Get on the Path to Cervix Health

Transcription

1 Get on the Path to Cervix Health Native American Cancer Research (NACR) 3022 South Nova Road Pine, CO Phone: ; Fax: Native American Cancer Survivors Network Sarah Allman (Oglala Lakota) Rosanne Wyman Mohawk 1. Introduction Excerpt from the Story of Cervix Patient Sarah Allman (Oglala Lakota) I didn't have anything [symptoms], except I had bladder infections, so I went in for that. Then [the doctor] said I should have a [Pap test]. I didn't have anything though [based on what the doctor could see] and in a few days my doctor called and said I had to come in for a visit. Then I went into the hospital and had my surgery [for cancer of the cervix]. [That was in 1970] ARS Knowledge 3 Native American Cancer Research ; 4 Native American Cervix Facts Sarah Allman (Oglala Lakota) Excerpt from the Story of Cervix Patient More American Indian women die from cancer of the cervix than do women from any other racial group [Before I had cancer, I didn't know anything about cancer] Nothing. I just thought it was a killer, you know. I was always so scared of that word "cancer"... I'm not even scared of that word anymore. I'm just thankful for having twenty-four years of cancer free... No, I just go on, doing my chores. And just have faith in God. There is no reason for any woman of any race to die from Cancer of the Cervix today Cancer of the Cervix is easy to diagnose as long as the woman does pelvic and Pap tests at least every 3 years Native American Cancer Research ; 5 Native American Cancer Research ;

2 Native Americans and Pap Tests A Pap test is done during a pelvic examination by a trained provider in a health clinic or medical screening van The Pap Test can tell if you have abnormal cells or cancer of the cervix while it is still in early stage of growth and easier to cure Many American Indian women quit having Pap Tests after their childbearing years Native Americans and Pap Tests But older women need Pap Tests too, including women who have gone through the change of life (menopause) 2007 study shows AIAN women not getting Paps (drop of over 20%) as recommended There is no reason for liquid prep tests unless the Pap is abnormal Native American Cancer Research ; 7 Native American Cancer Research ; Yesterday and Today Native Americans Cancer of the Cervix Facts and Myths OBJECTIVES By the end of this segment, the learner will be able to: 1. Distinguish between accurate information and common myths about Cancer of the Cervix in Indian Country. QUESTION: What is Cancer of the Cervix? Cancer (malignant [ma-lig-nant]) cells forming in the cervix (the lower part of the womb) NOTE: Cancer of the womb (uterus / endometrial [EN-doh-MEE-tree-ul]) is not the same as cancer of the cervix Cancer of the Cervix (cont.) In situ [in-sigh-2]: The cells have not become cancer cells or have not spread to neighboring tissue Dysplasia [dis-play-zha] are cells that look abnormal but have not become cancer yet (pre-cancerous) Native American Cancer Research ; 11 Native American Cancer Research ;

3 Cancer Yesterday and Today Cancer of the cervix was not common among our ancestors QUESTION: Why? Cancer Yesterday and Today (cont.) ANS: They had regular behaviors that were protective against cancer of the cervix; such as: Fewer lifetime sexual partners Less exposure to sexually transmitted diseases Saved tobacco for ceremonial uses Native American Cancer Research ; 13 Native American Cancer Research ; 14 Cancer Yesterday and Today (cont.) QUESTION: Why is cancer of the cervix more common today among Native people? We are not living in a healthy way like a lot of our ancestors Habitual tobacco use Many sexual partners over lifetime Cancer of the cervix is one of the few cancers that can be prevented Native American Cancer Research ; 15 Native American Cancer of the Cervix Facts There is no reason for a woman of any race to die from Cancer of the Cervix today It is pretty easy to diagnose and to treat if found in early stages of growth Cancer of the Cervix affects American Indian women anywhere from 2 to 5 times as often as women from other racial groups Native American Cancer Research ; 16 Native American Cervix Cancer Facts (cont.) American Indians have the highest death rates of cancer of the cervix than any other racial group in the United States Cancer of the cervix in American Indian women appears to be more aggressive (i.e., spreads and becomes invasive) than in women of other races. NOT SCIENTIFICALLY VERIFIED Native American Cervix Cancer Facts (cont.) Even though American Indian women have more cases of cancer of the cervix than do women of other races, they tend to have fewer risk factors (in comparison with women of other races) Cancer of the cervix is both preventable and curable Native American Cancer Research ; 17 Native American Cancer Research ;

