Caitlin Richman Epidemiology 4010
Cervical Cancer Caitlin Richman Epidemiology 4010 What is Cervical Cancer?
Lets start first by defining cancer in general. Cancer is a disease in which abnormal cells have uncontrolled growth in the body. The cancer is named by the part of the body where it starts, even if it spreads to other body parts later. There are three ways cancer can spread through the body and they are through tissue, the lymph system and the blood. Cervical cancer is when the cancer starts in cervix. For a brief description of the anatomy of the cervix, the cervix is the lower, narrow end of the uterus. The cervix connects the vagina and the birth canal to the upper part of the uterus. The uterus is where a baby grows and develops when a woman is pregnant. Research has shown Cervical cancer is the easiest gynecologic cancer to prevent by utilizing regular screening tests and follow ups. Other gynecologic cancers include Ovarian, Uterine, Vaginal and Vulvar cancer. When found and treated early, cervical cancer can be highly curable. Stages of Cervical Cancer
Cervical cancer is broken up into 4 stages. Stage 0- Carcinoma in situ, abnormal cells are found in the innermost lining of the cervix. These abnormal cells can become cancer and spread to nearby tissue. Stage I- in stage I cervical cancer, cancer is found in the cervix only. Stage I is divided into stages IA and IB based upon the amount of cancer that has been found. Stage II- in stage II cervical cancer, the cancer has spread beyond the cervix but not to the pelvic wall or to the lower third of the vagina. Stage II is also divided into 2 parts, IIA and IIB based upon how far the cancer has spread. Stage III- Stage III cervical cancer has spread to the lower third of the vagina and/or to the pelvic wall and is causing kidney issues. Stage IV- in Stage IV of cervical cancer the cancer has spread to the rectum, bladder or other parts of the body. Stage IVA is when cancer has spread to the bladder, rectum or nearby organs and Stage IVB is when the cancer has spread to other parts of the body such as the bones, liver, lungs or lymph nodes. Stages of Cervical Cancer
Stage I- IA and IB Stage II- IIA and IIB Copyright 2012 Terese Winslow LLC Stages of Cervical Cancer
Stage IV- IVA and IVB Stage III- IIIA and IIIB Copyright 2012 Terese Winslow LLC History of Cervical Cancer
Cervical cancer was first recorded by the Greek physician, Hippocrates in 400BCE. When he identified it, he declared it to be incurable. As a result, many women died from this disease for over 25 centuries. In 1905, radical hysterectomies were used to treat cervical cancer patients, surgically removing the uterus, cervix and surrounding lymph nodes. Dr. Hans Hinselmann invented the colposcope in this tool allowed doctors to examine the cervix closely to monitor and observe abnormalities so that some cancers could be found in time for surgery to be successful. In 1928, Georgios Papanikolaou could identify abnormal, possibly cancerous cells taken from the surface of the cervix. This was when the real progress began to fight against this cancer. In 1943, the Pap smear was introduced by Papanikolaou as a part of routine testing and it has helped save many lives around the world. It has been estimated that if a woman's cervical cancer is diagnosed by a Pap smear, rather than before the symptoms appear, she has a 92% chance of a full recovery. History of Cervical Cancer
It was noted in the early 20th century that epidemiologists thought that cervical cancer acted more like a sexually transmitted disease. In 1983, this observation was backed up when researchers found that most cervical cancers contained DNA from the human papillomavirus, and a link was established. In 1999, the FDA approved a new DNA based test to better detect the high risk strains of HPV that are known to cause cervical cancer. In 2006, the first HPV vaccine was FDA- approved which has helped decrease the HPV and cervical cancer in women and girls. In 2011, a CDC committee recommended that boys should also get an HPV vaccine to help prevent the spread of HPV to women, and protect against anal, penile and oral cancer. Symptoms of Cervical Cancer
Especially early on, cervical cancer may not cause any visible or noticeable signs or symptoms. When cervical cancer advances, it may cause bleeding or discharge from the vagina that is abnormal. An example of this is bleeding after sex. Below, I have added a chart from the Centers for Disease Control and Prevention that lists all the gynecologic cancers and their corresponding symptoms for reference. Centers for Disease Control and Prevention (2013, September 3) Significance of Cervical Cancer
For women in the United States, cervical cancer used to be the leading cause of death. In the past 40 years, the number of cases of cervical cancer and the number of deaths from cervical cancer have significantly decreased. What is the reason for this decrease? The decrease is result of many women getting regular Pap tests, which finds cervical pre cancer before it turns into cancer. There are also vaccines that have been widely utilized to help prevent the onset of cervical cancer. Cervical cancer is the second most common cancer in women worldwide. All women are at risk for cervical cancer, most often, it occurs in women over the age of 30 and each year an estimated 12,000 women get cervical cancer in the United States. Statistical Data for Cervical Cancer in the United States
