An MUSC Hollings Cancer Center researcher and colleagues at the University of Puerto Rico Comprehensive Cancer Center (UPRCCC) were recently awarded a new research grant from the National Cancer Institute to investigate novel strategies to improve the rates of cervical cancer screening on the island.
Cervical cancer screenings are on the decline in Puerto Rico, while cancer incidence is increasing rapidly – especially for advanced stage cancer. This has led to an increase in deaths; cervical cancer deaths in Puerto Rico are rising at the rate of 2.4% per year while they're decreasing by 1% per year in the rest of the U.S.
Ashish Deshmukh, Ph.D., co-leader of the Cancer Control Research Program at Hollings, studies the epidemiology of and prevention pathways for cancers caused by the human papillomavirus, or HPV. Almost all cervical cancers can be traced back to HPV infection.
He's working with Ana Patricia Ortiz, Ph.D., an investigator in the Division of Cancer Control and Population Sciences and director of the Office of Cancer Research Training and Education Coordination at UPRCCC.
They'll be testing four possible strategies to improve screening rates and developing a mathematical model to estimate how each method could affect lifetime outcomes, which will identify a cost-effective and sustainable strategy that could be potentially implemented in Puerto Rico.
"We'll be looking at the health services aspect and budget impact analysis and working with the Puerto Rican government to identify which strategy would provide us a maximum yield at the budget that we have so we develop an approach that's implementable, scalable and sustainable," Deshmukh said.
Ortiz said she's proud of the work that the research team has done to get to this point.
"This grant results from multiple previous research efforts that have been critical to justify the need and relevance of the proposed work," she said. "Being funded with a National Cancer Institute research project grant is a scientific recognition of the potential impact that our study will have on our population and public policy."
Deshmukh has documented how regions of persistent poverty can develop into cancer pockets because of barriers to prevention, screening and treatment services. He recently published a paper showing that counties in Appalachian Kentucky are experiencing an increase in cervical cancer diagnoses even though rates of this cancer are declining in the rest of the U.S. – including non-Appalachian Kentucky.
Like the people of Appalachian Kentucky, people in Puerto Rico may have difficulty getting transportation to screening and treatment services. But Deshmukh and Ortiz, who have been working together for about five years, identified two unique factors in Puerto Rico.
First, they've found that barriers to screening and follow-up care are more acute among women who live in poverty or who are overweight and obese.
Secondly, with each natural disaster that Puerto Rico has experienced, screening rates have dropped and have not recovered fully, particularly among the low-income population.
Hurricane Maria in 2017 caused almost 3,000 deaths, destroyed the island's power grid and disrupted daily life for months. Since then, lesser hurricanes and tropical storms have affected the island.
"We published a study a few years ago where we showed that every time a disaster event struck, screening uptake dropped. It dropped substantially, and we were not able to recover it for at least a few months," Deshmukh said.
Puerto Rico doesn't have a patient navigation system in place. Patient navigators are trained individuals, often with a social work background, who connect people with screening and treatment and help them to find resources to overcome barriers to care, such as a lack of transportation, child care or financial resources to cover co-pays.
Under the new grant, the UPRCCC/Hollings team will test four approaches:
- Patient reminder alone: This is the existing method, in which patients receive a reminder through a telephone call that they're due for cervical cancer screening.
- Patient reminder plus patient navigation: Patients will receive the reminder and patient navigation services.
- Patient reminder plus self-screening: Patients will receive the reminder as well as a kit in the mail that will enable them to collect a sample themselves and return it by postage prepaid mail.
- All of the above: A multicomponent intervention of patient reminder plus self-screening plus patient navigation.
Each of those four groups will then be measured on the percentage of patients who received the appropriate screening and the percentage who then received treatment if there was an abnormal result.
Ortiz has developed a network of partnerships with local clinics in San Juan that primarily serve low-income women, and the research team will partner with these clinics on this study.
They'll also evaluate the predicted effect on population-level outcomes, the cost-effectiveness and the budget impact of each of the three potential new methods compared to patient reminders alone.
As part of determining how sustainable each method is, they'll interview both patients and providers to assess their comfort level with each method and any barriers that may have come up.
Ortiz pointed out that this work can provide tangible benefits to individuals.
"We are honored to continue to work with Dr. Ashish Deshmukh and his research team on cancer prevention efforts to benefit the women living in Puerto Rico," she said.
