Did you know that cervical cancer disproportionately affects Black women? Please join Dr. Gizelka David-West, a gynecologic oncologist at Northwell Health, to learn more about the causes, symptoms, screening, and prevention of the disease. Dr. David-West will also discuss the factors that contribute to the cervical cancer disparities among Black women and what can be done to address them.

1. WHAT BLACK
WOMEN NEED TO
KNOW ABOUT
CERVICAL CANCER
January 19. 2023
Gizelka David-West, MD, FACOG
Gynecologic Oncologist
Northwell Health

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Dedicated to my patients with pre-cancer and cancer of
the cervix past and present

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 Impact of cervical cancer nationally, globally, and on diverse groups
 HPV and how it relates to cervical cancer
 Screening for cervical cancer and natural history of the disease
 Prevention of cervical cancer
OBJECTIVES
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HENRIETTA LACKS (8/1/1920 – 10/4/1951)
 Diagnosed with cervix cancer 1/1951
 Her cells were known as HeLa Cells, first
immortalized human cell line
 HeLa Cells involved in key medical discoveries such as :
Polio vaccine; Cancer drugs; In vitro fertilization;
COVID19 vaccine
 Paved the way for improved ethics and
consents for human research subjects
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Cervical Cancer incidence and mortality
 4th most common cancer worldwide
 Ranks after breast, colorectal, and lung cancers
0.7% of all new cancer cases in the U.S.
2022: 14,100 new cases of cervical cancer and 4280 deaths
STATISTICS
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 2018: ~570,000 new cases and 310,000 deaths
 Leading cause of cancer-related death in Africa
 China and India together contribute to >1/3 of the cervical cancer burden
worldwide
CERVIX CANCER: GLOBAL IMPACT
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 Disparity seen globally in developing countries
 Higher rates of infectious agents (i.e. HPV, Hepatitis, HIV)
 Decreased structural and financial resources for screening programs
 Individuals with poor socioeconomic status
 Individuals living in rural communities
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 Disparity in the U.S.
 Uninsured, immigrants, low educational attainment
 Individuals with poor socioeconomic status
 Individuals living in rural communities
 the South has the highest incidence rate of newly diagnosed cervix cancer
(8.5 per 100,000) and highest death rate (2.7 per 100,000)
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 Number of new cases and deaths differ by race
 White: 7 and 2 per 100,000
 Black: 9 and 3 per 100,000
 LatinX: 10 and 2.5 per 100,000
 American Indian/Alaska Native: 10 and 2.9 per 100,000
 Asian American/ Pacific Islander: 6.3 and 1.6 per 100,000

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 What is driving these disparities?
 Lack of Screening
 PAP smear and HPV Testing
 Lack of Prevention
 HPV (Human Papilloma Virus) Vaccination (Gardasil 9 vaccine)
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 Human Papilloma Virus (HPV) – 90 to 100% of cases
 Abnormal pap smear or pap test
 Immunodeficiency syndromes
 Early age of intercourse
 Multiple lifetime sexual partners
 High risk sex partners
 Smoking
 Low socioeconomic status
CERVIX CANCER: RISK FACTORS
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CERVIX CANCER: SYMPTOMS
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CERVIX CANCER: DIAGNOSIS AND TREATMENT
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 Diagnosis : tissue biopsy, CT scan, MRI, PETCT scan
 Treatment: Radical surgery, Chemotherapy with Radiation, Immunotherapy
 Prevention: the ONLY GYN Cancer with an effective screening tool for the general
population and a preventative vaccine!
 Pap smear or Pap test and HPV testing:
Georgios Papanicolau –
father of the pap smear
Epidemiologic studies confirmed HPV link
with pre-cancer pap smear and
development of cervix cancer
Identification of HPV in cervical
tumors
1923 1983 1993

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WHAT IS HPV?
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 Human papilloma virus – double stranded circular DNA, over 100 strains
 Sexually transmitted by both men and women through sexual intercourse and
sexual contact
 80% of sexually active men and women will be infected by HPV by age 50

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WHAT IS HPV?
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HPV Related non-cancer
• Ano-genital Warts
• Recurrent Respiratory
Papillomatosis
HPV related cancer
• Cervical Cancer
• Vaginal Cancer
• Vulvar Cancer
• Penile Cancer
• Anal Cancer
• Oropharyengeal Cancer

