Cervical cancer an odyssey: Israel De Alba
•Download as PPTX, PDF•
1 like•347 views
This document discusses the history and prevention of cervical cancer. It summarizes a research study that compared self-sampling and physician sampling for HPV testing among Hispanic women. The study found that self-sampling had a sensitivity of 88% compared to physician sampling. Women reported high satisfaction with self-sampling and those who tested positive for HPV through self-sampling were more likely to receive a Pap smear. The implications are that self-sampling could be an alternative to physician sampling and may help increase cervical cancer screening rates among groups with barriers to care.
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Cervical cancer an odyssey: Israel De Alba
Similar to Cervical cancer an odyssey: Israel De Alba (20)
Recently uploaded
Recently uploaded (20)
Cervical cancer an odyssey: Israel De Alba
- 1. Cervical Cancer: an Odyssey Israel De Alba, MD MPH President American Cancer Society California Division
- 3. 400 BCE
- 4. Cure sometimes, treat often, comfort always. Hippocrates What is the cause of this disease? How can I cure it? How can I prevent it?
- 8. "Of all the forms of inequality, injustice in health care is the most shocking and inhumane." — Martin Luther King Jr.
- 11. Italy, circa 1750 • cervical cancer rare in nuns • Common in sex workers • Common in second wives of men whose first wives died of cervical cancer • Rare in Jewish women
- 13. • Colposcope invented • Papanicolaou Technique • Pap smear screening • Prevention
- 15. He-La
- 16. HPV
- 17. Transformation
- 18. The HPV virus
- 19. HPV
- 20. HPV
- 21. HPV in men
- 22. RESEARCH
- 23. Research
- 24. Research
- 25. background • Latinas have the highest incidence of cervical cancer in California. • Despite recent progress in Pap smear use, multiple barriers to screening persist among Hispanic women. • Many of those barriers are: – lack of time, child care, or transportation. – Scheduling conflicts (office closed in PM or weekends) – Modesty • Testing positive for a sexually transmitted virus that may lead to cervical cancer – May provide women with a compelling motive to get screened for cervical cancer and may help overcome some of the barriers to cervical cancer screening.
- 26. AIMS 1. How does self sampling compare to physician sampling at identifying abnormal Pap smears? 2. How satisfied or comfortable are Latina women with self-sampling for HPV? 3. Are women who test positive for HPV more or less likely to get a Pap smear?
- 27. Methods • Hispanic women >18, no recent Pap • Community workers distributed self sampling kits • Participants collected samples on their own – Vaginal sample – At any time or place (home or at site) – Return sample to lay health worker for processing • All HPV+ and one HPV negative control were invited for: – Pap smear – Repeat HPV sample collected by the physician
- 28. Results: demographics • 1,213 women included • 386 had Pap smear and physician collected sample for HPV • Mexican/Mexican American origin (89.4%) • Age distribution • 18-34 y.o 31% • 35-49 y.o. 48% • 50 or older 21% • Pap test between 1-2 years prior 78.3% • 13.6%had a positive result for HPV on self sampling
- 29. How self-sampling and physician sampling compare to each other? • 87.8% had same HPV result in self and physician sampling • Self sampling as compared to physician sampling at identifying high risk HPV – Sensitivity 93% – Specificity 88%
- 30. How satisfied are Hispanic women with self-sampling? Table 3 Satisfaction with self sampling for HPV testing among Hispanic women (N = 1,213) Excellent (%) Very Good (%) Good (%) Fair (%) Overall experience 33.7 30.8 32.9 2.4 Clarity of instructions for using the kit 48.6 34.1 16.5 0.7 Ease of use of kit 48.7 34.0 16.5 0.7 Understanding of what the results mean 46.8 36.9 15.8 0.4 Convenience of self-sampling as compared to physician sampling at a clinic 45.3 36.5 16.4 0.2
- 31. Are HPV+ by self-sampling more likely to have a Pap ? • While 95% of the HPV positive scheduled a Pap smear, only 69% of the HPV negative did (p < 0.0001). • Among all women, 84% of the HPV+ received a Pap smear as compared to only 49% of the HPV- (p<0.0001).
