Cervical Cancer: Disparities and Models of Steps Toward a Solution
Marvella E. Ford, PhD
Associate Director for Cancer Disparities, Associate Professor, Medical University of South Carolina, Hollings Cancer Center, Charleston, South Carolina
The vaccine is new – long term results are not known, although 5-year results show no adverse effects. Gardasil only protects against HPV types 16 |~|/files/powerpoints_images/node251971/Slide3.JPG|~|563|~|422|~|0
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The vaccine is new – long term results are not known, although 5-ye...
For most women, the body’s own defenses will clear HPV and will not lead to health problems. Visual inspection of the genital tract is the most important tool for detection.|~|/files/powerpoints_images/node251971/Slide4.JPG|~|563|~|422|~|0
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For most women, the body’s own defenses will clear HPV and will not...
Multiple sex partners OR a partner with multiple sex partners.|~|/files/powerpoints_images/node251971/Slide6.JPG|~|563|~|422|~|0
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Multiple sex partners OR a partner with multiple sex partners.
Smoking may contribute to the process: concentration of carcinogens. Routine Pap test can provide early detection.|~|/files/powerpoints_images/node251971/Slide7.JPG|~|563|~|422|~|0
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Smoking may contribute to the process: concentration of carcinogens. ...
This chart shows that African American women have almost double the incidence of cervical cancer than white women AND are 2.5 times more likely to die of this disease.|~|/files/powerpoints_images/node251971/Slide8.JPG|~|563|~|422|~|0
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This chart shows that African American women have almost double the i...
At any time, if abnormal results are found, Pap test screenings will increase for the individual. The Pap test, or Pap smear, is a way to check cells from the cervix (the lower part of the uterus or womb) and the vagina. This test can find precancerous changes or cancer of the cervix or vagina. A Pap test will only rarely detect cancer of the ovaries or cancer of the upper part of the uterus (endometrial cancer). It can also find some infections of the cervix and vagina. A newer method called liquid-based cytology, or liquid-based Pap test, can remove some of the mucus, bacteria, yeast, and pus cells in a sample and can spread the cervical cells more evenly on the slide. Instead of being directly placed on a slide, the sample is placed into a special preservative solution. This new method, also known by brand names ThinPrep or AutoCyte, also prevents cells from drying out and becoming distorted. Recent studies show that liquid-based testing can slightly improve detection of cancers, greatly improve detection of precancers, and reduce the number of tests that need to be repeated. This method is more expensive than a usual Pap smear. |~|/files/powerpoints_images/node251971/Slide10.JPG|~|563|~|422|~|0
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At any time, if abnormal results are found, Pap test screenings will ...
Caucasian4,016 3.2% (N=129)African American1,2444.3% (N=54)Hispanic1063.1% (N=3)Established in 1984 by the Centers for Disease Control and Prevention (CDC), the Behavioral Risk Factor Surveillance System (BRFSS) is a state-based system of health surveys that collects information on health risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury. For many states, the BRFSS is the only available source of timely, accurate data on health-related behaviors. Currently, data are collected monthly in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. More than 350,000 adults are interviewed each year, making the BRFSS the largest telephone health survey in the world. States use BRFSS data to identify emerging health problems, establish and track health objectives, and develop and evaluate public health policies and programs. Many states also use BRFSS data to support health-related legislative efforts. This table represents only a small portion of the SC population. Think of these percentages magnified over the entire population.Clearly a number of women of all ethnicities in SC are not getting screened for cervical cancer. The cancer disparity must improve in SC as well as the screening rates of all races in SC.|~|/files/powerpoints_images/node251971/Slide11.JPG|~|563|~|422|~|0
These investigators developed models to address barriers to care and provide alternative methods for cervical cancer screening and awareness. I will now describe the models they used.|~|/files/powerpoints_images/node251971/Slide12.JPG|~|563|~|422|~|0
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These investigators developed models to address barriers to care and ...
Prior to establishing the Deep South Network, there was little or no infrastructure for cancer control in African American communities in Mississippi. Alabama had more infrastructure due to the NCI-designated Comprehensive Cancer Center at The University of Alabama at Birmingham, which included several community outreach and education projects. Rural and urban areas were included in the Deep South Network. Rural areas included the Mississippi Delta and the Black Belt of Alabama. Urban Mississippi areas were Hattiesburg in Mississippi, and Laurel in Jones County. The urban Alabama area was Jefferson County, home of the University of Alabama at Birmingham. |~|/files/powerpoints_images/node251971/Slide13.JPG|~|563|~|422|~|0
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Prior to establishing the Deep South Network, there was little or no ...
