Key Points on Disparities in Cancer Care - prIME Oncology
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Key Points on Disparities in Cancer Care

Identifying & Correcting Cancer Care Disparities for Minority Populations: Importance of Non-Oncologist Participation

Cervical Cancer Update 2017

Based on the presentation by Carol L. Brown, MD, FACOG, FACS, Memorial Sloan Kettering Cancer Center, New York, New York

Key Points

  • Cervical cancer mortality rates are significantly higher in African American women than white women
  • HPV vaccination and cervical cancer screening are important to reduce the risk of cervical cancer
  • Pap smears should be continued in African American women aged ≥65 years

African American women have an increased incidence of cervical cancer and a poorer survival compared to white women.1 In fact, cervical cancer mortality was 2.2 times higher for African American women versus white women when adjusting for the rate of hysterectomy, comparable to the mortality rate of women in many poor, developing countries.2 This was particularly evident in older African American women, with the risk of cervical cancer mortality increasing significantly over the age of 65.

“How can we eliminate the disparities in cervical cancer? Vaccinate. Tell your patients to get their children, their grandchildren vaccinated. (…) Do Pap smears yourself or refer. Remind your patients they need Pap smears.”
– C. Brown

Regardless of ethnic background, there are two key weapons in the fight to prevent cervical cancer: Human papillomavirus (HPV) vaccination and routine screening. By age 50, at least 80% of women will be infected with HPV.3 HPV infection is associated with up to 90% of cervical cancers as well as several other malignancies such as anal cancer, vaginal cancer, penile cancer, and oropharyngeal cancers.4 Two HPV vaccines are currently available that target 4 and 9 different types of HPV, termed quadrivalent and nonavalent, respectively.5 Both vaccines have demonstrated high levels of efficacy in preventing cervical dysplasia in thousands of patients, with the nonavalent vaccine preventing type-specific persistent HPV infection in 96% of recipients.5,6

HPV vaccination is well tolerated and the adverse events consist primarily of mild to moderate injection-site pain and headache.6-8 Long-term safety data show that HPV vaccination is not associated with increased risk for severe adverse events such as Guillain-Barré syndrome, stroke, blood clots, and multiple sclerosis.9 Current recommendations specify vaccination for all males and females aged 9 years to 26 years.10 Patient education is essential to improving vaccination rates, which are currently 63% for teen girls and 50% for teen boys.11 Unfortunately, the most prevalent type of HPV infection in African American women is type 35, which is not prevented by currently available HPV vaccines.12 This could contribute to further racial disparity in cervical cancer outcomes.

Cervical cancer screening with Papanicolaou (Pap) smears dramatically decreases cervical cancer mortality by identifying pre-invasive lesions and allowing early intervention. Current guidelines recommend cytology alone every three years for women aged 21-29 years and HPV and cytology co-testing every five years for women aged 30-65 years.13,14 No screening is recommended for women over the age of 65,13,14 although this may not be ideal for older African American women who have demonstrated an increased risk for cervical cancer mortality.2 Thus, physicians should strongly consider continuation of Pap smears in African American women over age 65, although not in the current screening guidelines, to increase early diagnosis and improve outcomes in this patient population.

Conclusions: Physicians should recommend HPV vaccination and remind patients to get screened regularly for cervical cancer. Any abnormal cervical lesions should be biopsied and patients with cervical cancer should be referred to a gynecologic oncologist for multidisciplinary care.

References

  1. American Cancer Society. Cancer Facts & Figures for African Americans 2016-2018. American Cancer Society website. 2016. www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2016-2018.pdf. Accessed September 19, 2017.
  2. Beavis AL, Gravitt PE, Rositch AF. Hysterectomy-corrected cervical cancer mortality rates reveal a larger racial disparity in the United States. Cancer. 2017;123(6):1044-1050.
  3. Centers for Disease Control and Prevention. Basic Information about HPV and Cancer. www.cdc.gov/cancer/hpv/basic_info/index.htm. Accessed August 25, 2017.
  4. Centers for Disease Control and Prevention. Cancers Associated with Human Papillomavirus (HPV). www.cdc.gov/cancer/hpv/basic_info/cancers.htm. Accessed August 25, 2017.
  5. Harper DM, DeMars LR. HPV vaccines – A review of the first decade. Gynecol Oncol. 2017;146(1):196-204.
  6. Joura EA, Giuliano AR, Iversen OE, et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 2015;372(8):711-723.
  7. HPV quadrivalent vaccine [prescribing information]. Whitehouse Station, New Jersey: Merck & Co, Inc.; 2015.
  8. Van Damme P, Olsson SE, Block S, et al. Immunogenicity and Safety of a 9-Valent HPV Vaccine. Pediatrics. 2015;136(1):e28-e39.
  9. Vichnin M, Bonanni P, Klein NP, et al. An Overview of Quadrivalent Human Papillomavirus Vaccine Safety: 2006 to 2015. Pediatr Infect Dis J. 2015;34(9):983-991.
  10. Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination – Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408.
  11. Reagan-Steiner S, Yankey D, Jayarajah J, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years – United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(33):850-858.
  12. Vidal AC, Smith JS, Valea F, et al. HPV genotypes and cervical intraepithelial neoplasia in a multiethnic cohort in the southeastern USA. Cancer Causes Control. 2014;25(8):1055-1062.
  13. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin. 2012;62(3):147-172.
  14. USPSTF Cervical Cancer Screening Recommendation Summary. www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening/. Accessed August 28, 2017.

