Cervical Cancer Surveillance, Screening, and Treatment Vicki B. Benard, PhD June 27, 2019 Chief, Cancer Surveillance Branch, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention

Vaccine Treatment Screening Thank you, you’ve heard from our speakers about the impact of the vaccine on HPV infection and its very possible to see impact in cervical cancer in the next decade or so with the vaccine. However, the decline immediately in cervical cancer will be due to better screening and treatment – and ensuring ALL women are giving the same opportunities for care. Screening

Trends in Cervical Cancer Incidence and Mortality, 1975–2016 After Decades of Declining Rates, Incidence and Mortality Rates Have Leveled Off Since 2007 Trends in Cervical Cancer Incidence and Mortality, 1975–2016 We have seen a dramatic decrease in cervical cancer over the last several decades, which has been attributed to the introduction of cervical cancer screening with the Pap test which was introduced in the late 50s. The blue line highlights new cervical cancer occurring, with a decrease from 15/100,000 in 1975 to a rate of approx. 7/100,000 in 2015— Similarly mortality rates have gone down from 6 to around 2/100,000. However, over the past few years the rates have remained remarkably stable – we have plateaued. How do we reach these 12,000 women developing cervical cancer and 4000 women dying each year? National Cancer Institute, Surveillance, Epidemiology, and End Results program: seer.cancer.gov/statfacts/html/cervix.html CDC, National Center for Health Statistics

Cervical Cancer Disparities in the United States Higher rates of cervical cancer in: Black and Hispanic women Women living in nonmetropolitan areas Women with lower socioeconomic status Women who have never been screened or not screened in past 5 years Who are these women? The rates for cervical cancer are not the same for all. There are higher rates of cervical cancer for black and Hispanic women. Women living in rural areas are more likely to die from cervical cancer—as seen on the graph on the right where you see a higher death rate in nonmetropolitan areas than metropolitan areas. Cervical cancer is a disease of poverty and those with lower SES are more likely to get and die from cervical cancer. And the MOST IMPORTANT factor – is that over 50% of cervical cancer cases occur among women who have not been screened for cervical cancer. I believe this is our call. AAPC: Average annual percent change NS: Non-significant Henley SJ, Anderson RN, Thomas, CC, et al. MMWR Surveill Summ 2017; Jul 7;66(14):1-13

Screening rates vary widely across the U.S. HP 2020 Goal: 93% Populations with lower Pap screening rates: Foreign-born women Women with low education levels and high poverty threshold Uninsured/underinsured Too many woman are still not getting screened! This slide shows the variation by screening rates across states as reported in this national self-reported survey. With the lightest colors having lower rates ranging from 65% to 85%. None of the states have reached the HP2020 goal of 93%. There are also disparities with screening including lower screening among foreign born, low SES and underinsured women. Source: 2016 BRFSS Data - https://www.cdc.gov/brfss/brfssprevalence/index.html

Guideline-based Treatment for Cervical Cancer Appropriate treatment of pre-cancers prior to invasion and invasive cancer is extremely important to increase the chances of survival of a long and health life. This graph shows proportion of patients receiving guideline-based care for cervical cancer by race. Noted white women (Blue) have a higher proportion of receiving the appropriate treatment for their cancer compared to Hispanic (green line) and black women (red). We need to assure that all women are getting the right care for their cancer as 5-year survival rates for invasive cervical cancer are fairly high – over 60%. Uppal. Et al Disparities in Advanced Cervical Cancer Care. Obstet Gynecol 2017.

Barriers to Cervical Cancer Prevention Individual Factors Low HPV awareness Poor understanding of HPV/Cancer link Cultural issues Poor screening uptake Compromised follow-up Provider and Facilities Factors Training and education Resource and facilities Advance therapeutics (chemo/rad) Palliation Systemic Factors Access to healthcare Un-insurance Surveillance and tracking systems Immigration status Over the years, we have discovered common factors associated with barriers to screening and appropriate treatment. These factors have been incorporated to interventions to target special populations but more is needed. We know low awareness and understanding of who can get cervical cancer is important, .. Study after study have shown when a woman with cervical cancer is asked why she did not get screened she says she just never thought she would get cervical cancer.. provider factors – making sure that the provider is taking every opportunity to screen and treat appropriately AND systemic factors with access to care as noted in difference in rural and urban rates, un and underinsurance is a barrier and tracking (recall systems) of when the women needs to return for screening. Spending resources around these barriers to target the high-risk women to ensure every woman is giving an opportunity to prevent this disease.

CDC’s National Program of Cancer Registries 1.66 million new cancer cases each year 200+ data items for each case Cancer site and histology Patient demographics Stage at diagnosis First course of treatment In order to capture the burden of cervical cancer and where and when this is occurring in the US, we support the National Program of Cancer Registries which collect ALL invasive cancers – without this form of data collection we would not be able to identify when the HPV-related cancers are increasing or decreasing and measure the impact of the interventions across all of the US. We recently released this new data visualization tool capturing the HPV-associated cancer cases in the US – this data is by state as well as demographic variables. Tracking the cancer cases is key to measure progress and target action. Resources to linking the data with other systems including vaccine and screening data through programs or claims can help with targeted interventions.