Global Health and Oncology

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:11Yale Cancer Answers features
00:11 --> 00:13the latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:20This week it's a conversation
00:20 --> 00:22about global health and oncology
00:22 --> 00:24with Doctor Donna Spiegelman. Dr.
00:24 --> 00:26Spiegelman is Susan Dwight Bliss,
00:26 --> 00:28professor of Biostatistics at
00:28 --> 00:29the Yale School of Medicine,
00:29 --> 00:31where Doctor Chagpar is a
00:31 --> 00:33professor of surgical oncology.
00:34 --> 00:36Donna, maybe we can start off by you
00:36 --> 00:38telling us a little bit more about
00:38 --> 00:40yourself and what it is you do.
00:40 --> 00:43I have a doctorate in
00:43 --> 00:45Biostatistics and epidemiology.
00:45 --> 00:47Epidemiology is formerly the definition
00:47 --> 00:50is the study of the distribution and
00:50 --> 00:52determinants of health and disease
00:52 --> 00:55and what it does on a practical level.
00:55 --> 00:57Many people have heard about epidemiology
00:57 --> 01:00now since we've had the COVID-19 epidemic
01:00 --> 01:04and it traces with infectious diseases
01:04 --> 01:08like COVID and flu and RSV and so forth,
01:08 --> 01:10it would trace the patterns of spread
01:10 --> 01:13of the disease and who might
01:13 --> 01:16be at higher risk, who might be at
01:16 --> 01:18higher risk for spreading the disease,
01:18 --> 01:20how effective vaccines and other
01:20 --> 01:22preventive measures are to stop the
01:22 --> 01:25spread of the disease and so forth.
01:25 --> 01:26And then on
01:26 --> 01:28what we call the chronic disease front,
01:28 --> 01:31chronic disease meaning diseases
01:31 --> 01:33that aren't infectious but occur
01:33 --> 01:35over time such as cancer,
01:35 --> 01:37the topic of today's discussion,
01:37 --> 01:39heart disease, diabetes,
01:39 --> 01:42mental health, and so forth.
01:42 --> 01:44Epidemiologists study the risk
01:44 --> 01:47factors for these diseases.
01:47 --> 01:49And in terms of cancer,
01:49 --> 01:52there's quite a bit known about the
01:52 --> 01:54risk factors for various common
01:54 --> 01:56and less common causes of cancer,
01:56 --> 01:58and still more to learn
01:58 --> 01:59about those causes of cancer.
01:59 --> 02:01And it's epidemiologists
02:01 --> 02:03that do that work primarily.
02:03 --> 02:06Biostatisticians are the people who once
02:06 --> 02:08data are collected,
02:08 --> 02:11figure out how to analyze the
02:11 --> 02:14data to answer questions such as
02:14 --> 02:16is high dietary fat intake a
02:16 --> 02:19risk factor for breast cancer?
02:19 --> 02:21The answer in general seems to be no.
02:21 --> 02:25Or do colonoscopies prevent
02:25 --> 02:27colorectal cancer incidents?
02:27 --> 02:29The answer is yes.
02:29 --> 02:31Does cigarette smoking cause lung cancer?
02:31 --> 02:33The answer is yes.
02:33 --> 02:35Biostatisticians and partnership
02:35 --> 02:37with Epidemiologists will take
02:37 --> 02:39often large amounts of data and
02:39 --> 02:42kind of crunch them down using
02:42 --> 02:44established statistical methods
02:44 --> 02:46to answer these kinds of questions
02:46 --> 02:48and also to quantify the uncertainty
02:48 --> 02:51there is in the data about these answers,
02:51 --> 02:53should we go on from there
02:53 --> 02:54or should I say a little
02:54 --> 02:55bit more about myself?
02:56 --> 02:58Yeah, I was about to ask,
02:58 --> 03:00tell us a bit more about what you do
03:00 --> 03:02and in particular you're interested
03:02 --> 03:07in global oncology.
03:07 --> 03:09I had been a professor at the
03:09 --> 03:10Harvard School of Public Health
03:10 --> 03:12for many years where I worked
03:12 --> 03:15on the kinds of chronic disease
03:15 --> 03:17epidemiology questions I've just
03:17 --> 03:22described and as my career matured,
03:22 --> 03:25I became more and more interested in
03:25 --> 03:27taking the information that we have
03:27 --> 03:30about these risk factors and actually
03:30 --> 03:31translating them into practice.
