Cervical Cancer Care

cervical cancer; women and cancer: cervical cancer; women and cancerWhile recent decades have seen a decline in cervical cancer incidence and mortality, some populations—such as women who live in the Appalachian region—still suffer disproportionately from this disease. Home to 25.6 million people, this area includes 420 counties and spans from southern New York state to Northern Mississippi. Around 42 percent of this region is considered rural. Compared to the rest of the country, Appalachia is less racially diverse with non-Whites making up 18.2 percent of those who live there compared to 38.7 in the U.S. as a whole (Appalachian Regional Commission, 2018). This region is also defined by geographic isolation, high poverty rates, low household incomes, and low educational attainment. The Appalachian Regional Commission reported that, among Appalachian adults age 25 and older, 23.2 percent have a bachelor's degree compared to 30.3 percent of the overall U.S. The poverty rate in the Appalachian region is higher than the U.S. average (16.7% vs. 15.1%) and 23.6 percent of children in this area live below the poverty level (Appalachian Regional Commission, 2018). Addressing Disparities Higher death and incidence rates have been observed with lower screening rates and lower uptake of the HPV vaccine, according to Electra Paskett, PhD, Professor and Director of the Division of Cancer Prevention and Control at The Ohio State University Comprehensive Cancer Center, who told Oncology Times that there are “many causes for these disparities that range from biology to policy.” Factors that may contribute to the cervical cancer disparities in the Appalachian region include a lack of health care providers and facilities, poor health behaviors, poor communication with health care providers, low income, and education (Cancer Prev Res 2020;13(3):223-8). What challenges exist when it comes to reducing disparities in this region? “Mainly resources (at the health system and patient level), negative beliefs, and lack of access,” said Paskett, who noted that the COVID-19 pandemic is an added hurdle. “During COVID, many people are not paying attention to regular screening and vaccination, as well as smoking more—this could cause higher rates of cervical cancer in the years to come. Moreover, many people do not know that HPV vaccination now can be given from ages 9 to 45 for men and women. “We are testing self-sampling strategies and we hope this gets approved by the FDA under EUA soon so we can use it widespread—especially now that women won't come into the clinic for regular testing,” she continued. The CARE Project The Ohio State University Center for Population Health and Health Disparities (CPHHD), called the Community Awareness Resources and Education (CARE) project, was initiated to better understand the reasons behind cervical cancer disparities, as well as identify potential solutions. CARE 1 (2003-2008), which included three projects, sought to determine why women living in this region have a higher burden of cervical cancer. Project 1 included 14 clinics in Ohio Appalachia. Women (n=286) who needed a Pap test were randomized to usual care (n=141) or a lay health advisor intervention (n=145) over a 10-month period (Cancer Prev Res 2020;13(3):223-8). In Project 2, women who were self-reported tobacco users were enrolled in either the intervention or control arm. Individuals in the intervention cohort received a nurse-managed protocol that incorporated nicotine replacement and behavioral counseling. Comparatively, control arm participants received a personal letter from their provider that directed them to quit smoking and request an appointment to discuss smoking cessation. Investigators reported that at 3- and 6-month follow-up, quit rates were significantly higher in the intervention group compared to the control group (Cancer Prev Res 2020;13(3):223-8). Project 3 took a closer look at predictors of abnormal cervical cytology. Data showed that the prevalence of high-risk HPV was higher in the Appalachian region than the general U.S. population, according to the study authors. CARE 1 also revealed that women in Appalachia had “high rates of abnormal Pap tests, high rates of smoking, higher rates of HPV infection, higher poverty, high rates of risky sexual behaviors, low rates of HPV vaccination uptake, fewer social contact among smokers, a genetic susceptibility to cervical cancer immunity due to psychosocial stress, high rates of binge drinking, and high rates of depression,” the research team reported. Building off of these findings, CARE 2 was initiated. The key questions of the four CARE 2 projects, according to Paskett and colleagues, were the following (Cancer Prev Res 2020;13(3):223-8): Project 1: What is the prevalence of a genetic polymorphism in Appalachians with cervical cancer versus control women? Project 2: Can the social network of Appalachian female smokers assist in smoking cessation? Project 3: Do Appalachian women who are “stressed” develop immunity to HPV after receiving the vaccine? Project 4: Can a multilevel intervention improve HPV vaccination rates among young girls? “Each project served to investigate separate domains of the multi-level model to understand cervical cancer disparities in Ohio Appalachian women [...]. When assembled in a multi-level model, a picture emerges as to the explanations of cervical cancer disparities in Ohio Appalachia,” wrote Paskett and colleagues. This includes biology, individual risk factors, social relationships, social/physical context, institutions, and social conditions and policies (Cancer Prev Res 2020;13(3):223-8). “This model of cervical cancer disparities in Appalachia has identified opportunities for intervention,” the study authors noted. “Future funded projects will focus on implementation science strategies involving collaborative efforts with Ohio State University, University of Virginia, University of Kentucky, and University of West Virginia with an overall goal of addressing the burden of cervical cancer morbidity and mortality in Appalachia using a clinic-based implementation science multi-focal strategy.” Ongoing Efforts CARE 3 is beginning to initiate clinic-specific implementation plans across four states to address three areas of cervical cancer prevention: tobacco use, HPV vaccination, and cervical cancer screening, according to Paskett. The factors contributing to cervical cancer disparities in Appalachia can be addressed, she emphasized, while noting that each population has its own barriers and solutions. “So, we use a multi-level approach and target the health system (e.g., set up automatic reminders and follow-up systems), providers (teach them what to do and how to offer screening and vaccination to patients and address hesitancy), and patients (provide culturally appropriate materials that answer most comment questions/reasons for non-adherence),” she explained. “This is what we are doing now in CARE 3,” Paskett concluded. “We are using an implementation science framework, which I think is the best way to go for sustainability and dissemination.” Catlin Nalley is a contributing writer.

Topic: Cervical Cancer and HPV Research
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences