# Burden of cervical cancer in Martinique, 2012–2021

Rémi Houpert, Emmanuelle Sylvestre, Anne-Déborah Bouhnik, Marc Karim Bendiane, Fatiha Najioullah, Thierry Almont, Wendy Boutant, Jonathan Macni, Julien Mancini, Clarisse Joachim, et al.

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## To cite this version:

Rémi Houpert, Emmanuelle Sylvestre, Anne-Déborah Bouhnik, Marc Karim Bendiane, Fatiha Najioullah, et al. Burden of cervical cancer in Martinique, 2012–2021. Cancer Epidemiology, 2025, 97, pp.102857. 10.1016/j.canep.2025.102857. hal-05162657

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# Burden of cervical cancer in Martinique, 2012–2021

Rémi Houpert<sup>a,b,*</sup>, Emmanuelle Sylvestre<sup>c,d</sup>, Anne-Déborah Bouhnik<sup>a</sup><sup>,d</sup>, Marc-Karim Ben-Diane<sup>c,j</sup><sup>,d</sup>, Fatiha Najiullah<sup>f</sup>, Thierry Almont<sup>b</sup><sup>,d</sup>, Wendy Boutant<sup>g</sup>, Jonathan Macni<sup>h</sup>, Julien Mancini<sup>a,i</sup>, Clarisse Joachim<sup>h</sup>, Jacqueline Veronique-Baudin<sup>b,c</sup>

## ARTICLE INFO

**keywords:**

Cervical neoplasm

Trends

Caribbean

Epidemiology

Latin America and Caribbean region

## ABSTRACT

**Objective:** To provide an updated overview of the burden and temporal trends in incidence, mortality and survival of cervical cancer in a French Caribbean region between 2012 and 2021.

**Methods:** This retrospective study included all cases of cervical cancer diagnosed and registered by the Martinique Population-Based Cancer Registry between 2012 and 2021. Data were recorded strictly according to international standards set by the International Agency for Research on Cancer, French and European Network of Cancer Registries. A descriptive epidemiological analysis and a survival analysis for invasive cases were performed. We calculated world age-standardized incidence and mortality rates, using the WHO standard world population. Overall survival, with a 95 % confidence interval, was calculated as the time from diagnosis to death from any cause. Patients were censored at the date of last follow-up or at the cut-off date of December 31, 2021. We used the Kaplan-Meier product limit method to estimate overall survival at 1, 3, 5 and 10 years.

**Results:** Over the study period, 1196 in situ tumors and 202 invasive cases were diagnosed. 45.0 % of women were aged 65 and over, and 67.3 % received chemotherapy and/or radiotherapy. Most invasive cases were diagnosed with locally advanced stage (43.1 %) and were squamous cell carcinomas (75.2 %). Trends in world age-standardized incidence and mortality rates were globally constant at 6 per 100,000 and 3 per 100,000 person-years, respectively. Overall survival at 5 years was 51.4 % (44.2 %; 58.1 %), and at 10 years, 41.8 % (33.8 %; 49.6 %).

**Conclusions:** In this retrospective cohort study, data from a qualified cancer registry comprehensively described the burden of cervical cancer in a Caribbean region. These findings are essential for planning, monitoring, and evaluating the ongoing impact of the national vaccination, screening, and treatment measures required to drastically contribute to the elimination of cervical cancer in these particularly high-burden regions.

**Abbreviations:** CC, Cervical Cancer; CépiDc-INSERM, French National Institute of Health and Medical Research (Centre d'épidémiologie sur les causes médicales de Décès); ENCR, European Network of Cancer Registries; FIGO, International Federation of Gynecology and Obstetrics; FRANCIM, French Network of Cancer Registries; HPV, Human Papillomavirus; INCA, French National Cancer Institute (Institut National du Cancer); INSEE, French National Institute for Statistics and Economic Studies (Institut National de la Statistique et des Etudes Economiques); LAC, Latin America and the Caribbean; PBCR, Population-Based Cancer Registry; W-ASIR, World Age-Standardized Incidence Rate; W-ASMR, World Age-Standardized Mortality Rate; WHO, World Health Organization.

* Correspondence to: University Hospital of Martinique, Oncology department, CS 90632, Fort-de-France 97 200, Martinique.

E-mail address: remi.houpert@chu-martinique.fr (R. Houpert).

<footnote><sup>a</sup> Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France</footnote>

<footnote><sup>b</sup> University Hospital of Martinique, Research & Development in Oncology, Oncology Hematology Urology department, Fort-de-France, Martinique</footnote>

<footnote><sup>c</sup> Université de Rennes, CHU Rennes, INSERM, LTSI - UMR 1099, Rennes, France</footnote>

<footnote><sup>d</sup> University Hospital of Martinique, Centre de Données Clinique, Fort-de-France, Martinique</footnote>

<footnote><sup>e</sup> AP-HM, Internal Medicine, Geriatrics and Therapeutic Unit, Marseille, France</footnote>

<footnote><sup>f</sup> University Hospital of Martinique, Department of Clinical research and Innovation, Fort de France, Martinique</footnote>

<footnote><sup>g</sup> Université des Antilles, UR6-1 AIHP-GEODE Caraïbe, UFR des Lettres, Langues, Arts et Sciences Humaines, Schoelcher, Martinique</footnote>

<footnote><sup>h</sup> University Hospital of Martinique, Martinique Population Based Cancer Registry, Oncology Hematology Urology department, Fort-de-France, Martinique</footnote>

<footnote><sup>i</sup> APHM, Hop Sainte Marguerite, BioSTIC, Biostatistique et Technologies de l'Information et de la Communication, Marseille, France</footnote>

<footnote><sup>j</sup> Aix Marseille Univ, Biocultural Anthropology, Law, Ethics and Health Research Unit, UMR 7268 ADES, CNRS and Etablissement Français du Sang, Marseilles, France</footnote>
# 1. Introduction

Cervical cancer (CC) is the eighth leading cause of cancer incidence and ninth for deaths among women worldwide. According to the Global Cancer Observatory, with 662,301 new cases diagnosed worldwide and 348,874 deaths in 2022, CC remains a significant public health problem in some regions[1,2]. CC incidence varies considerably worldwide, and although it is declining in the most developed countries, it is still one of the most common and deadliest cancers in women under 45 in sub-Saharan Africa, Central and South America, Southeast Asia, and the Caribbean, where it sometimes ranks ahead of breast cancer. In low- and middle-income countries where challenges in prevention, screening, and care management persists, particularly in underserved populations, early detection could reduce overall the CC global burden by 90%[3–6].

Disparities in the control of CC persist in Latin America and the Caribbean (LAC) region[5,7]. In 2018, an increasing gradient in global incidence rates was measured, with the lowest rates recorded in North America and Central America (6.4 and 13.0 per 100,000), compared in South America and the Caribbean (15.2 and 15.5 per 100,000)[8,9]. However, the World Health Organization (WHO) has launched a global initiative to eliminate CC as a public health problem in this region[3]. International data from population-based cancer registries (PBCRs) confirm that the incidence of CC is declining, and the associated mortality rates remain stable in some LAC countries, particularly in Puerto Rico, Brazil, Chile, and Colombia. Yet this decline is less marked than in Europe or North America, where the rates remain much lower[10,11].

Martinique, a French territory in the West Indies (360,700 inhabitants in 2021[12]), implemented a PBCR since 1983[13]. It is one of the oldest functional PBCR in the LAC region which provides epidemiological surveillance data on cancers and their trends[14]. In this region, Martinique PBCR reported the lowest world age-standardized incidence rate for CC between 2007 and 2016 (7.2 per 100,000 person-years), with an average of 79 women diagnosed with CC each year (5.6 % of cancers in women)[8].

Notably, Martinique implemented individual and organized CC screening programs using Pap smear tests in 1991, with pilot programs preceding the 2018 nationwide rollout in mainland France. Despite these efforts, the burden of CC persists, highlighting the need for continued research and intervention.

This study aims to improve knowledge of CC in Martinique, where recent data on incidence, mortality and survival remain scarce. By analyzing data from 2012 to 2021, we aim to provide an updated overview of the burden and temporal trends in incidence, mortality and overall survival of CC in this high burden region.

# 2. Materials and methods

## 2.1. Study design

This retrospective cohort study included all cases registered by the Martinique PBCR of CC diagnosed (International Classification of Diseases 10: C53 Malignant neoplasm of cervix uteri) between 2012 and 2021. The PBCR performs continuous and exhaustive recording of all new cancer cases occurring in the population resident in Martinique, regardless of where the diagnosis or the treatment takes place. Data were recorded in the Martinique PBCR in strict compliance with international standards set by the International Agency for Research on Cancer, the French Network of Cancer Registries (FRANCIM), and the European Network of Cancer Registries (ENCR). Registry procedures and data quality control, through data cross-checking and analysis across all available data sources, are in full accordance with national and international guidelines for cancer registries and are compliant with the General Data Protection Regulation (GDPR)[15,16]. STROBE guidelines for cohort studies were followed.

## 2.2. Data sources/collection

We recorded socio-demographic data and clinical variables: age at diagnosis, year of diagnosis, area of residence, histological type, FIGO stage, tumor size and treatment. Treatment data were collected from patient records. Age was divided into three groups: 24–44 years; 45–64 years; over 65 years. This classification considers the age groups defined in the French national guidelines for organized CC screening[17]. FIGO stages were classified into three categories according to the 2008 international classification updated in 2021[18]. Localized cancers were considered to have a FIGO stage between IA and IB3, advanced localized cancers (IIA and IIIC2), and metastatic cancers (IV). Areas of residence were classified according to the territorial organization established by the French National Institute for Statistics and Economic Studies (Institut National de la Statistique et des Etudes Economiques, INSEE) [19].

Data regarding deaths were obtained from the French epidemiological center on medical causes of death from the French National Institute of Health and Medical Research [20] (Centre d'épidémiologie sur les causes médicales de Décès, CépiDc-INSERM), ensuring completeness of death information.

Patients with missing clinical data were considered as missing stage. And based on the recommendations of an experienced oncologist, we also reclassified patients with tumor size less than or equal to 4 cm if FIGO stage was less than IB2, otherwise tumor size was considered greater than 4 cm.

## 2.3. Statistical analysis

Patient characteristics were described as number and percentage.

Epidemiological descriptive analysis for invasive cases was performed[21]. Age-specific incidence and mortality rates were for CC calculated for 18 age groups, ranging from 0 to 100 years, separated by 5-year increments. Crude age-specific incidence and mortality rates were calculated as the total of diagnosed cases or deaths divided by the total number of women at risk over the period 2012–2021 in Martinique (with 95 % confidence intervals). We used the direct method to calculate the world age-standardized incidence and mortality rates, using the standard world population of WHO as reference [22]. World age-standardized incidence and mortality rates were expressed in person-time. We also calculated the cumulative rate (0–74 years), which is the sum of the age-specific incidence rates from birth to age 74, weighted by the length of each age interval. This measure approximates the risk of developing cervical cancer before age 75, assuming no competing causes of death.

Overall survival (OS), with a 95 % confidence interval, was calculated as the time from diagnosis to death from any cause. The patients were censored at the date of last follow-up (defined as the last known record of vital status information), or at the cut-off date of December 31, 2023. We used the Kaplan-Meier product limit method to estimate the overall survival of invasive cervical cancer cases at 1, 3, 5 and 10 years after diagnosis.

A comparative analysis was carried out between the groups with and without missing data to investigate any differences in demographic characteristics. Missing data were excluded from the analysis if no differences were found.

All analyses were performed using STATA (v.18).

# 3. Results

1196 in situ tumors and 202 invasive cases of CC were diagnosed. Among the 202 invasive cases of CC, 108 deaths were recorded. Baseline characteristics of women with invasive CC are summarized in Table 1.

