Progress in Chronic Disease Prevention Chronic Disease Reports: Deaths from Cervical Cancer -- United States, 1984-1986

From 1984 through 1986, cervical cancer (International Classification of Diseases, Ninth Edition, Clinical Modification code 180) was the underlying cause of death in a mean of 4543 women per year in the United States.* Cervical cancer accounted for less than 3% of U.S. cancer deaths among women and was the 11th most common cause of cancer mortality (1). Worldwide, however, cervical cancer follows breast cancer as the second most common cause of cancer mortality among women (2).

Rates of cervical cancer mortality increase with age; in 1986, 53% of deaths from cervical cancer occurred among women aged greater than or equal to 60 years. When adjusted for age, the rate of cervical cancer mortality was 2.8 times higher for black than for white women (1). From 1984 through 1986, the highest mean annual rates of mortality (age-adjusted to the 1986 U.S. population) occurred in southeastern states and in North Dakota and Maine (Table 1, Figure 1). Utah had the lowest rate (1.8 per 100,000 females) and the District of Columbia the highest rate (6.2 per 100,000).

For 1974-1985, the National Cancer Institute reported an overall 5-year survival rate of 67% for women with cervical cancer, although rates varied by stage at diagnosis (1). Survival was 88% for women whose disease was diagnosed at the local stage; 51%, at the regional stage; and 14%, at the distant stage. At local and regional stages, survival was higher for whites than for blacks (1). Reported by: Div of Surveillance and Epidemiologic Studies, Epidemiology Program Office; Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: Sexual contact is a principal risk factor for cervical cancer. The risk varies directly with the number of sex partners and inversely with age at first intercourse. Certain serotypes of human papillomavirus are the infectious agents that may be related to risk for cervical cancer (3,4). Other risk factors include nonuse of barrier and spermicidal contraceptives, parity, socioeconomic status, and smoking (2). Nearly 29% of cervical cancer mortality is attributable to cigarette smoking among women (Table 2).

Early detection of cervical cancer using the Papanicolaou (Pap) test is effective in preventing deaths from cervical cancer (5). In Iceland, an upward trend in cervical cancer mortality was reversed following the introduction in 1964 of mass Pap screening for women aged 25-60 years (6). In 1970-1974, the risk of dying from cervical cancer was an estimated 12.5 times higher in Icelandic women not participating in screening than in screening participants.

The American Cancer Society (ACS) recommends annual Pap tests beginning with the onset of sexual activity; following three negative Pap tests, less frequent tests may be recommended by the woman's physician (7). In high-risk regions and high-risk populations, continued annual screening may be appropriate. In 1985, only 5% of U.S. women 20-80 years of age reported never having had a Pap test (8); however, an estimated 37% of cervical cancer deaths occur among these women (Table 2). Additional cervical cancer mortality can be prevented by greater compliance with recommended Pap smear guidelines (9). Through screening with the Pap test at least once every 3 years, cervical cancer mortality for women aged 20-70 years may be reduced by an estimated 70%-95% (10). Prompt, adequate follow-up of women with positive Pap smears and attention to laboratory quality assurance are also valuable in reducing cervical cancer mortality. Use of barrier methods or spermicides for contraception reduces exposure to infectious agents and may reduce the initial risk of developing cervical cancer (11,12).

From 1979 to 1986, age-adjusted mortality rates of cervical cancer declined by 18% for all women (13); rates declined by 23% among whites and 15% among persons of other races. However, mortality rates among women less than 45 years of age have remained stable during this period, and the incidence of cervical cancer diagnosed in this population appears to have increased (14). Continued efforts to reduce cigarette smoking and to increase Pap smear use among women not appropriately screened should lead to further declines in cervical cancer mortality.

References

1. National Cancer Institute. Cancer statistics review, 1973-1986.

Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1989; NIH publication no. 89-2789.

2. Munoz N, Bosch FX. Epidemiology of cervical cancer. In: Munoz N, Bosch FX, Jensen OM, eds. Human papillomavirus and cervical cancer. Oxford, England: International Agency for Research on Cancer, 1989. (IARC scientific publication no. 94).

3. Koutsky LA, Galloway DA, Holmes KK. Epidemiology of genital human papillomavirus in fection. Epidemiol Rev 1988;10:122-63.

4. Reeves WC, Rawls WE, Brinton LA. Epidemiology of genital papillomaviruses and cervical cancer. Rev Infect Dis 1989;11:426-39.

5. Day NE. Screening for cancer of the cervix. J Epidemiol Community Health 1989;43:103-6.  6. Johannesson G, Geirsson G, Day N. The effect of mass screening in Iceland, 1965-74, on the incidence and mortality of cervical carcinoma. Int J Cancer 1978;21:418-25.

7. American Cancer Society. Summary of current guidelines for the cancer-related checkup: recommendations. Atlanta: American Cancer Society, 1988; ACS publication no. 3347.01-PE.

8. Makuc DM, Freid VM, Kleinman JC. National trends in the use of preventive health care by women. Am J Public Health 1989;79:21-6.

9. Hakama M, Miller AB, Day NE, eds. Screening for cancer of the uterine cervix. Lyon, France: International Agency for Research on Cancer, 1986. (IARC scientific publication no. 76). 10. National Cancer Institute. Cancer control objectives for the nation: 1985-2000. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1986; NIH publication no. 86-2880. (NCI monographs, no. 2). 11. Slattery ML, Overall JC Jr, Abbott TM, French TK, Robison LM, Gardner J. Sexual activity, contraception, genital infections, and cervical cancer: support for a sexually transmitted disease hypothesis. Am J Epidemiol 1989;130:248-58. 12. Wright NH, Vessey MP, Kenward B, McPherson K, Doll R. Neoplasia and dysplasia of the cervix uteri and contraception: a possible protective effect of the diaphragm. Br J Cancer 1978;38:273-9. 13. CDC. Chronic disease reports: mortality trends--United States, 1979-1986. MMWR 1989;38: 189-91. 14. Winkelstein W Jr, Selvin S. Cervical cancer in young Americans (Letter). Lancet 1989;1:1385.

*A mean rate over a 3-year period is reported because the number of cases per year is small; however, in a year-by-year comparison, there is little variation in numbers of cases or in the rankings of states by rates of death from cervical cancer.

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