Disparities in cervical cancer in African American women: What primary care physicians can do
ABSTRACT
African American women are disproportionately affected by cervical cancer, with higher rates of incidence and mortality than white women. Most of the difference would disappear with equal treatment. As usual, primary care providers are on the front lines.
Additional infectious culprits
Coinfection with other sexually transmitted infections, specifically Chlamydia, herpes, and HIV, has been associated with cervical neoplasia and invasive cervical cancer. A positive linear association exists between the number of sexually transmitted infections and cervical neoplasia.50
C trachomatis is the most common sexually transmitted infection in the United States, with a 6-times higher rate in African American women.51 Women who are seropositive for C trachomatis are at twofold higher risk of developing squamous cell cervical cancer.52,53 Women who are seropositive for Chlamydia infection, herpes virus 2, or HPV are at markedly increased risk of invasive cervical cancer.50
Tobacco use
The negative impact of smoking on numerous other cancers resulted in investigation of its role in cervical cancer.
Early case-control studies found an association between cervical cancer and smoking,54 but because these studies did not account for HPV infection status, they could not establish causality. Subsequently, several studies did control for HPV infection; the risk of squamous cervical cancer was twice as high in women who had ever smoked.55 Furthermore, the more cigarettes smoked per day, the higher the risk of cervical neoplasia.41,56
According to the US Centers for Disease Control and Prevention in 2014, the highest prevalence of smoking was among American Indian and Alaskan Native women, 32.5% of whom said they smoked every day, compared with 17.2% of white women and 13.7% of African American women.57
HOW CAN PRIMARY CARE PHYSICIANS CLOSE THE GAP?
By promoting HPV vaccination to children and young adults, primary care physicians can help prevent cervical cancer. Moreover, primary care physicians will see most adolescents for a nonpreventive health visit, an optimal opportunity to discuss sexual activity practices and HPV vaccination.58 Including the HPV vaccine as routine with other vaccinations can close the gap.38
Screening and treatment of sexually transmitted infection during these visits can affect the risk that future HPV infection will progress to neoplasia or cancer. Persistent lifestyle modification counseling, especially smoking cessation through motivational interviewing, can lessen the risk of cervical cancer neoplasia progression.
Additionally, in light of recent changes in cervical cancer screening guidelines, the primary care physician’s role as educator is of utmost importance. In one study, although 99% of women had received a Pap test, 87% could not identify the purpose of the Pap test.59 The primary care physician’s role is perhaps the most influential in preventing disease and, as such, has the greatest impact on a patient’s disease process.
