Nearly 13,000 women are diagnosed with cervical cancer each year; approximately 4000 die. But did you know cervical cancer is one of the few cancers that is almost entirely preventable? Cervical cancer begins with a common sexually transmitted infection of the cervix called human papillomavirus (HPV). Most people who become infected with HPV get it within two to three years of their first sexual activity. A 2014 Sexually Transmitted Diseases article, The Estimated Lifetime Probability of Acquiring Human Papillomavirus in the United States, estimated the lifetime probability of adults in the U.S. acquiring HPV by age 45 at 80%.
The majority of people who become infected with HPV may never know it; many won’t have symptoms and will get over the infection without problems, although they can still pass the infection on to others. In some people, however, the HPV infection may be persistent, causing precancerous changes in the cells of the cervix. These changes may be very slow-growing – from five to more than 20 years – but if not detected and treated, they can eventually progress to cervical cancer. If the precancerous cells are detected early enough with a screening Pap smear, surgical removal can prevent progression to cervical cancer. And even if cancer has developed, if caught before the cancer has spread, the five-year survival rate is over 90 percent.
Screenings for HPV infection and precancerous changes are not the only weapons available to fight the development of cervical cancer, though. There is also a vaccine available since 2006 to prevent HPV infection for both males and females. The Centers for Disease Control and Prevention (CDC) recommends HPV vaccine delivery at ages 11–12 to optimize protection before a child ever has contact with the virus. However, teens and young adults through age 26 who didn’t start or finish the HPV vaccine series can also be inoculated. Vaccination is not generally recommended for those older than age 26 because more people in this age range have already been exposed to HPV, and the vaccine provides less benefit. However, speak with your doctor about your risk for new HPV infections and the possible benefits of vaccination if you are between the ages of 26 and 45.
So, if there is a vaccine to prevent the HPV infection that leads to cervical cancer, and screenings to detect HPV infection and early-stage cervical cancer when it is easily treatable, why are so many women still being diagnosed with and dying from cervical cancer?
Rural residents face multiple barriers to care
According to the 2020 U.S. Census, 17% of the total U.S. population lives in rural areas. A 2022 article, Rural–Urban Disparities in Cancer Outcomes: Opportunities for Future Research,
summarizes the results of a 2018 study undertaken by the American Society of Clinical Oncology, which found increasing evidence of overall cancer care disparities among rural populations, noting rural residents tend to be older, less educated with low health literacy, and lower socioeconomic status. These factors contribute to the level of health insurance coverage (or lack thereof), longer travel distances to appointments with associated transportation issues, and limited access to local health care, which can produce a domino effect of inadequate or absent screening and surveillance, advanced stage of cancer at diagnosis, and lower quality of treatment impacting survival rates.
A 2021 study abstract, Rural-Urban Differences in HPV Testing for Cervical Cancer Screening, in The Journal of Rural Health found that rural women were less likely than urban women to have current cervical cancer screening. Of those that did have current cervical cancer screening, rural women were significantly less likely than their urban counterparts also to undergo HPV testing, which could lead to delayed cervical dysplasia diagnosis with missed opportunities for early intervention when the condition is more treatable. The study found possible reasons for this, such as that preventive care guidelines may be slower to reach rural areas and the difficulty of integrating HPV testing into the rural practice model.
Regarding HPV vaccination rates, a 2020 Human Vaccines & Immunotherapeutics article found that 45.4% of teens aged 13 to 17 living in rural areas had not received the HPV vaccine compared to 32% of their urban counterparts. Reasons for the lack of HPV vaccination in rural areas, as outlined in a 2019 Implementation Science article, include access to healthcare and preventive services, poverty, lower health literacy, religious beliefs, and less parental engagement and communication with healthcare providers.
One Kentucky public health department saw success in overcoming many of these obstacles by collaborating with local rural school districts to provide the vaccines to students at school free of charge, as reported in a 2019 article, Effective Communication and Consistency in Increasing Rural Vaccination Rates. HPV fliers and parental consent forms were distributed in students’ back-to-school packets, on the school website, and in newspaper articles. Administering the vaccines on-site eliminated the logistics of parents having to take time off work, take the kids out of school, and drive to the doctor’s office. According to the article, of the 329 students whose parents had consented to vaccination (about 14% of the student population), 288 completed the full HPV vaccination series – a vaccine success rate of 88%.
Black women die from cervical cancer at a disproportionately high rate
With the scientific understanding of what causes cervical cancer and how it can be prevented, detected, and treated, virtually no one should succumb to this disease. However, an estimated 4300 U.S. women die of cervical cancer each year, mostly women of color, those living in poverty, and those without health insurance.
Research done by the American Cancer Society analyzed racial, ethnic, and socioeconomic disparities in U.S. cancer occurrences from 2014 through 2019, looking at risk factor exposure, patients’ ability to access preventive care and screenings, stage at cancer diagnosis, survival rate, and mortality rate. Research findings include
- Black people were the least likely of all races to have an early-stage diagnosis of cancers that have recommended screenings, including breast, cervix, and lung.
- Black people were the most likely of all races to have a late-stage diagnosis of cancers that have a recommended screening.
- People of color have higher incidence rates of cancers caused by infections, including the cervix, than white people. (The only exception was cervical cancer among Asian Pacific Islanders, which was comparable to rates among white women.)
- Shorter survival rate after a cancer diagnosis for people of all races with lower socioeconomic status and who live in a more rural area.
According to Annerieke Smaak Daniel, a women’s rights researcher at Human Rights Watch, Black women face many social determinants of health barriers to quality health care similar to rural residents, including poverty, lack of insurance, travel distance to providers, and lack of access to health information.
