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WHAT BLACK
WOMEN NEED TO
KNOW ABOUT
CERVICAL CANCER
January 19. 2023
Gizelka David-West, MD, FACOG
Gynecologic Oncologist
Northwell Health
Northwell Health®
February 6, 2023 2
Dedicated to my patients with pre-cancer and cancer of
the cervix past and present
Northwell Health®
 Impact of cervical cancer nationally, globally, and on diverse groups
 HPV and how it relates to cervical cancer
 Screening for cervical cancer and natural history of the disease
 Prevention of cervical cancer
OBJECTIVES
3
February 6, 2023
Northwell Health®
HENRIETTA LACKS (8/1/1920 – 10/4/1951)
 Diagnosed with cervix cancer 1/1951
 Her cells were known as HeLa Cells, first
immortalized human cell line
 HeLa Cells involved in key medical discoveries such as :
Polio vaccine; Cancer drugs; In vitro fertilization;
COVID19 vaccine
 Paved the way for improved ethics and
consents for human research subjects
February 6, 2023 4
Northwell Health®
Cervical Cancer incidence and mortality
 4th most common cancer worldwide
 Ranks after breast, colorectal, and lung cancers
0.7% of all new cancer cases in the U.S.
2022: 14,100 new cases of cervical cancer and 4280 deaths
STATISTICS
5
February 6, 2023
Northwell Health®
 2018: ~570,000 new cases and 310,000 deaths
 Leading cause of cancer-related death in Africa
 China and India together contribute to >1/3 of the cervical cancer burden
worldwide
CERVIX CANCER: GLOBAL IMPACT
6
February 6, 2023
Northwell Health®
 Disparity seen globally in developing countries
 Higher rates of infectious agents (i.e. HPV, Hepatitis, HIV)
 Decreased structural and financial resources for screening programs
 Individuals with poor socioeconomic status
 Individuals living in rural communities
7
February 6, 2023
Northwell Health®
 Disparity in the U.S.
 Uninsured, immigrants, low educational attainment
 Individuals with poor socioeconomic status
 Individuals living in rural communities
 the South has the highest incidence rate of newly diagnosed cervix cancer
(8.5 per 100,000) and highest death rate (2.7 per 100,000)
8
February 6, 2023
Northwell Health® 9
February 6, 2023
 Number of new cases and deaths differ by race
 White: 7 and 2 per 100,000
 Black: 9 and 3 per 100,000
 LatinX: 10 and 2.5 per 100,000
 American Indian/Alaska Native: 10 and 2.9 per 100,000
 Asian American/ Pacific Islander: 6.3 and 1.6 per 100,000
Northwell Health®
 What is driving these disparities?
 Lack of Screening
 PAP smear and HPV Testing
 Lack of Prevention
 HPV (Human Papilloma Virus) Vaccination (Gardasil 9 vaccine)
10
February 6, 2023
Northwell Health®
 Human Papilloma Virus (HPV) – 90 to 100% of cases
 Abnormal pap smear or pap test
 Immunodeficiency syndromes
 Early age of intercourse
 Multiple lifetime sexual partners
 High risk sex partners
 Smoking
 Low socioeconomic status
CERVIX CANCER: RISK FACTORS
11
February 6, 2023
Northwell Health®
CERVIX CANCER: SYMPTOMS
12
February 6, 2023
Northwell Health®
CERVIX CANCER: DIAGNOSIS AND TREATMENT
13
February 6, 2023
 Diagnosis : tissue biopsy, CT scan, MRI, PETCT scan
 Treatment: Radical surgery, Chemotherapy with Radiation, Immunotherapy
 Prevention: the ONLY GYN Cancer with an effective screening tool for the general
population and a preventative vaccine!
 Pap smear or Pap test and HPV testing:
Georgios Papanicolau –
father of the pap smear
Epidemiologic studies confirmed HPV link
with pre-cancer pap smear and
development of cervix cancer
Identification of HPV in cervical
tumors
1923 1983 1993
Northwell Health®
February 6, 2023 14
Northwell Health®
WHAT IS HPV?
