Health Disparities in HPV-Related Cancers

While almost everyone gets the human papillomavirus (HPV) at least at some point in their lives, some populations are significantly more likely to develop HPV-associated cancers. These differences in cancer rates and deaths are called health disparities, and they can have profound effects on individuals, families, and whole communities. Minority populations, especially black women, are disproportionately impacted by HPV-associated cancers.

HPV-Associated Cancers

HPV is the most common sexually transmitted infection in the United States. Nearly 80 million people in the United States are currently infected with the virus, and there are millions of new cases every year. Most of those cases (about nine in 10) will go away on their own in a year or two, but some will develop genital warts or cancer. So far, HPV has been linked to six different kinds of cancer:

More than 31,000 new cases of HPV-related cancer emerge every year in the United States. While the virus is perhaps most well-known for causing cervical cancer, HPV-related oropharyngeal cancer (at the base of the tongue in the neck) is the most common. Both cancers together make up more than two-thirds of all cancers caused by HPV.

Known Health Disparities

Most people have been impacted by cancer in some way, whether it be through their own experiences or through those of someone they love.

One out of every three people in the United States will get cancer at some point in their life, and more than 15 million people are currently living with it right now. Some groups are more impacted by cancer than others.

Health disparities are gaps in health that happen largely because of social or economic disadvantages and inequitable distribution of resources based on things like socioeconomic status, race, sex, or geography.

These gaps affect not just individuals but also whole communities, as cycles of sickness can often affect one generation after another. They’re also expensive. One report estimated that the United States could have saved nearly $230 billion dollars between 2003-2006 had the country eliminated health disparities on a national scale.

These health gaps exist for a wide range of conditions and illnesses, including HPV-associated cancers. Some of the biggest disparities are reported along racial or ethnic lines, though other factors like age, sex, and income also appear to be at play.

Sex

Right now, more women get HPV-related cancers than men, but that appears to be changing. Rates of cervical cancer, the most common HPV-related cancer in women, have gone down in recent decades, largely due to increases in early screening through Pap smears. Meanwhile, rates for all other HPV-related cancers have gone up, especially in men.

Men have much higher rates of oropharyngeal cancers compared to women, though survival rates are similar between the two groups. When it comes to anal cancer, however, rates between men and women are roughly the same, but there’s a substantial difference in mortality. About 70 percent of women with anal cancer survive, compared to just 60 percent of men.

Race and Ethnicity

Black women in the United States also have the highest rates for HPV-associated cancers in general, while Asian/Pacific Islander men have the lowest, though those gaps vary based on the specific type of cancer involved.

Survival rates for white individuals were higher than among black individuals for all HPV-associated cancers and at any age. This was especially true in oropharyngeal cases, where one study showed that 5-year survivorship was 53.5 percent for white individuals and 32.4 percent for black individuals—a difference of more than 21 percentage points. This is despite the fact that white individuals, in general, have much higher rates of oropharyngeal cancers compared to other groups, and white non-Hispanic men, in particular, have the highest rates of any race, ethnicity, or sex.

Likewise, Hispanic women have the highest rates of cervical cancer, but black women are the most likely to die from it. The proportion of black women who get regular pap smears isn’t significantly different than white women, but research suggests that black women are often diagnosed at a later stage than white women, making the cancer more difficult to treat.

Age

HPV-associated cancers affect adults of nearly all ages, but older populations tend to be disproportionately impacted. For vaginal, vulvar, penile, and anal cancers linked to HPV, the older the age group, the higher the rates. For cervical and oropharyngeal cancers, however, middle-aged individuals had higher rates than the youngest or oldest adult age groups. According to the Centers for Disease Control and Prevention, women between the ages of 30-60 have the highest rates of cervical cancer, with rates going down for women over 70. Oropharyngeal cancers overwhelmingly affect a slightly older population, adults age 50-80, but like cervical cancer, rates go down for the oldest age groups.

Age appears to play a big role in survival rates. Generally speaking, the younger people are when they’re diagnosed with an HPV-associated cancer, the more likely they are to survive. In one study, for example, more than 82 percent of women diagnosed with cervical cancer before age 40 were still alive five years later, while only 52 percent of women older than age 60 did.

This was true even when taking into consideration the stage of cancer. In that same study, 48 percent of those under 40 with late-stage oropharyngeal cancer survived at least five years, while only 30 of those over 60 with similar cases did.

Possible Contributing Factors

It’s difficult to pinpoint the specific forces behind the differences in who gets cancer and who dies from it. So many things can impact the chances you’ll get cancer, including diet, exercise, and stress—factors that can be shaped and impacted by socioeconomic issues and culture.

Implicit Bias

Studies show most health care providers show signs of implicit bias in their interactions with patients and health care decisions. Whether they are aware of it or not, physicians often have more negative attitudes toward minority patients in their care. More research is needed on how these biases specifically impact HPV-associated cancer rates and mortality, but if these attitudes lead physicians to treat minorities or older patients with cancer differently, it could help explain why some groups are more likely to die from certain HPV-associated cancers.  