For uninsured, low-income women – especially those living in states that haven’t expanded Medicaid – a decision must often be made whether to buy groceries or go to the doctor because they can’t afford to do both. The need to feed themselves and their family almost always wins out. The lack of nearby providers, especially specialists, is also an obstacle. When the nearest gynecologist is 45 minutes to an hour away, getting there requires reliable transportation, money to buy gas, and time off work.
An additional factor contributing to the reluctance of Black women to seek medical care is the historical mistreatment of minorities, which triggers a trauma response passed down from generation to generation. Daniel was quoted in a 2022 NPR article: “We had researchers who we worked with who spoke about the reasons why their own grandparents and their aunts did not go see doctors and did not encourage them to go see doctors. And this is passed down. So when you talk about a Black woman who might have been mistreated by a medical provider, who had an extremely demeaning experience that has turned her off, this has implications not only upon her health but also upon the health of those around her who might also, for the same reasons, not want to go seek out gynecological care.”
A lack of comprehensive sex education leading to low health literacy is another contributing factor to poor health outcomes. According to a report, Alabama Cancer Statistics 2022: Focus on Cervical Cancer, the cervical cancer mortality rate for all races in Alabama is 3.3, significantly higher than the U.S. rate of 2.3. Black females have a significantly higher mortality rate compared to white females, with a rate of 4.7 vs. 2.9. A University of Alabama at Birmingham article, “Improper Sex Education and the Effects on Women’s Health in Alabama,” notes the correlation with a lack of required sex education in public schools, stating, “While the United States as a whole has failed its constituency by refusing to mandate sexual education to be taught in schools, the state of Alabama stands as a paradigm for just how dangerous a lack of healthy and inclusive sex education can be. By refusing to provide access to healthy sex education, Alabama has left thousands of women without the proper knowledge that is necessary to lower the risk of cervical cancer.”
An ounce of prevention is worth a pound of cure
Eradicating cervical cancer for good
The World Health Organization (WHO) has an ambitious 100-year goal to eliminate cervical cancer as a global public health problem by the year 2120. An old adage states one doesn’t plant a tree expecting to sit under its shade. While those of us reading this article won’t be here to benefit from the hoped-for worldwide elimination of cervical cancer a century from now, there are steps we can take today to increase the odds of that happening.
According to WHO, the following targets must be met by 2030 for countries to be on the path toward cervical cancer elimination by 2120:
- 90% of girls fully vaccinated with HPV vaccine by age 15 years.
- 70% of women screened by 35 years of age, and again by 45 years of age
- 90% of women identified with cervical disease receive treatment (90% of women with precancer treated, and 90% of women with invasive cancer managed).
Additionally, a mathematical model illustrates the following interim benefits of achieving the above targets by 2030 in low- and lower-middle-income countries:
- median cervical cancer incidence rate will fall by 42% by 2045, and by 97% by 2120, averting more than 74 million new cases of cervical cancer;
- median cumulative number of cervical cancer deaths averted will be 300, 000 by 2030, over 14 million by 2070, and over 62 million by 2120.
Knocking out cervical cancer begins with preventing the infection that causes it. Per CDC guidance, all children, including both boys and girls, should receive the 2-dose HPV vaccination at age 11 or 12 (can start as early as age 9), in addition to everyone through age 26 who has not been vaccinated already. Please note that the vaccine prevents new infections, does not treat existing infections, and works best when given before any exposure to HPV.
The Vaccines for Children (VFC) program provides free vaccines through doctors who serve eligible children. Children younger than 19 are eligible for VFC vaccines if they are Medicaid-eligible, American Indian, Alaska Native, or have no health insurance. “Underinsured” children with health insurance that does not cover vaccination can receive VFC vaccines through Federally Qualified Health Centers or Rural Health Centers.
Ask for the HPV vaccine at doctor’s offices, community health clinics, school-based health centers, and local or state health departments.
Get screened on a regular basis
CDC recommendations for cervical cancer screening include:
21 – 29 years old: Begin Pap tests. If your Pap test result is normal, your doctor may recommend you wait three years until your next Pap test.
30 – 65 years old: Talk to your doctor about which testing option is right for you:
- An HPV test only is called primary HPV testing. If your result is normal, your doctor may recommend you wait five years until your next screening test.
- An HPV test along with the Pap test is called co-testing. If both results are normal, your doctor may recommend waiting five years until your next screening test.
- A Pap test only. If your result is normal, your doctor may recommend you wait three years until your next Pap test.
Older than 65: Your doctor may tell you that you don’t need to be screened anymore if:
- You have had at least three Pap tests or two HPV tests in the past 10 years, and the test results were normal or negative, and
- You have not had a cervical precancer in the past, or
- You have had your cervix removed as part of a total hysterectomy for non-cancerous conditions, like fibroids.
Cervical screening test results usually come back from the lab in about 1-3 weeks. Call and ask for your test results if you don’t hear from your health care provider. Make sure you understand any follow-up visits or tests you may need.
If you are uninsured or have low income, you may be able to get a free or low-cost screening test through the National Breast and Cervical Cancer Early Detection Program.
Where to get screened for cervical cancer
Doctors’ offices (primary care providers and OB/GYNs) and community health centers offer HPV and Pap tests.
If you don’t have a primary care provider or doctor you see regularly, you can find a clinic near you that offers cervical cancer screening by contacting:
- Your state or local health department: Missouri or Kansas
- The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) or call 1-800-232-4636; NBCCEDP provides low-income, uninsured, and underserved people access to timely cervical cancer screening and diagnostic services
- Planned Parenthood. Find a clinic here or call 1-800-230-7526
- NCI’s Cancer Information Service or call 1-800-422-6237