cervical cancer in california janet bates, md mph research program director research and...

Cervical Cancer in California

Janet Bates, MD MPH Research Program Director

Research and Surveillance Program California Cancer Registry

Overview

• Decline in cervical cancer mortality: a success story

• Cervical cancer burden in California

• Guidelines for cervical cancer screening and evaluation of abnormal Pap tests guidelines

Cervical Cancer Mortality Rates, U.S., 1946-1984

0

2

4

6

8

10

12

Year

Mor

tali

ty R

ate

(per

100

,000

)

Source: Program for Improving Clinical Pap Smear Programs and Management, Office of Population Affairs, DHHS, 1987.

Source: Program for Improving Clinical Pap Smear Programs and Management, Office of Population Affairs, DHHS, 1987.

Cervical cancer in California

In 2006 expect that

• 1550 new cases of invasive cervical cancer will be diagnosed among California women

• 400 California women will die from cervical cancer

Ten leading causes of cancer incidence and mortality among females, California, 2002

Ten most common cancer sites diagnosed by race/ethnicity, California, 1999-2003

Rank All Races Asian/PI Hispanic Non-Hispanic Black

Non-Hispanic White

1 Breast Breast Breast Breast Breast

2 Lung Colon/rectum Colon/rectum Lung Lung

3 Colon/rectum Lung Lung Colon/rectum Colon/rectum

4 Uterus Uterus Cervix Uterus Uterus

5 NHL Thyroid Uterus Pancreas Melanoma

6 Melanoma NHL Thyroid NHL NHL

7 Ovary Ovary NHL Cervix Ovary

8 Thyroid Stomach Ovary Ovary Urinary bladder

9 Pancreas Cervix Leukemia Myeloma Pancreas

10 Cervix Liver Kidney Kidney Thyroid

Source: California Cancer Registry, April 2006

Ten most common cancer sites diagnosed by race/ethnicity, California, 1999-2003

Rank Chinese Japanese Filipino Korean Vietnamese

1 Breast Breast Breast Breast Breast

2 Colon/rectum Colon/rectum Colon/rectum Colon/rectum Colon/rectum

3 Lung Lung Lung Stomach Lung

4 Uterus Uterus Uterus Lung Thyroid

5 Ovary NHL Thyroid Liver Cervix

6 Stomach Liver NHL Cervix Liver

7 NHL Pancreas Ovary Thyroid Ovary

8 Thyroid Ovary Cervix Uterus NHL

9 Liver Thyroid Pancreas Ovary Stomach

10 Oral/pharynx Urinary Bladder

Leukemia Pancreas Uterus

Source: California Cancer Registry, April 2006

Cervical cancer incidence trends by race/ethnicity, California, 1988-2003

0

5

10

15

20

25

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year of diagnosis

Ag

e-ad

just

ed i

nci

den

ce r

ate

per

100

,000

Non-Hispanic White Non-Hispanic Black Hispanic Asian/PI All races

Source: California Cancer Registry, April 2006

Cervical cancer incidence trends by race/ethnicity, California, 1988-2003

0

5

10

15

20

25

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year of diagnosis

Ag

e-ad

just

ed i

nci

den

ce r

ate

per

100

,000

Non-Hispanic White Non-Hispanic Black Hispanic Asian/PI All races

Source: California Cancer Registry, April 2006

Cervical cancer incidence trends: Asian subgroups, 1988-2001

0.0

10.0

20.0

30.0

40.0

50.0

1988-1989 1990-1992 1993-1995 1996-1998 1999-2001

Ag

e-ad

just

ed r

ate

per

100

,000

Asian/PI

Vietnamese

Korean

Filipino

Chinese

Japanese

Cervical cancer mortality trends, by race/ethnicity, California, 1988-2003

0

2

4

6

8

10

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year of death

Ag

e-ad

just

ed m

ort

alit

y ra

te p

er 1

00,0

00

Non-Hispanic White Non-Hispanic Black Hispanic Asian/PI All races

Source: California Cancer Registry

Cervical cancer mortality trends, by race/ethnicity, California, 1988-2003

0

2

4

6

8

10

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year of death

Ag

e-a

dju

ste