The median age at diagnosis was 61 years (25th - 75th percentiles: 47–75 years) with 46.0 % (n = 93) aged 65 and over. The youngest age at diagnosis was 24, and the oldest was 95. FIGO staging was available in
<table><caption>**Table 1**
Socio-demographic and clinical characteristics according to age group (n = 202).</caption><thead><tr><th rowspan="2"></th><th colspan="2">All</th><th colspan="2">24-44 years</th><th colspan="2">45-64 years</th><th colspan="2">≥ 65 years</th></tr><tr><th>n</th><th>%</th><th>n</th><th>%</th><th>n</th><th>%</th><th>N</th><th>%</th></tr></thead><tbody><tr><td><strong>Period of diagnosis</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>2012-2016</td><td>106</td><td>52.5</td><td>25</td><td>58.1</td><td>30</td><td>45.5</td><td>51</td><td>54.8</td></tr><tr><td>2017-2021</td><td>96</td><td>47.5</td><td>18</td><td>41.9</td><td>36</td><td>54.5</td><td>42</td><td>45.2</td></tr><tr><td><strong>Health Democracy Territory</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Center</td><td>87</td><td>43.1</td><td>22</td><td>51.2</td><td>30</td><td>45.5</td><td>35</td><td>37.6</td></tr><tr><td>North-Caribbean</td><td>12</td><td>5.9</td><td>2</td><td>4.6</td><td>3</td><td>4.5</td><td>7</td><td>7.5</td></tr><tr><td>North-Atlantic</td><td>41</td><td>20.3</td><td>7</td><td>16.3</td><td>12</td><td>18.2</td><td>22</td><td>23.7</td></tr><tr><td>South</td><td>62</td><td>30.7</td><td>12</td><td>27.9</td><td>21</td><td>31.8</td><td>29</td><td>31.2</td></tr><tr><td><strong>FIGO Stage</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Localized (I - IB3)</td><td>49</td><td>24.3</td><td>17</td><td>39.5</td><td>22</td><td>33.3</td><td>10</td><td>10.7</td></tr><tr><td>Locally advanced (IIA- IIIC2)</td><td>87</td><td>43.1</td><td>20</td><td>46.5</td><td>24</td><td>36.4</td><td>43</td><td>46.2</td></tr><tr><td>Metastatic (IVA-B)</td><td>42</td><td>20.8</td><td>3</td><td>7.0</td><td>12</td><td>18.2</td><td>27</td><td>29.0</td></tr><tr><td>Missing</td><td>24</td><td>11.9</td><td>3</td><td>7.0</td><td>8</td><td>12.1</td><td>13</td><td>14.0</td></tr><tr><td><strong>Histological type</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Squamous carcinoma</td><td>152</td><td>75.2</td><td>32</td><td>74.4</td><td>49</td><td>74.2</td><td>71</td><td>76.3</td></tr><tr><td>Adenocarcinoma</td><td>41</td><td>20.3</td><td>9</td><td>20.9</td><td>15</td><td>22.7</td><td>17</td><td>18.3</td></tr><tr><td>Others<sup>a</sup></td><td>9</td><td>4.5</td><td>2</td><td>4.6</td><td>2</td><td>3.0</td><td>5</td><td>5.4</td></tr><tr><td><strong>Tumor size</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>≤ 4 cm</td><td>136</td><td>67.3</td><td>37</td><td>86.0</td><td>46</td><td>69.7</td><td>53</td><td>57.0</td></tr><tr><td>> 4 cm</td><td>42</td><td>20.8</td><td>3</td><td>7.0</td><td>12</td><td>18.2</td><td>27</td><td>29.0</td></tr><tr><td>Missing</td><td>24</td><td>11.9</td><td>3</td><td>7.0</td><td>8</td><td>12.1</td><td>13</td><td>14.0</td></tr><tr><td><strong>Treatment</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Surgery</td><td>13</td><td>6.4</td><td>5</td><td>11.6</td><td>2</td><td>3.0</td><td>6</td><td>6.5</td></tr><tr><td>Chemotherapy / Radiation therapy</td><td>136</td><td>67.3</td><td>28</td><td>65.1</td><td>43</td><td>65.1</td><td>65</td><td>69.9</td></tr><tr><td>Palliative care / Others<sup>b</sup></td><td>13</td><td>6.4</td><td>1</td><td>2.3</td><td>3</td><td>4.5</td><td>9</td><td>9.7</td></tr><tr><td>Missing</td><td>40</td><td>19.8</td><td>9</td><td>20.9</td><td>18</td><td>27.3</td><td>13</td><td>14.0</td></tr></tbody></table>

88.1 % of cases, with 24.3 % localized, 43.1 % locally advanced and 20.8 % metastatic. Advanced localized and metastatic FIGO stages were most common in older women (≥ 65 years). Localized FIGO stage was mostly observed in women between the ages of 45 and 65. Most invasive cases were squamous cell carcinomas (75.2 %) and 19.8 % adenocarcinomas. 4.5 % of histological types were missing or rare (3.5 % missing, 0.5 % neuroendocrine squamous cell carcinoma and 0.5 % adenosquamous cell carcinoma). Most of women received chemotherapy and/or radiotherapy (67.3 %). Among women eligible for CC screening (age 25–65 inclusive), a total of 1129 in situ tumors and 110 invasive cases were identified by the PBCR.

### 3.1. Incidence and mortality of cervical cancer in Martinique

Over the period 2012–2021, the world age-standardized incidence rate (W-ASIR) for CC is 5.9 per 100,000 person-years (5.0; 6.9) and the world age-standardized mortality rate (W-ASMR) is 2.6 per 100,000 person-years (2.0; 3.3) (Fig. 1). The cumulative rate (0–74) is 0.6 % (0.58;0.59).

Trends in world age-standardized incidence rates were constant at around 6 per 100,000, except in 2015 and 2019, with W-ASIRs equal to 9.2 and 8.3 respectively per 100,000. World age-standardized mortality rates are around 3 per 100,000 person-years, except in 2020 with an W-ASMR of 0.9 per 100,000 person-years (Fig. 1).

