The OSU Center for Health and Health Disparities leads an effort to lower the incidence of cervical cancer and ease the suffering it causes among women in Appalachian Ohio.
A tapestry of great beauty and great poverty, Appalachia is 200,000 square miles of hills, mountains, rivers and forests withquaint small towns and pockets of modern enterprise. It follows the spine of the Appalachian Mountains, stretching from southern New York to northern Mississippi, and includes 14,300 square miles of Ohio.
Appalachian Ohio has about 1.5 million people. Were it a city, it would be the fourth largest in the state. But it would be a city with a problem: Appalachian Ohio, along with the Appalachian areas of Kentucky and West Virginia, has some of the nation’s highest death rates from cervical cancer.
Nationally, the American Cancer Society estimates that 9,710 women in the United States will develop invasive cervical cancer in 2006, with 3,700 women expected to die of the disease.
In Appalachian Ohio, however, the number of women who died from the disease in 2003 was one-third higher than elsewhere in the nation and 43 percent higher than elsewhere in the state. The number of new cases was 49 percent higher than elsewhere in the state.
For the women who are affected and their families, the problem is tragic: Cervical
cancer is one of the most easily detected and preventable of cancers, and it can be caught early through a simple procedure known as a Pap test.
Electra Paskett, PhD, MsPH and a group of collaborators are working to understand why cervical-cancer rates are so high in Appalachia and to learn how best to lower them.
Paskett directs OSU’s Center for Population Health and Health Disparities. She was awarded a five-year, $7.5 million grant from the National Cancer Institute to fund the center and a study known as the Community Awareness Resources and Education (CARE) Project.
“Our long-term goal is to reduce the incidence and suffering from cervical cancer,” says Paskett, who is also the Marion N. Rowley Designated Chair in Cancer Research in the School of Public Health and associate director for population sciences in the OSU Comprehensive Cancer Center. “But first we want to learn what’s behind the unusually high rate of this disease. Then we can design the most appropriate and cost-effective interventions to control it.”
The CARE Project
The CARE Project began in September 2003 and includes researchers from OSU and the University of Michigan. It focuses on the three major causes of cervical cancer – lack of screening, smoking, and infection with human papilloma virus (HPV). It involves rural clinics in 16 counties and is expected to include more than 10,000 women from 17 Appalachian counties (one clinic serves two counties).
The study consists of three related projects, each of which is guided by an internal and an external advisory committee of scientific experts and area residents.
The first project is designed to increase the number of women age 18 and older who receive regular Pap tests and to ensure that they return for follow-up care when necessary. It will involve 100 women from each of the 16 clinics.
First, the women are interviewed to identify the social, environmental, behavioral and biological factors that influence whether women seek Pap testing, says Cathy Tatum, program director for the CCC and Project CARE coordinator.
In particular, the women are asked about their sexual history, tobacco use and how often they get Pap tests. The questions are personal but important. Sexual activity at an early age, having multiple partners, smoking and not getting regular Pap tests all raise cervical-cancer risk.
The interviews are done by women who live in the region, says Karen Ahijevych, PhD, a member of the OSUCCC – James Cancer Control Program and director of the survey and intervention core for the project.
“We train the interviewers to be accepting and open,” she says. “The interviews are often held in the woman’s home, in the kitchen or family room with the children running around, or in a park or maybe even the library.”
After the interview, the researchers determine whether the participant is at risk for cervical cancer and should be encouraged to get a Pap test. If so, the woman is invited to participate in the next part of the project, which examines two ways of encouraging women to get regular Pap tests.
These women are randomly assigned to one of two groups. The women in one group receive several visits by a lay health adviser, a woman from the area who is trained to provide health information and to talk about the benefits of regular Pap tests and cervical-cancer screening.
In contrast, women in the other group are sent a letter and brochure to their home explaining the benefits of cervical-cancer screening and regular Pap tests, but are otherwise advised to follow their normal pattern of medical care.
At the end of the project, the researchers will compare the two groups to learn if screening occurs more often in one than the other.
Sarah Macklin (not her real name) of Franklin Furnace, Ohio was one of the first women to work with a lay health advisor. She is the mother of two adult children, a teenage daughter, and the grandmother of four.
“I wasn’t aware that having a Pap smear needed to be a regular thing,” Macklin says. “I kept putting it off until I was contacted by [my lay health adviser].” Macklin is enthusiastic about the study and wanted a Pap smear once she learned the dangers of cervical cancer. “This is a cancer you can catch early, so it’s certainly worth a few minutes of embarrassment and discomfort to save your life.”
