Gynecologic cancer disparities in the United States

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Gynecologic cancer disparities in the United States refer to differences in incidence, prevalence, and mortality from gynecologic cancers between population groups. The five main types of gynecologic cancer include cervical cancer, ovarian cancer, endometrial cancer, vaginal cancer, and vulvar cancer. [1] For patients with these and other gynecologic malignancies within the United States, disparities across the care continuum by socioeconomic status and racial/ethnic background have been previously identified and studied. [2] [3] The causes behind these disparities are multifaceted and a complex interplay of systemic differences in health as well as individual patient factors such as cultural, educational, and economic barriers. [3]

Contents

Cervix adenocarcinoma Cervix Adenocarcinoma in situ (1800597030).jpg
Cervix adenocarcinoma

Cervical cancer disparities

Since the development of the Papanicolou smear or Pap smear in 1941, cervical cancer has been highly preventable. [4] The implementation of Pap smear screening programs has resulted in a steady decline in incidence and mortality rates from cervical cancer since the mid-1970s. [5] Even with this technology, the American Cancer Society still estimates that within the U.S., about 12,820 new cases of invasive cervical cancer will be diagnosed and 4,210 women will die of cervical cancer by the end of 2017. [6]

Despite an overall decline in incidence and mortality rates from cervical cancer for women across the United States, significant disparities have been documented amongst racial and ethnic minorities and socioeconomically marginalized populations. [7] [8] Within the United States, Hispanic women have the highest incidence of cervical cancer, and African Americans have the highest mortality. [9]

Differences in screening practices

Disparities amongst different minority groups have been attributed to different Pap smear screening practices. [10] African Americans, American Indians, and non-white Hispanics have been found to be diagnosed at later stages than white women, which has been suggested as a potential contributing reason for their worse survival outcomes. [11] One 2001 study in California found that Asian women were the least likely ethnic/racial group to have ever had a Pap test. [12] This study also described varied trends existing within different Asian American subpopulations, identifying how Vietnamese women had the lowest screening rates (62.3%) and Filipino women had the highest screening rates (81.1%). [13] It has also been discovered that foreign-born women in the U.S. have lower screening rates than those born in the U.S. [14]

Not only does there exist disparity in screening, but there also exists post-screening disparities in follow-up practices. [15] [16] [17] Adherence to follow-up after abnormal Pap tests varies across minority groups. [17] [16] The National Breast and Cervical Cancer Early Detection Program, a national initiative focused on increasing access to cervical and breast cancer screening for underserved women followed more than 10,000 participants who had two or more abnormal Pap test results. They found 56% of these patients did not follow-up with a recommended cervical examination, and 27.7% of this group received no follow-up examination whatsoever. Within this study, African Americans had the highest rate of no follow-up. [15]

Across all racial/ethnic groups in the U.S., increased poverty and decreased education levels have been associated with higher mortality. [18] [19]

Differences in vaccination

Human papilloma virus (HPV) is consistently present in almost all cervical cancer cases across the world and is the main etiologic factor in cervical cancer. [20] The U.S. Advisory Committee on Immunization Practice advises that females receive the full series of three doses of quadrivalent HPV vaccine at 11–12 years of age. [21] For females aged 13–26 years who have not been previously vaccinated, catch-up vaccination is recommended. [21]

Despite these national recommendations, the rate of HPV vaccination in the U.S. remains low. [22] One study of 409 females aged 13–26 found that only 5% of participants had received one or more HPV vaccine dosages. [22] Since parents have a critical role in deciding the vaccination of their young daughters, studies have found that parenting beliefs and attitudes are important to HPV vaccine practices of girls throughout the U.S. [22]

Barriers to prevention

Cultural/personal barriers

Non-adherence to screening and vaccination have been found to be influenced by cultural and personal beliefs and conditions. [23] Interviews with females of ethnic minorities, specifically Chinese and Hispanics, have revealed that the implications of sexual activity that come with Pap smears impact females decisions to get screened. Some women revealed that they avoid screening to prevent others from thinking that they are sexually active or promiscuous due to embarrassment or concern about being discovered. [24] [25]

Socioeconomic and institutional barriers

Receiving a recommendation by one's physician is strongly correlated with patients seeking out to be screened by a Pap smear. [26] Across different racial and ethnic groups, having a regular doctor increases the likelihood of a patient undergoing regular Pap smearing. [27] [28] Additional barriers such as long wait times, lack of transportation, inability to take off work, lack of family support or available child care options can often impact patients' abilities to seek out and receive appropriate preventative measures and treatment. [29] [30]

