Racial Disparities and Cervical Cancer

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Racial Disparities and Cervical Cancer

• Michael L. Hicks, M.D.

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Disparities

• Inequalities
• Differences

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Areas of Disparities Related to Cervical Cancer

• Screening
• Survival

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Black Diaspora

• Cervical cancer is the most common female genital
  tract malignancy
• Only second to breast cancer as the most common
  caner in women of African descent

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Black Diaspora

• Unlike in the United States cervical cancer is
  the most lethal female genital tract malignancy
  in the Black Diaspora
• No screening programs
• In the United States ovarian cancer is the most
  lethal female genital tract malignancy
• Ovarian cancer is not amenable to screening

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Factors that can Lower Mortality from Malignancies

• Screening/Early detection
• Education of the population at risk to be
  screened
• Fears and Distrust
• Must be culturally sensitive
• Adequate resources for screening
• Proper infrastructure
• Prevention
• Lifestyle changes

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Factors that can Lower Mortality from Malignancies

• Screening
• Premalignant phase of the disease that is curable
• Inexpensive testing
• Prevalence rate of the disease must be high
  enough for the screening test to impact the
  disease in the population

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United States

• Cervical cancer is the 3rd most common female
  genital tract malignancy (following endometrial
  and ovarian cancer respectively)
• Very few cases per year
  (approximately 10,000 new cases per year)
  secondary to effective screening

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United States

• We have recourses and adequate infrastructure for
  cervical cancer screening
• Pathologist
• Labs
• Couriers
• Clinics with professional
• Follow-up strategies

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So in the United States are there Disparities
Related to Cervical Cancer?

• YES
• Why?

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Cervical Cancer Mortality Rates in the United
States

• 5.7/100,000 women for African American women
• 2.4/100,000 women for White American women
• Clegg et al. SEER Data
• Arch Int Med 2002 62 1985-93

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Why is there this Disparity?

• We have an excellent screening infrastructure
• There certainly is a premalignant phase of
  disease that is curable

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Obvious Answer Must be Screening/Pap Smear

• NO!
• In the general population African American women
  are significantly more likely than white American
  women to have a pap smear
• Hewitt M et al. Prev Med 2004 39 270-8

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Problem with this Study

• 1
• Not exclusively targeting the at- risk population
  of African American women where the incidence of
  cervical cancer is higher than in the general
  population

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Problem with this Study

• 2
• The methodology of obtaining data via
  self-reporting must be interpreted with caution
  and skepticism secondary to the possibility of
  recall bias

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So is there a Relationship between Screening and
Disparity in Cervical Cancer Mortality Rates?

• Yes

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Screening and Disparities in Cervical Cancer

• At risk population With higher mortality rates
  inside the African American female population

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At Risk Population

• Not the same as the general population
• Special circumstances that will not allow the
  current conventional screening programs to impact
  mortality
• Ultimately this populations is not being screened

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Characteristics of this at Risk Population

• Lack of education about the importance of
  screening and education in general
• No functional connection between the community
  at risk and the local health care system

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Characteristics of this at Risk Population

• Lack of resources (health care insurance or
  money)
• Cultural/historical distrust of the medical
  delivery system

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Studies have Evaluated this at Risk Population
and its Characteristics
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Study 1

• Study looking at African American women in public
  housing ( low socio-economic status )
• 22 reported not having had cervical cancer
  screening within the previous year
• Twenty-nine percent (29) reported no healthcare
  provider had ever informed them of the need for a
  Pap smear
• Bazargan et al. Prev Med 2004 39(3) 465-73

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Characteristics that are Highlighted by this Study

• Lack of education
• Lack of recourses
• Disconnect between the community at risk and the
  local healthcare system

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Study 2

• Study evaluating women from public housing
  projects ( low socio-economic status ) with
  abnormal Pap smears found
• That African Americans women were 53 less
  likely to accept an appointment
• 45 less likely to show up for their scheduled
  follow-up appointment
• Cardin et al Publ Healt Rept 2001 116(6) 608-16

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Characteristics that are Highlighted by this Study

• Lack of recourses
• Lack of education
• Cultural/historical distrust of the medical
  delivery system

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Study 3

• Showed that 45 of African American women
  referred for colposcopy had low levels of health
  literacy (lt 9th grade education)
• The authors found that low levels of health
  literacy was associated with increased levels of
  distress
• Increased levels of distress served as a barrier
  to treatment
• Concluded that culturally informed, effective
  interventions are needed
• Sharp et al. Ethn and Dis 2002 12(40 541-6

