficulties after diagnosis.
“If you do find a cancer case in a rural area, are they actually able to get into treatment in time to have effective treatment?” she asked. “Health care settings are closing in rural areas. There’s an infrastructure that needs investing in so that we can improve the health of our rural community, and especially within South Carolina, where a lot of the population is living in a rural area.”
That makes it important to understand how to improve prevention and treatment, Amboree said, suggesting that mobile outreach might be a way.
“If differences in preventive care are not urgently mitigated, disparities are likely to magnify in future years,” the study authors conclude.
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.
