Abstract
This study uses national cancer incidence data to evaluate calendar trends in cervical cancer incidence by age at diagnosis.
A recent US study reported that previously declining cervical cancer incidence has plateaued between 2012 and 2017.1 A significant reduction in cervical cancer screening uptake and adherence to guidelines-concordant recommendations has also been reported, particularly among women aged 21 to 29 years.2 We evaluated calendar trends in cervical cancer incidence by age at diagnosis.
Methods
We analyzed the 2001-2019 National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology, and End Results (SEER) data set. This data set includes cancer incidence data from all 50 states and the District of Columbia and covers more than 98% of the US population. Cervical cancer cases were identified based on the International Classification of Diseases for Oncology, Third Edition site codes C53.0 to C53.9 and histology codes 8010 to 8671 and 8940 to 8941. We calculated incidence rates and estimated piecewise-log-linear trends and annual percentage changes (APCs) by 5-year age group. Hysterectomy-corrected incidence trends were assessed by calculating the survey-weighted prevalence of hysterectomy from Behavioral Risk Factor Surveillance System data and then using it to correct the population at risk by removing the proportion of women with hysterectomy from the denominator. For age groups with increasing incidence, we examined trends by race and ethnicity, stage, and histology. Statistical analysis was conducted using SEER*Stat version 8.4.0 and Joinpoint Regression (National Cancer Institute) version 4.9.0. Statistical significance was tested at 2-sided P < .05. The University of Texas Health Science Center institutional review board deemed the study exempt from review and waived the requirements for informed consent because publicly available data were used.
Results
During 2001-2019, 227 062 cervical cancer cases were reported. Overall, hysterectomy-corrected cervical cancer incidence declined from 12.39/100 000 in 2001 to 9.80/100 000 in 2019 (APC, −1.2% [95% CI, −1.6% to −0.9%]). Reductions in incidence were observed for the youngest (<24 years) and oldest (≥55 years) age groups, and rates were relatively stable in recent years among women aged 35 to 54 years (Table 1). Among women aged 30 to 34 years, after an initial decline from 2001-2012 (incidence, 12.77/100 000 to 10.14/100 000; APC, −2.3% [95% CI, −2.8% to −1.7%]), incidence increased during 2012-2019 (APC, 2.5% [95% CI, 1.4% to 3.6%]), reaching 11.60/100 000 in 2019.
Table 1. Trends in Hysterectomy-Corrected Cervical Cancer Incidence Rates (2001-2019): NPCR and SEER Database.
| Cases from 2001-2019, No. (%) | Yeara | Rateb | APC (95% CI), % | P value | ||
|---|---|---|---|---|---|---|
| Year 1c | Year 2d | |||||
| Overall | 227 062 (100) | 2001-2019 | 12.39 | 9.80 | −1.2 (−1.6 to −0.9) | <.001 |
