Sharad Ghamande, MD, FACOG Professor and Director of Gynecologic Oncology Augusta University Cancer Center Presentation to the Georgia Senate Women's Adequate Healthcare Study Committee www.gacommissiononwomen.org

1. Cervix Cancer and GA
Sharad Ghamande, MD FACOG
Professor and Director Gynecologic Oncology, GRU
Associate Director Clinical Affairs , GRU Cancer Center, Augusta GA
Principal Investigator Minority NCORP GA Cares

3. 64,928
Europe
67,078
Africa
49,025
South America
14,845
United States/
Canada
1,077
Australia/
New Zealand
39,648
Southeast
Asia
51,266
Eastern Asia
21,596
Central America
151,297
Southcentral
Asia
Cervical Cancer: Worldwide Prevalence,
Incidence, and Mortality Estimates
Prevalence: 2,274,000 women have cervical cancer
Incidence: 510,000 new cases each year
80% in developing countries
Mortality: Second leading cause of female cancer-related deaths (288,000 annually)
Estimated individual loss of life: 25.9 years
(Breast Cancer: 19 years, Ovarian Cancer: 17.4 years)

4. Cervix Cancer in US
• American Cancer Society 2015
• 12,900 cases of cervix cancer a year, 4100
patients will die of it this year
• Additionally there are 300,000 cases of CIN2/3
which are true cancer precursors
• Another 1.2 million women in US have a low
grade dysplasia (CIN 1)
• Total health care costs of screening and treating
cervix cancer are estimated at 6 billion dollars a
year

5. 1. Jemal A et al. CA Cancer J Clin. 2009;59:225-49.
2. Saslow D et al. CA Cancer J Clin. 2007;57:7-28.
3. ACS. Facts & Figures. 2009.
High Impact of Cervical Cancer & Precancerous
Lesions in the United States
Every minute a woman is diagnosed with a precancerous lesion2,a,b
Every 2 hours a woman dies of cervical cancer3,a
Every hour a woman is diagnosed with cervical cancer3,a
aEstimated
bPrecancerous lesion = cervical intraepithelial neoplasia (CIN) grades 2/3
In the United States, cervical cancer is the second leading cause of cancer-related death in women between the
ages of 20 and 391

10. GA Racial Distribution
• According to the 2010 U.S. Census, Georgia had a population of 9,687,653.
In terms of race the population was:
• 59.7% White American (55.9% Non-Hispanic White, 3.8% White Hispanic),
• 30.5% Black or African American (including Hispanics)
• 0.3% American Indian and Alaska Native (including Hispanics)
• 3.2% Asian American (including Hispanics)
• 0.1% Native Hawaiian and Other Pacific Islander (including Hispanics)
• 4.0% from Some Other Race (including Hispanics)
• 2.1% Multiracial American (including Hispanics)
• 8.8% Hispanics and Latinos of any race.[5]

11. How can we make an impact ?
1) Prevention
- Widespread use of Pap smears
- Improve Vaccination
2) Treat CIN 2/3 and prevent invasive cancers ( Insurance and access
barriers)
3) Improve the care and outcomes of women with cervix cancer

12. Cervical Cancer: Have We Decreased the Incidence
in the U.S.?
• The curve has been
stable for the past
decade in part because
we are not reaching the
unscreened population.
 With the advent of the Pap
smear, the incidence of
cervical cancer has
dramatically declined.
 74% decline in death from
1955 to 1992
Reprinted by
permission of the
American Cancer
Society, Inc.

14. CIN 2-3 rates
• Annual incidence of CIN 1 is 1.6, CIN 2/3 is 1.2 per 1,000 women
• Incidence is highest
• women aged 21 – 30 years with CIN 1 is 3.3 per 1000 and CIN 2/3 is 3.6 per
1000
• women aged 31 – 40 years with 2.9 per 1000 for CIN1 and CIN 2/3 is 2.7 per
1000
• Costs per episode of care was higher for CIN 2/3 than for CIN 1
• $ 1,634 for CIN 2/3 vs $ 1,084 for CIN 1
• Estimated 412,000 women are diagnosed with CIN annually with an
associated cost of approximately $570 million [1]
[1] Henk et al.: Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population.
J lower tract dis, 2010, Vol 14, 29-36

15. Costs of Treating Cervical Cancer
• Cost of cervical cancer treatment: implications for providing coverage to low-income women under the Medicaid
expansion for cancer care. Subramanian S1, Trogdon J, Ekwueme DU, Gardner JG, Whitmire JT, Rao C.
• BACKGROUND:
• To date, no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries
younger than 65 years of age. This information is essential for assessing the cost effectiveness of
screening interventions for low-income women and the funding required for treatment programs
established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000.
• METHODS:
• Administrative data from the North Carolina Medicaid program linked with cancer registry data were used
to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6
and 12 months from diagnosis. We compared 207 beneficiaries diagnosed with cancer during the years
2002 to 2004 with 414 controls.
• FINDINGS:
• Total Medicaid costs at 6 months after diagnosis were $3,807, $23,187, $35,853, and $45,028 for in situ,
local, regional, and distant cancers, respectively.
• The incremental cost of cancer treatment for local and regional cancers was $13,935 and $26,174 and by
12 months increased to $15,868 and $30,917, respectively
• 2010 Nov-Dec;20(6):400-5. doi: 10.1016/j.whi.2010.07.002.

