Cervical Cancer
David Acosta,
M.D. and
Maribel Serrano, M.D.
Risk
Factors
| Beliefs About Cervical Cancer | Barriers
to Screening | Prevention
Strategies
Incidence
and Survival
Rates
Cervical cancer
risk is high
among Hispanic/Latina women (1). Women in
Mexico,
Central America, and South America experience approximately three times
the incidence of and mortality rates from cervical cancer compared with
non-Hispanic White women.
The incidence
rate of cervical
cancer among Latinas in the U.S. is 15.8 per 100,000 compared to 7.1
per
100,000 among non-Latino white women. In Washington State, the
incidence
rates were also higher for Hispanic women compared to non-Hispanic
women.
Figure 1 below demonstrates the incidence of cervical cancer for all
racial/ethnic
populations for Washington State from 1999-2001.
Figure 1
The incidence
rate of cervical
cancer among Hispanics in Washington State is 14.7 per 100,000 compared
to 15.8 per 100,000 nationally (2).The incidence
rate
for non-Hispanic White women in Washington State was the same as the
national
incidence rate.
The mortality
rate of cervical
cancer in Hispanic/Latina women in the U.S. is 40% higher than among
non-Hispanic
White women (3). Between 1998-2002, the cervical
cancer
death rate for Hispanic/Latina women was reported to be 1.4 times
higher
for Hispanic/Latina women compared to non-Hispanic White women - 3.5
deaths
per 100,000 per year compared to 2.5 deaths per 100,000 per year in
non-Hispanic
White women (4). Studies have demonstrated that
one
of the reasons for the disparity in mortality rates is that
Hispanic/Latina
women have a greater risk of being diagnosed at later stages of
cervical
cancer compared to non-Latino white women (5).
Risk
Factors for Cervical Cancer
Major risk
factors for the
development of cervical cancer in all women include early age at
initiation
of sexual activity, history of multiple sex partners or promiscuous
male
sexual partners. Studies have demonstrated that factors contributing to
the increased prevalence of cervical cancer among Hispanic/Latina women
include:
- Low
education
- No pap
smear
screening
- If pap
smear
was done, then
long intervals between pap smear screenings
- Non-use of
condoms
- Lack of
access
to healthcare
- Lack of
knowledge about the
need for screening
- Multiple
sexual contacts (6).
The lower rates of
cervical
cancer screening among Hispanic/Latina women are primarily associated
with:
- Lack of
health
insurance
- Low income
levels
- Acculturation
and
assimilation
levels
(7)
- Language
isolated households
(8)
Participation in
cervical cancer
screening has improved in the last two decades; however use by Latinas
has not increased to the same extent as that of other ethnic groups.
The
American Cancer Society (9) revealed that 83.4% of
Hispanic/Latina women had a pap smear in the past 3 years. In
comparison,
87.2% of non-Hispanic White and 88.8% of non-Hispanic Black women had a
pap smear. Fernandez et al (10) looked at low
income,
low literacy, Mexican immigrants in Washington DC and found that 96%
reported
ever having a pap smear done, but only 24% were compliant with age
recommendations.
Skar et al (11) studied Hispanic/Latina women that
used six migrant clinics in Eastern Washington State found that 15% had
never heard of a pap smear, 78% ever having a pap smear, but only 44%
were
compliant with age recommendations. The underutilization of pap smear
screening
is felt to play a large part in the higher mortality rates from
cervical
cancer among Hispanic/Latina women (1).
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Common-held
Beliefs About Cervical Cancer
Within the
Latina community
there are often misconceptions of cervical cancer. Studies have
revealed
some commonly held beliefs as to the cause of cervical cancer:
- Poor
hygiene
- Previous
abortion
- Vaginal
trauma
- Use of
antibiotics
- Having
sexual
intercourse during
menses (3)
Hispanic/Latina
immigrants are
also more likely than U.S.-born Hispanic/Latina and non-Latino White
women
to believe that fate played a role in the development of cervical
cancer
(fatalismo) and preferred to not know if they had cervical
cancer.
They also were less likely to identify family history as a contributing
factor for cervical cancer than U.S.-born Hispanic/Latina and
non-Latino
white women (3).
When
Hispanic/Latina women
indicate that physical trauma can cause cancer, one can interpret this
as a lack of knowledge regarding cancer etiology. However,
studies
have shown that they acquire this type of information from their peers
and cultural norms, and they are usually able to provide a rationale
for
such a belief. Thus, it is important to explore how these beliefs
and “knowledge” are acquired and maintained, as well as the relevance
to
the culture and the individual (3).
