HPVCervical Cancer : Unequal Health Burden C. Daniel Mullins, PhD

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HPV/Cervical Cancer Unequal Health BurdenC.
Daniel Mullins, PhD

• American Cancer Society
• Cervical Cancer Conference August 4 - 5, 2008
• Research Triangle Park, NC

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HPV/Cervical Cancer

• Burden of Human Papillomavirus (HPV)
• Prevalence
• Treatment Cost
• Mortality and Indirect Costs
• Discuss the Sociodemographic Factors Associated
  with HPV Burden
• Discuss Health Disparities of Cervical Cancer in
  Diverse Populations
• Examine the HPV vaccine and its Implications for
• Global Health Burden of HPV/Cervical Cancer
• Health Disparities

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HPV Burden Prevalence

• Current estimates show that 20 million people are
  infected with HPV in the United States.
• In 2005, an estimate 10,370 new infections and
  3710 deaths occurred.

• Mayeaux E. Reducing the Economic Burden of
  HPV-Related Diseases. J Am Osteopath Assoc.
  2008108 (suppl 2)S2-S7.

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HPV Burden Costs

• The cost for treating persons with HPV infection,
  preventing HPV infection, and prevention of
  HPV-related disease is greater than three of the
  most prevalent sexually transmitted diseases.
• In the United States, total direct medical
  expenditures for HPV is at 1.6 million annually.

Mayeaux E. Reducing the Economic Burden of
HPV-Related Diseases. J Am Osteopath Assoc. 2008
108 (suppl 2)S2-S7
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HPV Burden Indirect Costs

• Premature (and avoidable) deaths due to HPV
  produce significant costs
• Reduced productivity
• Impact on family

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Sociodemographic Factors

• Kahn J, Lan D, Kahn R. Sociodemographic Factors
  Associated With High-Risk Human Papillomavirus
  Infection. Obstetrics Genecology 2007 110 (1)
  87-95.

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Sociodemographic Factors

• The National Health and Nutrition Examination
  Survey (NHANES) offered type-specific HPV DNA
  testing to females participants in 2003-2004.
• The survey collected information on income and
  over samples of vulnerable populations.
• Aim 1- determine prevalence of high risk HPV and
  identify Sociodemographic factors
• Aim 2- to explore in-depth relationships between
  race and ethnicity, income, and high risk HPV
  infection

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Methods

• Data for the analyses were derived from the
  2003-2004 NHANES conducted by the National Center
  for Health Statistic of the Centers for Disease
  Control and Prevention.
• 2,026 participants ages 14-59 interviewed for the
  study were asked to complete a health examination
  component
• Outcome variables included any HPV infection,
  high-risk HPV infection, and HPV inflection
  contained in current vaccines (HPV-6,-11,-16,-18
  and HPV -16 and -18).
• Logistic regression models adjusted for variables
  associated with HPV infection in logistic
  analyses at a significant level of P. 1.

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Human papillomavirus (HPV) prevalence by race,
ethnicity, and poverty status. From Kahn.
High-Risk HPV Infection in U.S. Women. Obstet
Gynecol 2007 110(1).July 2007.87-95.
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Results

• Women 22-25 years of age and those unmarried had
  the highest odds of HPV infection
• HPV infection was substantially higher among
  those living below the poverty line
• Hispanics
• Non-Hispanic Whites
• Less differentiation among African American Women
  along poverty line

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Discussion

• Q1 How do we interpret these prevalence rates in
  terms of Health Disparities?

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Implications

• Insurance is key, however other barriers exist
• Education
• Pap test screening
• HPV vaccines
• Among those living above the poverty line, those
  factors associated with high-risk HPV infections
• Black race
• Lower mean income
• Unmarried status
• Younger age

Human papillomavirus (HPV) prevalence by race,
ethnicity, and poverty status.Kahn. High-Risk HPV
Infection in U.S. Women. Obstet Gynecol 2007.
From   Kahn Obstet Gynecol, Volume 110(1).July
2007.87-95.
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Recent Pap Tests
Behavioral Risk Factor Surveillance System Public
Use Data Tape 2006, National Center for Chronic
Disease Prevention and Health Promotion, Centers
for Disease Control and Prevention.
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Discussion

• Q2 What do these screening rates imply in terms
  of community-based interventions?

