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