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Cervix Cancer and GASharad Ghamande MD FACOG
Professor and Director Gynecologic Oncology GRU
Associate Director Clinical Affairs GRU Cancer Center Augusta GA
Principal Investigator Minority NCORP GA Cares
64928Europe
67078Africa
49025South America
14845United States
Canada
1077Australia
New Zealand
39648Southeast
Asia
51266Eastern Asia
21596Central America
151297Southcentral
Asia
Cervical Cancer Worldwide Prevalence Incidence and Mortality Estimates
Prevalence 2274000 women have cervical cancerIncidence 510000 new cases each year
80 in developing countries
Mortality Second leading cause of female cancer-related deaths (288000 annually)Estimated individual loss of life 259 years
(Breast Cancer 19 years Ovarian Cancer 174 years)
Cervix Cancer in US
bull American Cancer Society 2015
bull 12900 cases of cervix cancer a year 4100 patients will die of it this year
bull Additionally there are 300000 cases of CIN23 which are true cancer precursors
bull Another 12 million women in US have a low grade dysplasia (CIN 1)
bull Total health care costs of screening and treating cervix cancer are estimated at 6 billion dollars a year
1 Jemal A et al CA Cancer J Clin 200959225-492 Saslow D et al CA Cancer J Clin 2007577-28
3 ACS Facts amp Figures 2009
High Impact of Cervical Cancer amp Precancerous Lesions in the United States
Every minute a woman is diagnosed with a precancerous lesion2ab
Every 2 hours a woman dies of cervical cancer3a
Every hour a woman is diagnosed with cervical cancer3a
aEstimatedbPrecancerous lesion = cervical intraepithelial neoplasia (CIN) grades 23
In the United States cervical cancer is the second leading cause of cancer-related death in women between the ages of 20 and 391
GA Racial Distribution
bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was
bull 597 White American (559 Non-Hispanic White 38 White Hispanic)
bull 305 Black or African American (including Hispanics)
bull 03 American Indian and Alaska Native (including Hispanics)
bull 32 Asian American (including Hispanics)
bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)
bull 40 from Some Other Race (including Hispanics)
bull 21 Multiracial American (including Hispanics)
bull 88 Hispanics and Latinos of any race[5]
How can we make an impact
1) Prevention
- Widespread use of Pap smears
- Improve Vaccination
2) Treat CIN 23 and prevent invasive cancers ( Insurance and access barriers)
3) Improve the care and outcomes of women with cervix cancer
Cervical Cancer Have We Decreased the Incidence in the US
bull The curve has been stable for the past decade in part because we are not reaching the unscreened population
With the advent of the Pap smear the incidence of
cervical cancer has
dramatically declined
74 decline in death from 1955 to 1992
Reprinted by
permission of the
American Cancer
Society Inc
CIN 2-3 rates
bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women
bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per
1000
bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000
bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1
bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]
[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36
Costs of Treating Cervical Cancer
bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C
bull BACKGROUND
bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000
bull METHODS
bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls
bull FINDINGS
bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively
bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively
bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
64928Europe
67078Africa
49025South America
14845United States
Canada
1077Australia
New Zealand
39648Southeast
Asia
51266Eastern Asia
21596Central America
151297Southcentral
Asia
Cervical Cancer Worldwide Prevalence Incidence and Mortality Estimates
Prevalence 2274000 women have cervical cancerIncidence 510000 new cases each year
80 in developing countries
Mortality Second leading cause of female cancer-related deaths (288000 annually)Estimated individual loss of life 259 years
(Breast Cancer 19 years Ovarian Cancer 174 years)
Cervix Cancer in US
bull American Cancer Society 2015
bull 12900 cases of cervix cancer a year 4100 patients will die of it this year
bull Additionally there are 300000 cases of CIN23 which are true cancer precursors
bull Another 12 million women in US have a low grade dysplasia (CIN 1)
bull Total health care costs of screening and treating cervix cancer are estimated at 6 billion dollars a year
1 Jemal A et al CA Cancer J Clin 200959225-492 Saslow D et al CA Cancer J Clin 2007577-28
3 ACS Facts amp Figures 2009
High Impact of Cervical Cancer amp Precancerous Lesions in the United States
Every minute a woman is diagnosed with a precancerous lesion2ab
Every 2 hours a woman dies of cervical cancer3a
Every hour a woman is diagnosed with cervical cancer3a
aEstimatedbPrecancerous lesion = cervical intraepithelial neoplasia (CIN) grades 23
In the United States cervical cancer is the second leading cause of cancer-related death in women between the ages of 20 and 391
GA Racial Distribution
bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was
bull 597 White American (559 Non-Hispanic White 38 White Hispanic)
bull 305 Black or African American (including Hispanics)
bull 03 American Indian and Alaska Native (including Hispanics)
bull 32 Asian American (including Hispanics)
bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)
bull 40 from Some Other Race (including Hispanics)
bull 21 Multiracial American (including Hispanics)
bull 88 Hispanics and Latinos of any race[5]
How can we make an impact
1) Prevention
- Widespread use of Pap smears
- Improve Vaccination
2) Treat CIN 23 and prevent invasive cancers ( Insurance and access barriers)
3) Improve the care and outcomes of women with cervix cancer
Cervical Cancer Have We Decreased the Incidence in the US
bull The curve has been stable for the past decade in part because we are not reaching the unscreened population
With the advent of the Pap smear the incidence of
cervical cancer has
dramatically declined
74 decline in death from 1955 to 1992
Reprinted by
permission of the
American Cancer
Society Inc
CIN 2-3 rates
bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women
bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per
1000
bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000
bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1
bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]
[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36
Costs of Treating Cervical Cancer
bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C
bull BACKGROUND
bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000
bull METHODS
bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls
bull FINDINGS
bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively
bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively
bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Cervix Cancer in US
bull American Cancer Society 2015
bull 12900 cases of cervix cancer a year 4100 patients will die of it this year
bull Additionally there are 300000 cases of CIN23 which are true cancer precursors
bull Another 12 million women in US have a low grade dysplasia (CIN 1)
bull Total health care costs of screening and treating cervix cancer are estimated at 6 billion dollars a year
1 Jemal A et al CA Cancer J Clin 200959225-492 Saslow D et al CA Cancer J Clin 2007577-28
3 ACS Facts amp Figures 2009
High Impact of Cervical Cancer amp Precancerous Lesions in the United States
Every minute a woman is diagnosed with a precancerous lesion2ab
Every 2 hours a woman dies of cervical cancer3a
Every hour a woman is diagnosed with cervical cancer3a
aEstimatedbPrecancerous lesion = cervical intraepithelial neoplasia (CIN) grades 23
In the United States cervical cancer is the second leading cause of cancer-related death in women between the ages of 20 and 391
GA Racial Distribution
bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was
bull 597 White American (559 Non-Hispanic White 38 White Hispanic)
bull 305 Black or African American (including Hispanics)
bull 03 American Indian and Alaska Native (including Hispanics)
bull 32 Asian American (including Hispanics)
bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)
bull 40 from Some Other Race (including Hispanics)
bull 21 Multiracial American (including Hispanics)
bull 88 Hispanics and Latinos of any race[5]
How can we make an impact
1) Prevention
- Widespread use of Pap smears
- Improve Vaccination
2) Treat CIN 23 and prevent invasive cancers ( Insurance and access barriers)
3) Improve the care and outcomes of women with cervix cancer
Cervical Cancer Have We Decreased the Incidence in the US
bull The curve has been stable for the past decade in part because we are not reaching the unscreened population
With the advent of the Pap smear the incidence of
cervical cancer has
dramatically declined
74 decline in death from 1955 to 1992
Reprinted by
permission of the
American Cancer
Society Inc
CIN 2-3 rates
bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women
bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per
1000
bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000
bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1
bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]
[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36
Costs of Treating Cervical Cancer
bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C
bull BACKGROUND
bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000
bull METHODS
bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls
bull FINDINGS
bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively
bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively
bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
1 Jemal A et al CA Cancer J Clin 200959225-492 Saslow D et al CA Cancer J Clin 2007577-28
3 ACS Facts amp Figures 2009
High Impact of Cervical Cancer amp Precancerous Lesions in the United States
Every minute a woman is diagnosed with a precancerous lesion2ab
Every 2 hours a woman dies of cervical cancer3a
Every hour a woman is diagnosed with cervical cancer3a
aEstimatedbPrecancerous lesion = cervical intraepithelial neoplasia (CIN) grades 23
In the United States cervical cancer is the second leading cause of cancer-related death in women between the ages of 20 and 391
GA Racial Distribution
bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was
bull 597 White American (559 Non-Hispanic White 38 White Hispanic)
bull 305 Black or African American (including Hispanics)
bull 03 American Indian and Alaska Native (including Hispanics)
bull 32 Asian American (including Hispanics)
bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)
bull 40 from Some Other Race (including Hispanics)
bull 21 Multiracial American (including Hispanics)
bull 88 Hispanics and Latinos of any race[5]
How can we make an impact
1) Prevention
- Widespread use of Pap smears
- Improve Vaccination
2) Treat CIN 23 and prevent invasive cancers ( Insurance and access barriers)
3) Improve the care and outcomes of women with cervix cancer
Cervical Cancer Have We Decreased the Incidence in the US
bull The curve has been stable for the past decade in part because we are not reaching the unscreened population
With the advent of the Pap smear the incidence of
cervical cancer has
dramatically declined
74 decline in death from 1955 to 1992
Reprinted by
permission of the
American Cancer
Society Inc
CIN 2-3 rates
bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women
bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per
1000
bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000
bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1
bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]
[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36
Costs of Treating Cervical Cancer
bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C
bull BACKGROUND
bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000
bull METHODS
bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls
bull FINDINGS
bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively
bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively
bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
GA Racial Distribution
bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was
bull 597 White American (559 Non-Hispanic White 38 White Hispanic)
bull 305 Black or African American (including Hispanics)
bull 03 American Indian and Alaska Native (including Hispanics)
bull 32 Asian American (including Hispanics)
bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)
bull 40 from Some Other Race (including Hispanics)
bull 21 Multiracial American (including Hispanics)
bull 88 Hispanics and Latinos of any race[5]
How can we make an impact
1) Prevention
- Widespread use of Pap smears
- Improve Vaccination
2) Treat CIN 23 and prevent invasive cancers ( Insurance and access barriers)
3) Improve the care and outcomes of women with cervix cancer
Cervical Cancer Have We Decreased the Incidence in the US
bull The curve has been stable for the past decade in part because we are not reaching the unscreened population
With the advent of the Pap smear the incidence of
cervical cancer has
dramatically declined
74 decline in death from 1955 to 1992
Reprinted by
permission of the
American Cancer
Society Inc
CIN 2-3 rates
bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women
bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per
1000
bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000
bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1
bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]
[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36
Costs of Treating Cervical Cancer
bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C
bull BACKGROUND
bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000
bull METHODS
bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls
bull FINDINGS
bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively
bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively
bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
How can we make an impact
1) Prevention
- Widespread use of Pap smears
- Improve Vaccination
2) Treat CIN 23 and prevent invasive cancers ( Insurance and access barriers)
3) Improve the care and outcomes of women with cervix cancer
Cervical Cancer Have We Decreased the Incidence in the US
bull The curve has been stable for the past decade in part because we are not reaching the unscreened population
With the advent of the Pap smear the incidence of
cervical cancer has
dramatically declined
74 decline in death from 1955 to 1992
Reprinted by
permission of the
American Cancer
Society Inc
CIN 2-3 rates
bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women
bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per
1000
bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000
bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1
bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]
[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36
Costs of Treating Cervical Cancer
bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C
bull BACKGROUND
bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000
bull METHODS
bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls
bull FINDINGS
bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively
bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively
bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Cervical Cancer Have We Decreased the Incidence in the US
bull The curve has been stable for the past decade in part because we are not reaching the unscreened population
With the advent of the Pap smear the incidence of
cervical cancer has
dramatically declined
74 decline in death from 1955 to 1992
Reprinted by
permission of the
American Cancer
Society Inc
CIN 2-3 rates
bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women
bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per
1000
bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000
bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1
bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]
[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36
Costs of Treating Cervical Cancer
bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C
bull BACKGROUND
bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000
bull METHODS
bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls
bull FINDINGS
bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively
bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively
bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
CIN 2-3 rates
bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women
bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per
1000
bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000
bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1
bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]
[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36
Costs of Treating Cervical Cancer
bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C
bull BACKGROUND
bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000
bull METHODS
bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls
bull FINDINGS
bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively
bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively
bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Costs of Treating Cervical Cancer
bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C
bull BACKGROUND
bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000
bull METHODS
bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls
bull FINDINGS
bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively
bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively
bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Cervical Cancer ndash Risk Factors
bull Multiple sexual partners
bull Early age onset intercourse
bull Parity
bull HO STDrsquos
bull Smoking
bull Low socioeconomic status
bull Use of Oral Contraceptives
bull High risk male partner
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Cervical Cancer - Risk Factors
bull HIVbull RR 52-65 of cervical cancer
bull 1993 CDC AIDS defining illness
bull mean age at diagnosis 40
bull HPVbull OR 1582 for HPV
bull High risk 1618453133525835
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
0 20 40 60 80 100
16
18
45
31
HPV X
33
52
58
35
59
56
576
717
774
813
85
879
901
918
933
946
957
HPV types from 3045 Women with Cervical Cancer in 23 countries
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
HPV vaccination
bull HPV 4bull Approved for females and males 9 ndash 26
bull Contains HPV 1618611
bull HPV 2bull Approved for females and males 9 ndash 25
bull Contains HPV 1618
bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
HPV vaccination in GA adolescentsYear Females Males
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3 HPV ( 95CL)
gt 1 HPV ( 95CL)
gt 2 HPV ( 95CL)
gt 3HPV ( 95CL)
2014 654 563 471 412 280 210
2013 537 423 332 405 310 153
2012 523 368 29 195 87 NA
2011 484 NA 300 73 NA NA
2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV
2009 All adolescences gt or = to 1 HPV 386
2008 All adolescences gt or = to 1 HPV 185
Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
HPV Vaccination
bull CDC
bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years
bull For very additional year increase an additional 4400 women will go on to have cervical cancer
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
HPV vaccine recommendations
bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females
bull Vaccination schedule is 01-2 6 months
bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Can we create centers of excellence for cancer care
bull Impact of facility volume on therapy and survival for locally advanced cervical cancer
bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard
bull Gynecologic Oncology 132 (2014) 416
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Lin et al
bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy
bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)
bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Lin et al
bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)
bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively
bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)
bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care
Paradigm Shift in Care
bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions
bull Emerging survival data
bull Clinical trials participation
bull Multi Disciplinary team approach
bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)
bull Individualization of care