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Cervical Cancer Burden Prevalence
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(No Transcript)
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Age-adjusted cervical cancer death rates in the
South Atlantic Division1996-2005
Note Rates are suppressed for counties with
fewer than 10 deaths
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Cervical Cancer Death Rates by Race and Region
(1996 2005)
Data provided by ACS
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Cervical Cancer Death Rates by Race and Region
(1996 2005)
Data provided by ACS
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Cervical Cancer Death Rates by Race and Region
(1996 2005)
Data provided by ACS
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Discussion

• Q3 How would you present these prevalence rates
  to influence policy makers?

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The disparity of cervical cancer in diverse
populations

• Downs L, Smith J, Scarinci I, Flowers L, Parham
  G. The disparity of cervical cancer in diverse
  populations. Gynecologic Oncology 2008
  109S22-S30.

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The disparity of cervical cancer in diverse
populations

• Screening practices affects incidence and
  mortality among various populations
• African Americans have higher percentage of
  cervical cancer diagnosis at later stages
  although screening rates are consistent with
  other ethnic groups
• Geographical distribution of minority groups in
  the southern regions of the United States may
  attribute to disparities

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The disparity of cervical cancer in diverse
populations

• Cultural and personal barriers
• Lack of English proficiency
• A fatalistic attitude towards cervical cancer
• Belief that cancer is bad luck and would rather
  not know
• Socioeconomic barriers
• Low income
• Lack of medical insurance
• Low education

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The disparity of cervical cancer in diverse
populations

• Institutional barriers
• Long wait times at health clinics
• Lack of transportation
• No family support
• Lack of child care

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The disparity of cervical cancer in diverse
populations

• Effective strategies to overcome disparities
• Federally funded initiatives to determine
  effective methods and reduce disparities
• Community outreach programs to promote Pap test
  and cervical cancer
• The use of Prophylactic vaccines as a prevention
  for cervical cancer and strategy to enhance
  screening and follow up

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Human Papillomavirus 16/18 Vaccine

• Goldie S, Kohli M, Grima K, Weinstein M, Wright
  T, Bosch X, Franco E. Projected Clinical Benefits
  and Cost-Effectiveness of Human Papillomavirus
  16/18 Vaccine. JNCI 2004. 96 (8) 604-614.

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Cost-Effectiveness of HPV 16/18 Vaccine

• Cost effective of HPV 16/18 with Current Cancer
  Screening
• HPV 16/18 vaccine ranging from 70 to 100 would
  reduce the lifetime risk of cancer by 46-66
• 20,600 per QALY with a vaccine that prevents
  100 of persistent HPV 16/18 inflections
• 33, 700 per QALY with a vaccine that prevents
  70 of persistent HPV 16/18 inflections
• Cost-effectiveness of Primary and Secondary
  Cervical Cancer Strategies
• Combining vaccination at age 12 with triennial
  conventional cytological screening beginning at
  age 25
• Cancer would be reduce by 94 compared to no
  intervention

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Impact of Vaccine efficacy on Cost-effectiveness
of Cervical Cancer Prevention Strategies

• The use of vaccinations with at least 70
  effectiveness at age 12 combined with cytologic
  screening every 3 years beginning at age 25
• Provides 92 reduction in cervical cancer
  incidence
• Costs approximately 50,000 per QALY
• Is more effective than other screening programs

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Adding Human Papillomarvis Vaccine to Screening
Programs

• Kulasingam S, Myers E. Potential Health and
  Economic Impact of Adding a Human Papillomarvis
  Vaccine to Screen Programs. JAMA 2003
  290(6)781-789.

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Adding HPV Vaccines to Screening Programs

• A Markov model was used to estimate the lifetime
  (age 12-85) costs and life expectancy and life
  expectancy for cohort of women screened for
  cervical cancer.
• Strategies compared
• Vaccinations only
• Conventional cytological screening only
• Vaccinations followed by screening

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Adding HPV Vaccines to Screening Programs

• Vaccination only or adding vaccination to
  screening conducted every 3 years and 5 years was
  not cost effective
• Strategy for screening every 5 years beginning
  age 18 had an incremental cost of ratio of 6,030
  per life compared to no intervention.
• Using the same strategy for 3 years was 21,912
• At frequent intervals, using a combination of
  vaccination and screening was preferred with
  incremental cost-effectiveness ratios ranging
  from 44,889 to 236,250 for 2 year screening
  intervals from age 18.

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Summary

• There are differences in rates of
• Prevalence of HPV
• Prevalence of Cervical Cancer
• Screening Rates
• Health Disparities
• Not Consistent by Race
• SES Strong Driver of Disparities

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Discussion

• Q4 How do we address Health Disparities that are
  based in SES - not race?