Cervical Cancer Control in Minority Women-More ... - Europe PMC

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important public health challenge. MARTIN C. MAHONEY, PhD. State University ofNew York at. Albany, School of. Public Health. State University ofNew York at.
EDITORIALS

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Cervical Cancer Control in Minority Women-More Needs to Be Done THE ARTICLE by Becker and co-workers appearing elsewhere in this issue of THE WESTERN JOURNAL OF MEDICINE presents trends in cervical cancer incidence and mortality among Hispanics, Native Americans, and non-Hispanic whites in the state of New Mexico.1 The availability of data for a long period of time and the high-quality surveillance systems in this state make the information provided in this report unique. While the article documents notable achievements in decreasing the incidence and mortality of cervical cancer among specific population groups, it also indicates the need for further cancer control activities. When cervical cancer incidence patterns in New Mexico were compared for two periods (1970 to 1978 and 1980 to 1987), substantial declines (approximately a fourth to a third) were noted among all three population groups.' The incidence of invasive cervical cancer among both Hispanics and Native Americans continued to be high in comparison with non-Hispanic whites, however. Among the ethnic-racial groups in the United States, Native Americans in New Mexico had one ofthe highest incidence rates for invasive cervical cancer during the period 1977 through 1983 (J. Horm, MS, National Cancer Institute, written communication, May 1991). The incidence of in situ cervical cancer also decreased and became comparable among these three groups during the period of observation. Among Hispanics and Native Americans, age-specific incidence rates for both invasive and in situ cervical cancer were found to diverge considerably from age-specific rates among non-Hispanic whites in the later age groups. Despite these documented decreases in cervical cancer incidence and mortality, disease patterns for cervical cancer during recent time periods indicate the need for continued efforts directed toward eliminating the disparities that continue to exist. In the publication Healthy People 2000,2 the Public Health Service has developed objectives for a national initiative aimed at preventing deaths and reducing disease and disability during the coming decade. Healthy People 2000 proposes the goal of a reduction in cervical cancer mortality from a national rate of 2.8 per 100,000 in 1987 to not more than 1.3 per 100,000 by the year 2000. In the context of this objective, continued public health intervention is necessary because cervical cancer mortality rates in New Mexico during 1983 through 1987 among non-Hispanic whites (1.8/100,000), Hispanics (3.9/100,000), and Native Americans (4.8/100,000) exceeded this goal. Data from this report are specific to the state of New Mexico, but the general patterns of disease are consistent with previous reports noting an increased incidence and mortality of cervical cancer among both Hispanic and Native American women. Although Hispanics and Native Americans both include heterogeneous groups, consistency in cervical cancer patterns has been observed within these groups. Excess cervical cancer rates have been described among Hispanic populations residing in different geographic areas." 3 In addition, in a meta-analysis of cancer incidence patterns among Native Americans, we noted a generalized elevation in cervical cancer incidence.4 A constellation of risk factors for cervical cancer has been identified, including age at first coitus, number of sexual partners, non-white race, lower socioeconomic status,

