Focus on Cervical Cancer: Key Messages Cancer System Quality Index 2016
A first look at cervical cancer across the care continuum Cervical cancer starts in the cells of the cervix. The cervix is the lower part of the uterus or womb, and it part of the female productive system. Cervical cancer in Ontario In 2010-2012, cervical cancer was the thirteenth most common cancer and 3 rd most common gynaecological cancer Cervical cancer is more common in younger women. Incidence rates are highest in women aged 35-39. There is also an increase in incidence in the 52-67 year old age group as screening participation falls. From Prevention to Diagnosis Cervical cancer can be prevented Human papilloma virus infection (HPV) is the main cause of cervical cancer The HPV vaccine prevents infection due to HPV strains that cause the majority of cervical cancers Approximately 80% of eligible girls, which is less than the target, participated in Ontario s school-based HPV vaccination program The HPV vaccine is expected to decrease cervical cancer incidence rates in the future, but it is too early to see the impact from the school-based vaccination program Screening Ontario has an organized cervical cancer screening program While about 63% of eligible women participated in the program, this is below Ontario s participation target of 85% Screening with the Pap test detects precancerous conditions, and is largely responsible for the decrease in incidence and morality in recent decades Diagnosis About 50% of diagnosed invasive cervical cancers were early stage (stage I) In spite of our progress in preventing cervical cancer and identifying it earlier, there were still 1,954 Ontario women diagnosed over a 3 year period (2010 2012). There needs to be greater attention to reducing the number of women who are diagnosed at a later stage 2
A first look at cervical cancer across the care continuum (continued) Treatment Surgery, radiation and chemotherapy (cancer drugs) are used alone or in combination to treat cervical cancer Prior to treatment women should have a discussion with their physician about impact of treatment on fertility and fertility-sparing options (where appropriate) Partly due to the relatively small number of cervical cancer cases, there are limited data about many aspects of cervical cancer care Psychosexual issues are among the most significant symptoms for women dealing with cervical cancer Follow-up and End-of-Life Care Follow-up Care Women should be closely monitored in follow-up visits to manage symptoms, late effects of treatment and any possible recurrence End-of-Life Care Women are still dying of cervical cancer Patients at the end-of-life continue to be seen by their healthcare team in order to address their symptoms, optimize their quality of life and receive support for themselves and their families. 3
Between 2010 2012, there were 1,953 new cases of cervical cancer diagnosed, and despite a well organized screening program it remains the 3rd most common gynecological cancer among Ontario women 4
Cervical cancer incidence is decreasing or stable for most age groups Cervical cancer incidence rate is decreasing or stable for almost all age groups due to screening The exception is women aged 35 49, where the incidence increased slightly from 2006 to 2012 The impact of the HPV vaccine is expected to further decrease incidence rates in the future 5
Cervical cancer patient journey HPV vaccine Take action to reduce other risk factors (e.g. smoking cessation, safer sex) According to the Ontario Cervical Screening Program guidelines Appropriate investigation of abnormal screening tests Appropriate investigation of cervical/clinical abnormalities Staging Surgery Radiation +/- Chemotherapy 6
Cervical cancer is largely preventable Almost all cervical cancers and their precursor lesions are caused by persistent infection with cancer-causing HPV sub-types HPV infections are very common; the majority clear by natural processes Women who smoke and/or are immune-compromised are less likely to clear an HPV infection HPV immunization prevents infection with most but not all cancer-causing HPV types Women who have received the HPV vaccine should still have regular cervical cancer screening Public Health Ontario reports that in the 2012-2013 school year, participation in the school-based vaccination program was 80.2% 1 This is a significant improvement since the inception of the program although it does not meet the target of 90% 1. Public Health Ontario. (2014). Immunization coverage report for school pupils 2012-13 school year. Accessed on April 19, 2016 from: https://www.publichealthontario.ca/en/erepository/immunization_coverage_report_2012-13.pdf 7
Screening detects changes that can lead to cervical cancer Participation in cervical cancer screening is decreasing Between 2012 to 2014, 63% of eligible women were screened for cervical cancer. This is a decrease from the participation rate of 68% in 2009 to 2011. In 2013 the Ontario Cervical Screening Program began sending invitations, reminder and result letters to women eligible to participate in cervical cancer screening Participation data do not yet identify the potential impact of this process on participation rates 8
Participation in screening is not distributed evenly across the population Older women were less likely to be screened for cervical cancer. Women ages 30 to 39 had the highest participation rates (68%); women ages 60 69 had the lowest (53%) Cervical cancer screening participation also varied by: Income: Participation was 68% in urban high income areas versus 57% in urban low income areas Urban/rural: Participation was highest in rural areas (66%) and lowest in rural-very remote areas (61%) Immigration: Participation was 66% in areas with lower proportions of immigrant residents versus 59% in areas with higher proportion of immigrant residents (selfreported data) 9
Colposcopy Colposcopy is used to investigate an abnormal Pap test, and involves magnified visual inspection of the cervix to identify abnormalities Abnormalities can be biopsied to reach a diagnosis and inform a treatment plan Colposcopy services in Ontario are not currently organized or integrated with the screening program; patients in need of colposcopy require a referral from their primary care provider to a colposcopy clinic or to an individual colposcopist. CCO has developed organizational recommendations for colposcopy services, including wait times and the conditions under which colposcopy care should be provided (The Organization of Colposcopy Services in Ontario: Recommended Framework). Current colposcopy data are very limited and will be a priority as CCO moves towards an organized colposcopy system 10
