Challenges in Gynecologic Cancer Screening 8 th Asian Health - - PDF document

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 10/10/19 1

UCSF Helen Diller Family Comprehensive Cancer Center

8th Asian Health Symposium

October 10, 2019

Lee-may Chen, MD Department of Obstetrics, Gynecology and Reproductive Sciences

Challenges in Gynecologic Cancer Screening

1

Disclosure

I have no relevant financial relationships with any companies related to the content of this course.

2

Learning Objectives

§ To describe primary and secondary and secondary prevention strategies for cervical cancer § To identify areas for intervention to improve endometrial cancer diagnosis § To recognize the significance of referring appropriate women for genetic testing for hereditary cancer gene panels

3

3

Gynecologic Cancers

§Uterine: Endometrial, Sarcomas §Ovarian §Cervical §Vulvar §Vaginal §Fallopian Tube §Peritoneal §Gestational Trophoblastic Neoplasia

4

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 10/10/19 2

Cancer Statistics, 2016 Estimates

U.S. Women

• Est. New Cancer Cases

Breast 246,660 Lung 106,470 Colon/Rectum 63,670 Uterus 60,050 Thyroid 49,350 NH Lymphoma 32,410 Melanoma 29,510 Ovary 22,280 Cervix 12,990

• Est. Cancer Deaths

Lung 72,160 Breast 40,450 Colon/Rectum 23,170 Pancreas 20,330 Ovary 14,240 Uterus 10,470 Leukemia 10,270 NH Lymphoma 8,630 Cervix 4,120

ACS, 2016

5

Cancer Statistics, 2016 Estimates

U.S. Women

SEER Cancer Statstistics Review, 1975-2016

6

Cervical Cancer

Wright & Schiffman, N Engl J Med 2003

7

Cervical Cancer—Risk Factors

§HPV infection §Early age at 1st birth §Early age at 1st intercourse §Long term oral contraceptive use §High parity §Low socioeconomic status §Smoking §?Genetic factors §?Other sexually transmitted agents (chlamydia)

8

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 10/10/19 3

CDC Recommendations for HPV vaccination

§ Initiate routine HPV vaccination at age 11 or 12 years. § The vaccination series can be started beginning at age 9 years. § Vaccination is recommended up through age 26. § Shared decision making is recommended for ages 27-45.

MMWR August 16, 2019 / 68(32); 698-702

9

Race & Acculturation as associated with incomplete HPV vaccination completion

§ Retrospective cohort of 102,052 females at Kaiser, 41% complete HPV vaccination § Prevalence of Human Papilloma Virus Vaccine Series

• Hispanic

38.9% (95% CI 38.3-39.5)

• White

43.0% (42.5-43.5)

• Asian/PI

49.5% (48.8-50.2)

• Black

28.7% (27.8-29.6) § Asians had an age-adjusted OR of 1.29 compared to Whites § Less acculturated Hispanics were also more likely to complete vaccination

10

Freeman et al, Obstet Gynecol 2018

10

Screening for cervical cancer

2 approaches are currently in use in the USA

• Cytology (Pap test) every 3 years
• Cytology (Pap test) plus HPV testing every 5 years
• HPV testing detects the high risk HPV types associated with

cervical cancer

11

Cervical Cancer Screening in Asians

§ 84% of U.S. women have had appropriate Pap smear screening § 76% of Asian women have had appropriate Pap smear screening

• Just over 1/3 have had HPV vaccination

Robison et al, Women’s Health Issues, 2014 Behavioral Risk Factor Surveillance System (BRFSS), Centers for Disease Control and Prevention, 2016

12

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 10/10/19 4

Screening through the Chinese American Immigrant Experience

§ Qualitative interview of 12 Chinese American immigrant women between ages 34-64, mean age 52, most have lived in U.S. > 10 years, English or Mandarin speaking § Recruitment from Chinese American churches & clubs in LA § 5 met current cervical cancer screening guideline. None vaccinated § Four Themes emerged

• Belief in a healthy lifestyle
• Maintaining privacy for female health problems
• Fear of losing control
• Feeling vulnerable in an unfamiliar health care system

