Report from Cervical Cancer Committee

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Report from Cervical Cancer Committee Maryland
State Cancer Plan Strategies for Improving the
Control of Cervical Cancer in Maryland
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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
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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 1960s with Pap Test Programs
such as the CDC Breast and Cervical Program in
place and highly effective
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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?
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Our Committee Set An Ambitious Goal To Reduce
Cervical Cancer Mortality in Maryland by 50 by
2010. How Can We Best Do That?
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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.
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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?
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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
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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.
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• 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

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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?
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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.
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Take-Home Message Three Reasons Why Cervical
Cancer Control Is So Important
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1 Cervical Cancer Rates are Important
Indicators of Marylands 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
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2 Addressing Cervical Cancer Can Address A
Range of Womens Health Needs Many health
problems facing women in Maryland require
addressing gynecological health across the entire
life-course, not just during childbearing. Approa
ches to HIV/AIDS, STDS, and other health problems
can be combined with controlling cervical cancer,
to bring better health to Maryland women.
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• 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