4 Native American Cervix Cancer Facts (cont.) The primary reasons why women die of cancer of the cervix are: They are not screened (so not diagnosed) They don t receive proper or enough treatment NOTE: Medicine for Humanity is a 501(c)(3) that will provide full spectrum of cervix care Native American Cancer Research ; 19 Native American Cervix Cancer Facts (cont.) Many women do not have any signs or symptoms There are many different risk factors (possible behaviors that increase your chance of getting this cancer) If a woman has any risk factors, she should have a Pap at least once each year Native American Cancer Research ; 20 Cervix Cancer Facts or Myths There is nothing I can do about getting cancer of the cervix. Why? Most cancer of the cervix is preventable. Screening identifies the precancerous cells before they become cancer! No habitual smoking helps protect against cancer of the cervix Native American Cancer Research ; 21 Cervix Cancer Facts or Myths You don t need to have cervix health screenings once you have had all of the children you want to have. Why? You need cervix screening throughout life Begin Paps when become sexually active or by age 18 Gradually decreasing to every three years or longer intervals as you age (after discussing with your provider) Native American Cancer Research ; 22 Cervix Cancer Facts or Myths Cancer of the cervix is rarely fatal. Why? Cancer of the cervix is usually curable when detected early. Over 90% of cancer of the cervix treated in stage 1 are cured (do not recur) Cervix Cancer Facts or Myths You only need to have cervix health screenings if you are having symptoms. Why? Because cervix cancer symptoms are often silent. It is important to have regular screenings. Precancerous cells can grow and develop into a cancer over a period of five to seven years Native American Cancer Research ; 23 Native American Cancer Research ;

5 Cervix Cancer Facts or Myths Cervix screening tests are covered under most health plans. 3. Anatomy of the Cervix Why? Medicaid, WIC, IHS and most commercial health plans cover the cost of screening. Native American Cancer Research ; 25 OBJECTIVE By the end of this session, the learner will be able to: 1. Identify the anatomical structures of the cervix. Female Reproductive System The uterus or womb is located below your stomach. The cervix is located in the lower portion of the womb. The cervix opens into the vagina which leads to the outside of the body. Native American Cancer Research ; 28 Fallopian Tubes Ovary Uterus womb Ovary Side View Of Reproductive Organs Cervix Vagina Native American Cancer Research ; 29 Native American Cancer Research ;

6 4. Cancer of the Cervix in Indian Country OBJECTIVE By the end of this session, the learner will be able to: 1. Identify regions where Cancer of the Cervix incidence (new cases) and deaths are highest among Natives. QUESTION: How common is cancer of the cervix in Indian Country? Diagnosis of Cervix Cancer This is a very common cancer among Native women Cancer registries (state, federal) usually do not have accurate information about how common cancer of the cervix is among Native women It may be diagnosed at early ages (e.g., teens and 20 s) Most women are diagnosed in their 30 s and 40 s If diagnosed early, it is almost always curable!! Native American Cancer Research ; 33 Native American Cancer Research ; 34 Every year 15,000 women learn that they have Cancer of the Cervix in the US Deaths from cancer of the cervix are dropping for whites, but this is not true for Natives. Gay, Lesbian, Two-spirited women also develop cancer of the cervix. Cure? Chronic disease? Pass on? While some with cancer are cured and others will live a long time with disease, sadly, some also will pass on from the cancer. Native American Cancer Research ; 35 Native American Cancer Research ;

