Cervical Cancer Screening and Prevention in Latinas. Sandra Torrente, MD, MSc Kenneth Grullon, MD

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2 Cervical Cancer Screening and Prevention in Latinas Sandra Torrente, MD, MSc Kenneth Grullon, MD

3 Objectives Cervical cancer epidemiology Cervical cancer screening rates locally Health Disparities of cervical cancer in Latinas Prevention by vaccination Outreach efforts

4 ARS: Where are the highest incidence rates of cervical cancer worldwide? A. Latin America and the Caribbean B. South-Central Asia C. Sub-Saharan Africa 46% 4% 50% Latin America and the C... South Central Asia Sub Saharan Africa

5 Worldwide Most common gynecological cancer in the World 9% of new cases 8% of deaths

6 United States 12,000 new cases of invasive cervical cancer 4200 cancer related Deaths Third most common cause of female related deaths

7 Trends in Pap Test

8 California

9 Kaiser Cervical Cancer Screening 100% Cervical Cancer Screening Measurement period ending June 30, 2013 KPNC REGION 95% 90% 85% 80% 75% 70% 65% 60% All Members Black or African American Asian or Pacific Islander Hispanic or Latino Multiracial American Indian or Alaska Native White HEDIS 2013 National 90th Percentile

10 HEDIS measures KPNC REGION All Members Black or African American Asian or Pacific Islander Hispanic or Latino Multiracial American Indian or Alaska Native White HEDIS 2013 National 90th Percentile Breast Cancer Screening 84.4% 83.1% 84.8% 84.6% 81.7% 78.0% 84.5% 77.3% Cervical Cancer Screening 86.1% 85.9% 85.6% 87.0% 85.5% 81.1% 86.0% 80.0%

11 ARS case 39 y/o G3P3 El Salvadorian female presents to you for her well woman exam. She has not had health insurance for the past 10 years. She recently became eligible for CoveredCa, since she is now a permanent resident. Her last pap smear was prior to the birth of her last child. She thinks it was abnormal.

12 ARS: What are the major risk factors she has for cervical cancer? A. Persistent HPV 38% 42% B. Ethnicity C. Lack of screening D. All of the above 12% E. A and C 4% 4% Persistent HPV Ethnicity Lack of screening All of the above A and C

13 Etiology of Cervical Cancer 4 reliable Stages HPV acquisition HPV Persistence Progression» Invasion

14 Excessive Burden of Cervical Cancer Low Resources setting Underserved regions Two significant determinants of cervical cancer Persistent carcinogenic HPV infection Lack of access to screening

15 Cervical Cancer disparities

16 Prevention by Vaccination Decline of HPV infection Improved vaccination efforts Disparities in HPV vaccine series completion Disparities continue to exist when socioeconomic factors are controlled for

17 HPV Vaccination Rates

18 Likelihood of HPV-4 Vaccine Series Completion by Race/ethnicity Crude Odd Ratio (95% CI)* p value Race/ethnicity Hispanics 0.85 ( ) <.0001 Asian/PI 1.30 ( ) <.0001 Blacks 0.53 ( ) <.0001 Others/ Unknown 0.68 ( ) <.0001 Age Adjusted Race/ethnicity Hispanics 0.82 ( ) <.0001 Asian/PI 1.29 ( ) <.0001 Blacks 0.53 ( ) <.0001 Others/ Unknown 0.68 ( ) <.0001 * Whites as the reference group

19 Prevalence of HPV-4 Vaccine Completion by Degree of Acculturation in Hispanics Degree of Acculturation Prevalence (95% CI) * Low 44.2 ( ) Moderate 40.6 ( ) High 37.2 ( ) N= 10,936 *P value from Chi square test <.0001 Prevalence expressed as percentages

20 Association by Race Vaccination series completion is associated with race/ ethnicity: Asians were 30% more likely to complete the series Blacks were 47% less likely to complete the series Hispanics were 15% less likely

21 Effect of Acculturation Prevalence and likelihood of HPV vaccination completion varies according to degree of acculturation Prevalence in lower acculturated Hispanics was 16% greater than higher acculturated Hispanics Lower acculturated Hispanics were 34% more likely to complete the series

22 Pap Screening Intervals q 3 years pap only q 3 years pap + HPV

23 Outreach Efforts Post card sent 6 months before due If no response- phone call, centralized service If still no response sent to individual physician and medical assistant to call

24 In-reach Efforts Same day paps if seen in other depts and due this year Saturday pap only appointments (combined with Mammo and Flu during flu season) Roving NP to do paps in medicine offices

25 Spanish Language Cervical Cancer Screening Materials La Salud Permanente Website Cancer prevention Foto Novelas

26 Foto Novela: CCS Spanish

27 Questions/Preguntas?