Lack of knowledge and awareness

Understanding cervical cancer and its link to human papillomavirus (HPV) is closely related to agreeing to undergo Pap smear screening or get vaccinated against HPV across population types. [18] [31] Cervical cancer patients who have never had a Pap test were more likely to have previously not been aware that they were capable of developing cervical cancer. [29]

Differences in treatment

There have been documented racial and ethnic disparities in clinical treatment for cervical cancer. [32] Research has shown that African Americans are more likely than whites to go untreated. They are also less likely to receive clinical staging or be treated with surgery or combined therapy. [32]

Ovarian cancer disparities

While ovarian cancer accounts for only 3% of cancers for women in the U.S., it is the fifth leading cause of cancer-related deaths for this population. [33] [34] This cancer is known as the "silent killer" and is disproportionately lethal because of lack of effective screening and early detection strategies resulting from the absence of disease-specific symptoms. [35] If diagnosed in an early stage (stage I) while the tumor is confined to the ovaries, ovarian cancer is highly treatable with a five-year survival rate over 90%. [36] However the majority of ovarian cancer patients are diagnosed with stage III and stage IV cancer, which are associated with poor prognosis, even with aggressive therapy. [34]

Differences in screening

Barriers to early detection

Even with poor existing screening methods, around 20% of women with ovarian cancer are still effectively caught and diagnosed at early stages in the U.S. [37] Research has revealed that not having private health insurance coverage decreases a woman's chance of being diagnosed with early stage ovarian cancer. [37] African American women are less likely to be diagnosed at an early stage of ovarian cancer as compared to white women due to lower rates of private health insurance coverage. [37] As a result, African American women have been found to be at higher risk of presenting with advanced, late-stage aggressive ovarian cancer for which current treatment standards can only palliate symptoms. [38]

Genetic screening

Certain genetic components have been found to increase the susceptibility of carriers to develop ovarian cancer. [39] Possession of specific mutations of the BRACA1 and BRACA2 genes impose a lifetime risk of developing ovarian cancer as high as 20-65%, compared to the 1.4-2.5% risk for a woman from the general population with no affected relatives. [40] Hereditary nonpolyposis colorectal cancer, also known as Lynch syndrome, is also associated with elevated lifetime risk of developing ovarian cancer, at about 10-12%. [41]

Genetic screenings are strongly advised for high-risk women who possess a family history of ovarian cancer or any of the aforementioned genetic alterations or who have been diagnosed with early onset colorectal, breast, uterine, or endometrial cancer. [42] Within the U.S., African American women are less likely to undergo genetic counseling or testing as compared to Caucasian women. [43] A national study of 25,364 people revealed that more Caucasian women report having heard about genetic testing for cancer risk as compared to African American, Asian, or Hispanic women, indicating the need for more culturally competent approaches to improve awareness of these screening methods. [44]

Differences in treatment

In the U.S. and the rest of the developed world, surgery is the treatment standard for all stages of ovarian cancer. For later stages, adjuvant chemotherapy has been shown to improve patient survival. [45] Lymphadenectomy and lymph node chemotherapy have also been demonstrated to improve survival for ovarian cancer patients of all stages. [46]

The U.S. is the only country that has reported significant ovarian cancer treatment disparities. [47] Within the U.S., African American patients have the highest risk of receiving delayed treatment, non-standard treatment, or no treatment at all. [48] [49] [50] [51] A multi-institutional study of 47,390 patients revealed that uninsured and Medicaid-insured patients to be at higher risk of receiving non-standard treatment compared to privately insured patients. [52] Patients at community cancer hospitals compared to teaching hospitals were also at higher likelihood for receiving non-standard care. [52] Overall, even with treatment guidelines made by many different organizations, several ovarian cancer patients are not receiving appropriate treatment, especially older and minority women without private insurance. [50]

Endometrial cancer disparities

Endometrial cancer incidence is rising in the U.S across all racial/ethnic groups. [53] The highest increases in incidence rates for endometrial cancer have been observed in African American and Asian women, who tend to present with more aggressive subtypes of endometrial cancer. [53] The overall racial disparity in survival from endometrial cancer between African Americans and whites is greater than in any other type of cancer. [54] [55]