15
February 6, 2023
 Human papilloma virus – double stranded circular DNA, over 100 strains
 Sexually transmitted by both men and women through sexual intercourse and
sexual contact
 80% of sexually active men and women will be infected by HPV by age 50
Northwell Health®
WHAT IS HPV?
16
February 6, 2023
HPV Related non-cancer
• Ano-genital Warts
• Recurrent Respiratory
Papillomatosis
HPV related cancer
• Cervical Cancer
• Vaginal Cancer
• Vulvar Cancer
• Penile Cancer
• Anal Cancer
• Oropharyengeal Cancer
Northwell Health®
PAP SMEAR/ PAP TEST
17
February 6, 2023
 Pap smear screens for abnormal/ pre-cancer cells, HPV testing screens for high
risk HPV, and the diagnostic test is a cervical biopsy.
 Cervical Intraepithelial Neoplasia (CIN) is the premalignant condition that is
diagnosed by cervical biopsy and can progress to cancer if not treated.
0–1 Year 0–5 Years 1–20 Years
Invasive
Cervical
Cancer
Cleared HPV Infection
CIN 1
Initial
HPV
Infectio
n
Continuing
Infection
CIN
2/3
57%
22%
5%
32%
12%
Northwell Health®
TREATMENT AND PREVENTION
18
February 6, 2023
 Treatment of CIN (or pre-cancer of cervix)
 Excisional procedure with either LEEP (Loop Electrocautery Excisional Procedure) or CKC (Cold
Knife Cone) biopsy
 Prevention is with screening and the Gardasil 9 HPV Vaccine
 Screening starts at age 21
 HPV vaccine approved for men and women age 9yo to 45yo
 Screening and vaccination rates in the U.S. = 83% and 54%
Northwell Health®
TREATMENT AND PREVENTION
19
February 6, 2023
 How are we doing with screening in the U.S.?
Overall rate is 81%
– Health People 2020 goal was 93%
– Decline in screening by 5.8% was seen in 2000-2015 (women aged 21-65)
– COVID19 related decline in screening and treatment of pre-cancer
lesions
 Factors driving low screening rates:
– Personal (limited/lack education, distrust, fear)
– Structural (limited/lack insurance, cost, transportation, time off
work, rural communities, language barriers)
Northwell Health® 20
February 6, 2023
How can we improve screening disparities in the U.S.?
Supported by the Community Preventive Services Task Force
Evidence of its effectiveness
Utilized globally
Becoming more common here in the U.S.
Can be cost effective, may generate net cost savings, and promote health equity
Northwell Health®
HPV VACCINE
21
February 6, 2023
Gardasil ®
HPV 6 & 11 – Genital
Warts
90% of genital
warts
HPV 16 & 18 – Cervical
Cancer
70% of cervical
cancers
Approved June 8, 2006
Ceravix ®
HPV 16 & 18
70% of cervical
cancers
Offers cross-
protection against
other strains
– HPV 45, 31
Approved October 16,
2009
Gardasil-9 ®
HPV 6 & 11
90% of genital
warts
HPV 16, 18, 31, 33,
45, 52, 58
90% of cervical
cancers
Approved in December
2014
Northwell Health®
HPV VACCINE
22
February 6, 2023
Several phase II and phase III
trials have been conducted
confirming the efficacy of these
vaccines
Safety monitoring is on going and
confirms no major adverse effects
– Most common side effects: pain, redness, or
swelling in the arm where the shot was given;
fever; headache or feeling tired; nausea; muscle
or joint pain
– Rare side effects: syncope, anaphylaxis
– NO associations with autism, autoimmune
disorders, increased sexual promiscuity
Northwell Health®
HPV VACCINE
23
February 6, 2023
Who gets the HPV Vaccine?