So far, 2010 is the most recent year that statistical numbers are available. Prevalence- the number of existing cases of cervical cancer in the United States. There were approximately 250,000 cervical cancer survivors living in the United States as of January 2010. Incidence- The number of new cases of cervical cancer in a population during a certain period of time. In 2010, 11,818 women in the United States were diagnosed with cervical cancer. 3,939 women in the United States died from cervical cancer in 2010. It has been estimated that in 2013, 12,340 new cases of cervical cancer will be diagnosed in women in the United States and an estimated 4,030 women in the U.S. will die from cervical cancer. CDC Statistics for Cervical Cancer (2014) Contributing Factors to Cervical Cancer
The main cause of almost all (99.7%) cervical cancers is Human Papillomavirus (HPV). HPV is a common virus that a person most commonly acquires through sexual activity. It can however be transmitted by skin to skin contact with an area of the body infected with HPV. While at least half of sexually active people will obtain HPV in their lives, few women will get cervical cancer. HPV usually causes no symptoms so it can be very hard to tell if you have it. Some HPV will go away on its own, but if it does not and there is a persistent high risk infection present as well, there is a chance that over time it may cause cervical cancer. Contributing Factors to Cervical Cancer
More risk factors for cervical cancer include: Aging- the persistent high risk infection rate for women older than 55 is 50%, compared with a persistent rate in women younger than 25 of 20%, like mentioned previously, an HPV infection along with another persistent high risk infection can lead to cervical cancer. Sexual activity- early onset of sexual activity, high risk sexual partners, multiple sexual partners and failure to use a condom. Suppressed immune system- A weakened immune system caused by diseases or infections such as HIV or drugs, puts women at a higher risk for HPV infection, ultimately leading to cervical cancer. Smoking- smoking exposes the body to cancer causing chemicals and weakens the immune system. It also increases the risk of squamous cell cervical cancer for women. First full-term pregnancy at a young age- this risk factor in women younger than 17 nearly doubles the risk of developing cervical cancer cancer later in life when compared to women who were 25 and older when they have their first full term pregnancy. Family history of cervical cancer- a women who has a sister or mother with cervical cancer has 2 to 3 times the risk of getting cervical cancer than women without a family history of cervical cancer. Contributing Factors to Cervical Cancer
Multiple full term pregnancies- women with 3 or more full term pregnancies have an increased risk for developing cervical cancer. Possible reasons include hormonal changes and weaker immune systems during pregnancy due to age. Chlamydia infection- there is a higher relative risk of cervical cancer in women whose blood results show current or past infection with chlamydia. Diet and weight-a diet full of fruits and vegetables have been shown to help prevent cervical cancer. Being overweight places women at a higher risk for developing cervical cancer. Diethylstilbestrol (DES)- is a medicine given to some pregnant women in the US from 1940 to 1971 that has been shown to increase the risk of a rare form on cervical cancer in women whose mother took DES while pregnant. Oral contraceptives- research has shown that long term use of oral contraceptives increases the risk of getting cervical cancer. Epidemiological studies have shown that the risk increases with duration and decreases after use ceases. After 10 years of cessation, risk returns back to normal. Descriptive Epidemiology of Cervical Cancer
The descriptive epidemiology for the personal variables of cervical cancer include sex, age, race or ethnic group. Cervical cancer is a cancer only present in women, due to the fact it begins in the cervix, an anatomical body part that only women have. Although all women are at risk, cervical cancer is most commonly found among women over the age of 30 years old. It is reported by the Centers for Disease Control and Prevention (CDC) that more black and Hispanic women develop cervical cancer than women of other races or ethnicities. It is hypothesized that this is because of decreased access to Pap testing or follow-up treatment. I have included a graph to visualize the HPV Associated cervical cancer rates by race and ethnicity in the U.S. This graph was adapted from Centers for Disease Control and Prevention (CDC). Human papillomavirusassociated cancersUnited States, 20042008. MMWR 2012;61(15):258261. Descriptive Epidemiology of Cervical Cancer