The Community Health Advisor (CHA)model is based on the premise that in every community, there are “natural helpers” to whom others go for advice and assistance. The CHA model identifies, recruits, and trains volunteer natural helpers to enhance their innate abilities and knowledge of health issues. The CHA program involves building linkages between community members, local service providers, and formal community leaders. The CHA model was used to develop a volunteer, grassroots community infrastructure of CHAs to disseminate cancer awareness information and conduct community action planning for improved knowledge of community resources and better access to breast and cervical cancer screening and treatment. Community members thus develop ownership of problems and develop solutions to bring about community health improvement. The Empowerment Theory calls for transforming the research relationship so that communities are viewed as partners rather than as objects of study. The coalition-building model was used to build partnerships within communities and on a statewide level.|~|/files/powerpoints_images/node251971/Slide14.JPG|~|563|~|422|~|0
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The Community Health Advisor (CHA)model is based on the premise that ...
The Community Health Advisor (CHA) model is used to develop grassroots community infrastructure of volunteers for training. The CHA model notes that every community has people that others go to for advice and action. The CHA model seeks to identify such persons in the community, as to train “natural helpers.”The Empowerment theory transforms the relationship of research and community. Identifies that a community as a whole can come together to discuss problems, effects of a problem, and problem-solving. |~|/files/powerpoints_images/node251971/Slide15.JPG|~|563|~|422|~|0
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The Community Health Advisor (CHA) model is used to develop grassroot...
The trainees determined which methods would work best in their communities. By training people from a particular community, you get cancer awareness education tailored to that communities interests or needs.|~|/files/powerpoints_images/node251971/Slide16.JPG|~|563|~|422|~|0
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The trainees determined which methods would work best in their commun...
The pre/posttests each contained 20 questions to assess knowledge about breast and cervical cancers, including their prevention and prevalence among African Americans. Questions were also asked regarding the purpose and administration of clinical trials. Talking circles - Smaller than focus groups, TCs allowed CHAs to feel comfortable communicating their thoughts about the program. CHAs stated that they expected the following things from Deep South Network support staff: open lines of communicationgrant money/stipendsprint materials (e.g., pamphlets)Videotapes, posters, and chartsbreast modelstechnical supportand up-to-date information|~|/files/powerpoints_images/node251971/Slide17.JPG|~|563|~|422|~|0
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The pre/posttests each contained 20 questions to assess knowledge abo...
- 1,000 volunteers were recruited by community leaders and Deep South Network County Coordinators. 883/1,000 completed the training. NOTE: Since this paper was published, 317 additional CHA volunteers have been trained, for a total of 1,200 trained CHA volunteers. - Volunteers went through an 8 week training period (2 hours per week) in breast and cervical cancer awareness information, problem-solving action skills, and the importance of clinical trials research. After training, they attended monthly maintenance meetings during which they received - Retention strategies of the CHAs over the 5-year study period: expenses paid to attend conferences, door prizes, refreshments/dinner, special recognition, celebration of birthdays, holiday cards, and opportunities for sharing talents with other CHAs.- 26 were Caucasian and 2 were of other racial/ethnic backgrounds (not reported)|~|/files/powerpoints_images/node251971/Slide18.JPG|~|563|~|422|~|0
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- 1,000 volunteers were recruited by community leaders and Deep South...
The talking points were:1. All women are at risk for breast cancer2. Finding cancer early saves lives3. Get a mammogram every year4. Get a Pap test every year5. Clinical trials are keys to winning the war against cancer6. Cancer… there is hope!|~|/files/powerpoints_images/node251971/Slide21.JPG|~|563|~|422|~|0
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The talking points were:1. All women are at risk for breast cancer2. ...
The need to collect community-level baseline evaluation dataThe importance of careful selection, training, and support of staffThe importance of frequent communication with volunteers, especially regarding the program’s evolving scope and activitiesThe value of frequent meetings to build camaraderie among volunteers and staff |~|/files/powerpoints_images/node251971/Slide24.JPG|~|563|~|422|~|0
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The need to collect community-level baseline evaluation dataThe impor...
Inadequate funding for program staff and for CHA travel/training Transportation barriersPublic misconceptions and fears about cancer and cancer clinical trialsLimited outreach in much of the area outside of the designated countiesToo few providers for screening and treatment in many geographic areasThe need for sustainable funding sources for outreach and navigation activities|~|/files/powerpoints_images/node251971/Slide26.JPG|~|563|~|422|~|0
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Inadequate funding for program staff and for CHA travel/training Tran...
