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WINTER 2009 NATIONAL BLACK NURSES ASSOCIATION CERVICAL CANCER PREVENTION AND CONTROL: CARIBBEAN INITIATIVE Sandra Millon Underwood, RN, PhD, FAAN Edith Ramsay-Johnson, RN, EdD CERVICAL CANCER: CAUSE OF CONCERN AMONG WOMEN IN THE CARIBBEAN Cervical cancer is one of the most common forms of cancer diagnosed and one of the most cormmon causes of cancer death among women worldwide (International Agency for Research on Cancer, 2008; American Cancer Society, 2007; American Cancer Society, 2008a), Once the most common cause of cancer among women of child-bearing age, cervical cancer ranks as the 2nd most commonly diagnosed cancer and the 3rd leading cause of cancer death in women. There are significant global disparities in cervical cancer incidence and mortality. The most significant disparities appear to occur in low resource and middle-resource countries, regions and territories (Sloan & Gelband, 2007). Women in the Caribbean suffer one of the world’s highest rates of cervical cancer. According to reports published by the World Health Organization, the Pan American Health Organization and the American Cancer Society, women in Dutch-speaking and English-speaking Caribbean countries have cervical cancer incidence rates that are three times higher than women in North America (Caribbean Cervical Cancer Prevention and Control Project, 2003). Throughout the Caribbean, it is estimated that 1,260 women are diagnosed with cervical cancer and approxi- mately 530 women die from cervical cancer each year. Cervical cancer has been shown to affect women of all backgrounds. However, in the Caribbean the greater majority of women diag- nosed with invasive cervical cancer are young or middle-aged, impoverished, and among those who do not obtain regular cervical cancer screening. CERVICAL CANCER: CAUSE, TRANSMISSION, RISK AND PREVENTION Cervical cancer is an infection-related cancer (NCCN, 2008; NCI, 2004; ACS, 2008b). The main cause of cervical cancer is the human papilloma virus (HPV). There are more than 100 different types of HPV. HPV types differ in terms of the cutaneous or mucosal surfaces they infect. Over 40 HPV types infect mucosal surfaces, including the cervix, vagina, vulva, rectum, urethra, penis and anus. Fifteen HPV types have been associated with cervical cancer. Among the most common HPV types associated with cervical cancer are HPV 16 and HPV 18. HPV is usually transmitted skin-to-skin during penetrative vaginal or anal genital contact. Other types of genital contact can also lead to HPV infection. Sexual behavior is a primary risk factor for acquiring the HPV infection. Women with multiple sex partners have a higher risk of contracting HPV than monoga- mous wornen. Young women, between the ages of 15 and 25 have a two fold higher risk of developing an HPV infection compared to women over 35 years of age. Other factors that increase a woman's risk of acquiring the HPV infection are early age at first intercourse, having a sexual partner who has had many sex partners, and having sex with an uncircumcised male. Abstaining from all sexual contact is the only absolute way to prevent HPV infection. For most adults, complete abstinence is unrealistic, so other means of HPV risk reduction, early detection, and treatment are recommended. Being in a monogamous long-term relationship with an uninfected partner will greatly reduce a person’s risk of contracting the HPV virus. Limiting the number of sexual partners decreases a person's risk of contract- ing different strains of the HPV virus. Consistent and correct condom use provides some protection, but cannot completely protect against HPV infection. Likewise, the HPV vaccine has been shown to provide an excellent means of protection against HPV types that cause most cervical cancers. While the HPV vaccine does not protect against all strains of HPY, it does provide protection against HPV 16 and HPV 18. CARIBBEAN NURSES EFFECTING CHANGE IN CERVICAL CANCER PREVENTION AND CONTROL Reducing suffering, deaths and costs resulting from cervical cancer is a key objective of the World Health Organization, the Pan American Health Organization and the American Cancer Society. The need to address the prevalence of cervical cancer throughout the Caribbean has been well articulated by leaders within the international community. Yet, reports disseminated by the World Health Organization, the Pan American Health Organization and the United States Virgin Islands Department of Health suggest that