03:31 --> 03:34So we could really start
03:34 --> 03:35preventing some of these
03:35 --> 03:37diseases based on the knowledge.
03:37 --> 03:38And it's not as if that hadn't
03:38 --> 03:39been happening before.
03:39 --> 03:41It certainly had been,
03:41 --> 03:43but I hadn't been a part of that and
03:43 --> 03:45so I wanted to be a part of it and
03:45 --> 03:47by coming to Yale,
03:47 --> 03:48where I'm now the director
03:48 --> 03:51of our Center on methods for
03:51 --> 03:53Implementation and prevention Science,
03:53 --> 03:56I'm actually able to really dig in
03:56 --> 03:59very deeply to participate in projects
03:59 --> 04:01that are working on implementing
04:01 --> 04:03various ways of preventing cancer,
04:03 --> 04:06both here in the United States
04:06 --> 04:09as well as overseas and also in
04:09 --> 04:11developing statistical methods to
04:11 --> 04:14improve our ability to do this work.
04:14 --> 04:15So in terms of global
04:15 --> 04:16Oncology,
04:16 --> 04:18I had some experience with this
04:18 --> 04:21at Harvard and have quite a bit
04:21 --> 04:24more now that I've come to Yale
04:24 --> 04:26and the focus that we've had so
04:26 --> 04:29far has been on cervical cancer.
04:29 --> 04:33Cervical cancer is actually a rare
04:33 --> 04:36cancer in the United States and in
04:36 --> 04:39other high income countries in Europe,
04:39 --> 04:40whereas like for example,
04:40 --> 04:43if I have it right in front of me now,
04:43 --> 04:46the leading sites of new cancer
04:46 --> 04:48deaths 2022 from the American
04:48 --> 04:50Cancer Society among women,
04:50 --> 04:53cervical cancer isn't even on the list.
04:53 --> 04:55Whereas say in Mexico,
04:55 --> 04:58it's the second leading cause of cancer
04:58 --> 05:00incidence and death among women.
05:00 --> 05:02And in Nepal it's actually the 1st.
05:03 --> 05:04In India,
05:04 --> 05:05which is about 1/4
05:05 --> 05:07of the world's population,
05:07 --> 05:08if not more,
05:08 --> 05:09it's also the first or second
05:09 --> 05:11leading cause of cancer.
05:11 --> 05:14So we know how to prevent cervical
05:14 --> 05:16cancer because it used to be quite
05:16 --> 05:16common here,
05:16 --> 05:20say 50 or 100 years ago, now it's completely
05:20 --> 05:23prevented by our screening programs.
05:23 --> 05:25But this knowledge hasn't quite made
05:25 --> 05:28it over to many other countries
05:28 --> 05:31around the world who could use the
05:31 --> 05:33kind of technology that we have
05:33 --> 05:35for preventing cervical cancer,
05:35 --> 05:38possibly adapted to their special contexts.
05:38 --> 05:41So that's an example of the kind
05:41 --> 05:42of global oncology work that we're
05:42 --> 05:44doing here at Yale right now,
05:44 --> 05:46which brings us to
05:46 --> 05:49that other piece that you mentioned in
05:49 --> 05:51passing about implementation science.
05:51 --> 05:53So can you talk a little bit more
05:53 --> 05:55about how exactly implementation
05:55 --> 05:57science works and how it might
05:57 --> 05:59be applied to questions like you
05:59 --> 06:02mentioned in terms of cervical cancer
06:02 --> 06:04prevention in the global context?
06:06 --> 06:08That's a great question.
06:08 --> 06:12So implementation science is say compared
06:12 --> 06:15to Biostatistics and epidemiology,
06:15 --> 06:16a relatively new field.
06:16 --> 06:19It's one that I've really jumped into
06:19 --> 06:21over the past five or more years,
06:21 --> 06:23especially since I've come to Yale and
06:23 --> 06:27it being the focus of our center
06:27 --> 06:29here along with many investigators
06:29 --> 06:31at the medical school and the
06:31 --> 06:33Yale New Haven Hospital system,
06:33 --> 06:36the School of Public Health and elsewhere.
