Year of Publication



Public Health

Date Available


Degree Name

Master of Public Health (M.P.H.)

Committee Chair

Thomas Tucker

Committee Member

Bin Huang

Committee Member

Krystle Kuhs

Committee Member

Jaclyn McDowell


BACKGROUND/ OBJECTIVE: Cervical cancer is the fourth most commonly occurring malignancy in women worldwide, with an estimated 530,000 new cases and 270,000 new deaths each year (Small et al, 2017). While the incidence of cervical cancer has decreased by approximately 1.9% per year between 2007 and 2011, the death rate has remained stable (Bernard et al, 2014). Studies have shown that nearly all cervical cancer cases are associated with the Human Papilloma Virus (HPV). Many studies support the association of smoking with increased risk of invasive cervical cancer in women with high-risk HPV (Castle et al, 2002; Fang et al, 2018; Xi, et al, 2009). However, one study by Roura et al demonstrated the development of CIN3 irrespective of HPV serology in individuals with a history of smoking, and another study by Coker et al suggested that smoking reduced overall survival from cervical cancer (Roura et al, 2014, Coker et al, 2008). And yet, further studies have demonstrated differences in survival among cervical cancer patients with different HPV genotypes (Hallowell et al, 2018). The purpose of this study is to further explore survival differences among cervical cancer patients with specific HPV genotypes who had a history of smoking and cervical cancer patients with the same HPV genotypes who do not have a history of smoking.

METHODS: A total of 246 women with cervical cancer from the Kentucky Cancer Registry (KCR) were reviewed for inclusion in this study. Inclusion criteria included 18 years of age or older, a diagnosis of HPV with specific HPV genotyping, a diagnosis of cervical cancer between January 1st, 2004 and December 31st, 2005, or between January 1st, 2014 and December 31st, 2015, and smoking history information that was verified using health insurance claims data. A final population of 198 women were included. Univariate and bivariate analyses were conducted. Survival curves were stratified by smoking status. Cox proportional hazard regression was used to assess the risk of death due to smoking in women with any HPV genotype and additionally, women with HPV 16/18.

RESULTS: Smokers had an increased risk of dying compared to non-smokers with HPV 16/18 (HR=1.039, [0.669, 1.614], p=0.8647). However, this difference was not statistically significant. Appalachian women with any HPV genotype had a 61.1% increased risk of dying compared to non-Appalachian women (HR=1.611, [1.054, 2.461]), which was significant (p=0.0275). Similarly, Appalachian women with HPV 16/18 had a 66.4% increased risk of dying compared to non-Appalachian women (HR=1.664, [1.060, 2.614], p=0.0270). Adenocarcinoma was also associated with a significantly increased risk of dying in the unadjusted Cox Proportional Hazards Model (HR=1.604, [1.062, 2.421], p=0.0245] in women with any HPV genotype, as well as in women with HPV 16/18 (HR=1.559, [1.006, 2.416], p=0.0471).

CONCLUSIONS: There were no significant differences between the survival of cervical cancer patient with any HPV genotype or with HPV 16/18 who had a history of smoking compared to those who did not have a history of smoking. However, Appalachian status and histology were important factors when considering prognosis and overall survival in women with a diagnosis of HPV and cervical cancer.