Initially vaccine was approved for girls/women and boys/men age 9 to 26
– 10yrs after vaccine introduction, HPV related infections decreased by 86% in 14 to 19yo and
by 71% in 20 to 24yo
– 50% decrease in cervical pre-cancers from 2008 to 2015
In 10/2018, Gardasil-9 ® was approved by the FDA for an expanded age range of 9 to
45yo, for both men and women
– 3200 women 27 to 45yo followed for 3.5yrs
– 88% reduction in persistent HPV infections, genital warts, vulvar/vaginal/cervical pre-
cancers, cervical cancer
– Safety assessed in 13,000 men and women
Northwell Health®
HPV VACCINE
24
February 6, 2023
HPV Vaccine is a 3 dose series
Dosing schedule:
– Day 1/ Month 0 → 2 Months → 6 Months
– 2 dose schedule, 6 months apart, for children age 9 to 14 is recommended
• Data suggests a better antibody response in this age range
Northwell Health® 25
February 6, 2023
Northwell Health®
CERVIX CANCER
26
February 6, 2023
Northwell Health®
Stage 1A1 – simple hysterectomy
Stage 1A2 – 1B2 – radical hysterectomy, lymph node dissection
Stage 1B3 – IVA – radiosensitizing chemotherapy (cisplatin),
external beam pelvic radiation, internal brachytherapy
Stage IVB – systemic chemotherapy (cisplatin or carboplatin,
paclitaxel, bevacizumab) and immunotherapy (pembrolizumab)
CERVIX CANCER TREATMENT
27
February 6, 2023
Northwell Health®
TAKE HOME POINTS
28
February 6, 2023
 Cervical cancer is preventable, do not miss your annual
GYN visits!
 Effective screening with Pap smear/ Pap test and HPV
testing
 HPV Vaccine
 Disparity in care drives low screening and low
vaccination rates
 Treatable cancer with surgery, chemotherapy, radiation,
and immunotherapy
Northwell Health®
THANK YOU

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What Black Women Need to Know About Cervical Cancer

  • 1. WHAT BLACK WOMEN NEED TO KNOW ABOUT CERVICAL CANCER January 19. 2023 Gizelka David-West, MD, FACOG Gynecologic Oncologist Northwell Health
  • 2. Northwell Health® February 6, 2023 2 Dedicated to my patients with pre-cancer and cancer of the cervix past and present
  • 3. Northwell Health®  Impact of cervical cancer nationally, globally, and on diverse groups  HPV and how it relates to cervical cancer  Screening for cervical cancer and natural history of the disease  Prevention of cervical cancer OBJECTIVES 3 February 6, 2023
  • 4. Northwell Health® HENRIETTA LACKS (8/1/1920 – 10/4/1951)  Diagnosed with cervix cancer 1/1951  Her cells were known as HeLa Cells, first immortalized human cell line  HeLa Cells involved in key medical discoveries such as : Polio vaccine; Cancer drugs; In vitro fertilization; COVID19 vaccine  Paved the way for improved ethics and consents for human research subjects February 6, 2023 4
  • 5. Northwell Health® Cervical Cancer incidence and mortality  4th most common cancer worldwide  Ranks after breast, colorectal, and lung cancers 0.7% of all new cancer cases in the U.S. 2022: 14,100 new cases of cervical cancer and 4280 deaths STATISTICS 5 February 6, 2023
  • 6. Northwell Health®  2018: ~570,000 new cases and 310,000 deaths  Leading cause of cancer-related death in Africa  China and India together contribute to >1/3 of the cervical cancer burden worldwide CERVIX CANCER: GLOBAL IMPACT 6 February 6, 2023
  • 7. Northwell Health®  Disparity seen globally in developing countries  Higher rates of infectious agents (i.e. HPV, Hepatitis, HIV)  Decreased structural and financial resources for screening programs  Individuals with poor socioeconomic status  Individuals living in rural communities 7 February 6, 2023
  • 8. Northwell Health®  Disparity in the U.S.  Uninsured, immigrants, low educational attainment  Individuals with poor socioeconomic status  Individuals living in rural communities  the South has the highest incidence rate of newly diagnosed cervix cancer (8.5 per 100,000) and highest death rate (2.7 per 100,000) 8 February 6, 2023
