CERVICAL CANCER IN IRELAND. February 2017 International Rotation Amanda Heuszel, MS4 University of Kansas School of Medicine

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1 CERVICAL CANCER IN IRELAND February 2017 International Rotation Amanda Heuszel, MS4 University of Kansas School of Medicine

the size of Indiana) Gained independence from England in 1922 Formerly a Viking

2 DUBLIN, IRELAND Capital of Ireland Population: 1,345,402 urban, 1.9 million in greater Dublin Ireland population: 4 million 32,599 square miles (about the size of Indiana) Gained independence from England in 1922 Formerly a Viking establishment All speak English but they are taught in Gaelic in school Public healthcare with small copays

5 residents and 4 consultants National Maternity Hospital Opened 1894, Oldest maternity hospital in Ireland Employs 820 people

3 MATER MISERICORDIAE UNIVERSITY HOSPITAL Public hospital opened in 1861 Level 4 teaching hospital in north Dublin Over 600 bed, 85 day beds, 12 operating theaters Over last year, treated 21,500 inpatient, 60,000 day pt, 60,000 ED visits Gyn-onc team with 5 residents and 4 consultants National Maternity Hospital Opened 1894, Oldest maternity hospital in Ireland Employs 820 people Delivers over 9,000 babies a year 1/12 Irish citizens were born here Midwife-run deliveries Mater Misericordiae Hospital NMH

CERVICAL CANCER IN IRELAND 3 rd most common female cancer worldwide Approximately 300 new cases per year 90 deaths per year Screening protocol just began in 2008 Way behind USA 1950s start Became

4 CERVICAL CANCER IN IRELAND 3 rd most common female cancer worldwide Approximately 300 new cases per year 90 deaths per year Screening protocol just began in 2008 Way behind USA 1950s start Became a topic of interest after Jade Goody, a Big Brother contestant, died of metastatic cervical cancer Sparked a national trend to get pap smears HPV vaccine not routinely given until 2010 Jade Goody

CERVICAL CANCER SCREENING Ireland National screening began 2008 CervicalCheck Offer free pap smears to 25 to 65 year old Females Every 3 years for 25 to 44 Every 5 years for 45 to 60 Just test

5 CERVICAL CANCER SCREENING Ireland National screening began 2008 CervicalCheck Offer free pap smears to 25 to 65 year old Females Every 3 years for 25 to 44 Every 5 years for 45 to 60 Just test cytology, NOT HPV Abnormal results are sent for colposcopy and HPV testing United States Screening started in 1950s USPSTF to 29 yo every 3 years w/ cytology 30 to 65 yo every 5 years w/ HPV 74% decrease in cervical cancer deaths since screening began

HUMAN PAPILLOMAVIRUS HPV is a sexually transmitted disease Can cause cervical, anal, oropharyngeal, vulvar, vaginal, and penile cancer HPV 16 and 18 cause 70% of cervical cancers HPV 6 and 11 cause

6 HUMAN PAPILLOMAVIRUS HPV is a sexually transmitted disease Can cause cervical, anal, oropharyngeal, vulvar, vaginal, and penile cancer HPV 16 and 18 cause 70% of cervical cancers HPV 6 and 11 cause 90% genital warts Gardasil is a quadrivalent vaccine against HPV Targets HPV 6, 11, 16, 18 Efficacy trials ongoing but reports that 2/3 decrease in HPV subtypes 6, 11, 16, 18 Females 11 to 12 year old are encouraged to get the HPV vaccine in the U.S. and can be given up to 26 years old Males can also be vaccinated

HPV VACCINE IN IRELAND 2010 started free vaccination in first year of secondary school Only females, males not included due to money constraits No catch-up schedule due to funding Met with public

7 HPV VACCINE IN IRELAND 2010 started free vaccination in first year of secondary school Only females, males not included due to money constraits No catch-up schedule due to funding Met with public backlash R.E.G.R.E.T. support group started Young girls who had adverse effects (fatigue, muscle aches, etc) to vaccine Media attention has focused on their negatives views Leading many parents to refuse vaccination of their children 660,000 doses given to 220,000 girls in Ireland Only 1,054 case reports of adverse outcomes Study done at the Mater Misericordiae showed of the 38% healthcare providers in their study, only 56% would vaccinate their daughters From an Ireland video focused on vaccination

PERCEPTIONS OF CERVICAL CANCER Ireland is about 84% Catholic Very conservative country People are ashamed to admit they have cervical cancer Feel blamed View it as a STD that only promiscuous women