Differences in treatment

African American women are less likely than white women to receive primary surgery for endometrial cancer. [56] Their associated mortality rate from endometrial cancer has been found to be 84% higher than white women. [57]

Differences in biological factors

It has been suggested that variance at the molecular level might underlie racial disparities in survival outcome. High expression of the mutant p53 tumor suppressor protein has been found to be associated with poor survival rates for endometrial cancer, and this malignant over-expression has been discovered to occur twice as frequently in blacks than in whites. [58]

Vulvar cancer disparities

Vulvar cancer is the fourth most common gynecologic cancer with approximately 940 deaths from this disease in the United States each year. [59] If caught early without associated nodal involvement, vulvar cancer patients can be treated with a survival rate of 90%. [60]

African American women have been shown to have better survival outcomes compared to whites for vulvar cancer [61] even though they present with cancer at a significantly younger age. [62] This has been explained by African American's higher rate of human papilloma virus HPV infection. Research reveals that African American women have a higher frequency of HPV-associated vulvar cancers than white women. [63] HPV-positive vulvar cancer is associated with early age onset, less overall aggressive behavior, and better patient prognosis. [64]

Vaginal cancer disparities

Vaginal cancer is a rare cancer type that accounts for less than 1-2% of all gynecologic malignancies. [65]

Differences in screening

Patients who are uninsured or with Medicaid are more likely to be diagnosed with advanced stage vaginal cancer than those with private insurance. [66] Patients diagnosed at more advanced stages of vaginal cancer tend to have poorer survival outcomes. [67] Studies have revealed that African Americans have a higher likelihood of being diagnosed with advanced stage vaginal cancer and are less likely to survive than their white counterparts. [68] [66]

Differences in treatment

For early stage vaginal cancer patients, surgery helps reduce mortality risk. [69] One study revealed how a significantly lower proportion of African Americans with early stage vaginal cancer underwent surgery as compared to whites, which could partially explain differences in survival rates between these groups. [68]

Related Research Articles

<span class="mw-page-title-main">Pap test</span> Cervical screening test to detect potential cancers

The Papanicolaou test is a method of cervical screening used to detect potentially precancerous and cancerous processes in the cervix or, more rarely, anus. Abnormal findings are often followed up by more sensitive diagnostic procedures and, if warranted, interventions that aim to prevent progression to cervical cancer. The test was independently invented in the 1920s by the Greek physician Georgios Papanikolaou and named after him. A simplified version of the test was introduced by the Canadian obstetrician Anna Marion Hilliard in 1957.

<span class="mw-page-title-main">Cervical cancer</span> Cancer arising from the cervix

Cervical cancer is a cancer arising from the cervix or in any layer of the wall of the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal vaginal bleeding, pelvic pain or pain during sexual intercourse. While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer.

<span class="mw-page-title-main">Colposcopy</span> Medical examination of the cervix

Colposcopy is a medical diagnostic procedure to visually examine the cervix as well as the vagina and vulva using a colposcope.

<span class="mw-page-title-main">Endometrial cancer</span> Uterine cancer that is located in tissues lining the uterus

Endometrial cancer is a cancer that arises from the endometrium. It is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body. The first sign is most often vaginal bleeding not associated with a menstrual period. Other symptoms include pain with urination, pain during sexual intercourse, or pelvic pain. Endometrial cancer occurs most commonly after menopause.

<span class="mw-page-title-main">Anal cancer</span> Medical condition

Anal cancer is a cancer which arises from the anus, the distal opening of the gastrointestinal tract. Symptoms may include bleeding from the anus or a lump near the anus. Other symptoms may include pain, itchiness, or discharge from the anus. A change in bowel movements may also occur.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Cervical intraepithelial neoplasia</span> Medical condition

Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer. More specifically, CIN refers to the potentially precancerous transformation of cells of the cervix.

<span class="mw-page-title-main">Vulvar cancer</span> Cancer involving the vulva

Vulvar cancer is a cancer of the vulva, the outer portion of the female genitals. It most commonly affects the labia majora. Less often, the labia minora, clitoris, or Bartholin's glands are affected. Symptoms include a lump, itchiness, changes in the skin, or bleeding from the vulva.