Access to Health Services  

Minority groups often have a harder time accessing routine medical care that would prompt them to be screened for cancer. Nearly a quarter of black, nonelderly adults delayed getting care in 2014 because of concerns about cost. Some minorities, including Hispanics, are twice as likely as their white peers to be uninsured, which can make women less likely to be screened for cervical cancer. When medically underserved populations are diagnosed with cancer, they are often diagnosed at a later stage.

Income

Researchers digging into cancer registry info have also found people with lower education and lower income had higher rates of penile, cervical, and vaginal cancers. In contrast, higher education was associated with higher rates of vulvar, anal, and oropharyngeal cancers. While not all of these cases were caused by HPV infection, the CDC estimates that the virus is responsible for 63-91 percent of these types of cancers.

Behavioral Factors

Some things can increase your chances of getting HPV and/or HPV-associated cancers. When some groups participate in these behaviors more than others, it could contribute to gaps in both getting cancer and surviving it.  

  • Substance use: Smoking is linked to a whole host of cancers, including some HPV-associated cancers such as cervical cancer and oropharyngeal cancers. In addition to HPV infection, smoking and drinking alcohol can also cause oropharyngeal cancers, so it’s possible some head and neck cancers are due to a combination of HPV infection and alcohol or tobacco use. This connection could be a contributing factor to sex disparities in oropharyngeal cancer because smoking and drinking are both more common in men than women.   
  • Health care participation: Minorities in the United States tend to visit doctors or seek medical care less frequently than white Americans. According to the Kaiser Family Foundation, minorities are more likely than their white peers to forgo or delay needed medical care. In addition to higher uninsured rates in minority populations, cultural influences might also be a factor. Additionally, non-Hispanic black people surveyed expressed less trust in their doctors than their white peers.
  • Sexual activity: HPV is spread primarily through anal, vaginal, or oral sex. Like other sexually transmitted infections, high-risk sexual behaviors—such as multiple partners or starting to be sexually active at an early age—can increase your chances of getting infected with at least one type of cancer-causing HPV. It’s unclear, however, how directly or indirectly individual behaviors contribute to disparities in HPV-associated cancer. For example, the prior sexual activity of a person’s partner can play a significant role in the probability of HPV exposure, so more variables are involved than simply a person’s own choices or differences in sexual behaviors within a given demographic.

Gaps in Vaccination Coverage

HPV is sexually transmitted and can spread through contact alone, so condoms aren’t nearly as effective at stopping HPV transmission as they are with other sexually transmitted infections. And while cervical cancer can be caught in its pre-cancer stages through Pap smears, no screening tests are currently available for other HPV-related cancers. The best way to prevent HPV and its associated cancers is through vaccination.

Scientists have known about the link between HPV and cancer since the early 1980s, but it wasn’t until 2006 that the first HPV vaccine was approved in the United States. There are dozens of HPV subtypes, and some are more dangerous than others. At the time the first vaccine was released, it protected against four types of the virus—two that caused nearly all cases of genital warts and two most likely to cause cancer. Two more vaccines have since been approved to prevent HPV infections, and the current (and now only) vaccine protects against nine different strains, seven of which are cancer-causing.

It will take years to see the effects of vaccination on cancer rates, but early research is promising. Studies have shown significant drops in both infections of cancer-causing HPV subtypes and cervical dysplasia (precancerous lesions). Over the next few decades, public health professionals are anticipating to see similar drops in HPV-associated cancer, especially in vaccinated populations.

The gaps in HPV vaccination coverage could provide early information on how disparities in HPV-related cancers might shift in coming decades. So far, the vaccination coverage has remained relatively low. Only 43 percent of U.S. teens (ages 13-17) were up-to-date on the vaccine in 2016, but rates varied widely throughout the country. More than 70 percent of teens in Rhode Island were up to date that year, for example, while less than 27 percent of Wyoming teens were.

Disparities in HPV vaccination coverage are reported for a variety of factors, including a person’s income, race or ethnicity, and where they live. These are some of the biggest gaps seen in HPV vaccination rates in 2016:

Socio-Economic Status

Adolescents living at or above the poverty level have much lower HPV vaccination rates than those living in poverty. This is in stark contrast to other vaccines given around the same age, where rates among different income levels aren’t quite as apparent. In 2016, only 41.7 percent of teens living at or above the poverty level were up to date on the HPV vaccine series, compared to 50 percent of those living below the poverty line.

Race/Ethnicity

Non-Hispanic white teens had much lower vaccination coverage for HPV than any other race or ethnicity. At just 39.6 percent, the HPV vaccination rate among whites in 2016 was more than 10 percentage points lower than Hispanics.   

Urbanicity

Where you live also matters. People living in large cities had much higher HPV vaccination rates than those living in rural areas. Only about a third of teens living in rural communities had been fully vaccinated against HPV, compared to nearly half of those living in a large city.

Geographical Location

Northeastern states like Maine and Rhode Island had some of the highest vaccination coverage rates against HPV in 2016, while Southern states like Mississippi and South Carolina had some of the lowest.

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