The Smoking Section
The second part of the CARE Project aims to reduce cervical-cancer rates by helping women quit smoking. This portion of the study is led by Mary Ellen Wewers, RN, MPH, PhD, associate dean for research in the OSU School of Public Health and a specialist in smoking cessation.
“An estimated 30 percent of the 1,600 women who join the study will be smokers,” says Wewers, who also co-leads the OSUCCC-James Cancer Control Program with Paskett.
Women who agree to join the smoking cessation part of the study (25 from each county are being sought) will also be assigned one of two groups. One group will be visited by a lay health adviser who will provide health information and advise them about the importance of quitting smoking. The second group will receive general information about the benefits of quitting smoking.
“We also measure the cotinine levels of those who participate, in addition to asking about their smoking history,” Wewers says. Cotinine is a major metabolite of nicotine, and the researchers will test for its presence in saliva samples.
After each woman has been in the study for one year, the two groups will be compared for the number who have quit smoking and for their knowledge about the dangers of tobacco use.
Last But Not Least
Project Three addresses how HPV infection, together with smoking and sexual activity, contributes to the growth of abnormal cervical cells.
The project will ultimately recruit about 600 women from each of the 17 counties who come for Pap tests to participating clinics. Those who volunteer will complete a questionnaire and have cell samples taken from the cervix. In addition, a blood sample will be obtained from smokers.
“Eventually we will look for an association between cotinine levels and the development of abnormal cervical lesions,” Wewers says.
In the end, says Mack Ruffin MD, MPH, professor of family medicine at the University of Michigan and director of project three, “we want to determine if Appalachian women have unique risk factors for abnormal Pap smears that might contribute to the increased rate of cervical cancer.”
The CARE Project has been very rewarding for the researchers and lay health advisers, and it has been helpful to patients. “The advisers find the interactions intensely rewarding,” says Ahijevych, who is also an associate professor in the OSU College of Nursing. “They find themselves encouraging women in other areas of their lives.”
For participants like Sarah Macklin, the seeds of knowledge are also taking root. “I passed along the information that I’ve gotten to my teenaged daughter,” she says. “Kids grow up a lot faster today, and they need to know the facts.”
That’s an important step in preventing all kinds of cancer.
For more information about cervical cancer:
National Library of Medicine, Medline Plus: http://www.nlm.nih.gov/medlineplus/cervicalcancer.html
National Cancer Institute: http://www.cancer.gov/cancerinfo/pdq/treatment/cervical/patient
American Cancer Society: http://www.cancer.org
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| PAP TESTS PREVENT CERVICAL CANCER
Cervical cancer is easy to detect and treat, says OSU professor of public health Electra Paskett PhD, MsPH. “Widespread use of the Pap test for regular screening has dramatically lowered the incidence and death rates for cervical cancer nationally.”
The Pap test is the most effective way to detect the cervical changes that lead to cervical cancer. These changes can then be treated before cancer occurs.
It is a simple, painless procedure that involves collecting a small sample of cells from the cervix and examining them under the microscope. Sometimes these abnormal cells are difficult to detect, but cervical cancer develops slowly and can be nearly always caught early if a woman receives regular screening.
Unfortunately, many women stop seeing a doctor after they have had their children, following a tubal ligation or after menopause. Pap testing is therefore less common among women 65 years of age or older, and those who are widowed or retired, or who lack a high school education. Yet, more than one-fifth of women diagnosed with cervical cancer are over age 65.
The American Cancer Society provides the following guidelines for cervical-cancer screening.
All women should begin cervical cancer screening about three years after they begin having vaginal intercourse, but no later than age 21. Screening should be done yearly with the regular Pap test, or every two years using the newer liquid-based Pap test.
Beginning at age 30, women who have had three normal Pap test results in a row may get screened every two to three years with either the regular or liquid-based Pap test. Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HIV infection or a weakened immune system due to organ transplant, chemotherapy or chronic steroid use should continue to be screened annually.
Another reasonable option for women over 30 is to get screened every three years (but not more frequently) with either the conventional or liquid-based Pap test, plus an HPV DNA test.
Women age 70 or older who have had three or more normal Pap tests in a row and no abnormal Pap test results in the last 10 years may choose to stop having cervical cancer screening. Women with a history of cervical cancer, DES exposure before birth, HIV infection or a weakened immune system should continue to have screening as long as they are in good health.
Women who have had a total hysterectomy (removal of the uterus and cervix) may also choose to stop having cervical cancer screening, unless the surgery was done as a treatment for cervical cancer or precancer. Women who have had a hysterectomy without removal of the cervix should follow the guidelines above.
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Written by Sandra Gurvis; Photo Illustration by Jennifer Gundling