| Age group, y | ||||||
| <24 | 2266 (1.0) | 2001-2012 | 0.29 | 0.24 | −3.1 (−4.8 to −1.4) | .002 |
| 2012-2019 | 0.24 | 0.08 | −12.4 (−16.6 to −8.0) | <.001 | ||
| 25-29 | 10 001 (4.4) | 2001-2004 | 6.80 | 5.45 | −7.4 (−14.9 to 0.9) | .07 |
| 2004-2016 | 5.45 | 5.36 | −0.7 (−1.9 to 0.5) | .24 | ||
| 2016-2019 | 5.36 | 4.01 | −7.5 (−15.8 to 1.7) | .10 | ||
| 30-34 | 20 679 (9.1) | 2001-2012 | 12.77 | 10.14 | −2.3 (−2.8 to −1.7) | <.001 |
| 2012-2019 | 10.14 | 11.60 | 2.5 (1.4 to 3.6) | <.001 | ||
| 35-39 | 26 630 (11.7) | 2001-2019 | 15.69 | 14.38 | −0.3 (−0.8 to 0.1) | .09 |
| 40-44 | 29 961 (13.2) | 2001-2019 | 19.70 | 16.81 | −0.3 (−0.8 to 0.1) | .13 |
| 45-49 | 28 088 (12.4) | 2001-2019 | 20.18 | 18.54 | −0.5 (−0.9 to 0) | .04 |
| 50-54 | 24 877 (11.0) | 2001-2005 | 21.68 | 17.40 | −4.7 (−8.4 to −0.8) | .02 |
| 2005-2019 | 17.40 | 17.48 | −0.4 (−1.0 to 0.2) | .19 | ||
| 55-59 | 22 434 (9.9) | 2001-2005 | 24.16 | 18.47 | −6.2 (−10.3 to −1.8) | .009 |
| 2005-2019 | 18.47 | 18.12 | −0.8 (−1.4 to −0.2) | .01 | ||
| 60-64 | 18 366 (8.1) | 2001-2019 | 25.51 | 19.23 | −2.1 (−2.7 to −1.4) | <.001 |
| 65-69 | 14 566 (6.4) | 2001-2019 | 31.05 | 17.39 | −3.2 (−3.8 to −2.5) | <.001 |
| 70-74 | 10 640 (4.7) | 2001-2019 | 25.19 | 16.58 | −2.3 (−2.9 to −1.7) | <.001 |
| 75-79 | 8002 (3.5) | 2001-2019 | 21.00 | 15.70 | −1.5 (−2.0 to −1.1) | <.001 |
| 80-84 | 5669 (2.5) | 2001-2019 | 21.98 | 17.56 | −1.5 (−2.1 to −0.8) | <.001 |
| ≥85 | 4883 (2.2) | 2001-2019 | 17.28 | 14.95 | −2.3 (−3.2 to −1.5) | <.001 |
Abbreviations: APC, annual percentage change; NPCR, National Program of Cancer Registries; SEER, Surveillance, Epidemiology, and End Results.
The calendar period of each segment was defined based on the identification of calendar years when a statistically significant change in the APC occurred (ie, joinpoint).
Rates were calculated as number of cases per 100 000 person-years and age adjusted to the 2000 US population.
Year 1 represents the earliest year of the segment.
Year 2 represents the latest year of the segment.
During 2012-2019, for 30- to 34-year-old women, hysterectomy-corrected cervical cancer incidence increased significantly for Hispanic (APC, 3.0% [95% CI, 0.3% to 5.7%]), non-Hispanic White (APC, 2.8% [95% CI, 0.6% to 5.0%]), and other racial and ethnic (APC, 5.0% [95% CI, 2.7% to 7.4%]) groups; the APC for Black women was −0.8% (95% CI, −2.8% to 1.2%) (Table 2). Increases occurred for localized (2.8% [95% CI, 1.3% to 4.3%]) and regional (1.9% [95% CI, 0.7% to 3.1%]) stage cervical cancer as well as for squamous cell carcinoma (2.6% [95% CI, 1.0% to 4.2%]) and adenocarcinoma (3.0% [95% CI, 0.9% to 5.1%]) histology.
Table 2. Trends in Hysterectomy-Corrected Cervical Cancer Incidence Rates Among Women 30 to 34 Years Old by Race and Ethnicity, Stage at Diagnosis, and Histology (2012-2019): NPCR and SEER Database.