- 32. Summary • Almost 9 out 10 had same result on self and physician sampling • The sensitivity of self sampling for identifying high risk HPV was 88%
- 33. Summary • Satisfaction was high with self sampling • Testing positive for HPV favorably impacts scheduling and receipt of Pap smears among Hispanic women. • Among women with no Pap smear in the past three years or ever, a positive HPV test result increased the likelihood of scheduling or receiving a Pap smear.
- 34. Implications • Self sampling for HPV at home or in a non- clinical site may be an alternative to physician sampling • It may provide an additional tool for cervical cancer control • As a tool for cervical cancer screening where Pap smears are not easily available • For screening in women who refuse pelvic exam or in those with other barriers like time constrains, lack of transportation, etc
- 35. HPV Vaccine
- 38. What is the cause of this disease? How can I cure it? How can I prevent it?
Editor's Notes
- Imagine this:A 25 yo women, with vaginal bleeding,being checked by her doctor.As the physical examination progresses, the face of the doctor becomes more and more somber. You can read on his face, that the prognosis, is not good. thatit was a deadly disease.His wide open eyes, tell you that the doctor is puzzled. What is it? What causes it? How can it be prevented? How can it be cured?The disease did not even have a nameThe year: 400 BCE (2,400 years ago)The doctor: Hippocrates. Also known as the father of western medicine, the person who coined the word cancer to describe this aggressive disease. To the father of medicine, the tumor and its feeding blood vessels resembled crab claws reaching out. Therefore, the word Greek for crab, (cancer) was use to name this disease.
- The father of western medicine was wondering. What in the world is this? What is the cause of that cancer?Is there anything I can do to cure it?Is there anything I can do to prevent it?Now in 2011, after 2400 years and thanks the efforts , determination and contribution of millions of people we have some answers to Hippocrates's questions.But getting here was not easy
- To say that cervical cancer is a huge problem, is an understatement
- As you can see in the graph, cervical cancer is the second most common cause of cancer mortality in the worldHowever, in some parts of the world, such as in Africa, Central America and southern Asia, cervical cancer is the #1 cancer in incidence and mortalityEvery year worldwide Over half a million women (most younger than 45) are diagnosed with cervical cancer and About half of them, that is one quarter of a million, die of the disease.
- Listen to this, 1. In terms of prevention of cervical cancer; we have an effective vaccine that recently became available2. In terms of early diagnosis, we have a proven effective, widely available, inexpensive and easy to perform screening test that has been available for almost 60 years: the Pap test3. In terms of treatment, cervical cancer grows extremely slowly, taking up to 10 years before spreading; providing ample time for diagnosis and treatment.Every cervical cancer death is one too many.
- This is the annual cervical cancer mortality rates by age group in developed and developing regions. There is a disproportionately high burden of cervical cancer in developing countriesMostly due to the lack of screening. Plain and simpleYes, 80% of all cervical cancers occur in developing countriesCervical cancer has become the biological synonym for the words inequality and injustice.
- In the United States in general; the incidence of cervical cancer is lower,as compared to other parts of the world. There are around 11,000 new cases of invasive cervical cancer a year, and 4000 deaths.However, as I told you before, cervical cancer is the ultimate marker of inequality. Minority and low income populations in the US, are disproportionately affected by a higher incidence and mortality.As an example, the incidence of cervical cancer for Hispanics, is almost double that for non-HispanicsThe incidence of cervical cancer is about 30% higher, in African Americans than in whites, with about twice the mortality rate
- In California, each year about 1,400 women are diagnosed withcervical cancer. 400 die fromthe disease. However, each case of cervical cancer is one too many, each case, represents a missed opportunityfor prevention.
- Remember Hippocrates?One of the most urgent, burning, critical questions he had was about the cause of cervical cancer.The first clue, came about 2000 years later. Around 1750, an Italian physician, Bernardino Ramazzini and others noted that:Cervical cancer was common in female sex workersCervical cancer was rare in nuns, except for those who had been sexually active before entering the conventCervical cancer was more common in the second wives of men whose first wives had died from cervical cancerAnd that cervical cancer was rare in Jewish womenTherefore, for the first time, we had a clue to answer some of the questions Hippocrates asked.There was a clear connection between cervical cancer and sexual activity
- The next big step, towards understanding and preventing cervical cancer, came early in the 20th century.