Seo et al, JOGNN 2018

13

Cervical Cancer Take-home Summary

§Primary prevention of cervical cancer: HPV vaccination before exposure to HPV §Secondary prevention of cervical cancer: screening for detection and treatment of cancer precursors

14

Uterine Cancer: Risk Factors

§ Taking estrogen alone without progesterone § Obesity § Later menopause § Diabetes § Never becoming pregnant § Hypertension § Family history of endometrial or colon cancer § Use of tamoxifen

15

Uterine Cancer: by Race & Ethnicity

North American Association of Central Cancer Registries, 2018 National Center for Health Statistics, Center for Disease Control and Prevention, 2018

16

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 10/10/19 5

Uterine Cancer Outcomes in Asians

§ SEER data compared 2144 Asians to 32,999 Caucasian women with endometrial cancer.

• Mean age: 58.4 vs. 65.1 (p < 0.01)
• Advanced stage (III-IV): 21.5% vs 15.4% p < 0.01)
• 5 year survival: 79.4 vs. 75.2% (p < 0.01)

‒ Especially with endometrioid & serous histologies ‒ No difference with clear cell & sarcomas § Race did not predict outcome on multivariable analysis

• Only age, stage, grade, histology

Zhang et al, Obstet Gyncol 2006

17

Endometrial Cancer: Routine Screening is NOT recommended

Screening test must be noninvasive Screening test must be inexpensive Detection of tumors at an early stage to allow more successful treatment 90% of women with endometrial cancer present with postmenopausal bleeding No satisfactory or cost-effective screening for endometrial cancer Consider ultrasound or biopsy for Lynch Syndrome family members

18

Uterine Cancer in Asian Immigrants

§ U.S. born Asians are more likely to be diagnosed with Type I (grade 1-2 endometrioid) uterine cancer compared with immigrants. § 1.51 Hazard ratio (95% CI 1.33-1.70) § Over time, there has been a trend for increased cancer in U.S. born Asians.

Liao et al, Cancer Causes Control 2003 Simons et al, Am J Obstet Gynecol 2015

19

Endometrial Cancer: Screen for individuals at risk

§Prevention of endometrial cancer: Endometrial cancer is associated with unopposed estrogen, exogenous or endogenous. For earlier diagnosis, have a lower index of suspicion to biopsy at a younger age

20

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 10/10/19 6

Ovarian Cancer

21

Ovarian Cancer: Risk Factors

§Increasing age §Family history of ovarian, fallopian tube, primary peritoneal cancer, or premenopausal breast cancer §Personal history of premenopausal breast cancer §Infertility / never becoming pregnant §Oral contraceptive pill use is protective

22

Ovarian Cancer Outcomes in Asians

Fuh, Gynecol Oncol 2015

Improved 5 year survival Immigrant Asians had better survival than U.S. born

23

Ovarian Cancer: Routine Screening is NOT recommended

§ Screening test must be noninvasive § Screening test must be inexpensive § Detection of tumors at an early stage to allow more successful treatment Ultrasound CA125

24

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 10/10/19 7

Causes of Ovarian Cancer

1/27/15 Personalized Gynecologic Cancer Care through Genetics Helen Diller Family Comprehensive Cancer Center 25

Hereditary (15-24%)

Sporadic

Sporadic

Walsh et al, Proc Natl Acad Sci USA 2011

25

“Women diagnosed with epithelial ovarian, tubal, and peritoneal cancers should receive genetic counseling and be offered genetic testing, even in the absence of a family history.”

SGO Clinical Practice Guideline Genetic Screening for Ovarian Cancer October 2014

1/27/15 26 Personalized Gynecologic Cancer Care through Genetics Helen Diller Family Comprehensive Cancer Center

26

Race & Language are barriers to genetic testing for Ovarian Cancer

§ 53% of patients are currently offered genetic counseling and testing § Mean time from diagnosis to counseling: 4.6mo. § 36% counseled, 33% tested § High grade serous histology most likely to be referred

Manrriquez et al, Gynecol Oncol 2018

27

Ovarian Cancer: Screen for individuals at risk

Prevention of ovarian cancer: Genetic testing and risk-reducing surgery for high risk individuals. Oral contraceptive pills & salpingo-oophorectomy as appropriate

28

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 10/10/19 8

29