7 Cancer among Adults and Elders Elders (over 50 years old) are the most likely to experience cancer This is not to imply that young Natives do not experience cancer. Young Native adults (20s) do get Cancer of the Cervix. Childhood leukemia and brain cancers are increasing among AIAN youth and we do not know why Native American Cancer Research ; 37 DEATH RATES, LEADING CAUSES: AGES 45 TO 64 YEARS Diseases of the Heart Malignant Neoplasms Cancer Accidents Chronic Liver Disease Diabetes Mellitus Get on the Deaths Path to per Cervix 100,000 Health Population Native American Cancer Research ; 38 Office of Planning, Evaluation and Legislation, Indian Health Services, Regional Differences in Indian Health: 1997 R k ill MD I di H lth S i ) 1994 QUESTION: What Type Of Cancer Statistics Are Available In Indian Country? Very limited information The best information may be Local tribal or urban Indian data IHS data for reservations (e.g., 2007 Report to the Nation cancer incidence report) Native American Cancer Research ; 39 Cancer Statistics Available In Indian Country State data (state s racial misclassification makes the AIAN data of little use) National Cancer Institute (NCI) (basically only for the SW region and Alaska) Centers for Disease Control (CDC) = too much misclassified data received from the states It is very difficult and tedious to correct databases; no easy solutions Native American Cancer Research ; 40 Cancer Statistics Available In Indian Country Cancer Statistics Available In Indian Country There is no good / accurate information about how many new cases are diagnosed each year (prevalence) The 2007 Report to the Nation does document how common Cancer of the Cervix currently is in reservation Indian Country (incidence) Underreports urban data much more difficult to correct Native American Cancer Research ; 41 The IHS has good documentation of deaths (mortality) from breast cancer for the Northern Plains, Alaska, and gradually for other regions. With the 2007 Report to the Nation, incidence data are finally available This is a very good resource! Native American Cancer Research ;

8 AIAN Cancer Incidence Data (finally) THANK YOU! CHSDA Counties = IHS Contract Health Service Deliver Areas NHW = Non- Hispanic White Native American Cancer Research ; 44 All Breast Cervix Colon Incidence Rates ( )* AIAN Kidney 17.9 Lung 48.5 Prostate US NHW So. Plains AIAN NHW No Plains AIAN NHW Source: Cancer registries in Centers for Disease Control and Prevention's (CDC) National Program of Cancer Registries (NPCR) and National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results Program (SEER) D. Espey, Monograph Group. IHS Cancer Mortality Note cancers other than breast, cervix, colon, lung and prostate This is why AIAN comprehensive cancer plans cannot be limited to only those sites! Native American Cancer Research ; 47 If you are looking at other IHS death charts, notice how the horizontal bar changes 8

9 5. Cancer of the Cervix Risk Factors and Protective Behaviors OBJECTIVES By the end of this segment, the learner will be able to: 1. Identify at least 2 factors that increase your risks for developing Cancer of the Cervix. 2. Identify at least 2 factors that help protect you from developing Cancer of the Cervix. Will I get Cancer of the Cervix? This is not the type of cancer that is inherited from your parents There are many risk factors that may result in cancer of the cervix Native American Cancer Research ; 51 The shield in these slides represents your protection (shield of health) against things that may make you more susceptible to cancer (cancer risks) The larger the holes and the more number of holes in the shield, the less likely it is to protect you from cancer or other health problems NOTE: the web page version is animated for breast and CRC The woman s shield of protection against Cancer of the Cervix may include daily physical activity, healthy, low fat, limit tobacco to ceremonial use only, and so on What does this shield tell you about this woman s cancer risks? Cancer risks that damage her shield of protection include: 1. Early Age At First Intercourse (16 Years Old Or Younger) 2. More Than 5 Different Sexual Partners In Your Whole Life 3. Having Sex With Partners Who Have Had Many Sexual Partners 4. Sexually Transmitted Diseases (HPV -Human Papilloma Virus) Which May Also Cause Genital Warts 5. Herpes Virus 6. HIV Infection 7. Exposure To Cigarette Smoke (Smoking And Second Hand Smoke) 8. Giving Birth To More Than 4 Children 9. Long Term Use Of Oral Contraceptives 10.Diets Low In Carotene, Vitamins C And E 9

