Cervical Cancer Prevention Francisco García, MD, MPH Associate Professor Obstetrics & Gynecology Epidemiology & Biostatistics Mexican-American Studies

Objectives What is cervical cancer What causes cervical cancer How do you prevent cervical cancer

The Cervix

What is Cervical Cancer?  Most common gynecologic malignancy worldwide  US--about 10,520 new cases of invasive cervical cancer, and 3900 cancer deaths  Disproportionately affects poor women and communities of color

Global Cervical Cancer Cases

Cervical Cancer Incidence in the U.S. Incidence of cervical cancer has dramatically declined since the Pap Reprinted by permission of the American Cancer Society, Inc.

Screening Index (%) US Screening for Cervical Cancer

Cervical Cancer Life time risk 1/128 5 yr survival rate 73% Long pre-malignant disease Permits screening and early detection

US cervix cancer mortality, year rates, white females

Cervical Cancer Disproportionately affects poor women & women of color –50% in woman who never had a pap –Occurs twice as likely among Hispanics (14.8/100k v. 8.4/100k among whites) –More likely have advanced stage/invasive disease –pre-malignant disease –More likely die from cervical cancer

Cervical cancer mortality rates White Non-Hispanic Population

Cervical cancer mortality rates Black

Cervical cancer mortality rates Hispanic

AZ Cervix Cancer Mortality DIFFERENCES IN THE HEALTH STATUS AMONG ETHNIC GROUPS, ARIZONA Arizona Department of Health Services

Cancer Screening Utilization:

Percentage of Women Aged Who Had a Pap During the Preceding 3 Years, by Age Group and Education Level --- NHIS, 2005

Breast & Cervical Cancer Screening by Race, Income & Education

Trends in Recent* Pap Test Prevalence (%), by Educational Attainment and Health Insurance Status, Women 18 and Older, US, * A Pap test within the past three years. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for women 25 and older. Source: Behavior Risk Factor Surveillance System CD-ROM ( , , 1998, 1999) and Public Use Data Tape (2000, 2002), National Center for Chronic Disease Prevention and Health Promotion, Center for Disease Control and Prevention,1997, 1999, 2000, 2000, 2001, Women with no health insurance Women with less than a high school education All women 18 and older

Problems with Pap Smear Screening 50-60% are due to a failure to screen 10-15% due to inappropriate follow-up 35% are errors in sampling / evaluation % = sampling error % = screening error

Histologic Classification Cervical Neoplasia Normal CIN 1--Mild dysplasia; includes condyloma CIN 2/3--Moderate/severe dysplasia/CIS Cancer--Invasive disease Normal CIN 1 (condyloma) CIN 1 (mild dys) CIN 2 (mod dys) CIN 3 (severe dysplasia/CIS) Invasive Cancer Basal cell Basal membrane

0–1 Year0–5 Years1–20 Years Invasive Cervical Cancer Cleared HPV Infection 1. Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362. CIN 1 Initial HPV Infection Continuing Infection CIN 2/3 Natural History of Cervical Cancer

Normal Nulliparous Cervix

Normal Multiparous Cervix

Pre-invasive Disease Identified through screening Pap with or w/o HPV Diagnosis made with colposcopy and biopsy Asymptomatic

Low-grade Dysplasia (CIN1)

High-grade Dysplasia (CIN 2/3)

Signs & Symptoms of Invasive Disease May be silent until advanced disease Post-coital bleeding Bloody/copious chronic vaginal discharge Abnormal bleeding during/between menses Post-menopausal bleeding Pelvic pain/pressure Unilateral leg swelling/pain Pelvic mass

Cancer

Cervical Cancer Important source of morbidity and mortality for reproductive age women Disproportionately affects minority women and poor women Preventable disease if identified during the pre malignant phase and before invasion Prevention requires access to health care and screening Also requires women to be aware of opportunities for prevention

Pima County Cervical Cancer Prevention Partnership

REACH/Pima County Cervical Cancer Prevention Partnership Women continue to fall through significant gaps in the screening, dx, and treatment safety net Disproportionately affects poor women from communities of color Many partners already addressing different aspects of the cvx ca prevention Meaningful improvement in cvx ca incidence/ mortality requires systemic coordinated effort One death from cervical cancer is one too many!

Specific Challenges Science/practice of cervical prevention advance tremendously recent years Non-industry related patient education materials/health education reflect outdated paradigm Populations most in need of information has the least access to it Prophylactic HPV vaccination makes school districts major players Health care sector may be under prepared for new screening technologies and for the vaccine based cervical cancer prevention

CDC REACH 2010 Contract Address cervical cancer prevention through community-based participatory action grounded in culture/values of Pima County Targets Mexican-American women, but not exclusive of other underserved women 5 years of funding to develop and implement a community action plan Partnership awarded 1/40 new contracts

REACH Objectives 1.Develop/disseminate a cervical cancer prevention lay community health worker training program 2.Implement school-based parent education program to facilitate HPV vaccination decision making 3.Coordinate navigator program to facilitate the diagnosis and treatment 4.Provide technical assistance to public sector entities with evidence based data to inform policy decisions surrounding implementation of HPV vaccination and new screening technologies

Vision Pima County will be a community where women do not die from cervical cancer and instead lead healthy productive lives.

Mission Increase the awareness and knowledge of cervical cancer screening, prevention, and management, as well as to facilitate access to diagnostic and treatment services.

Partners Pima County Health Department FQHCs & CHCs School Districts Community-Based Organizations Elected Officials University of Arizona –Center of Excellence in Women’s Health –University Physicians –Arizona Health Sciences Library –Arizona Cancer Center

Next Steps Community input/guidance Identifying missing stakeholders Turning ideas into actionable items Developing/implementing an action plan Monitoring progress

Preventing Cervical Cancer Informed women Educated providers Access to screening and health care Cervical cancer should be entirely preventable One cervical cancer death is one too many

Francisco Garcia, MD, MPH