The age-specific incidence rate curve showed comparable rates between the ages of 25 and 54 (rates between 6 and 12 per 100,000), with a steady and apparent increase after age 60, reaching a first frequency peak between 75 and 79 and a maximum value among the more than 85 age group with a rate of 28.5 per 100,000 person-years (Fig. 2).

### 3.2. Overall survival

Table 2 shows the OS of women with CC according to the period of diagnosis, age at diagnosis, proximity health territory, FIGO stage and treatment.

OS at 1 year was 78.2 %. At 3 years, OS was 53.8 %, 51.4 % at 5 years, and OS at 10 years was 41.8 %. Median survival was reached at 6 years. For women over 65 years, median survival was 2 years, whereas

<figure><img src="image_3.png" /><figcaption>**Fig. 1.** Temporal trends of world age-standardized incidence and mortality rates of cervical cancer in Martinique (2012–2021).</figcaption></figure>

<footnote>a Others: 3.46 % missing, 0.5 % of neuroendocrine squamous cell carcinoma and 0.5 % of adenosquamous carcinoma</footnote>

<footnote>b Others: < 1 % Treated abroad or refused treatment</footnote>
Age-specific incidence rate among women with Cervical Cancer in Martinique (2012-2021)

Data from the Population-Based Cancer Registry of Martinique

<figure><img src="image_4.png" /><figcaption>Fig. 2. Age-specific incidence rate among women with cervical cancer in Martinique (2012–2021).</figcaption></figure>

median survival was not reached at the end of follow-up for women under 65 years. Fig. 3 plots the Kaplan-Meier survival estimates by age, FIGO stage, and treatment.

4. Discussion

This study, conducted in the LAC region, provides reliable and up-to-
date information on CC. Indeed, few epidemiological studies are avail-
able is the LAC region due to the limited number of PBCRs. These data
have significant implications for public health and screening programs,
particularly in the LAC region [5,9,10,23]. Our findings can guide ini-
tiatives to eliminate CC according to WHO recommendations [3].

Worldwide cancer data have shown that cervical cancer incidence and mortality have been declining steadily since the 1980s, with a slowdown in the 2000s. And the latest results of successive studies carried out in Martinique, between 2002 and 2016, showed a significant and constant decline in CC incidence and mortality rates in women aged over 30. This study confirms this epidemiological observation, with rather low incidence and mortality rates for the period 2012–2021 in women over 30.[8,24]. This transition began in the 2010s, as observed in most European and North American countries[11]. Nevertheless, the downward trend is less marked, particularly among women being diagnosed between age 50 and 60, for both incidence and mortality rates [9,10]. In Martinique, the W-ASIR over 2012–2021 remains similar to the average rate for mainland France in 2023 (5.9 versus 6.3)[25,26]. These rates, with those for Western and Northern Europe, remain the lowest in the world[1]. World age-standardized incidence of invasive CC in Martinique has decreased from 12.6 per 100,000 person-years in 2002–5.9 per 100,000 person-years in 2021[8,24]. World age-standardized mortality rates over the period studied in Martinique are slightly higher compared to mainland France in 2018 (2.6 versus 1.7)[25,26]. The decrease in incidence and mortality can be attributed to improved monitoring programs and the implementation of individual and organized Pap smear screening[27,28]. In several Western countries, where cytology screening programs have been in place for a long time, a comparable trend has been observed, with a reduction of almost 50 % over the last two decades[2,4].