06:36 --> 06:41And it's literally the science of
06:41 --> 06:44implementing evidence based interventions.
06:44 --> 06:48So for example, if we want to continue
06:48 --> 06:51on talking about cervical cancer,
06:51 --> 06:54we know that having regular pap
06:54 --> 06:57smears for women starting
06:57 --> 07:00say when they're 18 or so and going
07:00 --> 07:03into maybe age 50 or
07:03 --> 07:0660 and then treating those women
07:06 --> 07:07who have precancerous lesions
07:07 --> 07:11that appear on the PAP smears is
07:11 --> 07:13extremely effective in preventing
07:13 --> 07:15cervical cancer from developing.
07:15 --> 07:17And so the question is,
07:17 --> 07:19say in Mexico or in Nepal,
07:19 --> 07:21which are two places we're working,
07:21 --> 07:23why isn't this happening?
07:23 --> 07:27So implementation science will start out by
07:29 --> 07:32distributing surveys across the
07:32 --> 07:35spectrum of what we call stakeholders.
07:35 --> 07:37So stakeholders aren't just
07:37 --> 07:39the clients or patients,
07:39 --> 07:40they're also the providers,
07:40 --> 07:43which could be the providers who are
07:43 --> 07:45interacting one-on-one with women.
07:45 --> 07:47They could be with other providers who
07:47 --> 07:49are scheduling women to come in for
07:49 --> 07:52screening and then come back
07:52 --> 07:54for those women who have abnormal screens,
07:54 --> 07:57they can be the providers who are
07:57 --> 07:58actually treating abnormal screens.
08:01 --> 08:03They could be people on the social
08:03 --> 08:05networks of women such as their partners,
08:05 --> 08:07their family members,
08:07 --> 08:09their neighbors and coworkers.
08:09 --> 08:10They could be people who are
08:10 --> 08:12in the ministries of health,
08:12 --> 08:14who are actually making decisions
08:14 --> 08:16about policies and budget and
08:16 --> 08:18how much to allocate to different
08:18 --> 08:20aspects of their healthcare system.
08:20 --> 08:23And it can be politicians and what
08:23 --> 08:25we find around the world with
08:25 --> 08:27respect to cervical cancer as well
08:27 --> 08:29as many other health issues
08:29 --> 08:31that are preventable and prevented
08:31 --> 08:34in the United States and other high
08:34 --> 08:37income countries is that usually
08:37 --> 08:39the World Health Organization,
08:39 --> 08:42which is the international body
08:42 --> 08:45that considers global health issues
08:45 --> 08:47a very major role they play,
08:47 --> 08:50is also in making policy recommendations.
08:50 --> 08:53So the World Health Organization has
08:53 --> 08:56policy recommendations for the prevention,
08:56 --> 08:58screening, and treatment of
08:58 --> 09:00cervical cancer and most
09:00 --> 09:02countries around the world adopt those
09:02 --> 09:04recommendations so that we find,
09:04 --> 09:08let's say, in our work in Mexico and Nepal,
09:08 --> 09:09in the books,
09:09 --> 09:13the policies are exactly what they should be.
09:13 --> 09:15So the problem is not necessarily
09:15 --> 09:18that we need to convince policymakers
09:18 --> 09:20to change policy.
09:20 --> 09:22That might not be true for every
09:22 --> 09:25health issue, but it's quite common,
09:25 --> 09:27so it's further downstream from policy.
09:27 --> 09:30So then we have to figure out
09:30 --> 09:33we can start maybe from the bottom
09:33 --> 09:36up and speak to
09:36 --> 09:38women who are coming into clinics who
09:38 --> 09:40are eligible for screening find out
09:40 --> 09:42what they know about cervical cancer,
09:42 --> 09:45what their barriers might be
09:45 --> 09:47to seeking out screening,
09:47 --> 09:49and then for those who have
09:49 --> 09:51received an abnormal screen,
09:51 --> 09:53their barriers to following up with that.