d m

ort

ality

rate

per

100,0

00

Non-Hispanic White Non-Hispanic Black Hispanic Asian/PI All races

Source: California Cancer Registry

Cervical cancer five-year age-adjusted incidence rates by race/ethnicity,

California, 1998-2002

7.8

10.2

16.4

9.5

0

5

10

15

20

NH White NH Black Hispanic Asian/PI

Race/ethnic group

Ag

e-a

dju

ste

d i

nc

ide

nc

e r

ate

pe

r 1

00

,00

0

Source: California Cancer Registry

Cervical cancer five-year age-adjusted incidence rates, by socioeconomic

status, California, 1998-2002

17.3

11.6

9.2

7.15.6

0

2

4

6

8

10

12

14

16

18

20

1 2 3 4 5

SES quintile (low - high)

Ag

e-ad

just

ed i

nci

den

ce r

ate

per

100

,000

Source: California Cancer Registry

Cervical cancer five-year age-adjusted incidence rates by race/ethnicity and SES quintile,

California, 1998-2002

0.0

5.0

10.0

15.0

20.0

25.0

NH White NH Black Hispanic Asian/PI

Ag

e-a

dju

ste

d in

cid

en

ce r

ate

per

100,0

00

1(low) 2 3 4 5(high)

Source: California Cancer Registry

Cervical cancer risk factors

• Unprotected sex• Multiple sexual partners• History of abnormal Pap test• History of cervical cancer/pre-cancerous cervical

lesions• Immunocompromised• Smoking• Early age of intercourse• Poverty

Screening for cervical cancer in California

Women reporting ever having a Pap test by race/ethnicity, California, 1990-2004

0

20

40

60

80

100

White Black Hispanic Asian

Race/ethnicity

%

1990-1992

1993-1995

1996-1998

1999-2000

2002, 2004

Source: Behavioral Risk Factor Surveillance System (BRFSS)

Percentage of California women without a hysterectomy reporting a recent Pap test (within past 3 years)

88.9 91.787.2

73.5

0

20

40

60

80

100

Non-Hispanic White Non-Hispanic Black Hispanic Asian/PI

Race/ethnicity

%

Source: 2003 California Health Interview Survey

Cervical cancer screening disparities

Regular Pap testing is less frequent among:– Immigrants– Older women– Low-income women– Uninsured women– Women without a primary source of health

care

Pap Screening: When to Start• 3 years after onset of vaginal

intercourse, no later than age 21• Annually until age 30 (or every 2

years w/ liquid cytology)• At age 30, women with 3 consecutive

satisfactory normal Paps can be screened every 2-3 years

American Cancer Society Consensus Guidelines, 2002

Terminology for abnormal Pap tests

• ASC-US = Atypical squamous cells of undetermned significance

• LSIL = Low-grade squamous intraepithelial lesion

• ASC-H = atypical squamous cells – cannot excluded high grade intraepithelial lesion

• HSIL = high-grade intraepithelial lesion

2001 Guidelines for the Management of Abnormal Paps

JAMA 2001;287:2120-9

ASC-US Repeat Pap at 4-6 mo intervals OR Colposcopy OR HPV testing for triage to colposcopy

LSIL in adults Colposcopy

LSIL in adolescents Repeat Pap at 6 and 12 months OR HPV testing at 12 months OR Colposcopy

Persistent ASC-US or LSIL

Colposcopy

ACS-H or HSIL Colposcopy

HSIL300,000

CA15,000

LSIL1,000,000

ASC-US2,000,000

Modified from Hildesheim, A., National Cancer InstituteModified from Hildesheim, A., National Cancer Institute

Estimated Annual Abnormal Pap Tests, U.S.

Summary

• Cervical cancer incidence and mortality have declined dramatically after pap test use became widespread

• Disparities persist, with highest incidence rates among Hispanic women and highest mortality rates among non-Hispanic black women

Summary

Highest incidence is found among the poorest women

Pap test utilization varies by race/ethnicity, socioeconomic factors, immigrant status

Resources

California Cancer Registry

www.ccrcal.org

California Health Interview Survey

www.askchis.com