sexu-

ally transmitted viruses, cigarette smoking, oral contraceptive use, and selected dietary components. Several analytic studies have explored cervical cancer risk factors among Hispanics in various geographic areas, but the cause of their excessive susceptibility remains undetermined. Analytic studies of cervical cancer among Native Americans have not been completed. Widespread cervical screening results in an earlier stage at diagnosis with reduced mortality.5'6 A Papanicolaou screening test should be completed for all sexually active women at an interval of one to three years, or more frequently if recommended by a physician. Unfortunately, a sizable proportion of women do not receive a Papanicolaou screening test on a regular basis. At present, 75% of women in the general population report obtaining a Papanicolaou smear every one to three years.2 Among Hispanic women, 66% report obtaining a Papanicolaou smear within this interval.2 Papanicolaou screening practices among Native Americans are unknown. It is important to expand our understanding of preventive health practices among Hispanics, Native Americans, and other special populations in an effort to identify potential intervention strategies. The limited data currently available indicate that more comprehensive information on cancer screening practices among special population groups needs to be collected, analyzed, and applied in future interventions. Given the unique cultural milieu of special populations, these groups are unlikely to be responsive to a cancer education campaign of health promotion messages targeted to the general population. Barriers to the use of cervical cancer screening services, whether they relate to cultural or health system obstacles, need to be overcome. Community representatives and health professionals need to work cooperatively to develop culturally relevant and sensitive cancer control messages. Cancer education materials should communicate an understandable message and promote the adoption of personal preventive health practices. Efforts to develop culturally appropriate cancer education materials for special populations are components of community-based research studies currently under way in several communities across the United States. Health care professionals in the primary care setting should recognize the special responsibility to promote and to provide cancer screening services, including for cervical cancer. It is also necessary to ensure the prompt follow-up of women with unusual cytologic results. Cytologic screening and providing risk reduction materials represent cost-effective means of reducing both the economic and the social effects of cervical cancer in special population groups. It is hoped that primary care providers and public health professionals can assist in promoting the use of cervical cancer screening services. Further reductions in cervical cancer incidence and mortality, particularly among women of special population groups, remain as an important public health challenge. MARTIN C. MAHONEY, PhD State University of New York at Albany, School of Public Health State University of New York at Buffalo, School of Medicine and Biomedical Sciences

REFERENCES 1. Becker TM, Wheeler CM, Key CR, Samet JR: Cervical cancer incidence and

THE WESTERN JOURNAL OF MEDICINE * APRIL 1992 * 156 * 4 mortality in New Mexico's Hispanics, American Indians, and non-Hispanic whites. West J Med 1992 Apr; 156:376-379 2. Healthy People 2000-National Health Promotion and Disease Prevention Objectives. US Dept of Health and Human Services publication No. (PHS) 91-50212. Washington, DC, Public Health Service, 1991 3. Polednak AP: Racial and Ethnic Differences in Disease. New York, NY, Oxford University Press, 1989 4. Mahoney MC, Michalek AM: A meta-analysis of cancer incidence in United States and Canadian native populations. Int J Epidemiol 1991; 20:323-327 5. International Agency for Research on Cancer, Working Group on Evaluation of Cervical Cancer Screening Programs: Screening for cervical cancer: Duration of low risk after negative results of cervical cytology and its implications for screening policies. Br Med J 1986; 293:659-664 6. Guzick DS: Efficacy of screening for cervical cancer: A review. Am J Public Health 1978; 68:125-134

Pheo

or

Not a Pheo, That Is the Question

THE ADRENAL GLANDS have fascinated physicians over the centuries. The first anatomist to give a detailed description of the human adrenal glands was Eustachius in the 16th century, but his observations were unpublished for some time. Surprisingly, the adrenal glands were described as hollow by Bartholin in the 17th century. This concept was corrected in the 19th century when it was clearly recognized that the adrenal glands were solid structures and that there were two portions of the adrenal gland, the cortex and the medulla. The advent of microscopy and histochemistry provided definitive proof that the medulla was a distinct part of the adrenal gland. The chromaffin reaction, a brownish deposit in the adrenal medulla after the fixation of catecholamines in chromic acid, or dichromate salts, was described in the middle of the 19th century. Epinephrine was among the earliest hormones discovered and was isolated in crystalline form and the chemical structure elucidated in 1897. It was synthesized in 1904 and later was shown to be present in increased amounts in patients with pheochromocytoma. In 1886 Frankel described the case of a young woman with the symptoms of a pheochromocytoma in whom, at autopsy, bilateral adrenal tumors were found. In 1922 Labbe reported a case and was the first to attribute the symptoms to the adrenal tumors. The next year, Professor Villard of Lyon operated on a patient who died in shock. In 1926 C. H. Mayo at the Mayo Clinic and G. Roux in Switzerland successfully removed adrenal tumors and dramatically reversed hypertensive

episodes.