09:53 --> 09:56And then we can talk to providers
09:56 --> 09:59at the different levels to find out
09:59 --> 10:01why they're not following national
10:01 --> 10:03guidelines and reasons can be
10:03 --> 10:05things like they don't have the time
10:05 --> 10:08with all their other responsibilities,
10:08 --> 10:10they don't have the supplies that
10:10 --> 10:13are needed to actually do the
10:13 --> 10:14screenings and treatments,
10:14 --> 10:17they haven't properly been trained
10:17 --> 10:19and they don't feel comfortable doing
10:19 --> 10:22them or their stigma is also a big
10:22 --> 10:25issue in cancer for both men and women.
10:25 --> 10:28And both clients and patients as well
10:28 --> 10:31as providers can have stigma where
10:31 --> 10:34they want to avoid talking about
10:34 --> 10:38cancer and screening, screening,
10:38 --> 10:40preventing and treating cancer.
10:40 --> 10:42So implementation scientists will
10:42 --> 10:45try to figure out what are the
10:45 --> 10:47primary barriers at
10:47 --> 10:49these different levels?
10:49 --> 10:52And then also what are the
10:52 --> 10:53facilitators because oftentimes,
10:53 --> 10:55say in the clinics we're working
10:55 --> 10:57with in Nepal and Mexico,
10:57 --> 10:59it's not like there's no screening going on.
10:59 --> 11:01There is some screening going on,
11:01 --> 11:03but it's not adequate.
11:03 --> 11:05It's below the ideal
11:05 --> 11:07percentages, which may be is something
11:07 --> 11:10like 80% of women who are within the
11:10 --> 11:13eligible age range should be screened
11:13 --> 11:15who have had a previous normal screen,
11:15 --> 11:18say every three years,
11:18 --> 11:21and maybe 50% of women are
11:21 --> 11:23being screened rather than say,
11:23 --> 11:24the goal might be
11:24 --> 11:25of course we'd like 100%,
11:25 --> 11:28but maybe a more realistic goal might be 90.
11:28 --> 11:30So we have a long way to
11:30 --> 11:32go to get that other 40%,
11:32 --> 11:35but we can still learn about
11:35 --> 11:38What's facilitating the 50% and
11:38 --> 11:41then how can we leverage those
11:41 --> 11:44facilitators to improve the program.
11:44 --> 11:47Then once we collect all this information,
11:47 --> 11:49we might design a multi level,
11:49 --> 11:52meaning that we might want to be
11:52 --> 11:54doing things with providers,
11:54 --> 11:57with the facility administrators,
11:57 --> 12:00with the clients and even possibly people
12:00 --> 12:02in their social networks to address
12:02 --> 12:05the issues that have come up and then
12:05 --> 12:08design an intervention and test
12:08 --> 12:12it in the facilities to see if it worked.
12:12 --> 12:14Did it improve screening rates?
12:14 --> 12:16Did it improve follow-up rates?
12:16 --> 12:18Was it cost effective,
12:18 --> 12:20but is it sustainable?
12:20 --> 12:22And then go on from there.
12:22 --> 12:24So these are the kinds of things
12:24 --> 12:25implementation scientists do.
12:25 --> 12:27We're not coming up with new
12:27 --> 12:29treatments or new cures.
12:29 --> 12:31There's many causes of cancer where
12:31 --> 12:34all the materials are there to
12:34 --> 12:36drastically reduce cancer rates.
12:36 --> 12:38And the challenge for us
12:38 --> 12:40as public health professionals is
12:40 --> 12:43to get those interventions out,
12:43 --> 12:46to adapt them appropriately to different
12:46 --> 12:48cultural contexts and different
12:48 --> 12:51health systems and get them out.
12:51 --> 12:53So that's what implementation science is.
12:53 --> 12:55Does that make sense to you anyways?
12:55 --> 12:58Yeah, the question though,
12:58 --> 13:00I think, Donna, is that
13:00 --> 13:01in many cases,
13:01 --> 13:03this is multifactorial, right?
13:03 --> 13:06There's an element of stigma,
13:06 --> 13:07there's an element of cost,
13:07 --> 13:09there's an element of time.
13:09 --> 13:12There's multiple factors that go into
13:12 --> 13:15this and kind of putting that together
13:15 --> 13:19in a cultural context to really try
13:19 --> 13:23to design interventions that would be
13:23 --> 13:25effective in increasing
13:25 --> 13:28screening or other preventative measures.
