141 st APHA Annual Meeting November 2013 Richard A. Crosby, PhD University of Kentucky College of Public Health Department of Health Behavior

(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Richard A. Crosby, PhD Dr. Crosby served as a paid consultant for Merck Pharmaceuticals in Dr. Crosby is also a co-investigator on an investigator-initiated research project awarded to the University of Kentucky (E. Cohen, PI; MISP# 50154, ) by Merck Pharmaceuticals.

This presentation was supported by Cooperative Agreement Number 1U48DP from the Centers for Disease Control and Prevention (CDC). The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the CDC.

The Rural Cancer Prevention Center (RCPC) is a planned collaboration of community members, public health professionals, and researchers designed to reduce the health disparities associated with cervical, breast, and colorectal cancer among residents of the Kentucky River Health District in Appalachian Kentucky.

1.4 million new cases of low-grade cervical dysplasia 2 4,030 estimated deaths 1 Estimated Annual Burden of Cervical Abnormalities in the U.S. 360,000 new cases of genital warts 3 330,000 new cases of high- grade cervical dysplasia 2 12,340 new cases of invasive cervical cancer 1 1. American Cancer Society. Cancer Facts and Figures Atlanta, Ga: American Cancer Society. 2. Schiffman M et al. Arch Pathol Lab Med. 2003;127:946– Centers for Disease Control and Prevention. Genital HPV Infection – Fact Sheet. Atlanta, Ga: Centers for Disease Control and Prevention.

 Cervical cancer incidence and mortality rates have decreased 67% over the past 3 decades, with most of the reduction attributed Pap testing!  One of the most reliable and effective cancer screening tests available.  Between 60%-80% of women with advanced cervical cancer have not had a Pap test in the past 5 years.

Kentucky Cabinet for Health and Human Services (US). Kentucky Area Development District (ADD) Profiles: 2010 Behavioral Risk Factor Surveillance System (BRFSS) [Internet]. Frankfort (KY).

Lack of transportation Low income and education levels Embarrassment Healthcare provider shortages Lack of continuity of care

 A recent literature review revealed that self-collected cervico-vaginal samples for high-risk HPV testing are comparable to physician-collected samples in terms of accuracy in detecting cervical intraepithelial neoplasia grade 2 (CIN2) or higher  High rates of reported acceptance for self- administered cervico-vaginal specimen collection among various populations of women ◦ 75-93% ◦ Women living in low-resource settings both domestically and abroad ◦ Urban areas

The purpose of this exploratory study was to determine whether Appalachian Kentucky women would be amenable to self-collecting a cervico-vaginal specimen for HPV testing. Secondary purpose: implement and track the results of a patient counseling and navigation intervention promoting guideline-recommended cervical cancer Pap smear screening among all women participating in the study. Vanderpool et al. Self-Collecting a Cervico-Vaginal Specimen for Cervical Cancer Screening: An Exploratory Study of Acceptability Among Medically Underserved Women in Rural Appalachia. Gynecologic Oncology, in press.

 In November 2011, women were recruited over 6 separate days from a free primary care clinic in southeastern Kentucky.  Inclusion Criteria ◦ Women aged ◦ Not currently pregnant ◦ Not been screened for cervical cancer in the past 4 years ◦ Never tested positive for HPV  Women completed brief, self-administered questionnaire

 Women given written/verbal instructions for using the Fisherbrand * Cervex-Brush * Cervical Cell Sampler ◦ Results analyzed using the Digene Hybrid-Capture 2 HPV DNA Test which detects the presence of ≥1 of 13 types of high-risk HPV infection  Women were informed of results and referred for Pap screening according to current screening guidelines. ◦ Investigators offered patient navigation assistance, including facilitation of transportation and appointment support.  Follow-ups calls were made 2 months post-results notification ◦ Determine if Pap test appointments had been scheduled ◦ Ascertain if women had discussed test results with others

Characteristic N (%) Age (years) Mean (SD)38.5 (7.6) Range Race/Ethnicity Caucasian 31 (100) Income <$25, (77.4) >$25,000 7 (22.6) Health Insurance (n=30) Yes 17 (56.7) No 13 (43.3) Marital Status Single 8 (25.8) Married 18 (58.1) Separated/Divorced/Widowed 5 (16.1)

CharacteristicN (%) Current cigarette use (n=30) Yes 22 (73.3) No 8 (26.7) Lifetime Male Sex Partners (number) Mean (SD) Range 7.06 (5.6) 0-20 Past 12 Months Male Sex Partners (number) Mean (SD) Range 1.13 (.56) 0-3 Sex with male who had concurrent partners (n=30) Yes 5 (16.7) No 26 (83.3)

CharacteristicN (%) Ever had a Pap smear Yes 28 (90.3) a No 3 (9.7) Cervical Cancer Knowledge and Perceived Barriers to Gynecological Care Cervical cancer is caused by HPV 27 (87.1) Some or very little trust in doctors and healthcare system (n=30) 9 (30.0) No time to visit a gynecologist 9 (29.0) Very afraid of developing cervical cancer 12 (38.7) a 19.4% of women reported having at least one abnormal Pap smear result.

 Of the 31 women, five (16%) tested positive for oncogenic HPV. ◦ All 5 women reported history of Pap testing ◦ Two reported history of an abnormal Pap  No indeterminate findings, suggesting all of the women used proper self-collection methods.  Higher rates of navigation among high-risk HPV positive women compared to those testing negative.

 This novel, exploratory study found 100% acceptance of self- collecting cervico-vaginal specimens for HPV testing among a high-risk population of medically underserved women in Appalachian Kentucky.  Higher acceptance rate compared to previous studies ◦ We believe women found self-collection to be a favorable alternative to traditional, provider-performed Pap testing  Convenience, ease, privacy, brevity, and less invasive nature ◦ Recruited from a trusted healthcare clinic ◦ Women were aware that they were overdue for Pap test: tipping point ◦ APRN is indigenous to the community ◦ Women encouraged others to participate: family members, coworkers, and other acquaintances

 Self-collection may be useful for this rural population as an initial screening, as has been previously established in other low-resource areas. ◦ Likely that a greater number of cases would be identified in the application of a two-stage screening method (self-collection followed by Pap test) in a larger clinic or community sample. ◦ Results of our larger study of 400 women are forthcoming.  Tailoring alternative cancer screening strategies to meet complex needs of medically underserved rural women is likely to reduce the burden of cervical cancer among this vulnerable population.

Thank you!