Elmer E' Huerta, MD, MPH

1
ACS South Atlantic Division Cervical Cancer
Conference
Tipping the Scales Toward Better Health
Elmer E. Huerta, MD, MPH
Research Triangle Park, NC. August 4, 2008
2
Cervical Cancer

• Most common gynecologic malignancy worldwide
• US--about 10,520 new cases of invasive cervical
  cancer, and 3,900 cancer deaths
• Disproportionately affects poor women and
  communities of color
• Most common cause of death due to cancer among
  Latin American women in Latin America

3
Landmarks in cervical cytology screening
Widespread introduction of the Pap begins in
the US
Study of thin-layer Pap technology begins
FDA approves HC HPV testing out of
ThinPrep
ThinPrep
SurePath
Conventional Pap smear
LBP
1949
1979
1996
1999
4
Role of Clinical Guidelines Era of
clinically useful HPV tests
IARC studies confirm the causative role of
HPV in cervical cancer
Studies on clinical utility of HPV testing
begin
ALTS data confirms efficacy of HC 2 in
triaging ASCUS
1980s
1990s
2000s
1991
1995
2001
5
Emergence of Cervical Screening Guidelines
ASCCP Consensus Guidelines for the
Management of Abnormal Cervical Cytology
incorporates HPV testing in multiple
settings
New ACS ACOG screening guidelines
1980s
1990s
2000s
2003
2001
6
US cervix uteri cancer mortality, 1950-945-year
rates, white females
7
Mortality Rate for Cervical Cancer Across the
World
Source Parkin
8
Cervical Cancer Screening

• Exfoliative cervical cytology (Pap smear)
• Mainstay of cervical cancer prevention efforts
  since its description in the 1940s
• Credited for the drop in cancer incidence and
  mortality in the US and Western Europe in the
  latter half of the 20th century
• Cancer and precursor lesions identified from
  material collected from cervical scrapings
  during routine screening pelvic examination
• Relies on the pro-longed pre-invasive course of
  cervical cancer

9
Impact of Cytological Screening on US Cervical
Cancer Incidence
60

Screening

Index ()
40

Incidence per

100,000 women
20

1958 1965 1972

10
Category Percent Mean
Age
Screening Histories of Women with Cervical Cancer
in Connecticut (85-90)

• Never screened 29 65
• WNL Pap test
• lt 3 yrs 25 43
• gt 3 yrs 29 50
• Misread as WNL 7 46
• Not followed-up 11 47

Janerich. Am J Public Health 1995
11
Successful Cytology-Based Cervical Cancer Requires

• Informed/aware consumers
• Access to acceptability of screening services
• Trained service providers
• Infrastructure to follow-up abnormal results
• Access to diagnostic and therapeutic services
• Regular screening and long-term follow-up

12
Access to Care Is an Insurance Card Enough?
13
Health Insurance Coverage Among Individuals Under
Age 65 Years, 2006 (in Millions).
From Ward, E. et al. CA Cancer J Clin
2008589-31.
14
Insurance and Breast Cancer Stage
Uninsured patients were substantially more likely
to be diagnosed at a larger stage of cancer than
privately insured patients
Halpern et al. Cancer 2007110403-11
15
Insurance and Breast Cancer Stage
MEDICAID patients were substantially more likely
to be diagnosed at a larger stage of cancer than
privately insured patients
Halpern et al. Cancer 2007110403-11
16
Insurance and Breast Cancer Stage
African American and Hispanic women were
substantially more likely to be diagnosed at a
larger stage of cancer than White women
Halpern et al. Cancer 2007110403-11
17
Cancer Survival by Insurance Status
Patients who were uninsured and those who were
Medicaid-insured at the time of diagnosis were
1.6 times as likely to die in 5 years as those
with private insurance
From Ward, E. et al. CA Cancer J Clin
2008589-31.
18
Impact of Health Insurance Status on
Cancer Analyses of the NHIS and the Behavioral
Risk Factor Surveillance Survey have consistently
found that individuals without health insurance
have lower rates of cervical, breast, and
colorectal cancer screening than individuals with
health insurance.
From Ward, E. et al. CA Cancer J Clin
2008589-31.
19
Percent of women 40-60 years who had a mammogram
in the past 2 years.

