Commentary Sexual Health

Two Studies Bring Bad News About Cervical Cancer Deaths and HPV—So What Can We Do?

Martha Kempner

We need more people to be screened and vaccinated—and less stigma.

Two new studies suggest that human papillomavirus (HPV) and the health problems it causes—including cervical cancer—are more widespread than previously thought.

The first study recalculated the death rate from cervical cancer and found that if you exclude women who have had hysterectomies, the death rate for all women is higher and the disparity between Black and white women much larger. And while HPV is typically considered a women’s health issue, a second study found that 45 percent of men are infected with one or more types of the virus.

These studies not only remind us of the potential risks of this common sexually transmitted infection (STI), they also point to serious flaws in our prevention efforts. Even while we have vaccines to prevent many strains of HPV and tests to catch cervical cancer long before it is deadly, the virus and resulting health conditions continue to hurt so many.

Too Many Deaths

In the United States alone, there are approximately 12,000 new cases of cervical cancer and 4,000 deaths from the disease each year. These numbers have been relatively consistent since the late 1990s, but a study recently published in the journal Cancer suggests that researchers calculating the death rate from cervical cancer have made an important mistake.

Like with any disease, researchers have estimated the mortality rates of cervical cancer by comparing the number of people at risk (in this case, women) to the number who die from it each year. These calculations have yielded a death rate of 5.7 per 100,000 Black women and 3.2 per 100,000 white women.

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The problem is that these calculations include women who have had hysterectomies—surgery to remove the uterus, during which the cervix, fallopian tubes, and ovaries are also often removed. Anne Rositch, an epidemiology professor at Johns Hopkins University and the lead author on the new study, pointed out to the New York Times, “We don’t include men in our calculation because they are not at risk for cervical cancer and by the same measure, we shouldn’t include women who don’t have a cervix.”

So Rositch and her colleagues recalculated cervical cancer mortality rates excluding women who have had hysterectomies. They found that the mortality rate went up for all women and that the racial disparities between white and Black women were far greater than previously estimated. Among white women, the mortality rate rose from 3.2 per 100,000 to 4.7 per 100,000. For Black women, the mortality rate jumped from 5.7 to 10.1. These new rates show that Black women in the United States have a cervical cancer risk close to that of women living in many developing nations in Africa, Asia, and Latin America.

In fairness, this isn’t the first time someone has recalculated the cervical cancer death rate by excluding women who no longer have a uterus or cervix. Centers for Disease Control and Prevention (CDC) researchers calculated death rates for cervical cancer both ways from 1965 to 1988 and found that the corrected death rates (those excluding women who’d had hysterectomies) were 39 percent higher. They did, however, note that women who have hysterectomies as a result of cervical cancer and subsequently die from the disease are lost when the corrected calculations are done. It also isn’t clear whether the CDC data includes information about trans people, including those who underwent hysterectomies during transition.

This study did not look at the cause of the racial disparities, but research has shown over and over again that women of color and low-income women lack equal access to high-quality health care. One study examined care for more than 15,000 patients with advanced cervical cancer and concluded that those who had higher incomes, private insurance, and treatment at higher-volume medical centers were more likely to receive treatment that met the standard-of-care guidelines.

Of course, as Rositch noted in a press release, “this is a preventable disease and women should not be getting it, let alone dying from it.” Cervical cancer is typically a slow-growing disease that can be detected early with a Pap test to identify changes to cervical cells. The CDC estimates that with widespread use of Pap tests and vaccinations, 93 percent of cervical cancer cases in this country could be eliminated.

HPV Is Not Just a ‘Female Problem’

The second of the two recent studies underscores why it is so important for boys and men to play a role in preventing HPV and cervical cancer.

HPV is actually a group of more than 150 related viruses, 40 of which are sexually transmitted. Infection with HPV is often innocuous, as the body can clear the virus without the person experiencing any health consequences or even realizing they were infected. However, certain types of the virus are known as high-risk because they have been found to cause 99 percent of cervical cancers, as well as cancers of the vagina, vulva, penis, anus, head, neck, and throat.

For this study, published in JAMA Oncology, researchers examined data from 1,868 men ages 18 to 59 who participated in the National Health and Nutrition Examination Survey and received physical exams at a mobile examinations centers.