13:28 --> 13:29So, for example,
13:29 --> 13:31when we talk about cervical cancer.
13:31 --> 13:33Another one that is often missing
13:33 --> 13:36in the global context is vaccines.
13:36 --> 13:38It's something that often is
13:38 --> 13:40a little bit challenging,
13:40 --> 13:42So what I'd like to do is pick
13:42 --> 13:44up the conversation there.
13:44 --> 13:46But first we need to take a short
13:46 --> 13:48break for a medical minute.
13:48 --> 13:50So please stay tuned to learn more
13:50 --> 13:52about global health and oncology with
13:52 --> 13:53my guest doctor Donna Spiegelman.
13:54 --> 13:56Funding for Yale Cancer Answers
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14:00 --> 14:01Sexuality, intimacy,
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14:20 --> 14:21Completing treatment for cancer
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15:13 --> 15:15Connecticut public radio.
15:16 --> 15:18Welcome back to Yale Cancer Answers.
15:18 --> 15:20This is doctor Anees Chagpar and
15:20 --> 15:21I'm joined tonight by my guest,
15:21 --> 15:23Doctor Donna Spiegelman.
15:23 --> 15:26We're talking about global oncology care.
15:26 --> 15:27And right before the break,
15:27 --> 15:30Donna was telling us about an
15:30 --> 15:31example of cervical cancer,
15:31 --> 15:34which while relatively rare here in
15:34 --> 15:37the US is relatively common in many
15:37 --> 15:39low to middle income countries like
15:39 --> 15:42Mexico and Nepal where she has projects.
15:42 --> 15:44She was also talking to us
15:44 --> 15:46about implementation science.
15:46 --> 15:49This idea that we can translate knowledge,
15:49 --> 15:52so we know for example that implementation
15:52 --> 15:55of vaccines and pap smears has
15:55 --> 15:57been pretty effective here in the
15:57 --> 16:00US in preventing cervical cancer.
16:00 --> 16:02So why isn't that happening in other
16:02 --> 16:05low to middle income countries?
16:05 --> 16:06And Donna before the break,
16:06 --> 16:08as I was saying, it's really sounds
16:08 --> 16:10like this is multifactorial.
16:10 --> 16:13So there are issues with regards to time,
16:13 --> 16:16there are issues with regards to cost.
16:16 --> 16:19There are issues with regards to
16:19 --> 16:20cultural barriers.
16:20 --> 16:21There may be stigma,
16:21 --> 16:24there may be
16:24 --> 16:26health care workforce issues,
16:26 --> 16:28all of which play into this
16:28 --> 16:31very complicated puzzle.
16:31 --> 16:34So can you tell us a little bit more
16:34 --> 16:37about some of your projects in Mexico
16:37 --> 16:40and Nepal and what your results have been?
16:40 --> 16:43What strategies you've
16:43 --> 16:46tried to reduce cervical cancer?
16:46 --> 16:48What's worked, what hasn't,
16:48 --> 16:49and what are your next steps?
16:51 --> 16:53Thank you, Anees and I'd be
16:53 --> 16:55happy to share.
16:55 --> 16:59So in Nepal where we're the furthest along,
16:59 --> 17:02we've been looking at barriers
17:02 --> 17:04and facilitators to screening.
17:04 --> 17:07It turns out in many low
17:07 --> 17:08and middle income countries,
17:08 --> 17:10Pap smears doesn't appear to be
17:10 --> 17:12feasible as the way to screen.
17:12 --> 17:15And there are some other methods for
17:15 --> 17:19screening, including something called
17:19 --> 17:22visual inspection by acetic acid.
17:22 --> 17:25IA where it's a very low tech
17:25 --> 17:28way to screen where the women's
17:28 --> 17:31cervix is painted with a solution
17:31 --> 17:35of vinegar and then if there are
17:35 --> 17:37abnormal cells they turn white.
17:37 --> 17:39And then if those cells turn white,
17:39 --> 17:41those cells can be removed right
17:41 --> 17:44then and there through either a heat
17:44 --> 17:46treatment or a freezing treatment.
17:46 --> 17:49And so that's called the test and
17:49 --> 17:52and treat and it's a very appealing
17:52 --> 17:56option because it doesn't involve
17:56 --> 17:59this series of appointments and
17:59 --> 18:03visits that happen to have to take place,
18:03 --> 18:04say with Pap smears.