10 How Can I Help Myself? Avoid HPV Infection! 100 different types of human papillomavirus (HPV) But only a few types cause cancer of the cervix (e.g., HPV16, HPV18) Most women have no noticeable symptoms Some women get genital warts Most may not even know they have it How Can I Help Myself? Most people will get HPV if they have more than 5 sexual partners in their lifetime Sexual partners are likely to share the same HPV type and both partners need to be treated. HPV may be present on skin not covered by a condom = transmission is possible. Native American Cancer Research ; 55 Native American Cancer Research ; 56 HPV (Human Papillomavirus) Only about 12 of these 100 HPV types cause Cancer of the Cervix HPV Types 16 and 18 are present in most cervix tumors Both of the current HPV vaccines include HPV types 16 and 18 But, about 30% of Northern Plains women with Cancer of the Cervix have HPV, but NOT types 16 and 18 HPV (Human Papillomavirus) The genetic test is on the tumor and virus, NOT on the woman s genes! The HPV vaccine is likely to eliminate most Cancer of the Cervix, but it is not a cure-all Females still need to practice good behaviors that help prevent Cancer of the Cervix Native American Cancer Research ; 57 Native American Cancer Research ; 58 How Can I Help Myself? How Can I Help Myself? Talk with you provider about whether or not the HPV vaccine is appropriate for you (still not a cure-all) Get a Pap test every year or as often as your provider suggests If you have a sexually transmitted disease (STD), get treatment Native American Cancer Research ; 59 Limit the number of sexual partners: Lifetime mutual monogamy or abstinence are the best possibilities for prevention Use condoms (especially latex condoms with nonoxynol-9) Do not use manufactured tobacco habitually and reduce your exposure to second hand smoke Native American Cancer Research ;

11 6. Screening for Cancer of the Cervix OBJECTIVES By the end of this session, the learner will be able to: 1. Identify the types of recommended Cancer of the Cervix screening tests. 2. Describe what happens before, during and following most Cancer of the Cervix screening tests. 3. Identify who may pay for the costs of Cervix screening other than IHS. QUESTION: What are Pap Tests? The Pap Test can tell if you have abnormal cells or cancer of the cervix early, while it is still easy to cure The test is done during a pelvic examination by a trained provider in a health clinic or medical screening van Pelvic Exam Versus a Pap Test The Pap Test is usually part of your pelvic exam which is done during your well woman annual health exam After the Pap Test is done, the provider will also check your ovaries by placing a gloved hand into your vagina while pushing on your abdomen with the other hand Native American Cancer Research ; 63 Native American Cancer Research ; 64 Pelvic Exam Versus a Pap Test Who Needs To Get A Pap Test? The provider also will insert a gloved finger into your rectum (to check the ovaries and for rectal growths) Note: it is important that your ovaries be checked every year. If you had a hysterectomy, but did not have your ovaries removed, you still need to have the ovaries checked. Native American Cancer Research ; 65 All women once they are 18 years old All women who are having sex, regardless of age (which means you may need it earlier than 18 years old) Young girls who were molested / raped Native American Cancer Research ;

12 Who Needs To Get A Pap Test? Women need to continue having an annual test throughout life. Unless you have had 3 normal Pap tests in a row within the most recent 5-year period Your provider may recommend that you to have a Pap test every 3 years Who Needs To Get A Pap Test? Many American Indian women quit having Pap Tests after their childbearing years But women beyond their childbearing years need Pap Tests too, including women who have gone through the change of life (menopause). Dominga Rosetta Santo Domingo Pueblo Native American Cancer Research ; 67 Native American Cancer Research ; 68 QUESTION: How is the Pap Test Done? You get on a table, lying on your back with a sheet over the lower half of your body Your feet go into stirrups (not shown here) How is the Pap Test Done? The provider will ask you to Move your bottom to the edge of the table To spread your knees To relax Native American Cancer Research ; 69 Native American Cancer Research ; 70 How is the Pap Test Done? A speculum (metal or plastic, two-part device) is placed in the vagina by the provider. The provider opens the speculum so that they can see the cervix. Native American Cancer Research ; 71 How is the Pap Test Done? The provider gently collects cells from the surface of the cervix using a small soft brush, a small wooden spatula, or a cotton swab The provided must collect enough cells for the laboratory to examine Native American Cancer Research ;

13 How is the Pap Test Done? These cells are smeared onto a glass slide The provider sprays the slide to help fix the cells on the slide The slides are sent to a laboratory for examination How is the Pap Test Done? The Laboratory This is where a lot of errors occurred in the past inefficient labs=false negatives Laboratory staff send the results to the provider Native American Cancer Research ; 73 Native American Cancer Research ; 74 Women who had a Hysterectomy Today, most women have their cervix removed at the time of the hysterectomy This was not as common 30 years ago (i.e., if a woman had hysterectomy then, she will need a pelvic exam to find out if she still has a cervix) If they do not have a cervix, they do not need a Pap Test. Women who have had a Hysterectomy If the woman does still have a cervix, she needs a Pap Women who had a hysterectomy due to cancer need to follow the provider s recommendations for a Pap Test Native American Cancer Research ; 75 Native American Cancer Research ; 76 What you may Feel The test itself only takes a few minutes and is not painful. You may feel pressure or some discomfort What you may Feel Some women take a pain reliever before their appointment. Others do relaxation exercises or pray She s not looking too happy, is she? But, she also does not look in pain Native American Cancer Research ; 77 Native American Cancer Research ;