• 2005 National Health Interview Survey
• From Ward, E. et al. CA Cancer J Clin
  2008589-31.

20
CONCLUSION As our nation's investments in
cancer research provide greater understanding of
how to prevent cancer, detect it early, and treat
it effectively, access to health care becomes
even more important as a major public health
problem.
From Ward, E. et al. CA Cancer J Clin
2008589-31.
21
Although variations in health insurance coverage
likely contribute to racial and ethnic
disparities in cancer outcomes, disparities
persist for several outcomes even when
differences in insurance status are accounted for
From Ward, E. et al. CA Cancer J Clin
2008589-31.
22
Given that health insurance status is associated
with other sociodemographic characteristics, such
as race/ethnicity, immigration status/country of
birth, and level of education, it is possible
that differences in screening rates reflect
differences in knowledge about cancer prevention,
culture, or other barriers to care.
From Ward, E. et al. CA Cancer J Clin
2008589-31.
23
YES
The risk of dying of cancer in the US is
increasing
68
Living in a polluted city is a greater risk for
lung cancer than smoking a pack of cigarettes a
day
39
Some injuries can cause cancer later in life
37
Electronic devices, such as cell phones, can
cause cancer in the people that use them
30
What someone does as a young adult has little
effect on their chance of getting cancer later in
life
25
Long-time smokers cannot reduce their cancer risk
by quitting smoking
16
People who smoke low-tar cigarettes have less
chance of developing lung cancer
15
From Stein K. et al. Cancer online July 26, 2007.
24
Dont know
TRUE
Pain medications are not efective in reducing the
amount of pain people have from cancer
19
13
All you need to beat cancer is a positive
attitude, not treatment
7
5
Treating cancer with surgery can cause it to
spread throughout the body
41
13
27
14
There is currently a cure for cancer but the
medical industry wont tell the public about it
because they make too much money treating cancer
patients
Cancer is something that cannot be effectively
treated
7
6
From Gansler T. et al. Cancer 2005104653-60.
25
CONCLUSION As our nation's investments in
cancer research provide greater understanding of
how to prevent cancer, detect it early, and treat
it effectively, the design and delivery of
consistent, evidence-based, health promotion
programs become even more important to eliminate
cancer as a major public health problem.
26
THE REALITY
27
Most of the world has a disease-based medical
system model
28
Extremely busy, illness- loaded, primary care
system
They often use the emergency room...
People waiting for symptoms to appear
29
THE BARRIERS
30
Barriers That Underserved People Face When
Seeking Medical Care

• Lack of Information

• Linguistic Isolation

• Living in Poverty

• Lack of Adequate Health Insurance Coverage

31
Barriers That Underserved People Face When
Seeking Medical Care

• Lack of ethnically-sensitive, culturally-competen
  t programs

• Lack of understanding of the medical system

32
Changing the Paradigm
33
Extremely busy, illness- loaded, primary care
system
They often use the emergency room...
People waiting for symptoms to appear
34
To develop a health promotion/disease
prevention-based system
To develop a less illness-loaded primary care
system
How do we convince people to seek medical care
when asymptomatic?
35
How to go from
That saturates a cancer health system with
incurable, advanced cases
Advanced disease
36
to
A cancer health system more focused on the care
of early disease cases
Early disease
37
In order for that change to occur, one should
understand that the frequency of cancer in a
locality, not only depends on the biology of the
tumor, but also on