Despite a persistent decline in incidence and mortality overall in the LAC region, and Martinique to a lesser extent, two common epidemiological features should be noted for Martinique. Firstly, rates remain the highest in women over 65 in LAC region[10]. Our results show that many women diagnosed with CC are over 65 years of age (45 %), and most of them develop cancer diagnosed at a locally advanced (46 %) or metastatic stage (30 %). Many factors could explain the higher incidence of advanced cervical cancer among older women, particularly the ageing of the Martinique population. Changes in cancer risk are influenced by the prevalence of specific risk factors, population behavior and diagnostic practices[25]. However, the reasons for these disparities among older women are not totally conclusive. On the one hand, older women often have delayed consultations, due to a variety of psychosocial reasons, resulting in advanced diagnosis and/or potentially unfavorable tumor biology. They also go to their gynecologists less often, or do not perform gynecological follow-up checks as required. On the other hand, older women generally receive under-treatment, different from that of younger patients. The study by C. Sharma, et al. reports that older patients with cervical cancer are more likely to receive primary radiotherapy rather than surgery, and less likely to have radical hysterectomy, lymphadenectomy, adjuvant radiotherapy or brachytherapy [29]. Moreover, women over 65 may also present additional comorbidities and resistance to treatment, combined with the fact that they are no longer eligible for organized CC screening[30]. Secondly, a recent increase in incidence and/or mortality rates in the youngest age group (0–29 years). In Martinique, these rates rose from 1.3 per 100,000 in 2002–6.3 over the period studied [31]. The reasons for this increase could be linked to CC diagnosis at a more advanced stage, associated with a more critical prognosis. This unfavorable trend could also reflect an increase in the prevalence of high-risk oncogenic human papillomavirus (HPV), as well as a still too-low uptake of screening[2,5,9]. According to our study, Martinique has a mixed epidemiological pattern with favorable trends specific to developed countries, such as low incidence and mortality rates, but paradoxically unfavorable features specific to the LAC region, such as significant increases in incidence combined with high mortality rates, both in young people under 30 and women over 65.
<table><caption>**Table 2**
Overall survival (OS) at 1, 3, 5 and 10 years of invasive cervical cancer patients in Martinique, 2012–2021.</caption><thead><tr><th></th><th>1-year OS<br>% (CI 95)</th><th>3-year OS<br>% (CI 95)</th><th>5-year OS<br>% (CI 95)</th><th>10-year OS<br>% (CI 95)</th></tr></thead><tbody><tr><td><strong>Overall survival</strong></td><td>78.2 (71.8;<br>83.3)</td><td>53.8<br>(46.6;<br>60.4)</td><td>51.4<br>(44.2;<br>58.1)</td><td>41.8 (33.8;<br>49.6)</td></tr><tr><td><strong>Period of diagnosis</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>2012–2016</td><td>81.1 (72.3;<br>87.3)</td><td>55.6<br>(45.7;<br>64.5)</td><td>53.7<br>(43.8;<br>62.7)</td><td>43.4<br>(33.6;52.8)</td></tr><tr><td>2017–2021</td><td>75<br>(65.1;82.4)</td><td>51.6<br>(41.1;<br>61.1)</td><td>47.8<br>(36.8;<br>58.0)</td><td>NA</td></tr><tr><td><strong>Health Democracy Territory</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Center</td><td>73.6 (62.9;<br>81.6)</td><td>50.3<br>(39.4;<br>60.3)</td><td>47.6<br>(36.7;<br>57.7)</td><td>37.3 (25.1;<br>49.4)</td></tr><tr><td>North-Caribbean</td><td>58.3 (27.0;<br>80.0)</td><td>41.7<br>(15.2;<br>66.5)</td><td>41.7<br>(15.2;<br>66.5)</td><td>-</td></tr><tr><td>North-Atlantic</td><td>78.0 (62.0;<br>87.9)</td><td>58.5<br>(42.0;<br>71.8)</td><td>53.4<br>(37.1;<br>67.3)</td><td>49.6 (32.3;<br>64.2)</td></tr><tr><td>South</td><td>88.7 (77.7;<br>94.4)</td><td>57.8<br>(44.5;<br>68.9)</td><td>57.8<br>(44.5;<br>68.9)</td><td>44.6 (29.3;<br>58.9)</td></tr><tr><td><strong>Age</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>24–44 years</td><td>95.3 (82.7;<br>98.8)</td><td>74.4<br>(58.6;<br>84.9)</td><td>71.8<br>(55.7;<br>82.9)</td><td>64.3 (46.5;<br>77.5)</td></tr><tr><td>45–64 years</td><td>86.4 (75.3;<br>92.7)</td><td>58.9<br>(46.0;<br>69.7)</td><td>58.9<br>(46.0;<br>69.7)</td><td>51.7 (37.0;<br>64.6)</td></tr><tr><td>65–79 years</td><td>67.8 (54.3;<br>78.1)</td><td>42.1<br>(29.4;<br>54.3)</td><td>40.2<br>(27.6;<br>52.4)</td><td>31.8 (18.0;<br>46.5)</td></tr><tr><td>≥ 80 years</td><td>58.8 (40.6;<br>73.2)</td><td>38.2<br>(22.3;<br>54.0)</td><td>31.9<br>(17.1;<br>47.7)</td><td>17.2 (6.2;<br>32.7)</td></tr><tr><td><strong>FIGO Stage</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Localized (IA– IB3)</td><td>100</td><td>89.8<br>(77.2;<br>95.6)</td><td>87.5<br>(74.2;<br>94.2)</td><td>84.2 (69.3;<br>92.3)</td></tr><tr><td>Locally advanced<br>(IIA-IIIC2)</td><td>86.2 (76.9;<br>91.2)</td><td>57.1<br>(45.9;<br>66.8)</td><td>55.7<br>(44.5;<br>65.5)</td><td>42.7 (30.2;<br>54.5)</td></tr><tr><td>Metastatic (IV)</td><td>61.9 (45.5;<br>74.6)</td><td>19.0 (8.9;<br>32.0)</td><td>16.3 (7.0;<br>29.0)</td><td>5.4 (0.5;<br>20.2)</td></tr><tr><td><strong>Treatment</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Surgery</td><td>100</td><td>100</td><td>100</td><td>90 (47.3;<br>98.5)</td></tr><tr><td>Chemotherapy /<br>Radiation therapy</td><td>83.2 (76.5;<br>89.0)</td><td>51.9<br>(43.2;<br>59.9)</td><td>49.2<br>(40.4;<br>57.4)</td><td>35.0 (24.9;<br>45.3)</td></tr><tr><td>Palliative care /<br>Others</td><td>30.7 (9.5;<br>55.4)</td><td>23.1 (5.6;<br>47.5)</td><td>23.1 (5.6;<br>47.5)</td><td>23.1 (5.6;<br>47.5)</td></tr></tbody></table>

OS: overall survival. NA: Not available

Over the study period, most invasive cancers (43 %) were diagnosed at a locally advanced stage (FIGO stage II-III), and 67 % were less than or equal to 4 cm in size, which is probably due to the introduction of a pilot screening program in Martinique in 1991[27]. Overall survival has decreased by an average of 5 points compared with the previous period, 2002–2011[24]. Similar results were found in studies of black American women, with significant differences from the general population, with low survival probabilities and high incidence and mortality rates, particularly in older women diagnosed at advanced stages [32–34]. In our population-based study in Martinique, we observed better overall survival when cervical cancer was detected at a localized stage (IA- IB3), in women aged under 44 and treated by surgery. For the whole population, the overall survival estimates at 5 and 10 years were 51.4 % and 41.8 % respectively. These estimates are lower than the national

estimates of 62 % and 57 % [28,35], a difference that may be partly attributable to the older age structure of the population in Martinique [36]. Older women in Martinique have a higher all-cause mortality risk, which may partly explain their lower overall survival, whether in terms of quality of care or stage at diagnosis. However, the lower rate of healthcare utilization in Martinique than in mainland France could also partly explain these lower survival estimates (the healthcare utilization rate was 204.28 hospitalizations per 1000 inhabitants in Martinique in 2019 versus 281.38 hospitalizations per 1000 inhabitants in mainland France). Similar disparities are observed in access to cancer treatment, with lower rates of healthcare utilization for cancer treatment in Martinique compared to mainland France, for chemotherapy (2.00 per 1000 vs. 2.34 per 1000), radiotherapy (0.11 per 1000 vs. 0.23 per 1000) and surgery (4.09 per 1000 vs. 7.02 per 1000) [37]. Moreover, our results are similar to the study by Compaoré et al., which highlights that older women diagnosed at an advanced stage and not receiving usual care have a significantly increased risk of death [38]. Data from the literature report a decline in cervical cancer survival over time. Organized screening, which enables precancerous lesions to be identified and resected, is paradoxically linked to the decline in survival, with a consequent drop in cancer incidence. Even though fewer invasive cervical cancers are diagnosed, the proportion of cancers with a poor prognosis is higher.[8,26,28,30,35,39]. In our study, 91.1 % in-situ tumors and 8.9 % invasive cancers were diagnosed in the age group covered by screening (25–65 years). Within this group, 36.4 % were diagnosed at a local stage, and 40 % at a locally advanced stage.

