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Equity for Cervical Cancers
Opportunities to Improve Prevention, Screening, and Equitable Care of Cervical Cancer: A Call to Action

Released: October 21, 2024

Expiration: October 20, 2025

Linda R. Duska
Linda R. Duska, MD, MPH
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Key Takeaways
  • At-risk populations for presenting with cervical cancer, including underrepresented patients of color, underinsured or uninsured patients, and patients without access to available preventative healthcare could greatly benefit from preventive measures such as HPV vaccination and adequate age-appropriate screening/education.
  • A key remaining challenge in cervical cancer care is the standardized delivery of core primary treatments such as chemoradiation and brachytherapy, which requires continuing education of healthcare professionals in the community setting.
  • Recent advances in locally advanced cervical cancer (ie, INTERLACE and KEYNOTE-A18 trials) remain an area of potential confusion for oncology practitioners based on the similarities in the treatment setting and the various changes to FIGO staging systems in the past decade.

Disparities in gynecologic cancer incidence and mortality vary by race, ethnicity, and cancer type. However, morbidity and mortality associated with these cancers, cervical cancer in particular, could be substantially reduced with timely prevention, appropriate and guideline driven screening, early diagnosis, and adherence to guideline-concordant treatments. More than 90% of cervical cancer is caused by the human papillomavirus (HPV). Among patients with cervical cancer, Black and Hispanic/Latina women have a higher incidence and mortality compared with non-Hispanic White women. Moreover, Black and Hispanic/Latina patients experience more barriers to receipt of preventive vaccination, cervical cancer screening, and receipt of guideline-concordant care compared with White women. In this commentary, I discuss best practices and remaining—but addressable—unmet needs in the care of young and adult patients without and with a diagnosis of cervical cancer including my thoughts on improving HPV vaccination rates in the United States, guideline-driven screening, and care coordination of available treatments to be explored in an educational program for gynecologic cancers.

Early Cervical Cancer: Prevention and Screening
There is a substantial unmet need in educating healthcare professionals (HCPs) on the HPV vaccine. Ideally, the HPV vaccine is given by pediatricians, but I would say there is still a lack of education on how effective the vaccine is for preventing disease. Of note, from a gynecologic perspective, the vaccine prevents not only cervical cancer but also genital warts and cervical cancer precursors. To be most effective, the vaccine should be received prior to any HPV exposure; however, since the currently available vaccine covers 9 HPV types, the vaccine is still effective even after potential exposure occurs. The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommend children 9-12 years of age get vaccinated against HPV. These guidelines also recommend young adults up to the age of 26 to get vaccinated (catch-up) if not adequately vaccinated previously. However, whether these guidelines are followed can be highly dependent on where in the United States HCPs are located and what their biases are regarding vaccinating 9- to 12-year-old children for a sexually transmitted disease, their understanding about how the vaccine works for preventing disease, and the importance of giving the vaccine before sexual activity begins.

In the United States, we have become better at using preventive HPV vaccination, but we are still lagging behind places like Australia were they have almost eradicated HPV-related diseases. Vulnerable populations for not receiving the HPV vaccine in the United States continue to be those living in rural areas without access to appropriate healthcare, lack of HCP education, those who are uninsured, undocumented individuals, and those without access to routine care. In northern and central Virginia, for example, I come across many such patients. I believe there is lack of education of the HCPs and of the patients/caregivers themselves about how the vaccine can help with a very preventable disease.

Regarding screening, part of the challenge is that the guidelines have changed so much over the years—to the point that I tell my trainees to use an App on their phones—and depending on how old the patient in front of you is, the screening and treatment guidelines are different. Current American Cancer Society/US Preventive Services Task Force guidelines recommend cervical cancer screening in women 21-29 years of age every 3 years with cytology alone; women aged 30-65 years can undergo screening every 3 years with cytology alone or every 5 years with high-risk HPV testing alone (if 25 years of age) or in combination with cytology. I believe there are HCPs who are simply not keeping up with the literature and do not know what the current screening algorithms are. Here, as well, screening can vary whether the patient is seeing a gynecologist as the primary care physician or a family practitioner and their location. I think there is opportunity for education of HCPs who provide screening care for women, particularly when to refer patients who have a normal Pap test result but a high-risk HPV status. Do they know when to do HPV testing? When are you not supposed to do it? When do you need to act on it? Who should you refer the patient to with an abnormal result? All those are areas of opportunity for education. 

Making Available Options Work for Populations at Risk: Need for HCP as Well as Patient Education
Regarding using the tools that we already have (eg, vaccinations), access and cost continue to be a barriers for vulnerable individuals, particularly Black or Hispanic/Latina patients. I believe that offering free vaccinations for all eligible patients through a government mandate much like the hepatitis B vaccine, which is also a sexually transmitted disease, may be the best path forward to achieving universal preventive vaccinations. Currently, only 4 states in the United States (Virginia, Hawaii, Rhode Island, and the District of Columbia) mandate HPV vaccination for school entry (and parents may choose to “opt-out.”

With respect to funding the vaccine for those who are uninsured or under-insured, the Vaccines for Children program helps families of eligible children who might not otherwise have access to vaccines. The program provides vaccines at no cost to children ages 18 years and younger who are uninsured, underinsured, and receiving care in a Federally Qualified Health Center, Rural Health Center, or delegated institution, Medicaid-eligible, or American Indian/Alaska Native.

Another factor that compounds the issue of not receiving the HPV vaccine at a young age is that patients who receive the vaccine after they are 15 years of age are recommended to receive 3 doses instead of 2. We need to continue to educate patients and guardians/caregivers about this. Pediatricians will often say to a parent, “Would you like the HPV vaccine for your child?” And if the parent says, “No,” that may be the end of the conversation. It cannot be underestimated that this is a key conversation that the pediatrician needs to have with the parent. And if they are better armed with the latest data and resources to help parents understand the benefit of the vaccine, HPV-related cervical cancer would not be the challenge that it is today. It is also important to note that boys/young men need to receive the vaccine too.  

Achieving Equality/Equity in Access to Therapy for Cervical Cancer Treatment
Unfortunately, when preventive vaccination and adequate screening has failed, patients with an HPV infection that was not cleared by their immune system can present to our clinics with cervical cancer. Here, too, we still see clear but addressable unmet needs in the receipt of adequate therapy. Receipt of brachytherapy is critical to the treatment of cervical cancer. However, at this time, in the United States, we are not giving brachytherapy routinely, properly, and equitably to all patients who need it. There are studies that link lower survival with patients who do not receive brachytherapy in general, but particularly so for Black patients.

The treatment for cervical cancer, and particularly for locally advanced cervical cancer, can be very complex. It requires giving radiation sensitizing chemotherapy once weekly along with whole pelvic radiation, followed by internal radiation (brachytherapy). The whole pelvic radiation is generally given daily for 4-5 weeks, and the combination of chemotherapy with radiation (called chemoradiation, or CRT) often has significant acute side effects, including diarrhea, dehydration, anemia, and fatigue. Coordination of the overall treatment process and careful attention to managing side effects is a critical part of successful completion of all treatment within a pre-defined time frame for best results. For instance, in my practice, I give the chemotherapy and take care of the patient during the chemotherapy/radiation period, a radiation oncologist gives the radiation, and I am also there to assist with brachytherapy as needed for either placement of the tandem or radiation device. This lends itself to a multidisciplinary group approach whereby we are able to address any challenges along the way. However, in many parts of the country, patients do not have access to this type of coordinated multidisciplinary care. A few patients come to me after not having received all of their prescribed chemotherapy because they had to stop early because their local oncologist was not able to manage the adverse effects of the chemotherapy or radiation therapy, or they may have not received the brachytherapy at all due to toxicity from prior treatment, or they may not have completed therapy within the ideal timeframe. We need to do better at providing these standard-of-care therapies.