Over the midportion of the 20th century, the identification of norepinephrine, dopamine, other precursors, and metabolites led to rapid advances in the biochemical diagnosis of pheochromocytoma. Precision in the measurement of these compounds was further refined by high-pressure liquid chromatography and radioisotopic labeling techniques, which have substantially contributed to the preoperative diagnosis and follow-up in patients with catecholamineproducing tumors. The development of scanning techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), as well as radioisotopic (iodine 131) labeling of m-iodobenzylguanidine (MIBG), has greatly contributed to the preoperative localization of tumors. The recognition of the significance of abnormal DNA ploidy, that is, that this is associated with the potential for malignancy, has considerably improved patient care and follow-up. Pheochromocytoma is a rare tumor that can occur at any age, but the peak incidence is in the fourth through the sixth decades. Among the general population of Olmsted County,

Minnesota, the incidence of pheochromocytoma is 9.5 per year, in the Netherlands 0.4, Den-

million population per

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mark 1.9, and Sweden 2. 1. These rates vary, largely related acquisition of the material, both clinically and at autopsy. The incidence of pheochromocytoma among hypertensive persons has decreased greatly, largely because essential hypertension has been diagnosed in more people in recent years as the blood pressure limit for normal has been lowered. For example, from 1973 to 1975, the annual incidence of pheochromocytoma at the Mayo Clinic was estimated to be 0.4 per 1,000 hypertensive persons with diastolic pressures of 95 mm of mercury or more. Pheochromocytoma continues to be a diagnostic challenge as a substantial proportion of cases of pheochromocytoma found at autopsy are still undiagnosed clinically. Pheochromocytoma may be part of a polyglandular endocrine derangement or may be associated with other neuroectodermal disorders. There is an increased incidence in families, particularly when the index case is a child with pheochromocytoma and also when pheochromocytoma is present in both adrenal glands. Autosomal dominant inheritance is seen in persons with multiple endocrine neoplasia (MEN) type II, in association with pancreatic islet cell tumors, and in neuroectodermal disorders (such as neurofibromatosis and von Hippel-Lindau disease). Families with multiple adrenal and extra-adrenal pheochromocytomas unassociated with other tumors or syndromes also have been reported. The Carney multiple neoplasia triad of extra-adrenal paragangliomas, gastric leiomyosarcomas, and pulmonary chondromas is a rare but interesting triad of rare tumors that is not familial. Almost all of the reported Camey cases have been in young women, and the finding of any two components ofthis triad should raise serious consideration of this

to the

syndrome.2 Pheochromocytoma is not caused by a single genetic defect. The genetic locus for this tumor has been attributed to chromosome 10 for MEN II, chromosome 17q for neurofibromatosis type I, chromosome 22 for neurofibromatosis type II, and chromosome 3p for von Hippel-Lindau disease. In nonfamilial cases, several genetic locations have been attributed.

Pheochromocytoma arises from chromaffin cells that are located in the adrenal medulla, but also in paragangliomas, which may be located anywhere from the base of the brainsuch as the glomus jugulare-to the testicle, including the mediastinum and inside the heart arising from the interatrial cardiac septum and within the myocardium itself. Most (90%) pheochromocytomas arise in the adrenal medulla, and most of the extra-adrenal tumors also occur in the abdomen. This information is helpful when planning imaging studies. Malignancy is more frequent in extra-adrenal tumors and when tumors arise in young persons. The incidence ranges from 3% to 14%. Nuclear DNA-ploidy studies by flow cytometry have shown that patients with a normal DNA histogram follow a benign course, whereas 30% to 40% of the remainder have or develop evidence of malignant disease in follow-up studies.3 In the article on pheochromocytoma elsewhere in this issue of the journal,4 Philip Cryer, MD, describes the physiology of the sympathochromaffin system and notes the potential of the cells to produce a vast array of peptides and other compounds.2 The biologic action of these compounds in contributing to the symptoms of pheochromocytoma, in addition to the symptoms attributable to catecholamines, is unclear. While paroxysms of hypertension are by far the most com-