The descriptive epidemiology for the time variables include short or long term trends in health and disease. It has been reported that cervical cancers incidence and mortality rates have been declining in most developed countries since the 1960s. This reduction is due to the widespread screening practices as well as an increasing level of gynecological and obstetrical care being offered to women. Although there have been overall declines reported for the crude/ age adjusted incidence and mortality rates in western countries for cervical cancer, there have been increases reported among young women. This increase is reflected upon changes in sexual habits (more sexually active, starting at a younger age, preventative measures such as condoms are not being utilized) and increased transmission of HPV in younger generations. Preventative health education, screening tests and preventative vaccines such as the HPV vaccine are the main focus to help reduce these numbers in young women. Descriptive Epidemiology of Cervical Cancer
The descriptive epidemiology for the place variables include country or city of residence, urban or rural areas and the neighborhood in which one resides. The prevalence of cervical cancer is much higher in developing countries due to the lack of health education, screening tests, such as Pap tests, HPV tests, and HPV vaccines to help prevent contracting HPV and then that becoming cervical cancer. As far as in the western countries, cervical cancer is less prevalent and working towards becoming more controlled due to the medical advances, improving the screening Pap tests, HPV vaccines and health education and making sure these advances are available and accessible to all. Prevalence rates are widespread among western countries, most areas in developed countries are equally affected by cervical cancer, since all women can get cervical cancer. Factors that can affect which areas could be more prone to cervical cancer include Socioeconomic status, availability of resources such as screening tests and HPV vaccines and accessibility to these preventative measures. Because some parts of the western countries have less accessibility to these resources than others, it is important to remember some parts of the country may be susceptible to having more risk factors that contribute and lead to cervical cancer. Prevention Measures There are two tests that have been proven to help prevent cervical cancer: The Pap test (or Pap smear) is designed to look for precancerous cell changes on the cervix that could become cervical cancer if not treated appropriately. The human papillomavirus (HPV) test looks for the virus that causes these cell changes. It is most important to start regular screening tests at the age of 21 and to continue to see your doctor regularly for a Pap test to have the best chance of preventing cervical cancer. Even if you do not think any of the risk factors apply to you, it is still important to continue getting Pap tests to ensure you do not have cervical cancer. It has been mentioned that all women can be at risk for cervical cancer and one should stop getting Pap tests only when directed by a doctor. Prevention Measures There are currently two HPV vaccines available to protect females against the types of HPV that cause most cervical, vulvar and vaginal cancers. These two vaccines can be given to girls as young as 9 years of age. It is very important to remember that women who receive the vaccination against HPV still need to have regular Pap tests to screen for cervical cancer. The two HPV vaccine brand names are Gardasil and Cervarix which are both proven to be highly effective in preventing infection with the types of HPV they are made to target. Gardasil targets the HPV types 6, 11, 16, and 18 while Cervarix targets to prevent against types 16 and 18. Types 16 and 18 are shown to be responsible for around 70% of all cervical cancers. It is important that one becomes vaccinated before engaging in sexual activity, so before they could be exposed to HPV. Even if a person has HPV (one type or another) it is still beneficial to get the HPV vaccine because it can still prevent infection from HPV types that have yet to be acquired. Vaccination to prevent HPV is not a substitute for Pap tests screening. Those are still the most effective way to find changes in the cervix before cancer can develop. Reducing Your Risk Brief recap- what can increase a womans chance of getting cervical cancer? Having HPV Smoking Having HIV or any other health condition that can make it hard for your body to fight off additional health problems Having given birth to three or more children. Being overweight or obese SOwhat can you do to reduce your risk? Along with taking the preventative measures I previously listed, it is important to take these steps as well to reduce your risk of getting cervical cancer. Dont smoke Use condoms during sexual activity Limit your number of sexual partners Follow up with your doctor if your Pap test results are abnormal. Here is a great Info graph from the Centers for Disease Control and Prevention about key ways to prevent cervical cancer. A good summary of all the information I just shared! Control Measures Once one has been diagnosed with cervical cancer, they will be referred to a gynecologic oncologist, who is trained to control and treat cancers of a womans reproductive system. The extent of the disease is referred to as the stage, and there are four main stages, all of which have been previously covered (refer to slides 3-5) There are several ways that have been developed to treat and control cervical cancer. The treatment often received depends on what stage the cervical cancer the patient is in as