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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