The results suggest that 45 percent of men in this age group have HPV, and 25 percent have one of the high-risk types, such as HPV-16 and HPV-18. This means that more than five million men have one of these two types of the virus that are responsible for 70 percent of all cervical cancer. Only 10.7 percent of men who were eligible for the vaccine based on their age were vaccinated.

Many men who contract HPV will experience no symptoms and clear the virus naturally in six to 18 months. Some men, however, especially those who contract a high-risk type of virus, may develop cancer of the penis or anus. Of course, men who contract the high-risk types can also transmit the virus to female partners who are then at risk of developing cervical cancer, or to male partners.

While the majority of people exposed to HPV will experience no negative health side effects, many men and women will not be that lucky—approximately 17,600 women and 9,300 men are affected by HPV-caused cancers each year. Some will die as a result.

No Time for Vaccine Fears

Yet most of these deaths are preventable.

First and most importantly, they can be prevented through widespread use of the vaccine that’s been available in some iteration since 2006 and is suggested for both boys and girls. The CDC now recommends that all 11- and 12-year-old boys and girls receive two doses of the HPV vaccine over a six- to 12-month period. The goal is to protect them before they become sexually active. Catch-up vaccines are recommended for males through age 21, as well as females and transgender adults through age 26, who were not vaccinated when they were younger.

We have an effective vaccine that prevents cancer. It is as simple as that. Research has confirmed that the vaccine is working—one study found that six years after the vaccine was introduced, HPV rates were down 64 percent among teen girls and 34 percent among women in their 20s.

And yet, as of 2015, only six out of ten girls and five out of ten boys had received at least one of the recommended shots.

Unfortunately, HPV vaccine rates lag behind those of other routine immunizations, in part due to misinformation about all vaccines and in part because of a reluctance to vaccinate children against an STI at a young age.

Parents need to be reassured that vaccines, including the HPV vaccine, are safe. The Food and Drug Administration (FDA) requires years of research before a vaccine is approved, and the CDC collects data on all adverse effects once the vaccine is on the market. The HPV vaccine has been found to cause pain or swelling in the injection site, headache, fatigue, nausea, and joint pain. These side effects are usually mild. Some patients have fainted after the injection, but this can happen after any medical procedure.

One concern often raised about HPV specifically is that vaccinating girls against a sexually transmitted infection will somehow cause them to change their sexual behavior. This is part of an ongoing myth that resurfaces every time a new prevention method for STIs or pregnancy method becomes available. It’s seemingly based on the notions that negative consequences are the only thing keeping young women’s sexual behavior in line and that minimizing risks will increase promiscuity. These ideas are incorrect (not to mention offensive). Numerous studies have shown that young women who receive the HPV vaccine don’t have more sex than their unvaccinated peers and still believe it’s important to practice safer sex.

In addition to making sure all young people are vaccinated, we need to increase screening cervical cancer. The CDC recommends regular Pap tests for women ages 21 to 65 but found in 2012 that more than eight million women had not been screened in the previous five years. Pap tests can screen for pre-cancerous changes to cervical cells, which can treated before they become cancers. Since the 1950s, when the Pap test became widely used, U.S. deaths from cervical cancer declined 70 percent. And, the CDC reports that more than 50 percent of all newly diagnosed cervical cancers are in women who have never been screened or have not been screened in the previous five years of their lives. Increasing the number of women—especially Black women—screened for cervical cancer will undoubtedly reduce the incidence and death rate of this disease.

Finally, there are condoms. Latex condoms can reduce the risk of both HPV and related health problems. In one study, women who reported that their boyfriends always used condoms were 70 percent less likely to get HPV than those who said their boyfriends used condoms less than 5 percent of the time. In addition, none of the women who reported always using condoms was diagnosed with a cervical lesion during the study period.

There is no doubt that these two most recent studies are bad news. Cancer mortality is higher than we thought, especially for Black women, and almost half of men have at least one type of HPV, with a quarter of them having types known to cause cancer. But we have to remember that there is also good news. Between the vaccine, the Pap test, and condoms, we have tools to prevent almost all of this. I hope the bad news will motivate all of us to spread the word and take action.

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