Our results suggest similarities with the latest joint recommendations: (i) surgery as primary treatment for early-detection tumors and (ii) chemoradiotherapy as reference treatment for locally advanced cancers[40]. Overall survival was 90 % at 10 years for women treated with surgery. Concomitant or exclusive chemotherapy and radiotherapy showed an overall survival of 49 % at 5 years. Dose escalation strategies have improved local control rates, and advances in external radiotherapy techniques, with better control of organ doses, have reduced the risk of adverse complications.

The epidemiology of cervical cancer outlined could also be explained by the specific HPV genotype profile of women living in Martinique. The genotypes most frequently found are HPV51, HPV68 and HPV53, different from the genotypes commonly found worldwide (HPV16 and HPV18). Due to the specific epidemiological patterns and atypical distribution of HPV in Martinique[41], it would also be necessary to identify patients at high risk of metastatic disease as early as possible. [30]. The integration of HPV genotyping into cancer screening programs would be a valuable means of reducing incidence in this region. This would enable active surveillance of women to prevent unfavorable events such as cancer.

Previous work by the DEPIPAPUFR team in Martinique has highlighted the importance of integrating clinical approaches adapted to the local context as a potential strategy for cervical cancer control, particularly for older, younger, and marginalized women who continue to experience a higher burden [41]. Our findings support the need to adapt prevention efforts to these most at risk populations, although our study is descriptive and does not evaluate interventions. A coordinate strategy including HPV vaccination, Pap smear screening and HPV genotyping, combined with culturally appropriate community-based health promotion, would be a comprehensive approach to reducing the burden of cervical cancer in Martinique. By actively addressing these issues, Martinique could serve as a model for other high-prevalence regions in the LAC region.

## 4.1. Strengths

The main strength of this study lies in the multisource quality of the data. We have an internationally qualified PCBR, which guarantees the quality and completeness of cancer data in Martinique. The availability of clinical and biological data in partnership with local research teams
<figure><img src="image_5.png" /><figcaption>(a) Age group (24-44 / 45-64 / 65-79 / ≥ 80)</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>(b) FIGO stage (I-IB2 / IB3 -IIIC2 / IV)</figcaption></figure>

<figure><img src="image_7.png" /><figcaption>(c) Treatment (Surgery / Chemotherapy – Radiation therapy / Others – Palliative care)</figcaption></figure>

<caption>**Fig. 3.** Kaplan-Meier survival estimates of invasive cervical cancer according to (a) age group, (b) FIGO stage and (c) treatment in Martinique (2012–2021).</caption>

was also a major strength, as we were able to collect additional data not automatically recorded in the Martinique PBCR database.

## 4.2. Limitations

Missing data accounted for more than 10 % of our sample. A

comparative analysis was carried out between the groups with and without missing data in order to investigate any differences in demographic characteristics. None of these comparisons was significant. These results suggest that missing data are probably random and unrelated to the studied demographic characteristics.

Another potential limitation of this study is the potential exclusion of
women who died before the formal diagnosis of cervical cancer. Although the use of cancer registry data ensures the inclusion of all cases diagnosed in Martinique, undiagnosed cancers cannot be registered unless they are discovered during autopsy. Therefore, undiagnosed cases, particularly among women with significant comorbidities or limited access to healthcare, may not have been included. These women could have different socio-demographic or clinical characteristics, which could influence survival estimates. However, this limitation is probably mitigated by the generally high life expectancy of women in Martinique, which extends the period during which a cervical cancer can be diagnosed before death from other causes. This, combined with universal access to healthcare, increases the probability of cancers being detected and registered, thus reducing the potential underreporting of undiagnosed cases.

## 5. Conclusions

This study, of significant importance, provided a comprehensive overview of the burden of cervical cancer to guide national public health strategies. Data from the PBCR, based on active surveillance, has highlighted that incidence rates remain highest in women over 65, and that cervical cancer remains a particular concern for younger women. Efforts are still needed to limit the burden of this cancer, which remains avoidable.

### CRediT authorship contribution statement

**Jonathan Macni:** Writing - review & editing, Validation. **BOUTANT Wendy:** Writing - review & editing, Validation. **Thierry Almont:** Writing - review & editing, Validation. **Fatiha Najioullah:** Writing - review & editing, Validation. **Marc-Karim Ben-Diane:** Writing - review & editing, Validation. **Anne-Déborah Bouhnik:** Writing - review & editing, Validation. **Emmanuelle Sylvestre:** Writing - review & editing, Validation, Supervision, Methodology, Conceptualization. **Houpert Remi:** Writing - review & editing, Writing - original draft, Visualization, Methodology, Investigation, Formal analysis, Conceptualization. **Jacqueline Veronique-Baudin:** Writing - review & editing, Validation, Supervision, Methodology, Conceptualization. **Clarisse Joachim:** Writing - review & editing, Validation, Supervision, Methodology, Conceptualization. **Julien Mancini:** Writing - review & editing, Validation, Supervision.

### Ethics approval and consent to participate

The cancer registry of Martinique is authorized by the French Data Protection Authority, Commission National Informatique et Liberté (CNIL), authorization n° 987001 of November 16, 1987. (Date of last CNIL amendment: June 05, 2015) Given their public health mandate, French cancer registries are authorized by the French Data Protection Authority "Commission National Informatique et Liberté" (CNIL), to collect data on cancer cases with a waiver for written informed consent (CNIL deliberation n°03-053 of November 27, 2003). Patients' information is given by notices displayed in health care facilities, their attending physician or specialist. General information is also available on the National Cancer Institute website: https://www.cancer.fr/. The Privacy Impact Assessment (PIA) was voted by the data protection officer of the University Hospital of Martinique (dpo@chu-martinique.fr) in accordance to the General Data Protection Regulation (GDPR).