18:04 --> 18:06And then there's another method that's
18:06 --> 18:09being promoted now that has to do with,
18:09 --> 18:12as you've mentioned,
18:12 --> 18:13I haven't quite gotten into it,
18:13 --> 18:17that a necessary cause of cervical cancer
18:17 --> 18:20is infection with HPV,
18:20 --> 18:22the human papilloma virus.
18:25 --> 18:27And there's a vaccine that will
18:28 --> 18:31eliminate infection to the HPV virus
18:31 --> 18:34that's been found now to be effective
18:34 --> 18:37in preventing cervical cancer.
18:37 --> 18:39And again, this is available widely
18:39 --> 18:41in the United States and barely
18:41 --> 18:43available at all in many other
18:43 --> 18:45low and middle income countries,
18:45 --> 18:48including Nepal and Mexico.
18:48 --> 18:52So back to the
18:52 --> 18:53HPV virus,
18:53 --> 18:56because it's a persistent
18:56 --> 18:59infection with this virus is necessary
18:59 --> 19:01for cervical cancer to develop.
19:01 --> 19:04Another approach that's been suggested is
19:04 --> 19:08first to test women gynecologically for
19:08 --> 19:11infection with certain subtypes of HPV,
19:11 --> 19:13the 16 and 18 subtypes.
19:13 --> 19:15We're kind of used to these subtypes
19:15 --> 19:17of viruses now that we know about
19:17 --> 19:22COVID-19 subtypes and if women have that
19:22 --> 19:25viral infection then they can go
19:25 --> 19:29on to these further steps such as VIA
19:29 --> 19:32and that way it eliminates this
19:32 --> 19:35more invasive procedure and seems
19:35 --> 19:37to be more acceptable for women.
19:37 --> 19:38So in Nepal,
19:38 --> 19:41what we're doing right now is
19:41 --> 19:44looking at the acceptability,
19:44 --> 19:46appropriateness and feasibility
19:46 --> 19:50of an HPV approach to screening
19:50 --> 19:52versus the straight VIA
19:52 --> 19:54for everybody and we don't
19:54 --> 19:56have our results yet,
19:56 --> 19:58but things are going very well and
19:58 --> 20:00we'll soon see what our findings are.
20:00 --> 20:03And then from there we might go on and
20:03 --> 20:05develop an intervention using one or
20:05 --> 20:08the others of these and addressing further,
20:08 --> 20:11it may be a more systems level which
20:11 --> 20:13might be more acceptable and sustainable.
20:13 --> 20:15At the same time,
20:15 --> 20:16we're also looking at stigma.
20:16 --> 20:20So we've interviewed women and providers
20:20 --> 20:23about their feelings about cancer.
20:23 --> 20:26And the extent to which they have
20:26 --> 20:29fear associated with it,
20:29 --> 20:31how they may or may not stigmatize
20:31 --> 20:33other people who might have it,
20:33 --> 20:35how they feel their life
20:35 --> 20:38might change should they have it.
20:38 --> 20:41And we've found fairly high levels of
20:41 --> 20:45stigma both among providers and and women.
20:45 --> 20:50So what what we're now thinking about is
20:50 --> 20:53addressing stigma and its impact on health.
20:53 --> 20:55This is quite advanced
20:55 --> 20:58among the HIV AIDS world,
20:58 --> 20:59where it's a major issue,
20:59 --> 21:03but it's just really addressing cancer
21:03 --> 21:07stigma and its impact on preventing
21:07 --> 21:09screening and treatment among people
21:09 --> 21:12who are at risk for cancer or have
21:12 --> 21:14cancer is a relatively new field.
21:14 --> 21:17And so what we're working on as
21:17 --> 21:19well as others is how to adapt
21:19 --> 21:21what are called stigma reduction
21:21 --> 21:23interventions that have been used
21:23 --> 21:26successfully among people living with
21:26 --> 21:30HIV and providers working with them to
21:30 --> 21:33women who may have cervical cancer.
21:33 --> 21:35So that's where we are in Nepal
21:35 --> 21:36and actually in Mexico,
21:36 --> 21:38we're in a very similar place,
21:38 --> 21:40doing very similar things.
