2 figures, 1 table omitted
During 1973-1999, both the incidence of and death rates for cervical
cancer decreased approximately 50% in the United States.1 For
2002, approximately 13,000 new cases of invasive cervical cancer are expected,
and approximately 4,100 women will die of the disease.2 Although
invasive cervical cancer can be prevented by regular screening,3 the
prevalence of Papanicolaou (Pap) testing remains relatively low among minority
populations such as Hispanic women.4 To
characterize the incidence of invasive cervical cancer, CDC analyzed incidence
data for Hispanic and non-Hispanic women during 1992-1999 in 11 geographic
areas with population-based registries.5 This
report summarizes the results of this analysis, which indicate that the incidence
of invasive cervical cancer decreased for Hispanic and non-Hispanic women.
However, among women aged ≥30 years, cervical cancer incidence for Hispanic
women was approximately twice that for non- Hispanic women. To lower the incidence
of invasive cervical cancer, local health organizations should provide culturally
appropriate public health interventions that encourage participation in readily
accessible cervical cancer–screening programs.
Data were obtained from the Surveillance, Epidemiology, and End Results
(SEER) Program of the National Cancer Institute.5 Microscopically
confirmed invasive cervical cancer cases (International
Classification of Diseases for Oncology, Second Edition, codes C532–C539)
were selected. SEER*Stat version 4.25 was
used to compute incidences per 100,000 women and age-adjusted to the 2000
U.S. standard population by 5-year age groups. To test for significant trends,
linear regression was used to determine the estimated annual percent change
(EAPC) and the 95% confidence interval (CI). The chi-square test was used
to determine whether differences in incidences were significant. Invasive
disease confined to the cervix was categorized as localized; cancers that
had spread beyond the cervix to regional nodes or metastasized to other sites
were categorized as advanced.
During 1992-1999, a total of 14,759 invasive cervical cancer cases were
diagnosed (53% localized, 40% advanced, and 7% unstaged). After excluding
235 cases of persons with unknown ethnicity, the analysis included data from
14,524 invasive cervical cancer cases; 3,166 (22%) were among Hispanic women,
and 11,358 (78%) were among non-Hispanic women.
The incidence for invasive cervical cancer was 16.9 per 100,000 women
(95% CI = 16.2-17.5) for Hispanic women and 8.9 (95% CI = 8.8-9.1) for non-Hispanic
women. Regardless of the stage of disease at diagnosis, incidences for Hispanic
women were approximately twice those for non-Hispanic women in each year during
1992-1999. Overall incidences significantly decreased an average of 4.4% per
year for Hispanic women and 2.0% per year for non-Hispanic women. Incidences
of localized-stage cancer declined 3.3% per year for Hispanic women (EAPC
= -3.3; 95% CI = -6.0– -0.6); the decline for non-Hispanic women was
not significant (EAPC =-1.3; 95% CI = -2.9-0.4). Incidences of advanced-stage
cancer declined 4.5% per year for Hispanic women (EAPC =-4.5; 95% CI = -6.9–
-2.0); the decline for non-Hispanic women was not significant (EAPC = -2.1;
95% CI = -4.4-0.2).
Analyses of invasive cervical cancer incidences by age and stage at
diagnosis indicated that, except for women aged 20-29 years, incidences for
Hispanic women were significantly higher than those for non-Hispanic women,
regardless of stage at diagnosis. For both Hispanic and non-Hispanic women,
approximately 30% of all new invasive cervical cancers diagnosed among women
aged <50 years were at an advanced stage; among women who were aged ≥50
years, advanced-stage cervical cancer represented 52% of new diagnoses.
LR Armstrong, PhD, HI Hall, PhD, PA Wingo, PhD, Div of Cancer Prevention
and Control, National Center for Chronic Disease Prevention and Health Promotion;
S Kassim, MD, EIS Officer, CDC.
The findings in this report indicate that in a population defined by
11 SEER registry areas, overall incidences of invasive cervical cancer are
decreasing but that incidences remain relatively high for Hispanic women aged
≥30 years and for non-Hispanic women aged ≥50 years. The findings also
indicate that women who have cervical cancer diagnosed at age ≥50 years
are more likely to have advanced-stage cervical cancer.
Analyses of cervical cancer incidence by stage at diagnosis contribute
to the assessment of the impact of screening programs. Cervical cancer screening
identifies precancerous lesions and prompts early treatment to prevent advanced-stage
cancer and death.6 Risk factors for cervical
cancer include early onset of sexual activity, having multiple sex partners,
human papillomavirus infection, and smoking. However, the most important determinant
of invasive cervical cancer occurrence is infrequent or no cervical cancer
The decrease in incidence of localized and advanced-stage cervical cancer
for both Hispanic and non-Hispanic women in the United States reflects the
widespread use of cervical cancer–screening services.6 Recent
data indicate that increases in cervical cancer screening are greater for
Hispanics than for non-Hispanics (National Cancer Institute, Division of Cancer
Control and Population Science, unpublished data, 2002). To increase access
to screening services for women who lack health insurance or who are underinsured,
the Breast and Cervical Cancer Mortality Prevention Act was enacted in 1990.7 During the 1990s, all states, territories, and
Indian tribes, in collaboration with CDC, established cervical cancer–screening
Hispanics constitute the largest ethnic minority group in the United
States, representing 12.5% of the general population (2000 U.S. Census Bureau, http://factfinder.census.gov). Overall, the incidence of cancer among
Hispanics differs from those of other U.S. population groups.8 For
invasive cervical cancer, analyses of the SEER data for 1988-1992 indicated
that the incidence for Hispanic women was second only to that of Vietnamese
women, which was more than twice the incidence for Hispanics.9 Analysis
of the 1998 National Health Interview Survey indicated that the prevalence
of Pap testing within the preceding 3 years was 80% for non-Hispanic white
women, 83% for non-Hispanic black women, and 74% for Hispanic women.4 Barriers to using screening services among Hispanic
women include older age, low education, low household income, and lack of
health insurance.10 Nonuse of other screening
tests10 and unrecognized social-cultural
factors also might play a role. Research is needed to better understand barriers
to screening practices.
The higher incidence of invasive cervical cancer among both Hispanic
and non-Hispanic women aged ≥50 years and the greater likelihood that they
have advanced disease might be a result of the low use of screening services
among this population. Across all states, the use of Pap tests ranged from
84% to 93% among women of reproductive age (aged 18-44 years) and from 75%
to 91% among older women.4
The findings in this report are subject to at least three limitations.
First, SEER registries cover approximately 14% of the U.S. population and
might not be representative of the general U.S. population.5 Second,
although the U.S. Hispanic population comprises diverse communities, Hispanics
identified by SEER registries represent 25% of the U.S. Hispanic population
and are largely of Mexican origin.9 Third,
the classification "non-Hispanic women" includes other minority groups (e.g.,
Asians/Pacific Islanders and blacks) who also have high incidences of cervical
In the United States, the use of Pap tests has had an important impact
on cervical cancer morbidity and mortality. The findings in this report suggest
that Hispanic women aged ≥30 years and non-Hispanic women aged ≥50 years
need improved access to screening services. To decrease incidence of advanced-stage
cervical cancer, public health programs should target women with culturally
appropriate interventions that encourage screening. For women with abnormal
Pap test results, appropriate diagnostic and treatment services also should
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