Stage IV cervical cancer is on the rise. Why?

On the surface, there’s something paradoxical happening with cervical cancer in the United States. While overall rates are declining, distant stage cervical cancer diagnoses are stable—or increasing.

A study published in the International Journal of Gynecological Cancer may shed some light on this mystery.^[] It offers surprising findings about routine cervical cancer screenings, HPV vaccination, and who is adhering to preventative guidelines.

Inside the study

While comparatively rare, stage IVA-B is a serious type of cervical cancer with few treatment options and a 17% 5-year survival rate.

In 1999, CDC data put the age-adjusted rate of new cervical cancer cases at 9.7 per 100,000 women.^[] By 2019 (the latest year of data available) the rate dropped to 7.5 per 100,000 women.

The IJGC study adds some nuance to this picture. Researchers evaluated data from the US Cancer Statistics program spanning from 2001–2018. They also assed HPV vaccination rates and cervical cancer screening using the Behavioral Risk Factor Surveillance system and TeenVaxView.

Over 18 years, 29,715 women received distant stage cervical carcinoma diagnoses. The data sample contained a 1.3% annual increase of these diagnoses. Other standout findings included:

• Cervical adenocarcinoma had the largest average annual percent increase at 2.9%.

• Black women were diagnosed with distant stage cervical carcinoma at disproportionate rates compared with White women (1.55 per 100,000, compared with .92 per 100,000).

• Southern White women, ages 40 to 44, had the greatest increase in the rate of distant cervical cancer at 4.5%.

• Compared with Black women, White women had almost double the rate of missed or non-guideline-compliant screening (26.6%, compared with 13.8%).

• White teens (ages 13 to 17) were slow to receive the HPV vaccine, compared with other teens (66.1% compared with 75.3%).

“These findings come from different datasets, but they suggest that lower rates of screening and vaccination could be contributing to the disproportionately higher rates of increase in distant stage cervical cancer in White women,” the researchers wrote.

Lead study author Alex Francoeur, MD, a year-4 resident in the UCLA Department of Obstetrics and Gynecology, has some ideas.

Behind the trends

In an MDLInx interview, Dr. Francoeur said that there may be several likely drivers behind the increase in distant stage adenocarcinoma diagnosis. Hypotheses included increasing rates of screenings that do not follow the guidelines, increasing rates of obesity nationwide, and changes in Papanicolaou screening (known colloquially as “Pap smear“) guidelines.

Researchers noted, for example, that White women were more likely to report they’d gone for more than 5 years without a cervical cancer screening, compared with other racial and ethnic groups. Also, HPV vaccination rates were lowest among White teens, which is problematic, since more than 90% of cervical cancer cases stem from HPV.

“The lower rate of vaccination in White women coupled with non-guideline screening in this population could explain the trend toward the higher rate of increase in distant disease in White women,” the researchers wrote. “This challenges the idea that Black and Hispanic women have higher rates of distant stage diagnosis due to lower access to screening.”

Dr. Francoeur said that further research is required to better understand why White women are more likely to have skipped a childhood HPV vaccine or to have missed a Pap smear.

“Some studies show that parents of White children more commonly say that the vaccine does not apply to their children, as there is the misconception that the vaccine is for sexually active people,” Dr. Francoeur said.

For example, a 2019 study published in Human Vaccines & Immunotherapeutics indicated that from 2009–2016, non-Hipsanic White teens ages 13–17 lagged behind nearly all other ethnic and racial groups in their rate of HPV vaccination initiation.^[]

The data were a little less clear-cut when evaluating the rate of teens who completed the HPV vaccination series. For the most part, however, racial and ethnic groups other than White teens tended to complete the vaccination series at higher rates.

Putting it into practice

The IJGC study indicated that Black women are experiencing higher rates of distant stage cervical carcinoma.

Dr. Francoeur framed this as an access problem, saying that the expansion of screening access to minority populations hinges on expanding health insurance coverage, which typically covers routine screenings.

“Additionally, knowledge of the importance of pap test screening for cervical cancer is important,” he said.

For clinicians looking to stymie this trend, Dr. Francoeur said the tactics are straightforward.

“Cervical cancer is very preventable if proper screening is followed,” Dr. Francoeur added.

It should be noted, however, that screening alone does not prevent cervical cancer. Rather, it can help prevent a patient from presenting with advanced stage cervical cancer.