• Cancer control programs

• Laws

• Health policies

• Community health programs, and

• Individual behavior

Cancer Prevention Early Detection Facts and
Figures 2007
38
In other words
39
We should not concentrate only on the study of
the tumor
Thyrosine- kinase
Apoptosis
EGF
Angiogenesis
p53
Oncogenes
40
But also on the person with the tumor
41
(No Transcript)
42
Language
Lack of medical insurance
Poverty
Fears
False beliefs
Fatalism
Lack of information
Knowledge
Attitude
Behavior
43
How can we convince people that an ounce of
prevention is worth a pound of cure?
44
I am convinced that coherent, consistent,
media-based, public education programs need to be
created
45
An ethnically-sensitive, culturally-relevant,
media-based community outreach program was
progressively developed since 1989 following four
basic principles
46
Our Media Principles...
1. Use the media CONSISTENTLY
2. Develop COMPREHENSIVE health education
programs
3. Use all media channels available for the
community
4. Develop a TRUSTED MESSENGER
47
Our Media Principles...
CONSISTENCY EVERY DAY...
48
Our Media Principles...
COMPREHENSIVENESS EVERY THEME...
49
Our Media Principles...
ALL CHANNELS MULTIMEDIA...
50
Our Media Principles...
TRUSTED MESSENGER...
51
Media Tools
A. RADIO
1. Taking Care of Your Health. Only daily,
one-minute vignette produced and hosted by a
Latino physician in the United States.
(National/International)
2. Cita con el Doctor. Only daily, nationally
syndicated, health program on Spanish-language
radio in the United States. Two-hour daily
call-in program.
3. The Community Clinic of The Air International
Edition. Daily, 15-minute program to Peru.
4. The Community Clinic of The Air International
Edition. Monthly, one-hour talk show (Bolivia)
52
Media Tools
B. TELEVISION
1. Lets Talk About Health. One hour, weekly
call-in show. Distributed nationwide by WorldView
Television.
2. Taking Care of Your Health. Two-minute, weekly
segment in the newscast. Telemundo WZGS
Washington DC
3. Encounter With the Medicine.. Weekly segment
with CNN en Espanol.
53
Media Tools
C. INTERNET
www.prevencion.org
D. PRINT
Bimonthly health column in NEXOS, the in-flight
magazine of American Airlines
54
After the public has been convinced to take
preventive steps...
55
They need a place to go
56
Creation of a Cancer Preventorium
57
SANATORIUM NOUN 1.An institution for the
treatment of chronic diseases or for medically
supervised recuperation. 2. A resort for
improvement or maintenance of health, especially
for convalescents. Also called sanitarium.
ETYMOLOGY From neuter of Late Latin
sanatorius, curative, from Latin sanatus past
participle of sanare, to heal, from sanus,
healthy.
The American Heritage Dictionary of the English
Language Fourth Edition. 2000
58
In 1884 in New York, "Little Red", the first TB
Sanatorium in the country was opened.
59
Interior view of Little Red New York 1884
60
PREVENTORIUM A non-existent word in the
dictionary
61
PREVENTORIUM NOUN 1. An institution for the
prevention and early detection of chronic
diseases or for medically supervised patient
education. 2. A resort for maintenance of health,
especially for people without evident illness.
Our proposed definition
62
...people of the future will visit preventories
to receive health education, undergone cancer
screening tests, and even engage in community
activism...
Michael Shimkin, MD ASCO Founding
Member Preventive Medicine, June 1975
63
The Preventorium has two main goals

• To find and treat early asymptomatic conditions
  (cancer, diabetes, high blood pressure)

• To find and manage risk factors for those
  chronic conditions

64
The Washington Cancer Institute atWashington
Hospital Center
Cancer Preventorium

• Date Started

July 27, 1994

• Patients Seen (as of 04/17/08)

21,926
65
The Washington Cancer Institute atWashington
Hospital Center
Cancer Preventorium

• GENDER

6,181 (22)
Male
15,745 (78)
Female

• Asymptomatic Patients

80
66
The Washington Cancer Institute atWashington
Hospital Center
Cancer Preventorium
Patient Distribution by Ethnic Group (Percent)
Hispanic
90
10
Non-Hispanic
67
The Washington Cancer Institute atWashington
Hospital Center
Cancer Preventorium
Patient Distribution by Medical Insurance
(Percent)
Insured
No Insured
30
70
68
The Washington Cancer Institute atWashington
Hospital Center
Cancer Preventorium
Patient Distribution by Educational Attainment
(Percent)
More than High School
Less than High School
40
60
69
The Cancer Preventorium Model has its Theoretical
Frame on the Diffusion of Innovations Theory
70
Preventorium Model
CHRONIC DISEASES PREVENTORIUM
COMMUNITY
NAVIGATION
PREVENTORIUM
OUTREACH
PROGRAM
71
Knowledge exists in two forms -lifeless, stored
in books- and alive in the counciousness of men.
The second form is the essential one.
Albert Einstein
72
The Ivory Tower of Science
73
Thank You