A Review of Cervical Cancer: Incidence and
Disparities
Ama Buskwofie, M.D., Gizelka David-West, M.D., Camille A. Clare, M.D., M.P.H.
Dr. Buskwofie and Dr. David-West are Assistant Professors of Obstetrics and Gy-
necology, NYMC.
Dr. Clare is Associate Professor of Obstetrics and Gynecology, NYMC, Attending
Physician at NYC HþH/Metropolitan, & Associate Dean of Diversity and Inclusion,
NYMC
Abstract: Background: Cervical cancer is the fourth most common cancer
amongst women worldwide. In the United States, its incidence and mortality
have been declining due to the wide scale implementation of cytological
screening programs. However, there have been geographic disparities in
cervical cancer, particularly in the US.
Objective: This review will outline the overall incidence of cervical cancer and
discuss the causes for disparities in its incidence and mortality rates.
Methods: A literature review was performed from 1999 to 2020 of English
language manuscripts on the incidence and reasons for disparities in mortality
rates of cervical cancer.
Results: Racial and ethnic minorities, socioeconomically disenfranchised, and
those in rural areas have disparate rates of vaccination, screening and
treatment of cervical cancer, leading to worse outcomes.
Conclusions: By addressing these disparities via increased education, access to
care, and the expansion of screening and vaccination programs, reductions in
cervical cancer incidence and mortality may be achieved.
Keywords: Cervical cancer-Incidence-Mortality-Disparities
Author affiliations: Ama Buskwofie, New York Medical College, Department of Obstetrics
and Gynecology, Valhalla, NY, USA; Westchester Medical Center, Division of
Gynecological Oncology, Valhalla, NY, USA; Gizelka David-West, New York Medical
College, Department of Obstetrics and Gynecology, Valhalla, NY, USA; Westchester
Medical Center, Division of Gynecological Oncology, Valhalla, NY, USA; Camille A. Clare,
New York Medical College, Department of Obstetrics and Gynecology, Valhalla, NY, USA;
New York Medical College, School of Medicine, Office of Diversity and Inclusion, Valhalla,
NY, USA; New York City Health þ Hospitals/Metropolitan, Department of Obstetrics and
Gynecology, New York, NY, USA
Correspondence: Dr. Camille A. Clare, M.D., M.P.H., New York Medical College,
Department of Obstetrics and Gynecology, USA., email: cclare@nymc.edu
ª 2020 by the National Medical Association. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jnma.2020.03.002
G
lobally, cervical cancer is the fourth most common
cancer amongst women, ranking only after breast
cancer (2.1 million cases), colorectal cancer (0.8
million) and lung cancer (0.7 million).1 In 2018, there
were approximately 570,000 cases of cervical cancer and
311,000 deaths.1 The estimated age-related incidence of
cervical cancer was 13.1 per 100,000 women globally and
varied widely among countries. In Eastern, Western,
Middle, and Southern Africa, cervical cancer was the
leading cause of cancer-related deaths in women in 2018.
The highest incidence was estimated in Eswatini, with
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
approximately 6.5% of women developing cervical cancer
before age 75 years. China and India together contributed
to more than a third of the global cervical cancer burden
with 106,000 cases and 48,000 deaths in China, and
97,000 cases and 60,000 deaths in India. Globally, the
average age at diagnosis of cervical cancer was 53 years,
and the global average age at death was 59 years.1
While cancer incidence has been declining in Western,
developed countries, mainly as a result of lifestyle modi-
fications, such as smoking cessation and improvements in
screening and treatment modalities, low income and
developing countries have experienced increasing overall
cancer incidence and mortality.2 Developing countries are
disproportionately affected by infectious agents, such as
human papillomavirus (HPV), H. pylori and hepatitis B
and C viruses, and tend to have decreased structural and
financial resources to support robust screening programs.2
According to the 2002e2003 World Health Survey, which
evaluated the impact of income inequality on cervical
cancer screening in countries, the most significant factors
determining the rates of cervical cancer screening, inde-
pendent of individual demographic characteristics,
included having the poorest socioeconomic status, living
in a rural community and visiting a non-governmental
organization (as opposed to a private clinic or govern-
ment agency).2
In the United States, the incidence and mortality asso-
ciated with cervical cancer have steadily declined since the
1970s, mainly as a result of wide-scale implementation of
cytological screening programs utilizing the Papanicolaou
test.3 However, despite significant improvements, in 2020,
it is estimated that 13,800 women will be newly diagnosed
with cervical cancer in the US, and an estimated 4290
women will die as a result of their disease.4 In the US, the
largest geographic differences in cancer rates are seen for
the most preventable types, including cervical cancer.4
This disparity was described from 2012 to 2016, when
the incidence rates for cancers of the cervix in the US was
7.6 per 100,000 population overall, and varied from the
highest of 9.8 per 100,000 population in Arkansas
compared to 4.1 per 100,000 population in Vermont.4 It is
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INCIDENCE AND DISPARITIES IN CERVICAL CANCER
predicted that these geographic differences will persist,
and new cervical cancer cases in 2020 are estimated to be
among the highest in California (1,630), Texas (1,410),
Florida (1,130) and New York (930).4 These disparities by
states may be explained by differences in the uptake of the
HPV vaccination and Medicaid expansion, further
expounding geographic differences.