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Barriers
to
Preventive Screening
Scarinci et al (3)
demonstrated that cost, lack of transportation, and lack of
interpreters
are just a few of the barriers that impede Hispanic/Latina women from
seeking
pap smear screening. Hispanic/Latina women also have limited
knowledge
regarding cervical cancer screening and its purpose. This includes a
lack
of understanding of the reproductive system. Within the
Hispanic/Latina
community, there also tends to exist a stoic attitude toward health and
illness. As a result, Hispanic/Latina women only seek healthcare for
their
symptoms when they become severe or unbearable.
Rudolph et al (12)
found that many women may lack adequate health insurance or easy access
to a community health center. As a result, they usually are not
screened
regularly for cervical cancer and do not receive regular follow up care
once they have an abnormal pap test result or are diagnosed with
cervical
cancer.
Fernandez et al
(10)
found that fear of cancer, embarassment, lack of knowledge about cancer
and cost were the most significant barriers for Hispanic/Latina
immigrant
women obtaining pap smear screening.
Prevention
Strategies
There is a need
for all health
care providers to recognize and address the issues of access to care
(including
screening procedures) and follow up as well as increasing awareness of
cervical cancer within the community. It is important to
participate
in outreach in the Hispanic/Latino community and educate Hispanic
/Latino
women about cervical cancer. Programs such as “Home Health
Parties”
(see breast cancer prevention strategies) have been implemented by some
community health clinics to help Hispanic/Latina women become informed
about cervical cancer and the significance of pap smear
screening.
Media, such as television and radio, have also been used to help
increase
awareness and encourage women to seek preventative services.
In Washington
State, the
Department of Health, through a grant from the Centers for Disease
Control
and Prevention (CDC), administers a breast and cervical cancer early
detection
program for low-income women in Washington State (13).
Women
who
are
at or below 250% of the Federal Poverty Level, ages 40 -
64 years, and are uninsured or underinsured are eligible for
Washington’s
Breast and Cervical Health Program (WBCHP). Particular emphasis
is
placed on high-risk populations, including women ages 50 years and
older,
Native Americans, African Americans, Hispanics, Asian/Pacific
Islanders,
and lesbians. Program services are available statewide and include
screening,
public education, professional education, quality assurance,
tracking/surveillance,
and evaluation of service delivery components. The Department of
Health provides technical assistance and support to local WBCHP Prime
Contractors
who administer the program regionally. Clinics, private
physicians,
hospitals, local health departments, laboratories, and radiology
facilities
provide services. Reimbursement is at the Medicare rate and
includes
routine office visits, clinical breast exams, screening mammograms, Pap
tests and other authorized diagnostic procedures.
In May 2007,
the Washington
State Department of Health announced that the new vaccine against Human
Papillomavirus (HPV) known as Gardasil® will be available for women
through the Universal Childhood Vaccine Program (14).
This
vaccine
protects
against four types of HPV which cause 70% of cervical
cancers. Gardasil® was approved by the FDA for girls and women ages
9 to 26 years. The Federal Advisory Committee on Immunization Practices
recommends Gardasil® for all girls ages 11 to 12 years. The vaccine
is given as a series of three doses over a six month period. Most
providers
in Washington State will have State supplied vaccine to use and there
will
be no cost to parents for the vaccine. This may have a profound impact
on the incidence and prevalence of cervical cancer in Hispanic/Latina
women.
Dr. Gloria Coronado at the Fred Hutchinson Cancer Research Center is
the
Principal Investigator on a study that aims to test this cervical
cancer
intervention among rural Latinos in Eastern Washington. In addition,
she
is also working with Sea Mar Community Health Centers on a study
designed
to examine Latino parents' acceptability of the HPV vaccine. More
information
on Gardasil® can be found by << clicking
here >>(15).
A pilot study
conducted by
the Southwest Oncology Group Statistical Center based out of San
Antonio
trained Hispanic female cancer survivors as lay health educators (known
as promotoras) to convey cancer information and encourage
cervical
and breast cancer screening to women in Hispanic communities. The
promotoras
shared Information with friends, family and relatives and demonstrated
an increase utilization rate of screening services as a result of their
efforts (16). Further research is needed to test
this
prevention strategy in other Hispanic communities to demonstrate the
success
of its outcomes. Dr. Coronado (mentioned above) is a co-investigator on
a project to test a promotora-based intervention to improve
participation
in cervical cancer screening among residents in colonias along the
U.S.-Mexico
border.
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