Cervical Cancer Prevention

Francisco García, MD, MPHAssociate Professor

Obstetrics & GynecologyEpidemiology & BiostatisticsMexican-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.

1958 1965 1972

60

40

20

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, 1950-945-year rates, white females

0

2

4

6

8

10R

ate

/ 10

0,00

0

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 1990-2001

White Non-Hispanic Population

Cervical cancer mortality rates 1990-2001

Black

Cervical cancer mortality rates 1990-2001

Hispanic

AZ Cervix Cancer Mortality

DIFFERENCES IN THE HEALTH STATUS AMONG ETHNIC GROUPS, ARIZONA 2003. Arizona Department of Health Services

Cancer Screening Examinations, Adults, by American Cancer Society Guidelines, 2000 and

2001

81

82

83

84

85

86

87

88

Pap Test

Cervical Cancer, 2000

Per

cen

tag

e

% Hispanic

% White, non-Hispanic

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

--- NHIS, 2005

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

15 - 30% = sampling error

5 - 20% = screening error

Histologic Classification Cervical Neoplasia

NormalCIN 1--Mild dysplasia; includes condylomaCIN 2/3--Moderate/severe dysplasia/CISCancer--Invasive disease

NormalCIN 1

(condyloma)

CIN 1(mild dys)

CIN 2 (mod dys)

CIN 3(severe dysplasia/CIS)

Invasive Cancer

Basal cell

Basal membrane

0–1 Year 0–5 Years 1–20 Years

Invasive Cervical Cancer

Cleared HPV Infection

1. Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362.

CIN 1

InitialHPV

Infection

ContinuingInfection

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

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

520 626 8539

fcisco@u.arizona.edu