### Data access, responsibility, and analysis

The datasets generated and/or analyzed during the current study are not publicly available due to French legislation and cannot be shared without authorization but are available from the corresponding author on reasonable request.

### Funding

This work was supported by the French National Cancer Institute (INCa), Grant Awarding Decision "2019-177" following the "SHS-E-SP 2019" call for projects.

### Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Julien MANCINI reports financial support was provided by French National Cancer Institute. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

### Acknowledgments

The authors would like to thank the teams of Oncology-Hematology department of University Hospital of Martinique for their assistance, and specially for the teams working in the Oncology Research & Development Unit and the Population Based Cancer Registry of Martinique. We would also like to thank the board of the "Santé et Résilience" association for their support.

### References

[1] H. Sung, J. Ferlay, R.L. Siegel, M. Laversanne, I. Soerjomataram, A. Jemal, et al., Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries, CA Cancer J. Clin. 71 (2021) 209-249.

[2] S. Pimple, G. Mishra, Cancer cervix: Epidemiology and disease burden, Cytojournal 19 (2022) 21.

[3] Global strategy to accelerate the elimination of cervical cancer as a public health problem. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.

[4] L. Bruni, B. Serrano, E. Roura, L. Alemany, M. Cowan, R. Herrero, et al., Cervical cancer screening programmes and age-specific coverage estimates for 202 countries and territories worldwide: a review and synthetic analysis, Lancet Glob. Health 10 (2022) e1115-e1127.

[5] I. Riano, P. Contreras-Chavez, C.M. Pabon, K. Meza, L. Kiel, S. Bejarano, et al., An overview of cervical cancer prevention and control in latin america and the caribbean countries, Hematol. Oncol. Clin. North Am. 38 (2024) 13-33.

[6] K.N. Tin, C. Ngamjarus, S. Rattanakanokchai, J. Sothornwit, A. Aue-Aungkul, A. K. Paing, et al., Interventions to increase the uptake of cervical cancer screening in low- and middle-income countries: a systematic review and meta-analysis, BMC Women's Health 23 (2023) 120.

[7] L.L. Villa, Cervical cancer in Latin America and the Caribbean: the problem and the way to solutions, Cancer Epidemiol. Biomark. Prev. 21 (2012) 1409-1413.

[8] Joachim-Contaret C., Véronique-Baudin J., Macni J., Ulric-Gervaise S., Cariou M., Billot-Grasset A., Chatignoux É. Estimations régionales et départementales d'incidence et de mortalité par cancers en France, 2007-2016. Martinique. Saint-Maurice: Santé publique France, 2019. 106p. Disponible à partir des URL: https://geodes.santepubliquefrance.fr, http://lesdonnees.e-cancer.fr, https://www.sante.publiquefrance.fr.

[9] S. Pilleron, C.J. Cabasag, J. Ferlay, F. Bray, S. Luciani, M. Almonte, et al., Cervical cancer burden in Latin America and the Caribbean: Where are we? Int J. Cancer 147 (2020) 1638-1648.

[10] J.S. Torres-Roman, L. Ronceros-Cardenas, B. Valcarcel, J. Bazalar-Palacios, J. Ybaseta-Medina, G. Carioli, et al., Cervical cancer mortality among young women in Latin America and the Caribbean: trend analysis from 1997 to 2030, BMC Public Health 22 (2022) 113.

[11] S. Vaccarella, M. Laversanne, J. Ferlay, F. Bray, Cervical cancer in Africa, Latin America and the Caribbean and Asia: Regional inequalities and changing trends, Int. J. Cancer 141 (2017) 1997-2001.

[12] C. Douriaud, « 360 749 habitants en Martinique au 1er janvier 2021 », décembre, Insee Flash Martin. N. 193 (2023).

[13] Présentation des activités du Registre général de la Martinique, Institut National du Cancer (INCa) (2025). https://www.cancer.fr/toute-l-information-sur-les-cancer s/ comprendre-les-cancers/epidemiologie-et-donnees-en-cancerologie/les-donnees- sur-les-cancers/les-registres-des-cancers/registres-generaux/martinique. Présentation des activités du Registre général de la Martinique. Institut National du Cancer (INCa); 2023.

[14] M. Pineros, M. Saraiya, I. Baussano, M. Bonjour, A. Chao, F. Bray, The role and utility of population-based cancer registries in cervical cancer surveillance and control, Prev. Med 144 (2021) 106237.

[15] Jerzy E. Tyczynski, Eva Démaret, D.Maxwell Parkin. Standards and Guidelines for Cancer Registration in Europe: the ENCR recommendations. IARC Technical Publication No. 40: International Agency for Research on Cancer; 2003.
[16] D.M. Parkin, V.W. Chen, J. Ferlay, J. Galceran, H.H. Storm, S.L. Whelan, IARC Technical Report, No. 19: Comparability and Quality Control in Cancer Registration, International Agency for Research on Cancer, 1994.

[17] F.F. Hamers, N. Duport, N. Beltzer, Population-based organized cervical cancer screening pilot program in France, Eur. J. Cancer Prev. 27 (2018) 486-492.

[18] N. Bhatla, D. Aoki, D.N. Sharma, R. Sankaranarayanan, Cancer of the cervix uteri: 2021 update, Int J. Gynaecol. Obstet. 155 (1) (2021) 28-44.

[19] INSEE. Département de la Martinique. Date de création: avant 1943, première édition du Code officiel géographique. GÉOGRAPHIE.

[20] Centre d'épidémiologie sur les causes médicales de décès (CépiDc) - INSERM.

[21] P. Boyle, D.M. Parkin, Chapter 11. Statistical methods for registries, in: Cancer Registration: Principles and Methods, 95, IARC Scientific Publication, Lyon, 1991.