SAFe = Screening Adherence Follow-Up intervention model.Cervical cancer incidence and mortality rates are higher among women with low income than in the general population, in part due to poor adherence to recommended diagnostic follow-up after an index Pap test. |~|/files/powerpoints_images/node251971/Slide27.JPG|~|563|~|422|~|0
Screening Adherence Follow-Up Program (SAFe), an individualized, structured case management program designed to assess for and intervene in response to a variety of potential personal and systems barriers to follow-up adherence. Interventions included health education, counseling, and systems navigation.A clinical decision-making algorithm was used to determine service intensity and level of intervention. Services were provided to 196 predominantly Latina women with low income who had either a low-grade or high-grade squamous intraepithelial lesion (LGSIL or HGSIL) abnormal Pap result.Rationale: cervical cancer |~|/files/powerpoints_images/node251971/Slide28.JPG|~|563|~|422|~|0
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Screening Adherence Follow-Up Program (SAFe), an individualized, stru...
Women with low-grade squamous intraepithelial lesions (LGSIL) and HGSIL) (Bethesda system classification) who were prescribed follow-up repeat screening (within 1 year of the date of the index Pap), diagnostic tests, or treatment, were eligible to be recruited into the study after the medical provider had notified them of the results of their screens. Up to 5 telephone attempts were made plus one mailed invitation to call the study coordinator before a women was considered to be a non-enrollee.Women who had already completed an initial follow-up appointment were enrolled if they were prescribed additional follow-up visits or preventive treatment or had a cancer diagnosis. |~|/files/powerpoints_images/node251971/Slide29.JPG|~|563|~|422|~|0
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Women with low-grade squamous intraepithelial lesions (LGSIL) and HGS...
Project SAFe incorporates a multifaceted intervention aimed at reducing both patient and health system barriers to follow-up care. Baseline intervention includes individualized scripted assessment and health education counseling responses. A baseline clinical decision-making algorithm is used to distinguish the women who require more intensive follow-up interventions from those who do not and to assign a level of service consistent with individually assessed barriers.|~|/files/powerpoints_images/node251971/Slide30.JPG|~|563|~|422|~|0
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Project SAFe incorporates a multifaceted intervention aimed at reduci...
The group of non-enrollees (n=369) included study-eligible women who could not be located (n=313, 55% of eligible women) and women who refused consent to participate or declined services (n=56, 10% of eligible women)Low-grade or high-grade squamous intraepithelial lesion (LGSIL or HGSIL)A significantly higher proportion of women with HGSIL (s. LGSIL) was found in the enrollee group (chi-square – 6.043, df 1, p = 0.016). More African American women were represented among non-enrollees (11% vs. 4%, OR = 3.2; 95% CI 1.4-7.3; p = 0.006).|~|/files/powerpoints_images/node251971/Slide32.JPG|~|563|~|422|~|0
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The group of non-enrollees (n=369) included study-eligible women who ...
- Fully adherent = keeping all prescribed follow-up appointments after enrollment and baseline intervention- Partially adherent = keeping at least one appointment- Nonadherent = keeping no appointmentsCase managers addressed patient and health system barriers to adherence. Problems frequently reported by enrollees:1. Clinic system problems (21% of enrollees, n= 41)2. Minor depression or anxiety complaints (15%, n=29)3. Other systems navigation problems (14%, n=27)4. Financial or insurance-related concerns (13%, n=26)5. Other concerns (e.g., housing or employment-related issues, 31%, n=61)|~|/files/powerpoints_images/node251971/Slide34.JPG|~|563|~|422|~|0
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- Fully adherent = keeping all prescribed follow-up appointments afte...
SCDHEC Family Planning Services-Offers a yearly Pap test for women using the family planning service-Charge for service based on Medicaid eligibility and a sliding-scale fee-Federal money used for women with no income and not Medicaid eligibleSC Breast and Cervical Cancer Early Detection Program: Best Chance Network-Funded by the CDC-Coordinated by SCDHEC and the American Cancer Society-Provides free cervical and breast cancer screening to eligible womenSC Medicaid Breast and Cervical Cancer Program-SC Dept. of Health and Human Services, in agreement with BCN and SCDHEC-Executes the Breast and Cervical Cancer Prevention and Treatment Act of 2000-One million dollars in state funds -Provides treatment to women outside of BCNCancer Health Initiative-Palmetto Health’s Certificate of Public Advantage (COPA)-Community outreach in the Midlands and Pickens County-Cervical cancer screening to women aged 21-64 years old and below 200% of poverty-Yearly screenings and referral to a primary health provider in the presence of abnormal test results-Financial arrangements are made with the follow-up physician|~|/files/powerpoints_images/node251971/Slide38.JPG|~|563|~|422|~|0
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SCDHEC Family Planning Services-Offers a yearly Pap test for women us...
Lecture on Cervical Cancer and Health Disparities. The Deep South Network for Cancer Control and the Screening Adherence Follow-Up intervention model is described.
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Abstract
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References
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