| Characteristic | Cases, No. (%) | Ratea | APC (95% CI), % | P value | |||
|---|---|---|---|---|---|---|---|
| 2012-2019 | 2012 | 2019 | 2012 | 2019 | |||
| Overall | 8898 (100.0) | 1002 (100.0) | 1241 (100.0) | 10.14 | 11.60 | 2.5 (1.3 to 3.7) | .002 |
| Race and ethnicityb | |||||||
| Hispanic | 1916 (21.5) | 229 (22.9) | 287 (23.1) | 11.72 | 13.69 | 3.0 (0.3 to 5.7) | .04 |
| Non-Hispanic | |||||||
| Black | 1011 (11.4) | 133 (13.3) | 133 (10.7) | 9.72 | 8.79 | −0.8 (−2.8 to 1.2) | .35 |
| White | 5398 (60.7) | 588 (58.7) | 730 (58.8) | 10.28 | 12.08 | 2.8 (0.6 to 5.0) | .02 |
| Other | 573 (6.4) | 52 (5.2) | 91 (7.3) | 6.19 | 9.21 | 5.0 (2.7 to 7.4) | .002 |
| Stage at diagnosis | |||||||
| Localized | 5613 (63.1) | 634 (63.3) | 793 (63.9) | 6.42 | 7.41 | 2.8 (1.3 to 4.3) | .004 |
| Regional | 2393 (26.9) | 264 (26.3) | 333 (26.8) | 2.67 | 3.11 | 1.9 (0.7 to 3.1) | .008 |
| Distant | 539 (6.1) | 67(6.7) | 62 (5.0) | 0.68 | 0.58 | −0.8 (−4.1 to 2.5) | .56 |
| Unknown | 353 (4.0) | 37 (3.7) | 53 (4.3) | 0.37 | 0.50 | 6.8 (0.8 to 13.1) | .03 |
| Histologyc | |||||||
| Squamous cell | 5997 (67.4) | 690 (68.9) | 866 (69.8) | 6.98 | 8.09 | 2.6 (1.0 to 4.2) | .006 |
| Adenocarcinoma | 2362 (26.5) | 254 (25.3) | 313 (25.2) | 2.57 | 2.93 | 3.0 (0.9 to 5.1) | .01 |
| Adenosquamous | 264 (3.0) | 26 (2.6) | 30 (2.4) | 0.26 | 0.28 | −0.5 (−5.7 to 5.0) | .83 |
| Other | 275 (3.1) | 32 (3.2) | 32 (2.6) | 0.32 | 0.30 | −0.7 (−5.4 to 4.3) | .75 |
Abbreviations: APC, annual percentage change; NPCR, National Program of Cancer Registries; SEER, Surveillance, Epidemiology, and End Results.
Rates were calculated as number of cases per 100 000 person-years and age adjusted to the 2000 US population.
Race and ethnicity were categorized as Hispanic, non-Hispanic Black, non-Hispanic White, and other. The other category includes (non-Hispanic) American Indian or Alaska Native, Asian or Pacific Islander, and other unspecified. Race and ethnicity information was abstracted from medical records. Registries use standardized protocol for both race and ethnicity information, initially collected by health care facilities and practitioners.
Human papillomavirus–associated cervical cancers were identified based on the International Classification of Diseases for Oncology, Third Edition site codes C53.0 to C53.9 and histology codes 8010-8671/8940-8941. Histology codes 8050-8084, 8140-8550/8570-8576, and 8560-8563 were used for squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma, respectively. All the other histology codes were considered under other.
Discussion
Between 2001 and 2019, cervical cancer incidence declined or remained stable among US women except for the 30- to 34-year-old age group, in whom incidence increased 2.5% per year after 2012. The observed increase in incidence among 30- to 34-year-old women could be real as a result of a true increase in cervical cancer incidence or due to increased early detection with a stable disease occurrence. If the increase is real, it could be a result of missed screening opportunities at earlier ages, as suggested by the increase in squamous cell carcinoma and localized disease. It may also stem from a decrease in screening at younger ages. In 2012, the US Preventive Services Task Force recommended an increase in screening interval in 21- to 65-year-old women with cytology every 3 years or in 30- to 65-year-old women with a combination of cytology and human papillomavirus testing every 5 years.3 Beginning in 2013, declines in screening participation among 21- to 29-year-old women were observed.2 However, the recommendation for co-screening with human papillomavirus testing and cytology may have led to increased detection of early-stage cancers; if so, the increased incidence would be expected to decline in the future.4
Study limitations include the unavailability of information regarding risk factors and screening and that hysterectomy data were self-reported and subject to misclassification; however, self-report has been considered a valid approach with accuracy comparable with medical records.5 Future studies are needed to assess factors that underlie the increase in cervical cancer incidence among 30- to 34-year-old women.
Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Senior Editor.
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