Center for Prevention of Cervical Cancer

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepherd, a medical oncologist here at Cleveland Clinic overseeing our Taussig phase one and sarcoma programs. Today I'm happy to be joined by Dr. Sharon Sutherland, Director of the Center for Prevention of Cervical Cancer. She's here today to talk to us about that program. So welcome, Sharon.

Sharon Sutherland, MD: Oh, thank you so much for having me.

Dale Shepard, MD, PhD: Absolutely. So maybe just give us a little bit of an idea of what your overall role is here. We'll talk about the center, but what's your role here at the Cleveland Clinic?

Sharon Sutherland, MD: So I've been on staff since 2003 and now I work at main campus. The bulk of my practice is focusing on management of abnormal Paps and also treatment of high grade pre-cancerous of the cervix.

Dale Shepard, MD, PhD: Okay, excellent. So we're going to be talking about preventing cervical cancer, and let's just start really, really basic. How common is cervical cancer?

Sharon Sutherland, MD: In the US, there are about 14,000 cases a year. In Ohio that translates to about 500 cases per year. Our case rate in Ohio is about 35th in the nation. So we definitely have opportunity for improvement.

Dale Shepard, MD, PhD: And as part of that opportunity for improvement, we have a center. And so let's just jump right in. What exactly is the center that we have set up?

Sharon Sutherland, MD: The center is really based on the global call that World Health Organization put out in 2018. Whoever would've known the changes in the world since, but in 2018, they recognized that across the world we had opportunities to lower cervical cancer rates. There are three major tenets. First is to focus on vaccination, especially in the pediatric population. Second is to properly screen with both cytology and HPV testing. And then finally to manage those patients who have abnormal screening tests. It sounds very basic, but we have gaps in each one of those areas.

Dale Shepard, MD, PhD: In what area do you think is the greatest need right now? The introduction of that vaccine, has that led to the reduction that you would've liked to have seen?

Sharon Sutherland, MD: There are some small studies that suggest major improvement. So if we can give it prior to sexual debut, it reduces the risk of high grade pre-cancers of the cervix by about 90 percent. So we definitely want to get that message out to parents who are making those decisions for their kids.

Dale Shepard, MD, PhD: And then from the center standpoint, what kind of resources, what does it look like?

Sharon Sutherland, MD: At this point, we're really focusing on the patients right in front of us. We know they have a pre-cancer of the cervix, but they have just not been connected to the proper care. So we're really focusing on the work within gynecology to provide access primarily for colposcopy or surgery on those high grade pre-cancers. Once we get a very good access in place, then we'll really be able to expand screening efforts because by nature more screening is going to be more referral for abnormal. So we just need to build it, we're almost building it from the back end and then finally to be able to focus on those vaccination efforts.

Dale Shepard, MD, PhD: Okay. So you mentioned the things you had mentioned were vaccines and screening and then sort of what to do if there's something that looks abnormal, you're focusing on that kind of what to do. What's the biggest barrier usually to someone, they're trying to do the right thing, they go in, they have an exam and there's an abnormality. Where's the drop off? What happens?

Sharon Sutherland, MD: I think fear is probably our biggest barrier. For our young women who are considering future childbearing, hearing that they may be at risk for cervical cancer can be very scary. If they go and read about it, they'll see that cervical cancer, usually the first line of treatment, especially for an early cervical cancer, is hysterectomy. So really what we need to do is a better job of communicating that "No, this doesn't mean you're going to need a hysterectomy." And that we're going to work closely with them to not only prevent cancer but preserve their uterus.

Dale Shepard, MD, PhD: Are there efforts to sort of help that education and what might be useful from that standpoint?

Sharon Sutherland, MD: We're really hoping to develop kind of a patient focus. I was able to go to a really great event recently hosted in Taussig where we had the voice of the patients who actually had cervical cancer talk about their experiences and really to think about how can we engage women who've been through this to really be coaches, to be advocates, to say, "You know what? This is something you can totally manage." This is a cancer we can truly prevent.