The Society of Gynecologic Oncology (SGO), headquartered in Chicago, Illinois, is the premier medical specialty society for health care professionals trained in the comprehensive management of gynecologic cancers, affecting the uterus, fallopian tubes, ovaries, cervix, vagina, and vulva. As a 501(c)(6) organization, the SGO contributes to the advancement of women's cancer care by encouraging research, providing education, raising standards of practice, advocating for patients and members and collaborating with other domestic and international organizations.

Vaginal cancer is an extraordinarily rare form of cancer that develops in the tissue of the vagina. Primary vaginal cancer originates from the vaginal tissue – most frequently squamous cell carcinoma, but primary vaginal adenocarcinoma, sarcoma, and melanoma have also been reported – while secondary vaginal cancer involves the metastasis of a cancer that originated in a different part of the body. Secondary vaginal cancer is more common. Signs of vaginal cancer may include abnormal vaginal bleeding, dysuria, tenesmus, or pelvic pain, though as many as 20% of women diagnosed with vaginal cancer are asymptomatic at the time of diagnosis. Vaginal cancer occurs more frequently in women over age 50, and the mean age of diagnosis of vaginal cancer is 60 years. It often can be cured if found and treated in early stages. Surgery alone or surgery combined with pelvic radiation is typically used to treat vaginal cancer.

Gynecologic oncology is a specialized field of medicine that focuses on cancers of the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer. As specialists, they have extensive training in the diagnosis and treatment of these cancers.

Gynecologic cancer is a type of cancer that affects the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer.

Neuroendocrine carcinoma of the cervix is best defined separately:Neuroendocrine: Of, relating to, or involving the interaction between the nervous system and the hormones of the endocrine glands.Carcinoma: An invasive malignant tumor derived from epithelial tissue that tends to metastasize to other areas of the body.

<span class="mw-page-title-main">Clear-cell adenocarcinoma</span> Type of adenocarcinoma that shows clear cells

Clear-cell adenocarcinoma is a rare and aggressive form of cancer that typically arises in the female reproductive organs, particularly the ovaries and the endometrium as well as the kidneys and is characterized by the presence of clear, glycogen-rich cells. Specific criteria must be met for a tumor to be classified as clear cell adenocarcinoma. According to the WHO, these criteria include polygonal or hobnail or cells with clear or eosinophilic/oxyphilic cytoplasm and nuclear atypia, with different architectural patterns of growth, such as papillary, tubulocystic, or solid.

<span class="mw-page-title-main">Cervical screening</span> Type of medical screening

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<span class="mw-page-title-main">Postcoital bleeding</span> Non-menstrual vaginal bleeding during or after sexual intercourse

Postcoital bleeding (PCB) is non-menstrual vaginal bleeding that occurs during or after sexual intercourse. Though some causes are with associated pain, it is typically painless and frequently associated with intermenstrual bleeding.

<span class="mw-page-title-main">Squamous cell carcinoma of the vagina</span> Medical condition

Squamous cell carcinoma of the vagina is a potentially invasive type of cancer that forms in the tissues of the vagina. Though uncommonly diagnosed, squamous cell cancer of the vagina (SCCV) is the most common type of vaginal cancer, accounting for 80-90% of cases as well as 2% of all gynecological cancers. SCCV forms in squamous cells, which are the thin, flat cells lining the vagina. SCCV initially spreads superficially within the vaginal wall and can slowly spread to invade other vaginal tissues. Because of its slow growth, this cancer may cause no symptoms, or it may present with signs like irregular bleeding, pain, or a vaginal mass. This carcinoma can metastasize to the lungs or less frequently to the liver, bone, or other sites. SCCV has many risk factors in common with cervical cancer and is similarly strongly associated with infection with oncogenic strains of human papillomavirus (HPV). Diagnosis of SCCV is done by pelvic exam and biopsy of the tissue. Treatment and prognosis will depend on the stage, location, and characteristics of the cancer.

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<span class="mw-page-title-main">Ovarian squamous cell carcinoma</span> Medical condition

Ovarian squamous cell carcinoma (oSCC) or squamous ovarian carcinoma (SOC) is a rare tumor that accounts for 1% of ovarian cancers. Included in the World Health Organization's classification of ovarian cancer, it mainly affects women above 45 years of age. Survival depends on how advanced the disease is and how different or similar the individual cancer cells are.

Oscar Vidal Gutiérrez is a Mexican medical doctor and researcher. He was born in Mexico City and completed his medical studies at the UANL Faculty of Medicine and "Dr. José Eleuterio González” University Hospital from the Autonomous University of Nuevo León.

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