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Characteristics that are Highlighted by this Study

• Lack of education
• Disconnect between the community at risk and the
  local healthcare system
• Cultural/historical distrust of the medical
  delivery system

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Study 4

• A study of inner city African American women who
  equally received culturally-appropriate education
  interventions revealed
• That those women with private health insurance
  were significantly more likely to be screened
  than those covered by Medicaid or Medicare or
  those who were not insured
• Sung et al. Can Det Prev 2002 26(1) 28-32

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Characteristic that are Highlighted by this Study

• Lack of resources

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Other Factors Associated with Disparities and
Cervical Cancer Mortality Rates
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Treatment

• Lack of treatment for disease

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Studies Related to Cervical Cancer Survival
Disparities and Treatment
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Study 1

• Concluded that African American women had a 55
  increased risk of death from invasive cervical
  cancer compared to other women with the disease
• After adjusting for age at diagnosis, histology,
  stage and the first course of cancer-directed
  treatment, African American women still had a 26
  increased risk of death
• Patel et al. Gynec Oncol 2005 97(2) 550-8

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Study 1

• In this study the largest proportion of patients
  receiving no cancer directed surgical therapy
  were African Americans women (43.7)
• Patel et al. Gynec Oncol2005 97(2) 550-8

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Study 2

• This study noted a 33 higher risk of African
  American women dying of invasive cervical cancer
  than their white counterparts
• They found that African American women had less
  definitive primary therapy, conservative therapy
  and adjuvant therapy
• Shavers et al. J Natl Can Inst 2002 94(5)
  334-57

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Study 3

• The authors noted that a higher percentage of
  African Americans received no cancer directed
  therapy for cervical cancer
• Reason for no therapy
• Not recommendend
• Contraindicated secondary to comorbid conditions
• Refused
• Merrill et al. Ethn Dis 2000 10(2) 248-56

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Study 3

• Additionally African American women were more
  likely to be unstaged and unstaged patients were
  more likely not to receive therapy
• Merrill et al. Ethn Dis 2000 10(2) 248-56

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Comorbid Illness

• Brooks and Colleagues showed
• Stage for stage African American women had worse
  survival
• Felt that comorbid diseases may impact survival
• Diabetes
• Cardiovascular disease
• Renal disease
• Obesity

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Summary on Survival Disparities in Cervical Cancer

• Clearly there is a disparity
• Screening modalities work for the general
  population, but not for the at risk population
  for these patients are less likely to be screened

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Summary on Survival Disparities in Cervical Cancer

• At risk population defined as people with
• Lack of resources
• Lack of education
• Individuals with a distrust in the health care
  delivery system

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Summary on Survival Disparities in Cervical Cancer

• Treatment inequalities do exist and explain some
  of the disparities

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Summary on Survival Disparities in Cervical Cancer

• Do not bury your head in the sand
• Be aware of this problem
• Many of these problems emanate from historical,
  cultural and economic practices in our country
  (slavery, Jim Crow, racisms and discrimination)
  and social engineering

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Summary on Survival Disparities in Cervical Cancer

• However, some of the ownership of this problem is
  our own
• Lack of personal responsibility
• Expectations of someone else to fix our problem

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Recommendations

• Aggressive education of the at risk populations
  about cancer screening and personal
  responsibility
• Currently being done, but not by African
  Americans physicians and African American
  institutions
• Cultural and Language barrier

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Recommendations

• This type of education will break the cycle of
  distrust, lack of education about the importance
  of screening and lead to more effective
  screening which in turn will eliminate survival
  disparities

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Recommendations

• Aggressive education of our United States medical
  healthcare delivery systems about disparities
• Sensitivity training
• Quality assurance data to assure equality in
  treatment

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Recommendations

• Improvement of access to care for the patient
  with Medicaid or uninsured
• This is beyond the scope of this talk

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However

• As we can see from the current data, if we do a
  great job in education, build bridges of
  understanding between our communities and the
  healthcare delivery system without assuring
  access to care there will still be a major
  disparity in Cervical Cancer Mortality

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It all Boils down to the Economic Pendulum of
Health Care
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The at Risk Population in the United States is
Very Similar to the Population of Women of the
Black Diaspora in 3rd World Countries Except for
one Difference
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In Africa There is

• Poverty Amongst Poverty

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In the United States There is

• Poverty Amongst Affluence

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The Question We Must Answer in this Country on
both sides, as it Relates to Disparities is this

• When are we going to do the right thing to make a
  difference?

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