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. 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. 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.
Cervical cancer disparities Since the development of the Papanicolou smear or Pap smear in 1941, cervical cancer has been highly preventable. 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. 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. 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. Within the United States, Hispanic women have the highest incidence of cervical cancer, and African Americans have the highest mortality.
Differences in screening practices Disparities amongst different minority groups have been attributed to different Pap smear screening practices. 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. One 2001 study in California found that Asian women were the least likely ethnic/racial group to have ever had a Pap test. 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%). It has also been discovered that foreign-born women in the U.S. have lower screening rates than those born in the U.S. Not only does there exist disparity in screening, but there also exists post-screening disparities in follow-up practices. Adherence to follow-up after abnormal Pap tests varies across minority groups. 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. Across all racial/ethnic groups in the U.S., increased poverty and decreased education levels have been associated with higher mortality.
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. 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. For females aged 13–26 years who have not been previously vaccinated, catch-up vaccination is recommended. Despite these national recommendations, the rate of HPV vaccination in the U.S. remains low. One study of 409 females aged 13–26 found that only 5% of participants had received one or more HPV vaccine dosages. 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.
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. 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.
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. Across different racial and ethnic groups, having a regular doctor increases the likelihood of a patient undergoing regular Pap smearing. 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.
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. 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.
Differences in treatment There have been documented racial and ethnic disparities in clinical treatment for cervical cancer. 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. Black women have a higher risk of dying from cervical cancer by 50%.
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