16. Cervical Cancer – Risk Factors
• Multiple sexual partners
• Early age onset intercourse
• Parity
• H/O STD’s
• Smoking
• Low socioeconomic status
• Use of Oral Contraceptives
• High risk male partner

17. Cervical Cancer - Risk Factors
• HIV
• RR 5.2-6.5 of cervical cancer
• 1993 CDC: AIDS defining illness
• mean age at diagnosis 40
• HPV
• OR 158.2 for HPV
• High risk 16,18,45,31,33,52,58,35

18. 0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
57.6%
71.7%
77.4%
81.3%
85.%
87.9%
90.1%
91.8%
93.3%
94.6%
95.7%
HPV types from 3,045 Women with Cervical Cancer in 23 countries

19. HPV vaccination
• HPV 4
• Approved for females and males 9 – 26
• Contains HPV 16/18/6/11
• HPV 2
• Approved for females and males 9 – 25
• Contains HPV 16/18
• A 9-valent vaccine licensed in December 2014
• Contains additional 5 HPV types 31/33/45/52/58

20. HPV vaccination in GA adolescents
Year Females Males
> 1 HPV (
95%CL)
> 2 HPV (
95%CL)
> 3 HPV (
95%CL)
> 1 HPV (
95%CL)
> 2 HPV (
95%CL)
> 3HPV (
95%CL)
2014 65.4 56.3 47.1 41.2 28.0 21.0
2013 53.7 42.3 33.2 40.5 31.0 15.3
2012 52.3 36.8 29 19.5 8.7 N/A
2011 48.4 N/A 30.0 7.3 N/A N/A
2010 All adolescences 43.5 % received > or = 1 HPV, 22.8 % received > or = to 3 HPV
2009 All adolescences > or = to 1 HPV 38.6 %
2008 All adolescences > or = to 1 HPV 18.5 %
Estimated vaccination coverage among adolescents aged 13--17 years,* by state and selected areas and selected vaccines
and doses --- National Immunization Survey--Teen, United States, 2008 – 2014, MMWR – CDC, cdc.gov/mmwr/review

21. Estimated vaccination coverage with ≥1 dose of human papillomavirus (HPV) vaccine* among females aged
13–17 years. (United States, National Immunization Survey–Teen, 2014)

22. Estimated vaccination coverage with ≥1 dose of human papillomavirus (HPV) vaccine* among males aged
13–17 years (United States, National Immunization Survey–Teen, 2014)

23. HPV Vaccination
• CDC
• If we increase vaccination rates to 80%, an additional 53,000 new
cases of invasive cervix cancers could be prevented in the life time of
those younger than 12 years
• For very additional year increase, an additional 4400 women will go
on to have cervical cancer

24. HPV vaccine recommendations
• ACIP recommends routine vaccination at age 11 or 12 with HP4 for
males and females and HPV 2 for females
• Vaccination schedule is 0,1-2, 6 months
• ACOG and CDC proclaim that “the current vaccination rates are
unacceptable”

25. Can we create centers of excellence for
cancer care ?
• Impact of facility volume on therapy and survival for locally advanced
cervical cancer
• Jeff F. Lin a,⁎, Jessica L. Berger a, Thomas C. Krivak a,b, Sushil Beriwal
a, John K. Chan c, Paniti Sukumvanich a, Bradley J. Monk d,e, Scott D.
Richard
• Gynecologic Oncology 132 (2014) 416

26. Lin et al
• Methods: The National Cancer Data Base was queried for patients
with stage IIB – IIIB cervical cancer from 1/1998 through 12/2010.
Facility volumes were tallied. Overall survival was estimated using
Kaplan–Meier method. Univariate and multivariable analyses were
performed to determine variables affecting survival, receiving
standard therapy, and total duration of radiotherapy.
• Results. Total of 27,660 patients were treated at 1361 facilities.
Thirty of the facilities (2.2%) treated the highest quartile volume of
patients (9.4 patients annually) while 1072 facilities (78.8%) treated
(2.4 patients annually).
• The median age of patients was 53, the majority were Caucasian,
treated in a metropolitan area, and of squamous cell histology.

27. Lin et al
• Median survival of patients treated at lowest- and highest volume
centers were 42.3 months (95% CI 39.8–44.8) and 53.8 months (50.1–
57.5), respectively (p b 0.001).
• The proportions of patients receiving brachytherapy and chemotherapy
were 54.8% and 79.9%, respectively.
• On multivariable analysis, higher facility volume independently predicted
improved survival (p = 0.022), increased likelihood of receiving
brachytherapy (p b 0.0005) and chemotherapy (p = 0.013), and shorter
time to radiotherapy completion (p b 0.0005).
• Conclusions. Patients with locally advanced cervical cancer treated at high
volume centers are more likely to receive standard therapy, complete
therapy sooner, and experience better survival.

28. Paradigm Shift in Care ?
• Encouragement towards shifting care towards High Volume /
subspeciality staffed institutions ?
• Emerging survival data
• Clinical trials participation
• Multi Disciplinary team approach
• Technological advances ( PET/CT’s, Robot assisted radical surgeries)
• Individualization of care