Cervical Cancer in Black Women

Cervical cancer is one of the most preventable cancers there is. A vaccine blocks the virus that causes nearly every case. A screening test catches abnormal cells years before they can turn into cancer. And there is a clear national guideline telling clinicians exactly when to screen. Even with all of that, Black women in the United States die of cervical cancer at roughly twice the rate of white women once the numbers are counted correctly (Beavis et al., Cancer, 2017). The disease has not changed. The system around it works unevenly.

Nearly all cervical cancer starts with a persistent infection from a high-risk strain of human papillomavirus (HPV). Virtually all cervical cancer is caused by HPV (National Cancer Institute), and the two highest-risk types, HPV 16 and 18, account for about 76 percent of cases worldwide (World Health Organization, 2024). The virus enters cells at the transformation zone of the cervix and, over years, can push them from mild changes to precancer to invasive cancer. That slow runway is the whole reason screening works: a Pap or HPV test finds the problem while it is still a precancer that can be removed in a single office visit.

Early cervical cancer and precancer usually cause no symptoms at all. That is exactly why screening exists: to find the disease before you can feel it. Once it becomes invasive, the most common signs are:

• Bleeding between periods, after sex, or after menopause
• Menstrual bleeding that is heavier or longer than is normal for you
• Watery, bloody, or foul-smelling vaginal discharge
• Pelvic pain, or pain during sex
• Pain in the lower back, hip, or leg in more advanced disease
• Swelling in one leg, blood in the urine or stool, or unexplained weight loss in late-stage disease

None of these are unique to cervical cancer. Fibroids, infections, perimenopause, and benign polyps all cause overlapping symptoms. The point is not to diagnose yourself. The point is that any of these deserve an exam, not a wait-and-see.

Cervical cancer screening is one of the few places in medicine where doing the routine thing on schedule comes close to a guarantee. Two sets of guidelines are in use, and your clinician may follow either.

The U.S. Preventive Services Task Force (2018) gives a Grade A recommendation to screen women ages 21 to 29 with cervical cytology (a Pap test) every 3 years, and women ages 30 to 65 with one of three equal options: cytology every 3 years, high-risk HPV (hrHPV) testing every 5 years, or co-testing (Pap plus hrHPV) every 5 years. It recommends against routine screening before age 21 or after age 65 in women who have had adequate prior screening (USPSTF, 2018).

The American Cancer Society (2020) went further, recommending that screening start at age 25 and use primary hrHPV testing every 5 years as the preferred test through age 65, because HPV testing catches more precancers and stays safe over a longer interval; cytology every 3 years or co-testing every 5 years are acceptable alternatives where primary HPV testing is not available (Fontham et al., CA Cancer J Clin, 2020).

Access is part of the disparity, and in 2024 the FDA addressed one barrier directly by approving self-collection of the HPV sample. A woman can now collect her own vaginal swab in a healthcare setting, which is then run on an approved HPV test (Roche cobas and BD Onclarity), an option for people who cannot or will not sit for a speculum exam (The ASCO Post, 2024). If a pelvic exam is what has kept you away from screening, ask whether your clinic offers self-collection.

Prevention starts upstream of screening. The HPV vaccine (Gardasil 9) protects against the nine HPV types that cause about 90 percent of HPV-related cancers, including types 16 and 18 (American Cancer Society). The CDC recommends routine vaccination at ages 11 to 12, and it can be given as early as age 9, with catch-up through age 26 and shared clinical decision-making for some adults ages 27 to 45. Two doses are enough when the series starts before age 15; three doses are needed if it starts later.

Treatment depends on the stage and on whether you want to preserve fertility. This is a high-level map, not medical advice; a gynecologic oncologist stages the disease and builds the plan.

Precancer and very early disease. A loop electrosurgical excision procedure (LEEP) or a cold-knife cone removes the abnormal area of the cervix in an outpatient setting. For carefully selected earliest-stage disease, this can be the entire treatment, and it keeps the uterus.

Early invasive disease. The standard is radical hysterectomy with assessment of the pelvic lymph nodes. For women with small, favorable tumors who want to carry a pregnancy later, radical trachelectomy removes the cervix and surrounding tissue while leaving the uterus in place, though pregnancy afterward is high-risk and delivered by cesarean.

Locally advanced disease. The standard of care is concurrent chemoradiation: weekly cisplatin given alongside external-beam pelvic radiation, followed by brachytherapy, internal radiation placed against the tumor. Brachytherapy is not optional. Leaving it out lowers survival, so making sure you receive it, at a center that does it routinely, is one of the most important quality questions you can ask. In January 2024, the FDA approved adding pembrolizumab, an immune checkpoint inhibitor, to chemoradiation for FIGO Stage III to IVA disease, based on the KEYNOTE-A18 trial (U.S. FDA, 2024).

Recurrent or metastatic disease. First-line treatment for persistent, recurrent, or metastatic cervical cancer now includes pembrolizumab added to chemotherapy, with or without bevacizumab. In the KEYNOTE-826 trial, adding pembrolizumab reduced the risk of death by 36 percent in women whose tumors expressed PD-L1 (hazard ratio 0.64), lifting 2-year survival from 41.7 to 53.0 percent (Colombo et al., NEJM, 2021). Ask whether your tumor will be tested for PD-L1.