Dale Shepard, MD, PhD: And so it's an interesting approach going to patients who have experiences. And the thing comes to mind is the 4th Angel program, and we've had a previous podcast episode about the 4th Angel program, and I always think of that more as somebody who has an absolute diagnosis and they're kind of working through, but maybe pre-cancer in that setting might be useful.

Sharon Sutherland, MD: So I think it'll be interesting to see as this kind of builds out what our opportunities are. I think one of our other big opportunities is working with Taussig, the community outreach program. We had an opportunity to partner with them recently to expand screening. We know that we have patients who are really underserved, they're uninsured. They may not speak English as their primary language, and they may have immigration issues that make it harder for them to present for care. So as we can advance this to really expand to those unserved populations.

Dale Shepard, MD, PhD: Is there some sort of mechanism where you guys link into pathology reports to get people who might be good candidates to be seen in your program? Or how are you spreading the word about the program and getting people engaged?

Sharon Sutherland, MD: So where we first started is working with pathology and lab medicine. They have certain quality metrics that they must report nationally around what the rates of abnormal Paps are. So we found out, for example, we had about 9,000 abnormal Paps in '21 and what percentage of those had different abnormalities? And what we're doing is building a registry along with PLMI. They have requirements to report publicly, but then women's health is going to take that information and do active outreach to the patients. So really, we've been working together and it's really been a great collaboration so that we can close that gap. We found over 400 women who we knew had the highest risk Paps who did not get the proper care. So we need to close that gap.

Dale Shepard, MD, PhD: I guess just so people are thinking of sending a patient, referring a patient, what could they tell a patient say, "Well, if you go to the clinic and you get involved in this center, this is what happens." Give us a little bit of an idea from a patient view. What does it look like?

Sharon Sutherland, MD: So when we look at the patient view, part of it is we want to know where they are. Sometimes we may get a patient coming from an outside facility who's looking for a second opinion, who maybe already has a treatment plan, they're questioning whether or not this is in line with guidelines. So we're more than happy to facilitate conversations, give second opinions and so forth. And then we also have patients who are working already with a gynecologist but may have a more complicated case. So that gynecologist, for example, this patient may be pregnant and also has a high grade pre-cancer. So we can get involved to kind of support the patient through that more complicated intervention and then to be able to return them to their gynecologist. And then one thing that people don't think about is the majority of our Paps are done by our primary care caregivers.

So we're so grateful for our primary care doctors and nurse practitioners who are getting that screening done. And a lot of times they don't really have the capacity to follow up on the abnormal care. So we are there to pick up the ball and then make sure the patient gets all the necessary care.

Dale Shepard, MD, PhD: And then as part of the center, you have gynecologists involved. Are there other specialties that are engaged as well, social work or anything like that?

Sharon Sutherland, MD: At this point, we're engaging with primary care women's health because they are doing a lot of that work around the screening. We've had conversations with pediatrics and we're really hoping to have a vaccine group that evolves. That vaccination, as you well know, is marketed as a childhood vaccine, but now is approved up to age 45. In our GYN population, we're seeing big opportunities and we're really encouraging patients to get it. The other opportunities that we're hoping to work on in the future are improvements around anal cancer screening and to also collaborate with head and neck on some of the oral cancer screening work. So when we think about HPV, we have some common things that we can work on across these different disciplines to support improvements in vaccination and screening.

Dale Shepard, MD, PhD: Are there any research projects that are currently ongoing with this effort or things that you're sort of having expectations you might want to look at?

Sharon Sutherland, MD: I think in the short term, we're really looking at how much of our health system is a barrier. So when we talk about those barriers, if we put some of these measures in place to try to improve outreach the patient, how much will that in itself improve compliance? So that's really our first focus. With the GYN oncology group, we meet with them every week to review complicated cases, and so we really see that there'll be future opportunities. For example, there's been discussion with one of our Taussig oncologists, in fact around doing anal HPV and Pap on women who already have high grade pre-cancer lesions over age 50, for example. So we've been talking about some different opportunities and it'll just be a matter of finding the funding and the support to make those happen.