  • 9. Northwell Health® 9 February 6, 2023  Number of new cases and deaths differ by race  White: 7 and 2 per 100,000  Black: 9 and 3 per 100,000  LatinX: 10 and 2.5 per 100,000  American Indian/Alaska Native: 10 and 2.9 per 100,000  Asian American/ Pacific Islander: 6.3 and 1.6 per 100,000
  • 10. Northwell Health®  What is driving these disparities?  Lack of Screening  PAP smear and HPV Testing  Lack of Prevention  HPV (Human Papilloma Virus) Vaccination (Gardasil 9 vaccine) 10 February 6, 2023
  • 11. Northwell Health®  Human Papilloma Virus (HPV) – 90 to 100% of cases  Abnormal pap smear or pap test  Immunodeficiency syndromes  Early age of intercourse  Multiple lifetime sexual partners  High risk sex partners  Smoking  Low socioeconomic status CERVIX CANCER: RISK FACTORS 11 February 6, 2023
  • 12. Northwell Health® CERVIX CANCER: SYMPTOMS 12 February 6, 2023
  • 13. Northwell Health® CERVIX CANCER: DIAGNOSIS AND TREATMENT 13 February 6, 2023  Diagnosis : tissue biopsy, CT scan, MRI, PETCT scan  Treatment: Radical surgery, Chemotherapy with Radiation, Immunotherapy  Prevention: the ONLY GYN Cancer with an effective screening tool for the general population and a preventative vaccine!  Pap smear or Pap test and HPV testing: Georgios Papanicolau – father of the pap smear Epidemiologic studies confirmed HPV link with pre-cancer pap smear and development of cervix cancer Identification of HPV in cervical tumors 1923 1983 1993
  • 15. Northwell Health® WHAT IS HPV? 15 February 6, 2023  Human papilloma virus – double stranded circular DNA, over 100 strains  Sexually transmitted by both men and women through sexual intercourse and sexual contact  80% of sexually active men and women will be infected by HPV by age 50
  • 16. Northwell Health® WHAT IS HPV? 16 February 6, 2023 HPV Related non-cancer • Ano-genital Warts • Recurrent Respiratory Papillomatosis HPV related cancer • Cervical Cancer • Vaginal Cancer • Vulvar Cancer • Penile Cancer • Anal Cancer • Oropharyengeal Cancer
  • 17. Northwell Health® PAP SMEAR/ PAP TEST 17 February 6, 2023  Pap smear screens for abnormal/ pre-cancer cells, HPV testing screens for high risk HPV, and the diagnostic test is a cervical biopsy.  Cervical Intraepithelial Neoplasia (CIN) is the premalignant condition that is diagnosed by cervical biopsy and can progress to cancer if not treated. 0–1 Year 0–5 Years 1–20 Years Invasive Cervical Cancer Cleared HPV Infection CIN 1 Initial HPV Infectio n Continuing Infection CIN 2/3 57% 22% 5% 32% 12%
  • 18. Northwell Health® TREATMENT AND PREVENTION 18 February 6, 2023  Treatment of CIN (or pre-cancer of cervix)  Excisional procedure with either LEEP (Loop Electrocautery Excisional Procedure) or CKC (Cold Knife Cone) biopsy  Prevention is with screening and the Gardasil 9 HPV Vaccine  Screening starts at age 21  HPV vaccine approved for men and women age 9yo to 45yo  Screening and vaccination rates in the U.S. = 83% and 54%
  • 19. Northwell Health® TREATMENT AND PREVENTION 19 February 6, 2023  How are we doing with screening in the U.S.? Overall rate is 81% – Health People 2020 goal was 93% – Decline in screening by 5.8% was seen in 2000-2015 (women aged 21-65) – COVID19 related decline in screening and treatment of pre-cancer lesions  Factors driving low screening rates: – Personal (limited/lack education, distrust, fear) – Structural (limited/lack insurance, cost, transportation, time off work, rural communities, language barriers)
  • 20. Northwell Health® 20 February 6, 2023 How can we improve screening disparities in the U.S.? Supported by the Community Preventive Services Task Force Evidence of its effectiveness Utilized globally Becoming more common here in the U.S. Can be cost effective, may generate net cost savings, and promote health equity
