1. Brevard County Health Department: Heidar Heshmati M.D., M.P.H., PhD, Director

2. Cervical Cancer: Screening and Follow-up Presented By R. Bruce Pierce, MN, ARNP Director of Community Health Brevard County Health Department, Florida

3. Demographics Suburban HD: County population 500k County is 72 miles long and 15 miles wide Three clinic sites: Multiple services including FP, OB, STD, Peds Cervical cancer screening primarily in FP and Maternity clinics, some STD High Risk population: Multiple partners, STD’s, low socioeconomic

4. Background/Problem Pap screening long standing service in HD Cervical Ca100% curable if early ID and Tx BCHD 6 - 7,000 screenings per year Abnormality rates fluctuate but >10% (700/yr) Problem: Frustration in inability to get Dx and Tx services for our clients; we found it, therefore we feel a responsibility

5. Question How provide expensive services for population with limited resources? Is it worth pursuing?....YES What we already had: 1. Screening program 2. Desire 3. Qualified Staff What we needed: 1. Additional training 2. Funding/equipment

6. Problem: Scope 10-30% paps abnormal (600-2300/yr) Needed Dx and Tx services (200-700/yr) Private sector cost precludes service ~$ 300 for in-office colposcopy ~$ 300 for in-office cryocautery ~$ 600 for in-office Looped Electro Excision Procedure (Paradigm shift to Out Pt surgery $$$$$)

7. A Solution: Training Partnership with Regional Training Center (RTC) for Family Planning 1. Sent ARNP for training in 1996 2. Sent two more ARNP’s in 2001 All training expenses paid for through Title 10 funding. Cost to the HD was time Through a grant opportunity RTC able to provide an additional colposcopy and bx instruments

8. A Solution: Funding Partnership with Holmes Regional Medical Center (local hospital) Key Players: 1. Women’s advisory board 2. CEO of the hospital 3. Oncology Department Chair 4. OB/GYN’s 5. HOPE: Health Outreach Prevention Education

9. A Solution: Funding Original request was for $50K to include new equipment and staff cost. (one year) Second year was for $20K to sustain program Subsequent years have been funded from general revenue due to commitment of Senior leadership and success of program. Minimal Medicaid, EMBRACED billings

10. Service/Cost Services are provided County-wide Colposcopy – Cryocautery – LEEP LEEP: Pay $75/hr or $300/session for PMD consultant once per month = $3600/yr, 40 LEEP/yr = $90/LEEP (MD) Cryocautery done by ARNP’s (existing staff) Residents help with colpo – OB program

11. Service/Cost ARNP’s screen at the busiest site Income eligible for hospital outreach referrals (HOPE etc): no pay and hospital pays pathology at their institution Sliding fee for HD patients or Medicaid/Embrace Local pathologists essential - $25/container

12. Program Highlights Began in 1993 – bare bones, colpo/bx 1996 - First ARNP trained 1997 - Need became greater and funding sought for equipment and service – enabled expansion of service to other sites 1999 - OB/GYN left our practice, but retained as contract provider for LEEP 1999 – OB residents added to practice to continue with colpo/cryo services

13. Program Highlights 2000 new lab for paps – abn dropped from 30% to 10% (missing dz or closer to Nat'l standard?) Average about 50 high grade lesions – carcinoma in-situ per year (need tx) Average about 500 colposcopies/yr 1993- 2004 and still going strong

14. Results???

15. Lessons Learned Have a vision – be clear and well defined Sell it to your organization first – must believe not only in idea, but people Be flexible – a must in public health Do not lose sight of taking care of people – it truly is all about service