A group of Minnesota-based researchers found that LGBTQ people with a uterus, especially those who identify as Hispanic, are less likely than white heterosexuals to undergo routine screening for cervical cancer.
This lower rate of Pap testing, consistent across specific sexual minority groups and elevated in Hispanic communities, can result in higher rates of cervical cancer and lower rates of successful treatment of the disease. The results of the study were published in the journal Cancer, an international interdisciplinary journal of the American Cancer Society.
Ashley Stenzel, senior research scientist at Allina Health, explained that she worked on the study when she was a postdoctoral research fellow at the University of Minnesota. Her focus was cancer epidemiology and health disparities. Stenzel’s project colleagues worked in health-disparities research and gynecologic oncology.
“Our goal was to really see if there are specific populations that might be facing greater barriers to cancer screening,” Stenzel said. “There are certainly disparities that are linked to different racial and ethnic populations. Members of the non-Hispanic black population experience higher cancer rates and death.”
Stenzel and her research team colleagues used data from the National Health Interview Survey gathered between 2015 and 2018. They assessed disparities in cervical cancer screening in a group of 877 females aged 21 to 65 years who haven’t had a hysterectomy. They compared data about this group to a group of similarly aged heterosexual people.
“The research showed that people who identified as belonging to the LGBTQ community may be less likely to do some cancer screenings and also people who identify with different racial and ethnic backgrounds are also less likely to do cancer screenings,” Stenzel said.
Stenzel, who earned her doctorate at Roswell Park Comprehensive Cancer Center, explained that she was inspired to join the research team based on her long-term interest in uncovering reasons beyond common health disparities and possible ways to close health care gaps.
“There’s a lot of work that ends up being done to try to improve cancer screening,” she said. “We want to know if there are populations that face greater barriers to getting these screenings.”
After completing the survey, Stenzel and her colleagues conducted their own national follow-up study, where they interviewed members of the LGTBQ community about their experience in health care.
“Almost half of our study participants said they have experienced discrimination at a doctors’ appointment specifically related to their sexual orientation or gender identity,” she said. This experience of discrimination may play a role in patients’ reluctance to see a provider for cancer screening, she added: “This could be one of many potential explanations.”
Whatever the reason, the lower rates of cervical cancer screening among specific populations deserves a closer look, Stenzel said. “Our study demonstrates that there is still a huge need for research in these areas.”
She said she sees many possible avenues for future research and the development of cancer-prevention strategies among targeted groups. “The next steps are to look closer at multiple questions at the community level. Are there barriers in the community, like access to care, or are there differences of experience within the hospital setting that limits people’s ability to or comfort with seeking out care?”
A ‘preventable’ disease
Unlike many other forms of cancer, early testing and vaccine technology has made cervical cancer a largely preventable disease, Stenzel said.
With regular cervical cancer screening, she explained, “You can detect the disease at the pre-cancerous phase. Then you can act early on to try to resolve that.” Before joining Allina, Stenzel worked in clinical research, where she said she learned of “patients who had advanced, aggressive cervical cancer that could’ve been prevented or caught early on with cervical cancer screening.”
Nearly all cervical cancer is caused by an infection with the human papillomavirus, or HPV. A vaccination for disease-causing HPV is available for people of all genders between the ages of 9 and 26. Completing a two-dose course of the vaccine eliminates a person’s risk of contracting high-risk HPV, and therefore greatly reduces their — or their sexual partners’ — chance of contracting cervical cancer.
“It is a preventable disease but there are still a lot of people who need to be reached with regard to vaccination and the benefits for cervical cancer,” Stenzel said. Cervical cancer and HPV detection and treatment methods are widely available; encouraging people of all racial and ethnic backgrounds to take advantage of them may require changing the way medical care is delivered.
“I think that there’s a real need for multilevel interventions,” Stenzel said. “When I see these types of disparities I see it as more of a systematic failure. We are failing different populations.”
She posits that a significant reported history of bias in medical settings means that many people in ethnic and sexual minorities only seek health care for acute issues. Cancer screening may be seen as an “extra” step and therefore pushed to the side. “It’s important to address issues around care head-on at the institutional level, such as implicit biases and systemic discrimination to better serve patients.”
Systemic change requires community outreach and trust-building, Stenzel added. It is also key to train physicians how to treat patients from minority populations in a more culturally sensitive manner.
Stenzel’s work in health-disparities research was inspired by her innate sense of justice, and a general discomfort with the idea that some people receive better medical care than others.
“We know that people who come from different backgrounds in the U.S. and around the world don’t have the same medical experiences and safety in the medical setting or access to care as people in majority communities,” she said. “That’s just not right.”