January is cervical cancer awareness month.

Approximately 31 women in Vermont are diagnosed with cervical cancer each year. One of those women is Allison Hicks, a doula who was diagnosed at age 29 with advanced cervical cancer. Her message: Cervical cancer is preventable. Her foundation, the Hicks Foundation, sponsors, among other activities, a free Pap screening day each year in January. Allison also co-chairs the Vermonters Taking Action Against Cancer (VTAAC) Cervical Cancer Eradication Work Group that brings together interested community members to decrease the incidence of cervical cancer in Vermont (VTAAC). This group grew out of a 2006 legislative mandate to the Department of Health to address the issue of cervical cancer in the state.

In Vermont, the incidence of cervical cancer is significantly higher than the U.S. rate. Both the incidence of and mortality from cervical cancer decreased nationwide between 1997 and 2001. Yet in Vermont, there was no significant change in cervical cancer incidence or mortality. (Cervical Cancer in Vermont, VDH, May 2007)

Regular Screening

The cornerstone of prevention of cervical cancer is regular Pap testing with timely and adequate follow-up. Optimally, screening should be done for any woman with a cervix beginning at age 21 or three years after first sexual activity. An upper age limit to discontinue Pap testing has not been conclusively established. Women should continue to discuss Pap testing with their healthcare providers until at least age 65. In Vermont, women age 75 to 79 have the highest age-specific incidence of cervical cancer. Research has shown that lesbians are less likely to receive cervical cancer screening than heterosexual women; lesbian women should undergo regular Pap testing. Women who have undergone a total hysterectomy for cervical cancer or cervical dysplasia also need to be regularly screened for neoplasia of the vaginal wall.

It is important to educate patients that the Pap test is a screening modality. One normal test does not give a patient a "clean bill of health." In actuality, the sensitivity of the Pap test ranges from 61% to 95% which is why Pap testing must be performed regularly to prevent cervical cancer. The interval between Pap screenings depends on risk factors and medical history; in general, women with a history of three normal Pap tests in the previous 60 months can be screened with liquid-based technology (LBT) every two years. Approximately 98% of Vermont providers are using LBT (versus the conventional Pap slide).

Nationally, between 50 and 60% of women who are diagnosed with cervical cancer have not had a Pap during the preceding 5 years. Designated as "rarely or never" screened, these groups include foreign-born women living in the U.S. less than 10 years, minorities, women without health insurance and/or a regular primary care provider, and women with less than a high school education.

Incidence of and mortality from cervical cancer also varies significantly by ethnicity. According to data from the National Cancer Institute, Vietnamese women have the highest incidence of cervical cancer of any racial/ethnic group in the U.S. (43/100,000). Per 100,000 women, the same source reported white women's incidence to be 8 with a mortality of 2. Black or African American women had an incidence rate of 12 cases per 100,000 women with a mortality rate of 6, while Hispanic women's incidence was reported at 15 per 100,000 women with a mortality rate of 3. The highest death rates for cervical cancer in the United States are found in American Indian/Alaskan Natives and Black or African American women. (Women of Color Health Data Book, NIH)

In 1991, the U.S. Legislature mandated federal funds be appropriated to address reported healthcare disparities in cervical cancer incidence and mortality by creating the National Breast and Cervical Cancer Early Detection Program. In Vermont, this program is known as Ladies First and is available to Vermont women ages 18 to 64. The program provides screening and diagnostic services specifically related to breast and cervical cancer or dysplasia in conjunction with over 1,000 providers in the state. Uninsured or privately insured women at or below 250% of the federal poverty level are eligible as long as they are not currently enrolled in state health insurance plans. For more information on Ladies First, please call 1-800-508-2222 or see the website at www.LadiesFirstvt.org.

HPV and Cervical Cancer

Cervical cancer is one of the only cancers with a known cause--99% of cervical cancers are caused by certain strains (high-risk) of the HPV virus. While the majority of HPV infections are transient and asymptomatic (90% of new infections clear within 2 years), persistent infection with high-risk types of HPV, in combination with lack of routine screening or inappropriate follow-up, is a primary risk factor for development of cervical cancer. Progression from HPV infection to invasive cancer is a slow process, estimated to take 10 to 15 years or longer. Despite the causal relationship described between HPV and cervical cancer, it is important to counsel patients who have a positive HPV test that cervical cancer is an uncommon consequence of HPV infection.

HPVs are nonenveloped, double-stranded DNA viruses in the family Papillomaviridae and the most common sexually-transmitted infection in the U.S. There are approximately 100 known types of HPV and about 20 million Americans are currently infected. At any time, 50% of sexually active women are infected (percentages in men are currently being studied). Unlike other sexually transmitted infections, HPV is transmitted by skin-toskin contact. Genital HPV infection is primarily transmitted by genital contact, usually through sexual intercourse. Transmission of HPV through oral-genital, manual-genital, and genital-genital contact is not common but has been documented. Nonsexual routes of HPV transmission have also been observed, although rarely (i.e., mother to newborn). (MMWR, Vol 56, p. 3)

The most common clinically significant manifestations of HPV infection are genital warts and cervical intra-epithelial neoplasia, or CIN, detected by cervical biopsy following abnormal Pap test. These lesions, when high-grade, have some risk of progression to cervical cancer and are thus considered cancer pre-cursors. The object of Pap testing is to detect and treat these high-grade lesions. Treatment includes loop electrosurgical excision procedure (LEEP), cone biopsy, or cryotherapy.

In 2006, the FDA approved the use of Gardasil HPV vaccine in girls and women aged 11 to 26. Given in a series of three injections, the total cost of vaccination for one person is approximately $300.00. Efficacy against cervical cancer and dysplasia caused by types 18 and 16 approaches 100% for five years. Gardasil also protects against genital warts caused by HPV types 6 and 11 (reportedly 90% of cases). It is currently covered by most insurers in Vermont, including Medicaid and Catamount (prior approval is needed in some cases). Merck, the vaccine manufacturer, offers a patient financial assistance program that can be accessed through their website at: http://www.merck. com/merckhelps/vaccines/home.html. The Vermont Department of Health is distributing HPV vaccine through Vermont providers to girls and women aged 11 to 26. For more information, contact the Vermont Department of Health Immunization Program at 863-7638 or your local VDH district office.

Allison Hicks Free Screening Day (www.freepap.org) will be held January 12th at Maitri Healthcare for Women in Burlington. For more information, please contact the Hicks Foundation [e-mail] or 802-373-6597.

Submitted by: Lisa Hardy, RN, CNM, co-chair VTAAC Cervical Cancer Eradication Work Group

Lisa Hardy, RN, CNM co-chairs the VTAAC cervical cancer eradication work group. She can be contacted at [e-mail].