efforts to prevent the transmission of HPV infection, to prevent cervical cancer, to screen women for cervical cancer, and to manage women with early and advanced disease in the Caribbean, more often than not, are isolated CONTINUED > and uncoordinated (Caribbean Cervical Cancer Prevention and Control Project, 2003; USVIDOH, 2000). Concern for the well-being of women across the Caribbean is prompting faculty, staff and students from the Division of Nursing at the University of the Virgin Islands to undertake ef- forts to change this trend. Working in concert with the Directors of the Caribbean Exploratory National Center on Minority Health and Health Disparities Research Center for Excellence, faculty, staff, clinicians and students from the University of the Virgin Islands are designing programs within the academic arena and local community focused on reducing HPV transmission and enhancing cervical cancer control. Survey data are being collected to identify behaviors associated with the transmission of HPV and other sexually-transmitted diseases. The psycho- metric properties of instruments, data specific to HPV and cervical cancer, attitudes and beliefs, risk factors, and screening practices are being evaluated. Community education materials and theory-based interventions to reduce HPV transmission and improve cervical cancer screening, early detection, and control in the territory are also being designed. Each of these efforts will provide nurses within the Caribbean an opportunity to advance nursing science, to improve cervical cancer prevention and cervical cancer care within the territory, and to contribute to the management of a health concern of local and global significance. REFERENCES American Cancer Society. (2007). Global cancer facts and figures, 2007-2008. Atlanta, GA: American Cancer Society. Available online at: http://www.cancer.org/docroot/ST T/stt_O.asp. American Cancer Society. (2008). Cancer facts and figures, 2008. Atlanta, GA: American Cancer Society. Available online at: http:// www.cancer.org. American Cancer Society. (2008). Cervical cancer: Detailed guide. Atlanta, GA: American Cancer. Available online at: http://docu- ments.cancer.org/115.00/115.00.pdf. Caribbean Cervical Cancer Prevention and Control Project. (2003). Caribbean frarnework for developing national screen- ing and clinical guidelines for cervical cancer prevention and control. Trinidad and Tobago: Pan American Health Organization, World Health Organization, Caribbean Epidemiology Centre. Available online at: http://www.carec.org/docurnents/cccpcp/ CC Guidelines.pdf. International Agency for Research on Cancer. (2008). World cancer report 2008. Geneva, Switzerland: World Health Organization. Available online at: http://www.iarc.fr/en/ Publications/PDFs-online/World-Cancer-Report. National Cancer Institute. (2004). Understanding cervical cancer: A health guide for women. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Available online at: http://www.cancer. gov/cancertopics/understandingcervicalchanges. National Comprehensive Cancer Network (2008). NCCN Clinical practice guidelines: Cervical cancer. Available online at: www. nccn.org/professionals/physicians_gls?PDF/cervical.pdf. Sloan, F.A., Gelband, H., eds. (2007). Cancer contro! opportunities in low and middle income countries. Washington, D.C.: Institute of Medicine. United States Virgin Islands Department of Health. (2000). Healthy Virgin Islands 2010: Improving health for all. St. Thomas, Virgin Islands: USVI Department of Health, office of Minority Health. Sandra Millon Underwood, RN, PhD, FAAN, is a Professor in the College of Nursing at the University of Wisconsin Milwaukee, Consultant and Advisory Member of the Caribbean Exploratory National Center on Minority Health and Health Disparities (NCMHD) Research Center for Excellence, and rember of the Milwaukee Chapter of the National Black Nurses Association and can be reached at underwoo@uwm.edu or 414-229-6076, UWM College of Nursing, 1921 East Hartford, Milwaukee, WI 53211. Edith Ramsay-Johnson, RN, EdD, is a Professor Emerita of Nursing at the University of the Virgin Islands and Director of the Research Education/Training Core of the Caribbean Exploratory National Center on Minority Health and Health Disparities (NCMHD) Research Center for Excellence at the University of the Virgin Islands, and can be reached at eramsay@uvi.edu or 340-693-1178, University of the Virgin Islands #2 John Brewer's Bay, St. Thomas, VI 00802. WINTER 2009 NATIONAL BLACK NURSES ASSOCIATION