Dale Shepard, MD, PhD: What are the biggest barriers that, as you've tried to set this up, I mean certainly letting people know that you exist and how you can help and what are the biggest things you've had to overcome?

Sharon Sutherland, MD: I think really the biggest barrier in this day and age is communication. Especially in our own clinical group, we are now so diffuse and we've tried to overcome that by putting together a weekly meetings. So for example, there are 14 of us in our center who are meeting every single week and building those relationships and trying to support each other in developing this practice. So we are hoping that each one of them will become an ambassador of spreading that word locally and become an expert in this area as well. So I think time is always a big barrier, but I think as we advance, we're hoping we'll have more conversations with our payers. I have heard, for example, that 4C is going to partner with one of our Medicaid payers to have focus outreach to some of those patients in their program to do a screening event. So things like that as we get rolling, I think we'll have more and more partnerships evolve.

Dale Shepard, MD, PhD: And as you mentioned things about coverages and things. Are there barriers to patients in terms of coverage for the services you provide and what are those barriers?

Sharon Sutherland, MD: So I had not fully aware of Taussig's structure, but I so appreciate the work that the community outreach team is doing. However, once we get an abnormal screening result, sometimes when we think about that charity program that was a screening program, sometimes then we come into question about what about the further management of the patient? So we do have our charity programs in place, and then trying to think about what are different ways that we can overcome that and support the patient and make sure that she doesn't walk away for lack of coverage. To figure out how we can make it happen.

Dale Shepard, MD, PhD: And so I guess when we think about lack of coverage, are these primarily women who don't have health insurance coverage or even those who are insured, are these services that would typically be covered under their insurance?

Sharon Sutherland, MD: Sometimes it may be that patient who is covered but has a high deductible plan. And so we'll have these conversations with patients and they're deciding about what type of treatment they're going to have and they have to consider that if they choose to go to the operating room, that is going to be a bigger expense potentially. And many times we can do this treatment in the office, so of course that's the right thing to do if it's the right thing for the patient. But I think coming forth in thinking about the advances we had with screening, we had Accountable Care Act. It said, "Yes, we're going to cover cervical cancer screening", but then after that is where some women get into a bit of a bind.

Dale Shepard, MD, PhD: And I guess from that same sort of prevention standpoint, are there current barriers to coverage for the vaccines?

Sharon Sutherland, MD: At this point, we think that all major payers are covering the pediatric vaccine. And it took a while after that approval of expanded age, but it now seems like that is happening. If we could partner with our pharmacies throughout the communities, many of them are offering HPV vaccine, it's so easy to get, just like it was easy to get the COVID vaccine. If a patient's coverage permits them to do that, that may be a way for it to unleash access without them having to come to the health facility for example.

Dale Shepard, MD, PhD: And you've already mentioned the fact, and not only cervical but anal cancers and head and neck cancers and the importance of that HPV. And I think it does seem like there's still a tremendous misconception that it's really only for children. And so it seems like a really, really important message to get out there.

Sharon Sutherland, MD: Yeah, absolutely.

Dale Shepard, MD, PhD: When we think about what we do here at the clinic, we always think about things start out on main campus and then they sort of go out into the community and our regional sites. Is this something that this particular center, is it covering patients in the region as well?

Sharon Sutherland, MD: Yeah, so in fact, I spent the first 10 years of my career here in the region. So I have a very good sense of the different challenges and the different areas. Our GYN oncology team is based primarily here at main campus and a couple of our regional hospitals, but this program is exactly the opposite. It's very regionalized. And so we have over 30 GYN offices across several counties here in northeast Ohio. And so what we're doing is that outreach to connect the patient to wherever they are. So if it's better for them to be seen in Lorraine or in Medina or Lake County, we can connect them.