21:40 --> 21:43And even though cervical cancer,
21:43 --> 21:46as I mentioned, is rare in the United States,
21:46 --> 21:48we still have health disparities
21:48 --> 21:49based on race,
21:49 --> 21:52ethnicity, and socioeconomic status.
21:52 --> 21:53So for example,
21:53 --> 21:55here in the United States,
21:55 --> 21:57including here in New Haven,
21:57 --> 21:59Black and Hispanic women have around
21:59 --> 22:02a 30 to 40% higher incidence of
22:02 --> 22:05cervical cancer than do white and non
22:05 --> 22:07Hispanic women and black women have the
22:07 --> 22:10highest age adjusted mortality rates,
22:10 --> 22:12still much lower than those that
22:12 --> 22:14we see in Nepal, Mexico,
22:14 --> 22:15India and elsewhere,
22:15 --> 22:18but still unacceptably high given the
22:18 --> 22:21disparity we have within our own country.
22:21 --> 22:23It's so interesting that you
22:23 --> 22:25mentioned the work here in New Haven.
22:25 --> 22:27But I wonder,
22:27 --> 22:30it would seem to me that many of
22:30 --> 22:33the factors that go into why people
22:33 --> 22:36are suffering with cervical cancer
22:36 --> 22:39in New Haven versus in other parts
22:39 --> 22:41of the world may be different.
22:41 --> 22:42So for example,
22:42 --> 22:45we know that the HPV vaccines are
22:45 --> 22:47widely available here in the US
22:47 --> 22:50whereas in low to middle income
22:50 --> 22:53countries they may not be as available.
22:53 --> 22:55So have you looked into
22:55 --> 22:57these various factors that may
22:57 --> 22:59be playing in and can you tell
22:59 --> 23:00us about how they're different.
23:00 --> 23:04So the HPV vaccine is targeted to
23:04 --> 23:07younger women, even teenage girls,
23:07 --> 23:1112 and 13 year old girls up to
23:11 --> 23:14women who are previously have not
23:14 --> 23:17initiated sexual relations with men.
23:17 --> 23:22And what we've seen is maybe 20 or
23:22 --> 23:2630 years later when cervical cancer develops,
23:26 --> 23:30the rates are much lower among girls who
23:30 --> 23:33have been vaccinated at that early time.
23:33 --> 23:37So vaccinating girls is very important for
23:37 --> 23:39preventing cervical cancer in the future.
23:39 --> 23:42But in terms of those of us women
23:42 --> 23:44who are around now
23:44 --> 23:4630 plus, the vaccine is not likely,
23:46 --> 23:48is not believed to help us.
23:50 --> 23:52And these other sorts of screenings,
23:52 --> 23:56PAP, the VIA, HPV followed by
23:56 --> 24:00AIA etc are the approaches that are needed
24:00 --> 24:03to prevent cervical cancer among 30-60
24:03 --> 24:06year old women who are alive today.
24:06 --> 24:09So there are these two different
24:09 --> 24:12strategies based on age and then in
24:12 --> 24:16terms od differences by culture.
24:16 --> 24:19It seems to me that
24:19 --> 24:22Pap smear has been made widely
24:22 --> 24:24available in the United States,
24:24 --> 24:27such that cervical cancer is
24:28 --> 24:31a very rare disease here in the United
24:31 --> 24:34States with the disparity and
24:36 --> 24:38what are the causes of the
24:38 --> 24:40disparity here in the United States?
24:40 --> 24:44Might probably have similarities with
24:44 --> 24:46what's happening in Mexico and Nepal,
24:46 --> 24:47for example, stigma.
24:47 --> 24:49And there might be cultures where
24:49 --> 24:52stigma is within the United States
24:52 --> 24:54is more important than others.
24:54 --> 24:56We have a PhD student here in the
24:56 --> 24:58chronic Disease Epidemiology Department
24:58 --> 25:01who's working with me
25:01 --> 25:04on investigating the extent to
25:04 --> 25:07which cancer stigma is operating
25:07 --> 25:09among women in New Haven and
25:09 --> 25:12providers in the Cornell Scott clinics
25:12 --> 25:14who are treating them, and we'll have more
25:14 --> 25:15information about that in the
25:15 --> 25:17next six months to a year,
25:17 --> 25:20there can also be
25:20 --> 25:23issues with provider training,
25:23 --> 25:27provider overload, burnout.