In women ages 20e39 years, cervical cancer continues
to be the second leading cause of mortality from cancer,
causing 10 premature deaths per week in this age group.5
Increasing trends in late stage diagnoses and cervical
adenocarcinoma, which is often not detected by cytology,
point to a consideration for increasing HPV vaccination
rates and possible pap smear and HPV co-testing algo-
rithms. These preventative and screening measures are the
cornerstone to eradicating cervical cancer, given the well-
established and researched link between HPV and cervical
cancer.5 For over 30 years, the oncogenesis of HPV has
been investigated, and several low and high-risk strains
have been identified and linked to the most common types
of cervical cancer.5,6 The most high-risk HPV strains, ac-
counting for more than 70% of cervical cancers, are HPV
16 and 18.7 To date, there are a total of 15 high-risk strains
of HPV identified, and seven of those strains (HPV 16, 18,
31, 33, 45, 52, 58) are covered by the commercially
available HPV vaccine, Gardasil-9.7,8 The randomized
trial, which led to FDA approval of the vaccine, demon-
strated that the vaccine was 97% effective against these
high-risk strains.8 Additionally, several safety studies were
conducted prior to its approval, and ongoing safety
monitoring systems continue to confirm that the vaccine is
safe.9 The HPV vaccine is recommended for routine
vaccination of adolescent children ages 11 or 12, with
catch-up vaccinations through the age of 26 for those not
vaccinated, and shared decision making for those 27e45
years.9 Despite these advances in screening and preven-
tion, the US population at risk for cervical cancer
continues to lag behind other developed countries with
only approximately one-half of adolescent girls being
fully vaccinated, and only 43% of women in their 30s
receiving recent Papanicolaou/HPV DNA screening tests
in 2015.4
Although there has been an overall decrease in inci-
dence and mortality associated with cervical cancer,
marked disparities in vaccination, screening, treatment,
and overall mortality exist amongst the most vulnerable
populations, including racial and ethnic minorities, the
socioeconomically disadvantaged, and women residing in
rural and isolated areas.3,10 According to the SEER data-
base, between 2012 and 2016, the mortality rate for black
women was 3.5 per 100,000 versus 2.2 per 100,000 for
white women. Additionally, black women had a 58% five-
230 VOL. 112, NO 2, APRIL 2020
year relative survival for all stages of cervical cancer,
compared to 71% for white women. The World Health
Organization’s (WHO) global strategy for the elimination
of cervical cancer by 2030 outlines the three main pillars
for the elimination of cervical cancer, which are preven-
tion, screening, and treatment. The WHO recommends that
in order to meet elimination global targets by this time,
every country must achieve 90% coverage of HPV
vaccination of girls (by 15 years of age); 70% coverage of
screening and 90% treatment of precancerous lesions; and
management of 90% of invasive cancer cases.11 Dispar-
ities exist in each of these areas, which have the potential
to threaten the achievement of these goals, and thus, must
be addressed.
Vaccination and screening mark the first opportunities
for the prevention of and/or intervention prior to the
development of cervical cancer. The vaccine for the pre-
vention of cervical cancer-causing strains of HPV has been
commercially available since 2006, however, in the United
States, vaccine uptake has been slow, and varies widely
among different geographic and racial/ethnic pop-
ulations.12 Overall in 2017, 48.6% of adolescents aged
13e17 were up to date with their HPV vaccination se-
ries.13 Initially, lower vaccination uptake among blacks,
Asians, and Latinas compared to whites in the United
States has been reported.14,15 However, more recent data
has shown a steeper increase in vaccine uptake amongst
racial and ethnic minority adolescents, resulting in higher
coverage comparatively amongst these groups in com-
parison to their white counterparts.13,16 Estimated HPV
vaccination rates amongst adolescents in 2017 was 44.7%
for whites, 50.2% for blacks, 56.4% for Hispanics, and
52.5% for Asians.13
Vaccination coverage trends vary wildly geographically
and tend to be lower in non-metropolitan areas and
amongst women without health insurance. In 2018, among
adolescents aged 13e17 years, HPV vaccination rates
ranged from 38% in Kansas and Mississippi to >70% in
Washington, DC and Rhode Island among girls, and from
27% in Mississippi to >70% in Massachusetts and Rhode
Island among boys.4 Increased vaccination uptake among
minority populations over time is thought to be secondary
to strong provider recommendations and increased patient
awareness and understanding of HPV.16 Knowledge of
HPV and strong provider recommendations have had an
important impact on the initiation of HPV vaccination and
could be instrumental in increasing uptake and decreasing
disparities geographically.
