Cervical Cancer: an Odyssey Israel De Alba, MD MPHPresidentAmerican Cancer Society California Division

400 BCE

Cure sometimes, treat often, comfort always.

Hippocrates

What is the cause of this disease?

How can I cure it?

How can I prevent it?

Cervical Cancer

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane." — Martin Luther King Jr.

Italy, circa 1750

• cervical cancer rare in nuns

• Common in sex workers

• Common in second wives of men whose first wives died of cervical cancer

• Rare in Jewish women

PapanicolaouTest

• Colposcope invented

• Papanicolaou Technique

• Pap smear screening

• Prevention

He-La

HPV

Transformation

The HPV virus

HPV

HPV

HPV in men

RESEARCH

Research

Research

background

• Latinas have the highest incidence of cervical cancer in California.

• Despite recent progress in Pap smear use, multiple barriers to screening persist among Hispanic women.

• Many of those barriers are: – lack of time, child care, or transportation. – Scheduling conflicts (office closed in PM or weekends)– Modesty

• Testing positive for a sexually transmitted virus that may lead to cervical cancer – May provide women with a compelling motive to get screened for cervical cancer

and may help overcome some of the barriers to cervical cancer screening.

AIMS

1. How does self sampling compare to physician sampling at identifying abnormal Pap smears?

2. How satisfied or comfortable are Latina women with self-sampling for HPV?

3. Are women who test positive for HPV more or less likely to get a Pap smear?

Methods

• Hispanic women >18, no recent Pap• Community workers distributed self sampling

kits• Participants collected samples on their own– Vaginal sample– At any time or place (home or at site)– Return sample to lay health worker for processing

• All HPV+ and one HPV negative control were invited for:– Pap smear– Repeat HPV sample collected by the physician

Results: demographics

• 1,213 women included• 386 had Pap smear and physician

collected sample for HPV• Mexican/Mexican American origin

(89.4%)• Age distribution• 18-34 y.o 31%• 35-49 y.o. 48%• 50 or older 21%

• Pap test between 1-2 years prior 78.3%

• 13.6%had a positive result for HPV on self sampling

How self-sampling and physician sampling compare to each other?

• 87.8% had same HPV result in self and physician sampling

• Self sampling as compared to physician sampling at identifying high risk HPV– Sensitivity 93%– Specificity 88%

How satisfied are Hispanic women with self-sampling?

Table 3

Satisfaction with self sampling for HPV testing among Hispanic women (N = 1,213)

Excellent

(%)

Very Good (%)

Good

(%)

Fair

(%)

Overall experience

33.7

30.8

32.9

2.4

Clarity of instructions for using the kit

48.6

34.1

16.5

0.7

Ease of use of kit

48.7

34.0

16.5

0.7

Understanding of what the results mean

46.8

36.9

15.8

0.4

Convenience of self-sampling as compared to physician sampling at a clinic

45.3

36.5

16.4

0.2

Are HPV+ by self-sampling more likely to have a Pap ?

• While 95% of the HPV positive scheduled a Pap smear, only 69% of the HPV negative did (p < 0.0001).

• Among all women, 84% of the HPV+ received a Pap smear as compared to only 49% of the HPV- (p<0.0001).  

Summary

• Almost 9 out 10 had same result on self and physician sampling

• The sensitivity of self sampling for identifying high risk HPV was 88%

Summary

• Satisfaction was high with self sampling

• Testing positive for HPV favorably impacts scheduling and receipt of Pap smears among Hispanic women.

• Among women with no Pap smear in the past three years or ever, a positive HPV test result increased the likelihood of scheduling or receiving a Pap smear.

Implications

• Self sampling for HPV at home or in a non-clinical site may be an alternative to physician sampling

• It may provide an additional tool for cervical cancer control

• As a tool for cervical cancer screening where Pap smears are not easily available

• For screening in women who refuse pelvic exam or in those with other barriers like time constrains, lack of transportation, etc

HPV Vaccine

What is the cause of this disease?

How can I cure it?

How can I prevent it?