Evaluate and Claim Credit

This educational activity is specifically designed to meet the needs of internists, general practitioners, surgeons, obstetricians/gynecologists, urologists, gastroenterologists, and other healthcare providers.

After successful completion of this educational activity, participants should be able to:

  • Employ current evidence-based best practices regarding the utilization of diagnostic tools for patients with prostate cancer
  • Assess the implications of disparities on the diagnosis of patients with breast cancer and utilize strategies to overcome these disparities to improve outcomes
  • Integrate recent data regarding the potential influence of racial disparities on the diagnosis and, ultimately, clinical outcomes of patients with cervical cancer
  • Evaluate the implications of disparities on screening and diagnosis for patients with Lynch syndrome

This educational activity is supported by grants from Astellas; Lilly USA, LLC; and Merck and Co, Inc.

Continuing Education

prIME Oncology is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Key Points on Disparities in Cancer Care - prIME Oncology

prIME Oncology designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Each newsletter may provide the following credits:

  • Prostate Cancer: 0.25
  • Breast Cancer: 0.25
  • Cervical Cancer: 0.25
  • Lynch Syndrome: 0.25

Provider

This activity is provided by prIME Oncology.

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There are no fees for participating in and receiving CME credit for this activity. In order to receive credit, participants must successfully complete the online posttest and activity evaluation. Your participation in this CME activity will be recorded in prIME Oncology’s database. However, upon request, your CME credit certificate will be emailed to you. Technical requirements may be found under the Terms of Use.

A link to the posttest is available on the newsletter page.

In order to receive credit, participants must successfully complete the online posttest with 75% or higher.

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prIME Oncology assesses relevant financial relationships with its instructors, planners, managers, and other individuals who are in a position to control the content of CME activities. Any potential conflicts of interest that are identified are thoroughly vetted by prIME Oncology for fairness, balance, and scientific objectivity of data, as well as patient care recommendations. prIME Oncology is committed to providing its learners with high-quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial entity.

The faculty reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interest related to the content of this activity:

Dr Brown has disclosed that she has no relevant financial relationships to report. She has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in her presentation.

Dr Burnett has disclosed that he has received consulting fees from Astellas, Auxillium, Inc., Genomic Health Inc., Reflexonic LLC, and Vivus. He also received contracted research fees from American Medical Systems/Boston Scientific, Coloplast, Endo Pharmaceuticals, Medispec, and Pfizer. He has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in his presentation.

Dr Hall has disclosed that he has no relevant financial relationships to report. He has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in his presentation.

Dr Mitchell has disclosed that she has received fees for participation in advisory or review activities from Novartis. She has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in her presentation.

Dr Newman has disclosed that she has no relevant financial relationships to report. She has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in her presentation.

The employees of prIME Oncology have disclosed:

  • Lee Lokey, MD (medical director content reviewer/planner) – no relevant financial relationships
  • Zach Hartman, PhD (scientific content reviewer/planner) – Stock ownership in Advaxis, Inc., and Ariad Pharmaceuticals.
  • Amy Furedy, RN, OCN (scientific content reviewer/planner) – no relevant financial relationships
  • Jessica Mastrodomenico, MPH (editorial content reviewer) – no relevant financial relationships

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Disclosure Regarding Unlabeled Use

This activity may contain discussion of published and/or investigational uses of agents that are not indicated by the US Food and Drug Administration or European Medicines Agency. Please refer to the official prescribing information for each product discussed for discussions of approved indications, contraindications, and warnings.