well as how far it has spread. The CDC mentions 3 main treatment options Surgery- to remove the cancer tissue. Chemotherapy- use of drugs to stop or slow the growth of cancer cells. There are many known side effects of chemotherapy, but they have been reported to get better or even go away after the treatment is over. Radiation therapy- this treatment option uses high energy rays to try to kill the cancer cells and cease them from spreading. Complementary and alternative medicines are also used to help control cervical cancer. Examples such as meditation and yoga are said to be beneficial when used along with standard treatments (complimentary) and Supplements such as vitamins and herbs are examples of alternative medicines some can use. Centers for Disease Control (2014) Interventions The best interventions I found for cervical cancer prevention and control were on the national level from The Community Guide. These client based interventions were designed to increase cervical cancer screenings. The interventions for clients either provided education to increase cancer screening or made it easier for clients to get screened. The following interventions are the ones I am going to summarize for cervical cancer: Client reminders Small media Group education One-on-one education Interventions Increasing Cancer screening: Client Reminders
The client reminders are written or telephone messages advising people that they are due for screening. These reminders may be enhanced by one or more of the following: follow up printed telephone reminders, additional text with information about benefits or ways to overcome barriers to screening and assistance in scheduling appointments. These interventions can be untailored to address the overall target population or tailored with the intent to reach one specific person. After the intervention was conducted, the Community Preventative Services Task Force found this intervention to be highly effective and they strongly recommend the use of client reminders to increase screening for cervical cancer. The results from this test include a median increase with 2.8 percentage points for women receiving Pap tests. Enhanced telephone reminders showed an increase of 1.6 to 31.4 percentage points. It was concluded that the client reminder interventions data to increase cervical cancer screening should be applicable to a variety of settings and populations, as long as the messages are adapted to the target population. The Community Guide to Preventative Services (2014, March 19) Interventions Increasing Cancer Screening: Small Media Targeting Clients This small media targeting for cervical cancer screening intervention include videos and printed materials such as letters, brochures and newsletters. These materials were used to inform and motivate women to get screened for cervical cancer. These messages can provide information tailored to specific individuals or targeted to general audiences. The Community Preventative Services Task Force found strong evidence of this methods effectiveness and recommends interventions that use small media. This intervention definitely showed an increase in cervical cancer screening by Pap test to be at an increase of 4.5 percentage points. Tailoring this intervention was found to be no more effective than untailored interventions It is important to note that these studies were conducted in both rural and urban communities and among different ethnic, racial and socioeconomic groups. The Community Guide to Preventative Services (2014, March 19) Interventions Increasing Cancer Screening: Group Education for Clients
Group education is designed to encourage group members to get screened for cervical cancer by discussing the benefits of screening and share helpful ways to overcome barriers to screening. Health professionals are taught to give group education to a variety of groups in different settings using role modeling, lectures, teaching aids and other styles that best fit for the intervention. The Community Preventative Services Task Force found insufficient evidence to determine the effectiveness of group education in increasing screening for cervical cancer because of the small number of studies with methodological limitations and inconsistent findings. The Community Guide to Preventative Services (2014, March 19) Interventions Increasing Cancer Screening: One-on-One Education for Clients. In one-on-one education, a health professional discusses the benefits of screening and ways to overcome barriers to screening to one person, by telephone or in person. This one-on-one education can take place in a workplace, a medical office, a community setting or at home. A beneficial aspect of one-on-one education is that this message can be generic or tailored to the recipients characteristics, beliefs or barriers to screening for cervical cancer. Based on the intervention, the Community Preventative Services Task Force recommends the use of one-on-one education for educating clients on screening for cervical cancer because of the strong evidence of effectiveness. The results of this intervention showed an increase of 8.1 percent in completed Pap tests, after this intervention was given. The Community Guide to Preventative Services (2014, March 19) What are Some Campaigns to Help Raise Awareness of Cervical Cancer?
