Cervical cancer, once a death sentence, has trended dramatically downward in the U.S. since the 1970s, mainly due to early detection through screening and a vaccine.
But in Louisiana, death rates have seen little change since the 1990s. That's because nearly two decades after a vaccine that prevents most cervical cancers arrived in the state, just 36% of teens receive it, according to the Louisiana Department of Health. In some parishes, uptake is as low as 13%. The national average is about 63%.
Louisiana ranks fifth among states for the rate of cervical cancer deaths, according to the Centers for Disease Control and Prevention. Among Black women, the state ranks second.
“This is a disease that no one should get,” said Dr. Jessica Shank, gynecological oncologist at Tulane University.
In Australia, where a school-based vaccination program was started, cervical cancer has been eliminated thanks to screenings and vaccines. In the United States, where cervical cancer was once the most common type, deaths and cases have dropped 40% since the 1990s.
But in Louisiana, about 80 people each year die of the disease.
A 'magically effective' vaccine
Around 90% of cervical cancers are caused by the human papillomavirus, or HPV. It’s the most common sexually transmitted infection in the U.S.
Most cases go away without causing health problems in about two years. But when the virus sticks around, it can cause genital warts and cancer. HPV can also cause vaginal, vulvar, oral, anal and penile cancers.
When the HPV vaccine came to market in 2006, it offered the ability to slash the risk of infection significantly.
“The HPV vaccine is magically effective,” said Charles Stoecker, a health economist who studies vaccine policy at Tulane University.
The vaccine is given as a series of two or three shots, depending on age when the vaccination is started. The inoculation tricks the body into thinking it has been exposed to the virus by employing a lab-grown protein that looks like HPV, but does not contain HPV genetic material. The lookalike triggers the immune system to produce antibodies.
The CDC recommends all adolescents between 9 and 12 receive the vaccine, but it is licensed for use up to age 45.
There is no treatment for HPV once it is transmitted and condoms do not always prevent infection, which is why health experts see it as so beneficial.
But the HPV vaccine has an image problem, pediatric experts said. Parents don’t think their preteens need a vaccine for a sexually transmitted virus, said Dr. Mark Kline, pediatric infectious disease expert and physician in chief of Children’s Hospital New Orleans.
“That layers on a level of concern or judgment that doesn't apply to other vaccines,” said Kline. “I think there are parents who feel like, ‘Why in the world would I want to get my 11- or 12-year-old a vaccine against a sexually transmitted virus; they're not sexually active.’”
It’s hard for parents to make the connection between a 9-year-old and preventing cancer decades from now, said Kline. Some parents also say they worry the vaccine’s protection will promote sexual activity, which research has disproven.
And misinformation about vaccines fueled by the COVID-19 pandemic will likely further chip away at uptake.
The vaccine's effectiveness is about 90% when given by age 13, but drops to as low as 35% if given between 16 and 18. In part, that is due to limiting the chances of exposure prior to vaccination, but also because younger immune systems develop a more robust defense when vaccinated.
Pap tests could help
By the time patients make it to Shank, the gynecological oncologist, the preventable measures aren’t much use. She sees people who have later-stage cancer and often have gone without screenings that would catch it at a more treatable point.
Pap smears can catch abnormalities, especially if done with an HPV test that detects early signs of cancer. They are recommended every three years for women between the ages of 21 and 65. After 30, doctors should give a HPV test every five years.
If the HPV test comes back positive, further tests can detect precancer, which doctors can remove, typically in an outpatient procedure.
“The problem is in Louisiana, women aren't getting their Pap tests,” said Shank. “And they didn't get vaccinated, and a lot of times they don't come in until they're having a lot of bleeding.”
Many of her patients are in their 30s and 40s. Watching them die of a preventable disease is “awful,” said Shank. Often, there are young children left behind.
The five-year survival rate for cervical cancer in Louisiana is among the lowest at 62%. But groups are taking steps toward detecting it earlier. Shank is starting a registry with data from Pap tests and cervical biopsies to better understand what treatments work and which populations need to be targeted for screening and vaccination.
A research team from Louisiana State University received $1.2 million from the American Cancer Society to increase cervical cancer screenings. The team will recruit women from New Orleans and rural areas for screenings, and try to understand what prevents them from getting care.
“If women say things like, ‘I have child care issues,’ we would try to develop some kind of intervention where someone can watch their kids,” said Reni Elewonibi, one of the researchers.