25:27 --> 25:30And there can be issues,
25:30 --> 25:31similarly to other countries,
25:31 --> 25:34with not having the time to go in,
25:34 --> 25:36not being able to get off work,
25:36 --> 25:38not having the money to be able
25:38 --> 25:41to get to the clinic and so on.
25:41 --> 25:43And so all of these things need to be
25:43 --> 25:45looked at and we'll see how different
25:45 --> 25:48they are from one place to another.
25:48 --> 25:49My personal bias,
25:49 --> 25:52having done quite a bit of public
25:52 --> 25:54health research both in the United
25:54 --> 25:56States as well as overseas,
25:56 --> 25:58is that people are pretty similar
25:58 --> 25:59everywhere and on the issues
25:59 --> 26:01that come up are pretty similar.
26:02 --> 26:05Of course there's exceptions and we
26:05 --> 26:08always have to be mindful of those
26:08 --> 26:10and to adapt our interventions
26:10 --> 26:13to optimally reach the people we are trying to.
26:17 --> 26:19Yeah, I mean, I think some of
26:19 --> 26:21the issues that you mentioned
26:21 --> 26:23are pretty ubiquitous, right?
26:23 --> 26:27Lack of time, physician overload,
26:27 --> 26:32burnout, you know, etcetera, etcetera.
26:32 --> 26:35To address these issues, however,
26:35 --> 26:39it seems like there would need to be
26:39 --> 26:43larger societal policy changes that are
26:43 --> 26:45made that really address these issues.
26:45 --> 26:49Can you talk a little bit about
26:49 --> 26:51where we are in terms of work that's
26:51 --> 26:54moving the issue on the policy level?
26:55 --> 27:00Well globally I think that
27:00 --> 27:02the main effort that I know about is
27:02 --> 27:05that the World Health Organization
27:05 --> 27:09initiated a zero Cervical Cancer campaign.
27:09 --> 27:11I don't remember the year,
27:11 --> 27:13the target goal of the year.
27:13 --> 27:15And oftentimes when they
27:15 --> 27:19have say zero polio or zero TB
27:19 --> 27:22it does stimulate governments to
27:22 --> 27:25put more effort and money into
27:25 --> 27:27implementing their national
27:27 --> 27:29policies because like I said,
27:29 --> 27:32in every country that I've ever
27:32 --> 27:34worked in on any health issue,
27:34 --> 27:36the policies that we would
27:36 --> 27:39like to see are in the books.
27:39 --> 27:43So the question is more the political
27:43 --> 27:46will to increase implementation.
27:46 --> 27:47And you know,
27:47 --> 27:49unfortunately in many countries it's
27:49 --> 27:52sort of a 0 sum situation and that if
27:52 --> 27:55more money is put into cervical cancer,
27:55 --> 27:56less money
27:56 --> 27:57was put into HIV.
27:57 --> 27:59And you know,
27:59 --> 28:01that's not always true but it's
28:01 --> 28:03often true unless new donor money
28:03 --> 28:06can be raised for a specific health
28:06 --> 28:09issue and sometimes that happens.
28:11 --> 28:13So I guess what we're trying to
28:13 --> 28:15do is maybe go a little bit from
28:15 --> 28:17the bottom up and demonstrate that
28:17 --> 28:19these issues can if there's the
28:19 --> 28:23political will to implement its scale,
28:23 --> 28:26we have effective and
28:26 --> 28:28cost effective implementation
28:28 --> 28:31strategies that can address the issue.
28:33 --> 28:35Doctor Donna Spiegelman is Susan
28:35 --> 28:37Dwight Bliss professor of Biostatistics
28:37 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu
28:43 --> 28:46and past editions of the program
28:46 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week
28:51 --> 28:53to learn more about the fight
28:53 --> 28:54against cancer here on Connecticut
28:54 --> 28:56Public radio. Funding for Yale
28:56 --> 28:58Cancer Answers is provided
28:58 --> 29:00by Smilow Cancer Hospital.

Information

Global Health and Oncology with guest Dr. Donna Spiegleman January 29, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095