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PAP SMEAR/ PAP TEST
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 Pap smear screens for abnormal/ pre-cancer cells, HPV testing screens for high
risk HPV, and the diagnostic test is a cervical biopsy.
 Cervical Intraepithelial Neoplasia (CIN) is the premalignant condition that is
diagnosed by cervical biopsy and can progress to cancer if not treated.
0–1 Year 0–5 Years 1–20 Years
Invasive
Cervical
Cancer
Cleared HPV Infection
CIN 1
Initial
HPV
Infectio
n
Continuing
Infection
CIN
2/3
57%
22%
5%
32%
12%

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TREATMENT AND PREVENTION
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 Treatment of CIN (or pre-cancer of cervix)
 Excisional procedure with either LEEP (Loop Electrocautery Excisional Procedure) or CKC (Cold
Knife Cone) biopsy
 Prevention is with screening and the Gardasil 9 HPV Vaccine
 Screening starts at age 21
 HPV vaccine approved for men and women age 9yo to 45yo
 Screening and vaccination rates in the U.S. = 83% and 54%

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TREATMENT AND PREVENTION
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 How are we doing with screening in the U.S.?
Overall rate is 81%
– Health People 2020 goal was 93%
– Decline in screening by 5.8% was seen in 2000-2015 (women aged 21-65)
– COVID19 related decline in screening and treatment of pre-cancer
lesions
 Factors driving low screening rates:
– Personal (limited/lack education, distrust, fear)
– Structural (limited/lack insurance, cost, transportation, time off
work, rural communities, language barriers)

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How can we improve screening disparities in the U.S.?
Supported by the Community Preventive Services Task Force
Evidence of its effectiveness
Utilized globally
Becoming more common here in the U.S.
Can be cost effective, may generate net cost savings, and promote health equity

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HPV VACCINE
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Gardasil ®
HPV 6 & 11 – Genital
Warts
90% of genital
warts
HPV 16 & 18 – Cervical
Cancer
70% of cervical
cancers
Approved June 8, 2006
Ceravix ®
HPV 16 & 18
70% of cervical
cancers
Offers cross-
protection against
other strains
– HPV 45, 31
Approved October 16,
2009
Gardasil-9 ®
HPV 6 & 11
90% of genital
warts
HPV 16, 18, 31, 33,
45, 52, 58
90% of cervical
cancers
Approved in December
2014

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HPV VACCINE
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Several phase II and phase III
trials have been conducted
confirming the efficacy of these
vaccines
Safety monitoring is on going and
confirms no major adverse effects
– Most common side effects: pain, redness, or
swelling in the arm where the shot was given;
fever; headache or feeling tired; nausea; muscle
or joint pain
– Rare side effects: syncope, anaphylaxis
– NO associations with autism, autoimmune
disorders, increased sexual promiscuity

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HPV VACCINE
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Who gets the HPV Vaccine?
Initially vaccine was approved for girls/women and boys/men age 9 to 26
– 10yrs after vaccine introduction, HPV related infections decreased by 86% in 14 to 19yo and
by 71% in 20 to 24yo
– 50% decrease in cervical pre-cancers from 2008 to 2015
In 10/2018, Gardasil-9 ® was approved by the FDA for an expanded age range of 9 to
45yo, for both men and women
– 3200 women 27 to 45yo followed for 3.5yrs
– 88% reduction in persistent HPV infections, genital warts, vulvar/vaginal/cervical pre-
cancers, cervical cancer
– Safety assessed in 13,000 men and women

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HPV VACCINE
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HPV Vaccine is a 3 dose series
Dosing schedule:
– Day 1/ Month 0 → 2 Months → 6 Months
– 2 dose schedule, 6 months apart, for children age 9 to 14 is recommended
• Data suggests a better antibody response in this age range

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CERVIX CANCER
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Stage 1A1 – simple hysterectomy
Stage 1A2 – 1B2 – radical hysterectomy, lymph node dissection
Stage 1B3 – IVA – radiosensitizing chemotherapy (cisplatin),
external beam pelvic radiation, internal brachytherapy
Stage IVB – systemic chemotherapy (cisplatin or carboplatin,
paclitaxel, bevacizumab) and immunotherapy (pembrolizumab)
CERVIX CANCER TREATMENT
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TAKE HOME POINTS
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 Cervical cancer is preventable, do not miss your annual
GYN visits!
 Effective screening with Pap smear/ Pap test and HPV
testing
 HPV Vaccine
 Disparity in care drives low screening and low
vaccination rates
 Treatable cancer with surgery, chemotherapy, radiation,
and immunotherapy

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THANK YOU