Dale Shepard, MD, PhD: That's fantastic. This is a really important kind of service to provide. So if anyone's sort of listening and go, "Why don't I have one of those? Why am I not doing that?" What kind of advice would you give?

Sharon Sutherland, MD: Start the conversation, ask a lot of questions, and I think data drives action. And so for us, when we started to look at these gaps, and a lot of us felt we had opportunity when we looked at individual cases, but when you can see the amount of impact that's possible, I think that engages people to think differently about how we do our work.

Dale Shepard, MD, PhD: Yeah, that's great. Talk about gaps. I guess the question you had mentioned specifically with screening about cytology and HPV, is there anything that's sort of coming around in terms of other ways to screen other tests, to do other ways to assess risk? Tell us a little bit about anything that might be going on in that area.

Sharon Sutherland, MD: So there has been movement on different parts of the world for HPV only screening, it usually results in a positive HPV test and then reflexes to cytology. So that would be a big change in workflow for us. And when you look at the opportunity, 95 percent of cervical cancers are going to be positive for HPV. So there's definitely potential there. We did explore this in women's health along with PLMI and did a very small study where we were actually collecting a vaginal swab to simulate a home HPV test at the same time we were sending one to the lab. What we found though is that that test wasn't really giving us reliable results. So it's the type of thing that before we would scale anything like that, we have to make sure that that test is going to give the patient just as reliable of results, but we think that that's a great potential, if we could have home HPV tests.

Dale Shepard, MD, PhD: That'd be fantastic.

Sharon Sutherland, MD: That would be amazing.

Dale Shepard, MD, PhD: Because they certainly, one of the barriers is getting people into the office and there are populations that may not want to come in and again, because of fear and things. So doing a home test would be fantastic.

Sharon Sutherland, MD: So hopefully we'll have another go with that and see what others are doing. Maybe somebody has a better assay or collection method.

Dale Shepard, MD, PhD: Is there anything else, though? Certainly the thinking about genotypes and things of HPV, but is there anything else on a more of a genomics standpoint that's coming around that's interesting?

Sharon Sutherland, MD: Well, I think it's difficult because we know that this is always evolving. A lot of our focus is really on the types of 16 and 18. I haven't gotten enough information on the data of our own population. Fortunately, we were able to pull data from all of our cervical cancer patients here at the clinic. It's very interesting to think about what percentage of our patients in current day with vaccine availability are going to be HPV 16 or 18 positive. Don't know the answer to that yet, but whether that will change how we're monitoring.

Dale Shepard, MD, PhD: I mean, I'm going to throw out here as from a screening standpoint, I think one thing that anybody studying for boards would love is something just really straightforward and not remembering like what to do and when.

Sharon Sutherland, MD: Well, I think that's the thing about ASCCP. For those who are familiar, this is an international organization really to drive standardization, and I think it's really brought us a long way. This last iteration in 2019 is over 30 pages long. Even for those who do it every day, it's very, very difficult to get it right. So that's why we're forming this consult order. Just hand it off to us, we can take these more complicated cases, kind of sort through. It kind of come up with a good management plan because it has been difficult and we don't want people just to stop screening 'cause they don't want to deal with that.

Dale Shepard, MD, PhD: Yeah. Well, it sounds like you're doing some incredible things. If you look forward, what's on the wish list? Where would you like to be as you move forward?

Sharon Sutherland, MD: Once we can get a very strong referral workflow internally, we want to work with our local clinics and we know that Taussig has standing meetings with them in our community clinics so that as they're finding abnormal Paps that we can expedite referral and get them in for management.

Dale Shepard, MD, PhD: That's great. Well, you doing great work and you've revised some great insights, so thanks for being with us.

Sharon Sutherland, MD: Thank you so much. We appreciate the opportunity.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You'll find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real time updates from Cleveland Clinic's Cancer Center experts on our consult QD website, at consultqd.clevelandclinic.org/cancer.

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