Disclosure UCSF Helen Diller Family Comprehensive Cancer Center I have no relevant financial relationships with any companies related to the content of this course. Challenges in Gynecologic Cancer Screening 8 th Asian Health Symposium Lee-may Chen, MD Department of Obstetrics, Gynecology and Reproductive Sciences October 10, 2019 1 2 Learning Objectives Gynecologic Cancers § Uterine: Endometrial, Sarcomas § To describe primary and secondary and secondary prevention § Ovarian strategies for cervical cancer § Cervical § To identify areas for intervention to improve endometrial cancer § Vulvar diagnosis § Vaginal § To recognize the significance of referring appropriate women for § Fallopian Tube genetic testing for hereditary cancer gene panels § Peritoneal § Gestational Trophoblastic Neoplasia 3 3 4 1 10/10/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Cancer Statistics, 2016 Estimates Cancer Statistics, 2016 Estimates U.S. Women U.S. Women Est. New Cancer Cases Est. Cancer Deaths Breast 246,660 Lung 72,160 Lung 106,470 Breast 40,450 Colon/Rectum 63,670 Colon/Rectum 23,170 Uterus 60,050 Pancreas 20,330 Thyroid 49,350 Ovary 14,240 NH Lymphoma 32,410 Uterus 10,470 Melanoma 29,510 Leukemia 10,270 NH Lymphoma 8,630 Ovary 22,280 Cervix 4,120 Cervix 12,990 SEER Cancer Statstistics Review, 1975-2016 ACS, 2016 5 6 Cervical Cancer—Risk Factors Cervical Cancer § HPV infection § Early age at 1 st birth § Early age at 1 st intercourse § Long term oral contraceptive use § High parity § Low socioeconomic status § Smoking § ?Genetic factors § ?Other sexually transmitted agents (chlamydia) Wright & Schiffman, N Engl J Med 2003 7 8 2 10/10/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
CDC Recommendations for Race & Acculturation as associated with incomplete HPV vaccination completion HPV vaccination § Retrospective cohort of 102,052 females at Kaiser, 41% complete HPV vaccination § Initiate routine HPV vaccination at age 11 or 12 years. § Prevalence of Human Papilloma Virus Vaccine Series § The vaccination series can be started beginning at age 9 years. • Hispanic 38.9% (95% CI 38.3-39.5) § Vaccination is recommended up through age 26. • White 43.0% (42.5-43.5) § Shared decision making is recommended for ages 27-45. • 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 MMWR August 16, 2019 / 68(32); 698-702 Freeman et al, Obstet Gynecol 2018 10 9 10 Screening for cervical cancer Cervical Cancer Screening in Asians 2 approaches are currently in use in the USA § 84% of U.S. women have had appropriate Pap smear screening • Cytology (Pap test) every 3 years • Cytology (Pap test) plus HPV testing every 5 years § 76% of Asian women have had appropriate Pap smear screening • HPV testing detects the high risk HPV types associated with cervical cancer • 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 11 12 3 10/10/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Screening through the Chinese American Cervical Cancer Take-home Summary Immigrant Experience § Qualitative interview of 12 Chinese American immigrant women § Primary prevention of cervical cancer: HPV between ages 34-64, mean age 52, most have lived in U.S. > 10 vaccination before exposure to HPV years, English or Mandarin speaking § Recruitment from Chinese American churches & clubs in LA § 5 met current cervical cancer screening guideline. None § Secondary prevention of cervical cancer: vaccinated screening for detection and treatment of cancer § Four Themes emerged precursors • 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 14 Uterine Cancer: by Race & Ethnicity Uterine Cancer: Risk Factors § Taking estrogen alone without progesterone § Obesity § Later menopause § Diabetes § Never becoming pregnant § Hypertension § Family history of endometrial or colon cancer North American Association of Central Cancer Registries, 2018 § Use of tamoxifen National Center for Health Statistics, Center for Disease Control and Prevention, 2018 15 16 4 10/10/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Uterine Cancer Outcomes in Asians Endometrial Cancer: Routine Screening is NOT recommended § SEER data compared 2144 Asians to 32,999 Caucasian women Screening test must be noninvasive with endometrial cancer. Screening test must be inexpensive • Mean age: 58.4 vs. 65.1 (p < 0.01) • Advanced stage (III-IV): 21.5% vs 15.4% p < 0.01) Detection of tumors at an early stage to allow more successful treatment • 5 year survival: 79.4 vs. 75.2% (p < 0.01) ‒ Especially with endometrioid & serous histologies 90% of women with endometrial cancer present with postmenopausal ‒ No difference with clear cell & sarcomas bleeding § Race did not predict outcome on multivariable analysis No satisfactory or cost-effective screening for endometrial cancer • Only age, stage, grade, histology Consider ultrasound or biopsy for Lynch Syndrome family members Zhang et al, Obstet Gyncol 2006 17 18 Uterine Cancer in Asian Immigrants Endometrial Cancer: Screen for individuals at risk § U.S. born Asians are more likely to be diagnosed with Type I § Prevention of endometrial cancer: Endometrial (grade 1-2 endometrioid) uterine cancer compared with cancer is associated with unopposed estrogen, immigrants. exogenous or endogenous. For earlier § 1.51 Hazard ratio (95% CI 1.33-1.70) diagnosis, have a lower index of suspicion to § Over time, there has been a trend for increased cancer in U.S. biopsy at a younger age born Asians. Liao et al, Cancer Causes Control 2003 Simons et al, Am J Obstet Gynecol 2015 19 20 5 10/10/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Ovarian Cancer 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 21 22 Ovarian Cancer Outcomes in Asians Ovarian Cancer: Routine Screening is NOT recommended Improved 5 year survival § Screening test must be noninvasive Immigrant Asians had better survival than U.S. § Screening test must be inexpensive born § Detection of tumors at an early stage to allow more successful treatment Ultrasound CA125 Fuh, Gynecol Oncol 2015 23 24 6 10/10/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
“Women diagnosed with Causes of Ovarian Cancer epithelial ovarian, tubal, and peritoneal cancers should Sporadic receive genetic counseling and Sporadic be offered genetic testing, even in the absence of a family Hereditary (15-24%) history.” SGO Clinical Practice Guideline Genetic Screening for Ovarian Cancer October 2014 Walsh et al, Proc Natl Acad Sci USA 2011 Personalized Gynecologic Cancer Care through Genetics Personalized Gynecologic Cancer Care through Genetics Helen Diller Family Comprehensive Cancer Center 25 1/27/15 26 Helen Diller Family Comprehensive Cancer Center 1/27/15 25 26 Race & Language are barriers to genetic Ovarian Cancer: Screen for individuals testing for Ovarian Cancer at risk § 53% of patients are currently offered genetic counseling and testing § Mean time from diagnosis to counseling: 4.6mo. Prevention of ovarian cancer: Genetic testing and § 36% counseled, 33% tested risk-reducing surgery for high risk individuals. Oral contraceptive pills & salpingo-oophorectomy as § High grade serous histology most likely to be referred appropriate Manrriquez et al, Gynecol Oncol 2018 27 28 7 10/10/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
29 8 10/10/19 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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