Report from Cervical Cancer Committee

Maryland State Cancer Plan

Strategies for Improving the Control of

Cervical Cancer in Maryland

Background Information - The Good News

Cervical Cancer is a Uniquely

Controllable Cancer

Thanks to: Good Understanding of Viral Pathway

Effective Diagnostic Tools (Pap Test)

Effective Treatment Tools

Ability to Diagnose and Begin Treatment at a Pre-cancerous Stage

More Good News

Burden of Cervical Cancer in State is relatively low

In 1999, in Maryland:

226 women diagnosed with invasive cervical cancer

77 women died from cervical cancer

Enormous improvement Since 1960’s with Pap Test

Programs such as the CDC Breast and Cervical Program in place and highly effective

BUT: Have we gotten too complacent

about cervical cancer?

Some women remain unscreened, and some cases receive less than optimal treatment

New Maryland populations represent new risk groups for the disease

We have a new understanding of the role of infectious agents, and different types of risk (HPV)

Can we count on mortality rates continuing to decrease?

Our Committee Set An

Ambitious Goal: To Reduce

Cervical Cancer Mortality

in Maryland by 50% by 2010.

How Can We Best Do That?

“It is a truism of all public health programs that

the closer one comes to full effectiveness, the

costlier will be the achievement of the last few

percentage points of success.”

Anthony Miller, American Journal of Public Health, 1995.

In Order to Plan and Use Resources Wisely -

If all Invasive Cases and Deaths Represent Failures,

We Need to Know:

What Proportion Represent Failures of Detection?

Who Are Those Women? What Can Be Done?

What Proportion Represent Failures of Treatment?

Who Are Those Women? What Can Be Done?

The First Task

Establish a Statewide Follow-Back Study Mechanism

Long Term Goal: On-going Monitoring of Failures Through Follow-Back

Ability to Evaluate and Modify Intervention Strategies

Prior Examples: Connecticut, New York, Hopkins

Problem – Failure of Detection:

Women who have not been screened in the past five years may be at risk for cervical cancer

BRFSS shows 85% of Maryland women report a Pap in past 3 years. This proportion is not increasing.

Groups at High Risk for Poor Screening Include:

Older Women

New Populations to Maryland

Low Resource Populations: uninsured, fewer years of school, low income.

Where could we capture these women?

•Inpatient Visits

Maryland law requires offer of Pap Test

Hopkins experience with inpatient screening shows high rates of abnormalities are found among inpatients

•Emergency Room Use

University of Maryland experience shows high abnormal rates among ER users also

Although follow up is difficult, these in-reach strategies do capture under-screened, high risk women

•Care by Providers who are not Ob-Gyns

Problem – Failure of Treatment:

After a Non Negative Pap Test, Diagnosis and Treatment may not Follow Best Practices

Some women may go without necessary care

Providers may be over-testing or treating other women

Local resources may be overburdened, or misused

Example: Long waiting times in some areas for diagnostic procedures such as colposcopy – Are all women who are referred actually needing this test?

Solutions:

Disseminate ASCCP* management guidelines to all providers who treat or manage women with cervical abnormalities.

(*American Society for Colposcopy and Cervical Pathology)

Continuously disseminate up-to-date recommendations as new information is known.

Determine true volume of need, and investigate ways to bring colposcopy services to underserved areas of the State.

Continue to identify strategies for reducing barriers to completing work-up and treatment.

Take-Home Message: Three Reasons Why

Cervical Cancer Control Is So Important

#1: Cervical Cancer Rates are Important

Indicators of Maryland’s Health

In 2002, no woman in the US should die of cervical cancer

40 years after the introduction of the Pap test, women who fall through the cracks with invasive cervical cancer represent substandard cancer control

Even a few women each year is too many

Understanding these failures may lead to better approaches to health disparities overall

#2: Addressing Cervical Cancer Can

Address A Range of Women’s Health Needs

Many health problems facing women in Maryland require addressing gynecological health across the entire life-course, not just during childbearing.

Approaches to HIV/AIDS, STDS, and other health problems can be combined with controlling cervical cancer, to bring better health to Maryland women.

# 3: Lessons Learned In Cervical Cancer Control

Are Important to Other Cancers

Strategies and Solutions We Test for Cervical Cancer

•Creative In-reach and Out-reach Mechanisms

•Removing Barriers along Treatment Pathways

•Initiatives to Disseminate and Implement Best Practices

•Approaches Tailored to Diverse Populations

Can Help Us Tackle Those Issues in More Common Cancers