Abstract IA12: Addressing cervical cancer disparities in Appalachia: From biology to policy
Authors: Paskett Electra D. 
Published: May 2016

Abstract
Background: Cervical cancer is mainly preventable with Pap testing and now Human Papillomavirus (HPV) vaccination and testing. There still are, however, certain populations that suffer from disparities in incidence and mortality from cervical cancer. One such population is found in Appalachia, a federally-designated region of the United States that includes 320 counties in 13 states along the Appalachian mountain range [1-3]. This area is distinguished by poverty and lower education, as well as lack of access to quality health care [1-3]. While cardiovascular disease is the number one killer in the United States, in Appalachia, cancer is the number one killer [4-5]. Reasons for this include higher smoking rates, higher prevalence of obesity with less physical activity, poor diet, and lower rates of screening uptake. Moreover, access to timely and quality care is hampered due to fewer health care facilities, lower income, and greater distances to travel to receive care at larger metropolitan centers.
In 2003, a team of trans-disciplinary researchers from the Ohio State University and University of Michigan successfully applied for a Center for Population Health and Health Disparities (CPHHD) from the NCI to investigate why rates of cervical cancer were elevated in Appalachian Ohio and to develop and test intervention strategies to improve these rates. The hallmark of the CPHHD initiative is Community-Based Participatory Research (CBPR) conducted by trans-disciplinary research teams using a multi-level framework [6] based on the Social Determinants of Health (SDH) [7] that includes levels from basic biology to policy. This presentation will describe the work of the OSU CPHHD over the last 10 years in using this methodology to examine and intervene on the high cervical cancer rates in Appalachian Ohio.
Methods: The first 5 years of funding, the Center focused on the 3 major causes of cervical cancer known at that time – lack of Pap testing, smoking, and HPV infection. Three projects address each risk factor, with the Pap testing and smoking cessation projects being randomized controlled trials (RCT) of Lay Health Worker (LHW) interventions. The last project was a case-control study to determine the prevalence of HPV infection, by type, in the population. Additional pilot funding helped to quantify the uptake of the HPV vaccine in the area, once approved, as well as attitudes about HOV, cervical cancer, and the HPV vaccine. Basic biology projects assessing the influence of the immune system on HPV infection as well as genetic factors in cervical cancer etiology were also conducted.
In the second round of funding, the Center built upon the results from the first 5 years and proposed 4 research projects to examine genetic influences in cervical cancer, the effect of social networks on smoking status, the effect of stress on immunity to HPV, and a RCT to test a multi-level intervention (clinic, provider, and parent-focused) to improve the uptake of the HPV vaccine among adolescent girls. All projects were guided by the CBPR approach with input from a Community Advisory Board (CAB) and 6 community-based cancer coalitions helped investigators implement aspects of the studies.
Results: The RCTs demonstrated the ability of the LHW intervention to improve Pap testing and smoking cessation rates compared to the usual care groups [8-9]. The case control study determined high rates of HPV infection among women getting regular Pap tests as well as high rates of abnormal Pap tests, compared to the US. Results also indicated high rates of binge drinking, smoking, and risky sexual behavior. Moreover, women reported feeling stressed about the poor economy and reported geographic isolation [10]. Low rates of HPV vaccine uptake were also documented [11] and there was some evidence that stress might impact the functioning of the immune system, causing greater susceptibility to prevalent HPV infection and cervical abnormalities. The second set of projects has recently been completed. Genetic alterations in the Transforming Growth Factor β Receptor Pathway were found, with differences observed by smoking status. Smokers were found to have different social network structures than non-smokers. All women, regardless of baseline level of stress, were able to mount an immune response to the HPV vaccine. A multi-level intervention did improve the uptake of the HPV vaccine among girls, however, uptake overall was very low. High rates of refusal of vaccinations and dislike of school mandates for vaccines were also identified.
Conclusions: In a population that suffers from health disparities in cervical cancer, our CPHHD identified several multi-level causes of these rates. Some interventions that reduce risk were successful, however, the uptake of newer interventions like the HPV vaccine are still being met with negative attitudes and fear. The social factors impact health decisions as does the geographic isolation which reduces access to quality health care. Basic biological risk may also be elevated given the prevalence of genetic alterations. Moreover, poor risk factor profiles, eg smoking status, risky sexual behaviors, and low screening with Pap tests, can cause biologic profiles to manifest. Thus, given the biologic platform, risk factor profile, social attitudes about HPV vaccination, and lack of health care access, it is no surprise that the rates of cervical cancer are elevated. Future work will have to address many of these factors at the same time in order to reduce the observed disparities.
References:
1. Appalachian Regional Commission. County economic status designations in the Appalachian region-fiscal year 2006. Columbus (OH): Cancer Incidence Surveillance System, Ohio Department of Health, Ohio State University; Available from: http://www.arc.gov/index.do?nodeId=2934.
2. Ohio Department of Health Primary Care Office. Ohio primary care-health professional shortage areas. Columbus (OH): Ohio Department of Health; 2005.
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11. Paskett ED, McLaughlin JM, Reiter et al. Psychosocial predictors of adherence to risk-appropriate cervical cancer screening guidelines: A cross sectional study of women in Ohio Appalachia participating in the Community Awareness Resources and Education (CARE) project. Prev Med. 2010 Jan;50(1-2):74-80
Citation Format: Electra D. Paskett. Addressing cervical cancer disparities in Appalachia: From biology to policy. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr IA12.