  • 21. Northwell Health® HPV VACCINE 21 February 6, 2023 Gardasil ® HPV 6 & 11 – Genital Warts 90% of genital warts HPV 16 & 18 – Cervical Cancer 70% of cervical cancers Approved June 8, 2006 Ceravix ® HPV 16 & 18 70% of cervical cancers Offers cross- protection against other strains – HPV 45, 31 Approved October 16, 2009 Gardasil-9 ® HPV 6 & 11 90% of genital warts HPV 16, 18, 31, 33, 45, 52, 58 90% of cervical cancers Approved in December 2014
  • 22. Northwell Health® HPV VACCINE 22 February 6, 2023 Several phase II and phase III trials have been conducted confirming the efficacy of these vaccines Safety monitoring is on going and confirms no major adverse effects – Most common side effects: pain, redness, or swelling in the arm where the shot was given; fever; headache or feeling tired; nausea; muscle or joint pain – Rare side effects: syncope, anaphylaxis – NO associations with autism, autoimmune disorders, increased sexual promiscuity
  • 23. Northwell Health® HPV VACCINE 23 February 6, 2023 Who gets the HPV Vaccine? Initially vaccine was approved for girls/women and boys/men age 9 to 26 – 10yrs after vaccine introduction, HPV related infections decreased by 86% in 14 to 19yo and by 71% in 20 to 24yo – 50% decrease in cervical pre-cancers from 2008 to 2015 In 10/2018, Gardasil-9 ® was approved by the FDA for an expanded age range of 9 to 45yo, for both men and women – 3200 women 27 to 45yo followed for 3.5yrs – 88% reduction in persistent HPV infections, genital warts, vulvar/vaginal/cervical pre- cancers, cervical cancer – Safety assessed in 13,000 men and women
  • 24. Northwell Health® HPV VACCINE 24 February 6, 2023 HPV Vaccine is a 3 dose series Dosing schedule: – Day 1/ Month 0 → 2 Months → 6 Months – 2 dose schedule, 6 months apart, for children age 9 to 14 is recommended • Data suggests a better antibody response in this age range
  • 27. Northwell Health® Stage 1A1 – simple hysterectomy Stage 1A2 – 1B2 – radical hysterectomy, lymph node dissection Stage 1B3 – IVA – radiosensitizing chemotherapy (cisplatin), external beam pelvic radiation, internal brachytherapy Stage IVB – systemic chemotherapy (cisplatin or carboplatin, paclitaxel, bevacizumab) and immunotherapy (pembrolizumab) CERVIX CANCER TREATMENT 27 February 6, 2023
  • 28. Northwell Health® TAKE HOME POINTS 28 February 6, 2023  Cervical cancer is preventable, do not miss your annual GYN visits!  Effective screening with Pap smear/ Pap test and HPV testing  HPV Vaccine  Disparity in care drives low screening and low vaccination rates  Treatable cancer with surgery, chemotherapy, radiation, and immunotherapy

Editor's Notes

  1. I always like starting any talk with a case presentation. I thought it would be fitting to describe Henrietta Lacks and how she presented at time of diagnosis. I will then contrast her case to a recent case, 70yrs later. I will then describe her legacy in honor of her today and then we will dive into the finer details on cervical cancer screening, prevention, and the impact on racially/ethnically/economically diverse groups. Her story has been immortalized in a best selling book by Rebecca Skloot and a movie starring Oprah. Her story also paved the way for improved ethics and consents for human research subjects, she has received several awards/honors in her memory, and her family…
  2. So what is driving these disparities That we see globally and here in our own country within our diverse communities…. So lets dive in and see how we can prevent and hopefully eradicate cervix cancer!
  3. Adding up incidence of all these cancers equals approx. 40K cancers yearly that are caused by HPV!!
  4. Data from 2019 looks similar