14 QUESTION: Why Should You Get a Pap Test? A Pap Test can detect abnormal cells before they become cancer. It may actually be a prevention test. Early detection of abnormal cells allows for treatment before cancer exists Take care of yourself so that you can teach your grandchildren traditional skills Native American Cancer Research ; 79 Why You Should Get a Pap Test American Indian women have the highest rates of cancer of the cervix than any other racial group in the United States. A woman can have cancer of the cervix and have no symptoms Native American Cancer Research ; 80 Getting the Results Wait for a letter or call with the results of the Pap Test. A lot of Native women say their clinic never lets them know the results. If you don t get the letter or call within 2 weeks of your test, call the clinic and ask for the results. Getting the Results Results are reported as abnormal and normal. Most abnormal Pap tests are not cancer, however, they may require follow-up care. Have repeat Pap tests or treatments as recommended by your provider. Native American Cancer Research ; 81 Native American Cancer Research ; 82 Some Concerns About Cervix Screenings My husband / partner doesn t want me to see a male provider Some Concerns About Cervix Screenings I m not sure what they re looking at I m afraid that they re going to sterilize me The tests hurt I am embarrassed I never see the same provider at the tribal clinic This graphic is from IHS Four Corners Area. Native American Cancer Research ; 83 I don t want any provider to look at my private parts I m afraid they may try to infect me with something Native American Cancer Research ;

15 How can I Get a Pap Test? How can I get a Pap Test? (cont.) Almost all IHS / Tribal and Urban Indian clinics (that have direct services) do Pap tests. Private insurance can pay for Pap Test. Native American Cancer Research ; 85 If you are 65 years or older, Medicare can pay for the Pap Test. State, community programs may also pay for the cost of Pap Test. Native American Cancer Research ; 86 How can I Get a Pap Test? (Cont.) The CDC National Breast and Cervical Cancer Early Detection Program (BCCEDP) also pays for women who meet certain eligibility criteria ~12 Tribal programs Every state Most Territories Native American Cancer Research ; 87 Tips To Help You Prepare For Your Pap Test Native American Cancer Research ; 88 Some Tips To Help You Get Ready For Your Pap Test. You will be asked to remove your underpants You will be given a gown and/or sheet to protect your modesty Some Tips To Help You Get Ready For Your Pap Test. Don t have Pap Test during your moon or period. Don t douche or use birth control foams, creams, or jellies for two days before the test. Native American Cancer Research ; 89 Native American Cancer Research ;

16 Wall Street Journal Article on Liquid Preparation The DNA Pap is a two-in-one process that combines the standard Pap test with a test for the human papilloma virus, which causes cervical cancer. Excerpts from Wall Street Journal, May 2, 2002 New Test Helps Spot Cervical Cancer, But Concern Reigns Over Implications By LAURA JOHANNES, Staff Reporter Native American Cancer Research ; 91 Wall Street Journal Article on Liquid Preparation (cont.) The DNA Pap's effectiveness means some women who test negative may not need to get tested again for several years -- potentially eliminating the hassle of making an annual trip to the gynecologist only a fraction of those with HPV will ultimately get cancer. By LAURA JOHANNES, Staff Reporter Native American Cancer Research ; 92 Wall Street Journal Article on Liquid Preparation (cont.) DNA Pap costs more -- as much as $60 QUESTION: How much do Pap tests cost? About $14 The DNA Pap test would likely come up positive in 5% of women over 30 But fewer than 10% of those women would get cervical cancer Native American Cancer Research ; 93 Wall Street Journal Article on Liquid Preparation (cont.) American College of Obstetricians and Gynecologists testified to the FDA panel in March that Digene's test is not clinically useful. QUESTION: So what does this mean? Native American Cancer Research ; 94 Sensitivity versus Specificity Distinction developed by NORAD Radar that could identify incoming bombers/fighters = sensitive This same radar would not recognize a flock of birds as bomber planes = specificity Sensitivity is the ability of the test to find cancer or pre-cancerous cells Sensitivity versus Specificity Radar that would identify a flock of birds as a bomber = poor specificity Good Specificity is a person without cancer has a negative test Liquid Prep tests have poor specificity Native American Cancer Research ; 95 Native American Cancer Research ;