Cervical Cancer Awareness Month Pearl of Wisdom Cervical Cancer Awareness Month
January is the month dedicated to raising awareness of issues related to cervical cancer, HPV disease and the importance of early detection. Popular topics of discussion are recent advances and research in prevention, detection and treatment of cervical cancer or HPV. Also popular to cover when discussing the importance of cervical cancer awareness are highlighting the success of local or regional cervical cancer early detection screening and treatment programs as well as the importance of early detection and education on cervical cancer and HPV. Contacting the local media is a great way to help publicize your message on cervical cancer awareness and the National Cervical Cancer Coalition (NCCC) website lists many ways to gain the medias interest and share your message to ensure it reaches the greatest amount of people possible. The NCCC also lists many ways you can become involved to help support cervical cancer locally. Pearl Of Wisdom The Pearl of Wisdom is a campaign to prevent cervical cancer and raise awareness of the opportunities available to prevent this disease. This program is designed to increase awareness of the tools accessible to prevent cervical cancer and they also encourage women to take advantage of these methods. They strongly advocate for the accessibility to cervical cancer prevention for girls and women everywhere. This campaigns goal is to promote the Pearl of Wisdom as the global symbol for cervical cancer prevention. All profits made from this campaign directly support cervical cancer prevention activities. This campaigns slogan is Wearing your pearl which means when a women is wearing their pearl, they are helping to spread the message that cervical cancer is preventable with the Pap test, HPV test and HPV vaccine. Thank you! References: Borruto, F., & De Ridder, M. (2012). HPV and Cervical Cancer Achievements in Prevention and Future Prospects. New York:Springer. Centers for Disease Control and Prevention. (2012, December 20). Cervical Cancer Statistics. Retrieved from Centers for Disease Control and Prevention. (2012, July). Cervical Cancer,Inside Knowledge: Get the Facts About Gynecological Cancer. Retrieved from Centers for Disease Control and Prevention. (2012, August 13). Human Papillomavirus- Associated Cancers. Retrieved from National Cancer Institute at the National Institutes of Health. (2014, March 14). Stages of Cancer. Retrieved from ent/page2 References: National Cervical Cancer Coalition. (2013). January is Cervical Cancer Awareness Month. Retrieved from online.org/index.php/january Pearl of Wisdom Campaign to Prevent Cervical Cancer. (2010). Get the Facts. Retrieved from Prevent Cancer Foundation. (2014, February). Cervical Cancer. Retrieved from cancers/cervical-cancer/ Quality Assurance Project Every Women Counts, Resources for Health Professionals. (2013, August 25). Cervical Cancer Facts and Stats. Retrieved from https://qap.sdsu.edu/screening/cervicalcancer/facts.html The Community Guide, The Guide to Community Preventative Services What Works to Promote Health. (2014, January 3). Retrieved from oriented/index.html