- It was the roaring 20’s, Ford’s model T was in production, Charles Chaplin was the great star. But in Germany, Dr. Hinselmann was busy inventing the Colposcope, which allowed a clear visualization of the cervix.This came really handy to a Greek zoologist, who was studying the menstrual cycle of guinea pigs through vaginal scrapings. He applied the same technique to study menstrual cycle in women, and this led to a chance discovery of malignant cells.One of the greatest merits was to recognize the potential of this techniqueto detect cervical cancer in humans through examination of cervical scrapings. The zoologist I am talking about is Dr. GeorgiosPapanicoalou who developed… the Pap test. Dr. Pap in addition to having a degree in zoology, also had a degree in medicine.
- The rest is history, the Pap test has been one of the most effective interventions in the fight against cancer in the history of mankind.It led to a sustained reduction in cervical cancer incidence and mortality as you can see in the graph.Something interesting, the Pap was invented in 1928, but it did not became available as a generalized screening tool until 1947. Dr. Pap retired in 1961, died in 1962 in Florida.In the US, cases of invasive cervical cancer are more likely to represent failure to perform appropriate screening than inaccuracies of screening when performed. More than half of women who develop cervical cancer either have never had cervical cytology, have been screened sporadically, or have not been screened within the previous five years.
- During the roaring 20’s, a very bright and outgoing girl was born in Virginia. Her nave was Henrietta Shehad a tough life, she married, and had her first child at age 14. In 1951, at the age of 30, Henrietta participated in a march for polio in NYC when she noted vaginal bleeding. A biopsy confirmed her worst suspicion, it was cervical cancer. But Henrietta's cancer was not an ordinary cancer, it was extremely aggressive, and she died only 9 months after diagnosis. Cells from Henrietta's tumor were put in a culture media and the physicians discovered that [Henrietta's] cells did something they'd never seen before: They could be kept alive and grow.“Henriettas cancer cells were the first human cells that could be grown in a labThey were "immortal" (did not die after a few cell divisions), they could then be used for scientific research. This represented an enormous boom to medical and biological researchHenriettas cells have been used in thousands of life saving studies. They were used to help test the polio vaccine, so that it could be approved for use in peopleThey went up in the first space missions, to observe the effects of zero gravity on human cellsHers were the first cells ever cloned.This invaluable line of cells still available today is named He-La, in honor of Henrietta Lacks
- By the 1950’s, it was really clear that cervical cancer was related to an sexually transmitted agent
- The prime suspect was herpes, it had all the right signs. It was very common, it was sexually transmitted, etcBut another agent was smegma, a pasty combination of epithelial cells, skin oils and moisture that accumulates in the glans of men. But, there were other candidates, such as the papilloma virus. The rabbit papilloma virus was carcinogenic in rabbitsIn 1976 HaraldzurHausen published the hypothesis that human papilloma virus plays an important role in the cause of cervical cancer. This was confirmed In 1983 and Dr. Harold zurHausen receive the Nobel Prize for this discoveryFinally, another of Hippocrates questions had been answeredIn work that was initiated in the mid 1980s, the HPV vaccine was developed.
- Human papillomaviruses (HPV) only cause disease in humans. There are close to: 200 different types, 40 infect the genital tract, but only 15 can cause cervical cancer The papilloma virus that causes warts, does not cause cervical cancer, and viceversaHPV infection is the most commonly diagnosed sexually transmitted disease in the United States 20 million Americans, right now, are currently infected with HPV; 6 million people become newly infected each year. In addition to cervical cancer, HPV is also associated with vaginal, vulvar, penile, anal, mouth and throat cancers. It may also be a co-factor in some lung cancers. Most infections clear within 2 years, and nothing happens. But in a small number of women, the infection does not clear for unknown reasons. Leading to cell changes than may end in cancer. the median age of cytologically-detected precancerous lesions occurs approximately 10 years after the median age of sexual Factors associated with oncogenic HPV infection included smoking, higher numbersexual partners and increased frequency of intercourse, whereas condom use was associated with a reduced likelihood of HPV infection.It has been estimated that at least 50 percent of sexually active women (and men) are exposed to HPV once in their lifetime
- Some very, very interesting factsDolphins get infections by papillomaviruses, the dolphin papilloma virus, but never cervical cancer itself. Dolphins are the only species, besides humans, that can harbor co-infections, or infections of multiple papillomavirus types at the same time. So why dolphins don’t get cervical cancer? The answer to this question, may help us fight cervical cancer in humans
- Another surprising fact:The infection that leads to cervical cancer is contagious, but not cervical cancer itselfHowever, reality is stranger than fiction.There are cancers that are contagious, the tumor metastasizes to other organisms of the same species. The DNA of the tumors is not the same as the DNA of the dogsThat is right, the canine transmissible venereal tumor is unique because the cells of the tumor itself are transmitted from dog to dog during sex. Making it a unique case in nature.