Variation in cervical cancer screening rates represents
an additional cause and potential exacerbating factor in
disparate cervical cancer incidence and mortality.
Although the overall cervical cancer screening rates in the
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United States is relatively high at 81%, this has fallen short
of the Healthy People 2020 goal of 93%.17 Additionally,
there has been a significant decline in screening with pap
smear testing between 2000 and 2015 (5.8%) among
women aged 21e65 years.18 Given the correlation be-
tween inadequate screening and increased risk of cervical
cancer, this fact is extremely concerning. Women who are
uninsured, are immigrants, have low educational attain-
ment, and/or do not have an established health care pro-
vider, tend to report the lowest rates of cervical cancer
screening. Asian (75.8%) and Hispanic women (78.6%)
reported lower screening rates than non-Hispanic whites
(83.7%) and blacks (85.3%). Cervical cancer screening
was lowest amongst women without a usual source of
health care (65.1%) and women who were uninsured
(63.8%).19
Additionally, geographic location has been implicated
as a point of variation in cervical cancer screening with
women living in rural areas being less likely to undergo
screening than women living in urban or suburban areas.20
Additionally, in the United States, southern states have
reported significantly higher proportions of women who
have not been screened for cervical cancer in the past five
years. This was unfortunately correlated with the fact that
compared to other census regions, the South had the
highest incidence rate of newly diagnosed cervical cancers
(8.5 per 100,000) and the highest death rate (2.7 per
100,000).21 These disparities in screening geographically
are thought to be linked to a decreased number of pro-
viders in rural areas and an increased uninsured
population.
Barriers to cervical cancer screening can be both per-
sonal as well as secondary to structural obstacles in
accessing care. Personal factors, such as lack of education
regarding screening and risk factors, fear of being diag-
nosed with cancer, embarrassment, and distrust of the
medical system have been identified as barriers to
screening.20 Additionally, structural hindrances, for
example, transportation, cost, time off work, language
barriers, and lack of physician access or recommendation
have been associated with inadequate screening amongst
our most vulnerable populations.20
Missed opportunities for prevention through vaccina-
tion and screening are directly correlated to the develop-
ment of cervical cancer. However, not only are there
disparities in the opportunities for prevention of cervical
cancer, but also once a diagnosis of cervical cancer has
occurred, there are also disparities in treatment and mor-
tality associated with that diagnosis for the most vulner-
able populations. Black women after controlling for age,
stage, histology, and initial treatment type, remained at a
19% increased risk of dying from their disease compared
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INCIDENCE AND DISPARITIES IN CERVICAL CANCER
to their white counterparts.22 However, more recent data
showing mortality rates corrected for rates of hysterectomy
have demonstrated that the reported disparity in mortality
between black and white women may have been under-
estimated by 44%.23 For black women, the corrected
mortality rate was 10.1 per 100,000 (uncorrected 5.7 per
100,000) versus 4.7 per 100,000 (uncorrected 3.2 per
100,000). Additionally, the corrected mortality rates
among black women became even more dramatic with
increased age, that is, 29.7 per 100,000 among those
75e79 years old, 33.4 among those 80e84 years old, and
37.2 among those 85þ years old.23
Racial and ethnic disparities in morbidity have been
linked to differences in treatment adherence and access to
care. Recent studies have shown that disparities in stan-
dard of care therapy for women with early stage disease
(IA1-IIA) has abated in recent years as black women have
received the indicated surgery or chemo-radiotherapy.
However, for later stage disease (stage IIB-IVA), black
women were less likely to receive chemo-radiotherapy
than other women (75.6% versus 80.4%). Although the
magnitude of the disparity has decreased over time, the
odds of receiving chemo-radiotherapy were 35% lower
among black women after adjustment for known cova-
riates.24 Studies regarding access to care, contributing to
disparity in outcomes, have been mixed. A recent National
Cancer Data Base (NCDB) study of stage IB2-IVA cer-
vical cancer patients reported that disparities in guideline-
based care were highest at high-volume hospitals, sug-
gesting that access was not the main issue.25 However,
other studies have shown that equal access to care has
resulted in similar survival rates.26
In conclusion, cervical cancer remains the fourth most
common cancer amongst women globally and a continues
to remain a significant source of morbidity and mortality in
the United States. The most vulnerable populations,
including racial and ethnic minorities, the socioeconomi-
cally disenfranchised, and those living in rural or remote
areas, continue to have disparate rates of vaccination,
screening, treatment, and consequently, worse outcomes.
The WHO has outlined a strategy for elimination of cer-
vical cancer by 2030 through tackling each of these areas.
Increasing education, access to care, and the expansion of
screening and vaccination programs both here and globally
will bring us closer to this goal.
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