USA Health researcher presents national talk on cervical cancer

Even as new therapies show promise, disparities continue to plague the management of cervical cancer in the United States, a USA Health gynecologic oncologist recently told the annual meeting of the American Society of Clinical Oncologists.

Jennifer Young Pierce, M.D., M.P.H., program leader of cancer control and prevention at the USA Health Mitchell Cancer Institute and professor of gynecologic oncology at the USA College of Medicine, presented a broadcast educational session on disparities in cervical cancer in the U.S. as part of a larger panel on gynecologic cancers around the world at the virtual meeting of ASCO, an organization that represents nearly 45,000 oncology professionals who care for people living with cancer.

In the presentation, Pierce pointed out research showing that Black, Hispanic and Native American women in the U.S. die at a higher rate from cervical cancer than do white women. She noted that disparities have decreased as women’s access to guidelines-based care has improved over time. However, ongoing disparities still exist and often track with social determinants of health including poverty, access, education and rurality.

“Race is not the only category where we see ongoing disparities. In each state, there are a multitude of differences,” she said. “In our data, we show an overlap between HPV-associated cancer incidence, and rurality and poverty in Alabama.”

She reviewed a variety of factors that contribute to health disparities in cervical cancer:

HPV vaccination

HPV vaccination rates range from less than 39 percent in some states to more than 60 percent in others. Vaccination against the human papillomavirus, which causes six different cancers in women and men, including cervical cancer in women, is recommended for adolescents ages 11 or 12 and all adults through age 45.

In Alabama, having private insurance correlated with a lower vaccination rate, as did rurality and a higher household income.

Screening and treatment

The increasing complexity of cervical cancer screening guidelines makes it unlikely to be generalized for populations, especially where screening is rare, Pierce said.

She also pointed out research showing that differences in cervical cancer screening do not account for higher mortality among women, as there are no differences by race among those who received a recent Pap test. Nor were there differences by race or rurality in the women’s adherence to screening.

“There may be some differences in adherence to follow-up, and this is where access to care and trust in the healthcare system really play a role,” she said. “We know that these social determinants of health including access to childcare, transportation or flexibility at work that allow women to keep those follow-up appointments can be so important.”

Diagnosis and treatment

A research study in Maryland showed that white women with cervical cancer were more likely to receive surgery, and Black women were more likely to receive radiation and also were more likely to receive no treatment, Pierce said.

Research studies have explored access to care versus aggressive cancer as causes for higher mortality rates.

“Maybe both are correct -- that racial disparity does exist in Black vs. non-Black women when no brachytherapy is given, but when both sets of patients receive guideline-based care with brachytherapy, survival is uniform,” she said. “This population-based study speaks to the importance of guideline-based care.”

New immunotherapies for gynecologic cancers are emerging, but differences at the tumor mutational burden by race may affect a patient’s response to immunotherapy treatment, she said.

“We know there are differences in tumor mutational burden by race, and we know that the tumor mutational burden plays a role in response including in the trials used for FDA approval [of immunotherapy for cervical cancer] and other HPV-related cancers including anal and vulvar cancer,” she said.

“So, how do we move forward, taking into account all of these factors?” she said. “Research is absolutely the answer.”

However, Pierce added the race of enrollees has not always been reported in clinical trials, and that minority enrollment in clinical trials has declined significantly in recent years. “We’ve got to do better,” she said.

An article by David K. Gaffney, M.D., published in Gynecologic Oncology in 2018, recommended increasing access to HPV vaccination, nontraditional screening methods, improving adherence to guidelines through healthcare access and ethnically similar physician population, ensuring widespread access to chemoradiation, including brachytherapy, and identifying new targets and mutation-specific trials.

Pierce added further recommendations: increasing nonwhite enrollees in clinical trials and continued evaluation of genetic and post-genetic associations with race and/or racism that may affect tumor responses to new treatments