- Are men also affected? You bet, aach year in the U.S. there are about: 8000 men who get HPV-related penile, anal or head and neck cancers What factors are associated with higher risk of HPV infection in men? These include current and past sexual behaviorabsence of condom useprior STDsand circumcision statusTwo years ago, the FDA approved the HPV vaccine for boys and men ages 9–26 for the prevention of genital warts and anal cancer
- Inclusion: Hispanic womenage 18 years or olderno Pap smear in the past yearno history of hysterectomy or invasive cervical ExclusionPregnancyunwillingness to follow study protocol. Self sample collectionVaginal sampleAt any time or place (home or at site)Return sample to lay health worker for processingAll HPV+ and one HPV negative control were invited for a Pap smear and a repeat HPV sample collected by the physicianHybrid capture II for high risk HPV was used
- Satisfaction4-point Likert scale in the following items:Overall experienceClarity of instructionsEase of use of kitUnderstanding of what the results meanConvenience as compared to doctor collection1,213 women included386 had Pap smear and physician collected sample for HPVMexican/Mexican American origin (89.4%)Age distribution18-34 y.o 31%35-49 y.o. 48%50 or older 21%Pap test between 1-2 years prior 78.3%13.6%had a positive result for HPV on self sampling
- More women were positive on self sampling than on physician samplingAlmost 9 out 10 had same result on self and physician samplingThe sensitivity of self sampling for identifying high risk HPV was 88%
- Self sampling was more sensitive but less specific for identifying abnormal Pap smear as compared to physician samplingSatisfaction was high with self sampling
- Unsupervised self sampling for HPV at home or in a non-clinical site may be an alternative to physician samplingIt may provide an additional tool for cervical cancer controlAs a tool for cervical cancer screening where Pap smears are not easily availableFor screening in women who refuse pelvic exam or in those with other barriers like time constrains, lack of transportation, etc
- In 2006, many years after Hippocrates, the U.S. Food and Drug Administration (FDA) approved the first preventive vaccine for HPV: “Gardasil”
- Currently; two vaccines are available to prevent infection by some HPV typesGardasil and CervarixBoth protect against initial infection with HPV types 16 and 18, which cause 70% of the HPV associated cancer cases. But Gardasil, also protects against HPV types that cause 90% of genital warts.The vaccine is recommended:primarily for those women who have not yet been exposed to HPV during sex (no benefit in who is positive already)females 11-12, and catch up vaccination in 13-26 year olds. We, the ACS, recommend vaccination from in girls 11-12 and females 13 to 18 years old who have not started the vaccines, or who have started but not completed the seriesMales 9 to 26
- Something that is very, very important; Both vaccines offer protection against 70% of cervical cancers, not 100%.Women already with HPV do not benefit from the vaccine. Therefore, Pap smear screening should continue as scheduled
- Over 2000 years ago, Hippocrates the father of western medicine, reported and treated cases of cervical cancer. He asked fundamental questions about the cause, prevention and treatment of cervical cancerAnswering those questions, getting to where we are now, has taken a lot of effort, energy and commitment of millions of people. Like the Greek hero, Odysseus on his long way home after the end of the Trojan war, in these 2000 years we have Been driven off course,have faced Cyclops who saw only part of the truth, and have heard many “sirens songs”The only difference is that Odysseus is already home and we are not. Cervical cancer grows at a slow pace providing ample opportunity for detection and early treatment, we have an effective vaccine,We have a proven effective, widely available, inexpensive and easy to perform screening test that has been available for 60 years, yet,every year worldwide over quarter of a million women die of the disease.Every one of the 11000 cases we have annually in the US is one cervical cancer too many.Thanks