8 PERCEPTIONS OF CERVICAL CANCER Ireland is about 84% Catholic Very conservative country People are ashamed to admit they have cervical cancer Feel blamed View it as a STD that only promiscuous women get Also a reason parents will not allow their children to get HPV vaccine Will often hide a family history of gynecological cancer Loss of femininity associated with any gyn cancer Nurse clinical specialists present in all gyn-oncology clinics to serve as a resource to help them through the struggle

CONCLUSIONS Ireland still has a long way to go on cervical cancer screening and prevention Social media is to blame for a lot of the current issues The first step they need to address is getting

9 CONCLUSIONS Ireland still has a long way to go on cervical cancer screening and prevention Social media is to blame for a lot of the current issues The first step they need to address is getting physicians in the country to trust the vaccine enough to suggest it to patients Address the stigma surrounding cervical cancer Make public aware that most people have HPV at some point in their life but transiently clear it Showing people the result of not preventing/treating their cervical cancer by giving pictures/accounts from people with pelvic evisceration

CULTURAL EXPERIENCE PUBLIC HEALTHCARE Both private and public system in Ireland Both NMH and the Mater were public Rooms had 6 patients in them with a curtain between patients No real respect

the best physicians to be in the public system No barriers to access care Disadvantages LONG wait times Around 1 year from time of cancer diagnosis until surgery To see a specialist, it may

10 CULTURAL EXPERIENCE PUBLIC HEALTHCARE Both private and public system in Ireland Both NMH and the Mater were public Rooms had 6 patients in them with a curtain between patients No real respect for patient privacy Advantages Low payment $200 for whole hospital admission $80 for ED visit All care provided at local GP s office, only referred to specialist if indicated High benefits for the best physicians to be in the public system No barriers to access care Disadvantages LONG wait times Around 1 year from time of cancer diagnosis until surgery To see a specialist, it may take 6 months 2-3 month wait to get a CT/MRI Could wait in clinic for 2-3 hours since there are no set appointment times Middle area of Mater Example of a pt room (not actual one because of privacy

CLINICAL EXPERIENCE Rounded with Endocrine team at Mater Misericordiae University Hospital Patients on list with LOS 60-100 days Medically discharged Waiting on placement at facilities Not a

11 CLINICAL EXPERIENCE Rounded with Endocrine team at Mater Misericordiae University Hospital Patients on list with LOS days Medically discharged Waiting on placement at facilities Not a lot of ancillary support Only 1/30 patient on their list needed acute treatment Hospital full cancelled surgeries every day because of no beds, but people who were stable were occupying the beds

12 Wicklow Mountains Temple Bar, Dublin Cliffs of Moher

13 Finland Cliffs of Moher Dublin Castle Galway, Ireland Christ Church, Dublin Custom House, Dublin

14 Al-Kalbani M., Price J., Thompson G., et al. Does Cervical Screening in Young Women Aged Years Lead to Unnecessary and Harmful Interventions? Asian Pacific Journal of Cancer Prevention; Dec 2015, pp Centers for Disease Control and Prevention. (2016). Global Cancer Statistics. Retrieved from Cheung M., Cosgrave E., Fonseca-Kelly Z., et al. The HPV vaccine crisis! Poster presented at: Mater Misericordiae University Hospital. Flannelly, GM, et al. Establishment of a national cervical screening programme in Ireland, CervicalCheck: the first 6 years. European journal of cancer prevention, Nov , pp.1. Flannelly, GM. Ireland s National Cervical Screening Programme-CervicalCheck. National Cancer Screening Service. Web. 28 Mar HPV Vaccine. Primetime. RTE. Nov 24, Television. Markowitz L.E., Liu G., Hariri S., et al. Prevalence of HPV after introduction of the vaccination program in the United States. Pediatrics 2016; 137: pp Rodriguez, AC and Salmeron, J. Cervical cancer prevention in upper middle-income countries. Preventive Medicine, May 2017, pp U.S. Preventative Services Task Force. Cervical Cancer: Screening. Retrieved from: nstatementfinal/cervical-cancer-screening#consider Uptodate HPV vaccine Citations

HPV, Cancer and the Vaccination Programme

HPV, Cancer and the Vaccination Programme Dr Brenda Corcoran Consultant in Public Health Medicine HSE National Immunisation Office What is HPV? Human papillomavirus Over 200 types identified Spread by