[22] F. Bray, M. Colombet, J.F. Aitken, A. Bardot, S. Eser, J. Galceran, et al. (Eds.), IARC Scientific Publication, 169, International Agency for Research on Cancer, Lyon, France, 2024. (https://publications.iarc.who.int/641). Available from:

[23] A. Diaz, J. Kang, S.P. Moore, P. Baade, D. Langbecker, J.R. Condon, et al., Association between comorbidity and participation in breast and cervical cancer screening: a systematic review and meta-analysis, Cancer Epidemiol. 47 (2017) 7-19.

[24] K. Melan, E. Janky, J. Macni, S. Ulric-Gervaise, M.J. Dorival, J. Veronique-Baudin, et al., Epidemiology and survival of cervical cancer in the French West-Indies: data from the Martinique Cancer Registry (2002-2011), Glob. Health Action 10 (2017) 1337341.

[25] B. Lapôtre-Ledoux, L. Remontet, Z. Uhry, E. Dantony, P. Grosclaude, F. Molinié, et al., Incid. Des principaux Cancers En. Fr. M. étropolitaine En. 2023 Et. Tend. depuis 1990. Bull. Épidémiol Hebd. (12-13) (2023) 188-204. (http://beh.santepubliquefrance.fr/beh/2023/12-13/2023_12-13_1.html).

[26] Defossez G., Le Guyader-Peyrou S., Uhry Z., Grosclaude P., Colonna M., Dantony E., et al. Estimations nationales de l'incidence et de la mortalité par cancer en France métropolitaine entre 1990 et 2018. Volume 1 – Tumeurs solides. Saint-Maurice(Fra): Santé publique France, 2019. 372 p. Disponible à partir des URL: http://www.santepubliquefrance.fr/; https://geodes.santepubliquefrance.fr; http://lesdonnees.e-cancer.fr/; https://www.e-cancer.fr/.

[27] Duport N., Haguenoer K., Ancelle Park R., Bloch J. Dépistage organisé du cancer du col de l'utérus. Evaluation épidémiologique des quatre départements "pilotes". Institut de Veille Sanitaire 2007;Maladies chroniques et traumatismes:32 p.

[28] C.M.A. Le Bihan-Benjamin, C. Audiger, I. Khati, S. BarréPierrel, Quel déploiement du Programme national de dépistage organisé du cancer du col de l'utérus en France en 2022 ? Bull Épidé, miol Hebd. (2024) 82-91.

[29] C. Sharma, I. Deutsch, D.P. Horowitz, D.L. Hershman, S.N. Lewin, Y.S. Lu, et al., Patterns of care and treatment outcomes for elderly women with cervical cancer, Cancer 118 (2012) 3618-3626.

[30] C. Chargari, S. Gouy, P. Pautier, C. Haie-Meder, Recent data in cervical cancer: radiation oncologist's perspective]. Cancer Radiother 22 (2018) 502-508.

[31] M. Ervik, F. Lam, M. Laversanne, M. Colombet, J. Ferlay, A. Miranda-Filho, et al., Global Cancer Observatory: Cancer Over Time, International Agency for Research on Cancer, Lyon, France, 2024.

[32] E. Abdalla, R. Troy, S. Fall, I. Elhussin, O. Egiebor-Aiwan, D. Nganwa, Racial differences in 5-year relative survival rates of cervical cancer by stage at diagnosis, between African American (black) and white women, living in the state of Alabama, USA, BMC Cancer 20 (2020) 830.

[33] C.M. Cohen, N. Wentzensen, P.E. Castle, M. Schiffman, R. Zuna, R.C. Arend, et al., Racial and ethnic disparities in cervical cancer incidence, survival, and mortality by histologic subtype, J. Clin. Oncol. 41 (2023) 1059-1068.

[34] M. Matz, H.K. Weir, E. Alkhalawi, M.P. Coleman, C. Allemani, Group UCW. Disparities in cervical cancer survival in the United States by race and stage at diagnosis: an analysis of 138,883 women diagnosed between 2001 and 2014 (CONCORD-3), Gynecol. Oncol. 163 (2021) 305-311.

[35] Coureau G., Mounier M., Tretarre B., Dantony E., Uhry Z., Monnereau A. et al. Survie des personnes atteintes de cancer en France métropolitaine 1989-2018 – Synthèse. Boulogne-Billancourt: Institut national du cancer, juillet 2021, 20 p. Disponible à partir des URL: https://www.e-cancer.fr/Expertises-et-publications/ Les-donnees-sur-les-cancers/Survie-des-personnes-atteintes-de-cancer-en-France-metropolitaine/ et https://www.santepubliquefrance.fr.

[36] 1990-2022 Recensement de la population - 2023-2025 Estimations localisées de population. Institut national de la statistique et des études économiques (INSEE).

[37] ScanSanté. Taux de recours MCO par Territoire de Santé.

[38] Z.C. Compaore, E. Monnet, A. Gerazime, F. Molinie, A.V. Guizard, P. Delafosse, et al., To what extent do age, stage and treatment influence survival after invasive cervical cancer: a French population-based study, Cancer Causes Control 33 (2022) 403-415.

[39] C. Joachim, J. Deloumeaux, E. Chirpaz, M. Imounga-Desroziers, M. Boullard, J. Macni, et al., Survie des personnes atteintes de cancer en Martinique 2008-2018, Institut national du cancer, février, Boulogne-Billancourt, 2024, p. 43. Disponible à partir des URL: e-cancer.fr et santepubliquefrance.fr.

[40] D. Cibula, R. Potter, F. Planchamp, E. Avall-Lundqvist, D. Fischerova, C. Haie-Meder, et al., The European society of gynaecological oncology/European society for radiotherapy and oncology/European society of pathology guidelines for the management of patients with cervical cancer, Virchows Arch. 472 (2018) 919-936.

[41] F. Najioullah, M.J. Dorival, C. Joachim, C. Dispagne, J. Macni, S. Abel, et al., Genotype distribution of cervical HPV among Caribbean women in a population-based study in Martinique: the DEPIPAPUFR study, PLoS One 16 (2021) e0257915.