There were more pre-cancers than invasive cervical cancers identified Screening is intended to identify precancerous conditions (precursors) before they become cancer There were many more cases of cancer precursors identified by screening compared to number of cases of invasive cervical cancer Of invasive cervical cancers diagnosed in 2014, half were early stage (Stage I) Generally, early diagnosis improves outcomes Reducing the number of the women who are diagnosed at later stages is the most significant opportunity to improve outcomes for these women 11
Quote from a patient with cervical cancer I think about cancer and I tell people, cancer is just a name. You know. And knowing that if they hadn t found it in me, I would be overwhelmed by it. And I m really grateful that they did what they did, the tests, everything I had to have done. - Patient with cervical cancer 12
Surgery was the most common treatment for early stage cervical cancer I knew going in that I was going to lose my fertility. But once you are faced with the fact that you will never have children, even if you weren t sure you wanted them, it s really hard. - Patient with cervical cancer Status of cancer (size, stage, etc.) and desire to preserve fertility are main factors affecting type of surgery provided About 65% of women with stage IA cervical cancer and 24% of patients with stage IB had fertility sparing surgery. All women who undergo surgery for cervical cancer should have fertility-sparing options considered where appropriate 13
Cervical cancer patients who undergo surgery should be assessed by a gynecologic oncologist Based on CCO recommendations: Gynecologic Oncology Centres (GOCs) have been established to improve care and outcomes Most surgery for invasive cervical cancer was done by gynecologic oncologists at GOCs Eighty-three (83%) of cervical cancer surgeries in Ontario were done at a GOC in fiscal year 2014/2015 Plans for management should be balanced with patient desire to receive care close to home. Where appropriate, patients can receive some types of treatment close to home; other types of treatment are available only at specialized/designated centers (i.e. affiliated centres) CCO guidelines on Gynecologic Oncoloy Centres: Organization Guidelines for Gynecologic Oncology Services in Ontario 14
Chemotherapy is also used to treat cervical cancer When treating cervical cancer patients with radiation, concurrent chemotherapy is the standard of care offering optimal outcomes Chemotherapy can also be used in the palliative care setting There are currently no provincial chemotherapy indicators for cervical cancer treatment; such data would be useful in evaluating outcomes and patient experience The chemo nurses were phenomenal. Right from the beginning, the chemo nurses everyday asked How are you feeling? Are you having any symptoms? - Patient with cervical cancer 15
There is evidence that radiation (including brachytherapy, a type of internal radiation) completed within 56 days is associated with better outcomes In Ontario, about 80% of cervical cancer patients complete all their radiation treatments (both external beam and brachytherapy) within 56 days Improved outcomes associated with completing radiation treatment within 56 days includes better survival and pelvic control The majority of patients are completing radiation in an appropriate time 16
Symptoms and side effects Generic assessment of symptoms as captured by the Edmonton Symptom Assessment System (ESAS) shows: Anxiety - 11% of women with cervical cancer reported high severity, and 17% report moderate severity Tiredness - 14% of women with cervical cancer reported high severity and 24% report moderate severity Well-being - 10% of women with cervical cancer reported high severity, and 26% report moderate severity The data shown includes women diagnosed at different stages, and for whom symptoms may significantly vary The Edmonton Symptom Assessment System (ESAS) is a system assessment tool that looks at common symptoms. It is not specific to cervical cancer or its treatment. Among the most significant symptoms specific to cervical cancer patients is psychosexual dysfunction (vaginal dryness, pain during intercourse, decreased interest in sex, and relationship stress). We do not currently capture these data. 17
Addressing symptoms, late effects of treatment and quality of life are important components of follow-up care after treatment If cervical cancer recurs, it tends to do so within 2-3 years of treatment Follow-up visits are determined based on risk, and are typically scheduled more frequently in the first 3-5 years post-treatment. Discharge, in the absence of recurrent disease, and long-term surveillance is individualized I find I m a little more anxious since I don t know if everything worked. I feel like I m going to be living scan to scan. - Patient with cervical cancer CCO has published guidelines on the most appropriate follow-up strategy for cervical cancer patients after treatment: Follow-up for Cervical Cancer 18
Women are still dying of cervical cancer Between 2010 and 2012, about 500 women died from cervical cancer Patients at the end-of-life require adequate palliative care to optimize quality of life and to provide support for her and her family. In Ontario, limited survivorship and end-of-life data specific to cervical cancer patients are available. 19
Summary Cervical cancer is highly preventable HPV vaccine prevents infection from most common HPV strains causing cervical cancer Screening with Pap test detects precancerous lesions, which when treated appropriately, prevent progression to cervical cancer Organized screening is effective and needs to continue to be improved There is an opportunity for better integration of services, such as between screening and colposcopy Improvements to data collection are needed in many areas across the cervical cancer care continuum, including colposcopy, treatment, symptom management, recovery and end-of-life care 20