Cervical cancer incidence trends in Puerto Rico differed by age group from 2001 to 2023, with recent declines among women younger than 35 years and increasing long-term rates among women aged 35 to 49 years, according to a registry-based analysis published in JAMA Network Open.
Puerto Rico has among the highest cervical cancer incidence rates in the United States, at 11.5 vs 7.5 cases per 100,000 women, and remains above the World Health Organization cervical cancer elimination target of 4 cases per 100,000 women, the researchers noted.
The cross-sectional study included 4,636 cervical cancer cases diagnosed in Puerto Rico from 2001 to 2023, with a median diagnosis age of 49 years. Cases were identified through the Puerto Rico Central Cancer Registry. Researchers calculated both uncorrected and hysterectomy-corrected incidence rates, standardized to the 2000 US population, and used Behavioral Risk Factor Surveillance System data to estimate hysterectomy prevalence.
Hysterectomy correction is important because women who have undergone hysterectomy are no longer at risk for cervical cancer; uncorrected rates may therefore underestimate incidence in the population still at risk.
Overall hysterectomy-corrected cervical cancer incidence increased by about 3% annually from 2001 to 2014, then decreased by about 3% annually from 2014 to 2023. Across the full study period, annual corrected incidence rates remained above 11.5 cases per 100,000 women.
Among women younger than 35 years, hysterectomy-corrected incidence increased from 2001 to 2010 before stabilizing through 2019, then declined by about 20% annually from 2019 to 2023 — a reversal of the earlier upward trend. Human papillomavirus vaccination became available in Puerto Rico in 2006, meaning women younger than 35 years during the later study period would have included cohorts eligible for adolescent vaccination. The researchers described the decline as consistent with vaccination uptake but cautioned that the study lacked individual-level vaccination data.
Puerto Rico required private insurers to cover human papillomavirus vaccination for adolescents aged 11 to 18 years in 2010 and implemented a school-entry vaccination requirement for children aged 11 to 12 years in 2018.
Among women aged 35 to 49 years, hysterectomy-corrected incidence increased by about 4% annually from 2001 to 2015 and then showed no statistically significant change from 2015 to 2023. Across the full 2001 to 2023 period, this was the only age group with a statistically significant average annual increase.
“The increasing cervical cancer incidence among women aged 35 to 49 years observed between 2001 and 2023 is of public health concern and underscores the need to assess adherence to screening and timely follow-up care,” wrote lead study author Ana P. Ortiz, PhD, of the University of Puerto Rico Comprehensive Cancer Center, and colleagues.
Trends were more stable among older women. Incidence among women aged 50 to 64 years remained stable during the study period, whereas incidence among women aged 65 years or older declined from 2005 to 2023.
The researchers noted that cervical cancer screening uptake in Puerto Rico has remained stable at about 79%. However, Hurricane Maria, the COVID-19 pandemic, and a decline in the number of gynecologists in Puerto Rico may have affected health care access and follow-up care, although the study could not directly evaluate the contributions of screening adherence, abnormal-result follow-up, or human papillomavirus vaccination to incidence trends.
The findings should be interpreted as population-level trends rather than evidence that any specific intervention caused the observed changes. The study did not include patient-level data on human papillomavirus vaccination, cervical cancer screening, screening results, or follow-up care. Researchers also excluded July to December 2017 incidence data to account for population shifts following Hurricane Maria and excluded 2020 incidence data from annual trend analyses because of COVID-19–related disruptions.
“In conclusion, these findings show that overall cervical cancer incidence trends are stabilizing in [Puerto Rico],” Dr. Ortiz and colleagues wrote. “The decline among women younger than 35 years is consistent with HPV vaccination uptake, while increases among women aged 35 to 49 years warrant public health interventions.”
Disclosures can be found in the published study.
Source: JAMA Network Open