17 Liquid Preparations in Place of a Standard Pap Test More expensive (~ $30 + additional laboratory tests due to high number of false positives ~$70 per follow-up) Heavy lobbying by laboratories who are losing money on Paps (~ $7 each at the time of the lobbying, now ~$14 per Pap) Insignificant increase in Years of Life Lost About 2 days rather than years? Native American Cancer Research ; 97 Liquid Preparations in Place of a Standard Pap Test QUESTION: Why would the laboratories pay for strong lobbying for states to use this test? More expensive About $30 for initial test as compared to $14 for Standard Pap Significant number of false positives = Additional laboratory tests [~$70] No improvement in diagnosing pre and existing cancer of the cervix Native American Cancer Research ; 98 Problems with Liquid Preparation (e.g., ThinPrep or AutoCyte ) Incorrect result = woman upset unnecessarily CHS for those tribal programs who do not have access to appropriate follow-up equipment If money spent on unnecessary follow-up = less money available from CDC for cervix screening Native American Cancer Research ; 99 Key Points to Remember Info from American Social Health Association (ASHA) updated from women.cfm Linda B checked website in 2009 and information unchanged = good advice Key Points to Remember** 1. Cervical cancer is preventable. Early detection of abnormal cell changes is important. Key Points to Remember** 2. Almost all women and men will have HPV at some point, but very few women will develop cervical cancer. The immune system of most women will usually suppress or eliminate HPV. Only HPV infection that does not go away over many years can lead to cervical cancer, for example. **updated from Native American Cancer Research ; **updated from Native American Cancer Research ;

18 Key Points to Remember** 3. It can be helpful to know your HPV status. This can help determine how often your clinician will recommend that you be tested. 4. Don t blame yourself or your partner. Your HPV status is not a reliable indicator of your sexual behavior or that of your partner. **updated from Native American Cancer Research ; HPV info for Males*** 1. Can HPV infections be treated? There is currently no treatment available for the virus itself. However, good treatments do exist for the diseases HPV can cause, such as cell changes or genital warts. Your health care provider will discuss these treatment options with you, if you need them. **updated from Native American Cancer Research ; HPV info for Males*** 2. How are men screened for HPV? Men are typically screened clinically with a visual inspection to check for lesions (such as warts) there is no specific way to test directly for HPV in men that is approved for clinical use. Researchers are looking at ways to better screen men, but the current lack of testing options for males can be very frustrating. **updated from Native American Cancer Research ; HPV info for Males*** 2. How are men screened for HPV? (continued) While still not routinely done, anyone with a history of receptive anal sex may want to speak with his or her health care provider about having an anal Pap test. Anal cancer is uncommon, but screening can still be an important precaution talk to your provider if you have questions. **updated from Native American Cancer Research ; HPV info for Males*** 3. What about partners? Most sexually active couples share HPV until the immune response suppresses the infection. Partners who are sexually intimate only with each other are not likely to pass the same virus back and forth. **updated from Native American Cancer Research ; HPV info for Males*** 3. What about partners? (continued) When HPV infection goes away the immune system will remember that HPV type and keep a new infection of the same HPV type from occurring again. However, because there are many different types of HPV, becoming immune to one HPV type may not protect you from getting HPV again if exposed to another HPV type. **updated from Native American Cancer Research ;

19 7. Symptoms that May be Related to Cancer of the Cervix QUESTION: What are symptoms or signs that may be related to cancer of the cervix? Early stages usually have no symptoms Possible Signs (may or may not appear as the cancer grows): Native American Cancer Research ; Possible Signs of Cancer of the Cervix Unusual bleeding or discharge Longer and heavier "moons" or menstrual periods Bleeding between periods or after having sex Bleeding after menopause Pain (lower abdominal area) Native American Cancer Research ;