Ongoing Limitations in Resource-Limited Settings
Studies suggest that survival from cervical cancer depends on how far away from a National Cancer Institute (NCI)–designated cancer center the patient is. The further away the patient is, the worse the prognosis because presumably the treatment is being given by a site that is not familiar with providing gynecologic cancer treatment. As stated earlier, and as revealed by a recent poll and short surveys from Clinical Care Options, community oncologists and family care practitioners are not as familiar with how to treat and manage the adverse events associated with gynecologic cancer therapy. In particular, the CRT delivery required for the primary therapy of locally advanced cervical cancer requires daily radiation treatment for 4-5 weeks along with weekly chemotherapy. Thus, if patients live 50 miles away from an NCI-designated cancer center, commuting that far to receive care might not be a reasonable option, especially if they are trying to take care of their family, their children, and their jobs.

For the first time in 25 years we have 2 new strategies to improve upon the standard CRT regimen for locally advanced cervical cancer described above. However, I do not think HCPs in the United States are in full agreement on when to use induction chemotherapy followed by chemoradiotherapy (ie, intravenous weekly cisplatin for 5 weeks plus 45-50 Gy external beam radiotherapy in 20-28 fractions plus brachytherapy) vs chemoradiotherapy alone for stage IB1 with nodal involvement through stage IVA (excluding patients with International Federation of Gynecology and Obstetrics [FIGO] 2008 IIIA or with positive para-aortic nodes) as presented in the phase III INTERLACE trial. It is important to note that the INTERLACE regimen requires that the patient begin radiation within 7 days of her last dose of weekly induction chemotherapy to avoid repopulation of tumor; we need to be certain that HCPs are aware of this requirement before using this regimen in practice.

There is also lack of consensus on how to integrate the results from the phase III KEYNOTE‑A18 trial, which showed improved progression-free survival and overall survival with the addition of pembrolizumab during and after concurrent chemotherapy plus radiotherapy in patients with FIGO 2014 stage IB2-IIB with pelvic nodal metastases and in those with stage III-IVA regardless of nodal status. The FDA made the decision to approve the use of pembrolizumab only in patients with stage III-IVA disease (FIGO 2014); it is notable that our current FIGO 2018 staging includes node positive patients in the stage III category (85% of subjects on A18 had node positive disease). Some are talking about using both regimens, but this approach has not been studied and in my opinion recommending this course of treatment is premature. Educating gynecologic cancer care professionals about which regimen would be appropriate or which patient might need less vs more therapy is key. For instance, the medical oncologists I talk to know that they are supposed to be giving pembrolizumab to patients with cervical cancer but remain unclear about which groups of patients benefit the most from this therapy. I think there is a tremendous need for education there. 

In a collaboration with Dr. Leslie Randall, I coauthored an editorial in The Lancet where we go into detail about the INTERLACE and KEYNOTE-A18 trials. There, we argue that to better be able to integrate novel therapies for cervical cancer, we need to be able to give chemoradiotherapy appropriately, which can represent a challenge in areas where coordination of complex multidisciplinary cancer care may be difficult. Cisplatin and pelvic radiation is one of the toughest treatments that we give, but I see these patients every single week, and we have the support systems in place when issues arise. I do believe that involving other members of the care team (eg, nurses, physician associates) is very important for improving outcomes in this patient population. Other members of the care team help educate patients so they understand all of the required supportive care needed to get them through treatment in an appropriate time frame. It is crucial to get patients through chemotherapy and radiation in 56 days without any unnecessary breaks and to ensure patients receive 5 weeks of cisplatin—which can be difficult to do. If I give them chemotherapy on Monday, I ensure my nurse calls them on Thursday. Sometimes patients come in for intravenous fluids on Thursday. A main reason for patients not completing their chemotherapy in the community setting is because symptom management for this type of treatment is not always addressed timely or appropriately understood. But I think that by educating the overall team (eg, nursing staff) about supportive care and how to best manage these patients regarding supportive care could get more of those patients through the chemotherapy and radiation therapy needed.

Your Thoughts?
What is your experience in addressing the current challenges in the diagnosis and treatment of patients with cervical cancer? Join the discussion by leaving a comment and answering the polling question. Also continue to visit the Clinical Care Options website for upcoming live programs on gynecologic cancers, access clinical data updates via downloadable slides and patient-oriented resources, and watch on-demand webcasts from this program covering equitable care delivery for ovarian, endometrial, and cervical cancers.

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For which of the following topics would you like more information to help you care for patients with locally advanced cervical cancer?

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