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Association of Alcohol Consumption and Cervical Cancer among Women

Association of Alcohol Consumption and Cervical Cancer among Women in Los Angeles, California.

Chapter 1: Introduction

Background

Alcohol consumption and cervical Cancer are overlapping epidemics that contribute significantly to the burden of disease affecting women in Los Angeles, California.  Alcohol is a psychoactive ingredient with dependence-producing properties that has been commonly used for centuries in diverse cultures (World Health Organization [WHO], 2015).  Alcohol consumption carries a risk of adverse health effect such as cancer and social consequences that are connected to its toxic, intoxicating, and dependence-producing properties (WHO, 2015).  Alcohol consumption is a serious health epidemic that has been attributable to over 3million deaths around world in 2012 (WHO, 2015). According, to American Cancer Society (ACS) who reported that most people have the knowledge that consuming more than one alcoholic drink per day could cause a serious health problem. However, only few people might not know that drinking alcohol could raise their risk of cancer (ACS, 2014a; Centers for Disease Control and Prevention [CDC], 2014a). In California, alcohol consumption resulted in 10,572 deaths and 304,472 years of potential life lost between 2006 and 2010. In 2010, excessive alcohol intake cost $35 billion, (approximately $2.05 per drink) as a result of healthcare expenses, and lost workplace productivity (CDC, 2016a; CDC, 2015). In 2001, approximately 3,596 deaths occurred from alcohol related in California (Lund, 2004). Over 54 percent of Los Angeles men and women reported alcohol consumption during the past month in 1999 as compared to 60 percent for California as a whole.   Almost 950 (40%) death attributed to alcohol consumption was due to chronic causes (such as, cancer), 440(18%) death to other acute causes (CDC, 2014b).  In 2005, report revealed that in the last 30 days n = 1,974 women (47.5) and n =1,641 men (65.2) among California residents who claimed to have used alcohol.  Among these numbers 55% males and 40% females consumed alcohol (CDC, 2015). However, the association of alcohol consumption and cervical cancer is still uncertain.  Olesen et al., 2012, suggested that alcohol consumption were contributive factors to several types of cancer, including cervical cancer.

Cancer is a major health problem in California. It is the second leading cause of death.  In 2013, about 6,703 new cases of cervical and 1,484 deaths, including 105,500 (13%) existing cases of cervical of cancer was reported (CDPH, 2016). In 2008, about n = 1,400 women were diagnosed and 400 cervical cancers death-related was projected to occur yearly (Brenda et al., 2008). California cancer registry (CCR), estimated in 2009, that over 140, 000 were diagnosed with some form of cancer that year, skin cancer not included. Same year about 24% death was attributed to cancer compared to heart disease (25%), which was the leading cause of death among Californians (CCR, 2009), Hispanics have the highest death of 14.4%, followed by non-Hispanic black (8.7%), and Asian pacific islander (8.3%), and on-Hispanic white (7%), (Brenda et al., 2008; CCR, 2009).  Even though in California a declined in cervical cancer was shown in the overall incidence and death among women, though this decline has not been equally shared among women. Between 2000 and 2004. incidence rates of cervical cancer among Hispanic (14.4%) women were twice higher than non-Hispanic white women (7%), while death rate was higher among non-Hispanic black women compared among women of other races and ethnicities (Brenda et al., 2008).

Alcohol consumption is increasing in several countries, including the US and is a compelling cause of cancer worldwide (Boffetta and Hashibe, 2006). Approximately, 88, 000 alcohol related-deaths and 2.5 million years of potential life lost were attributed to excessive alcohol consumption each year in the US.  In 2006, the economic cost of alcohol consumption was estimated at $223.5 billion (CDC, 2014a). Epidemiological data on alcohol consumption and its contribution to the development of cervical cancer are still limited.  Not much is known about the safety and efficiency of quitting drinking alcoholic beverages, especially for people diagnosed with cervical cancer. Thus, there continues to be a gap in the literature about creating the awareness on the danger of consuming   alcohol while diagnosed with cervical cancer. To date, no studies have explicitly analyzed alcohol consumption as a potential cause for cervical cancer. This gap in related literature could be due to HPV-associated to cervical cancer.

The main interest of this research is in alcohol consumption as a potential risk factor for developing cervical cancer. In the United States, cervical cancer is rated as the third common cause of cancer among women, this is preceded by the breast cancer as the second common cause of cancer among women.  Even though, cervical cancer can be caused by other risk factors such as alcohol consumption, however, most efforts to prevent cervical cancer have emphasized on HPV screening program (ASC, 2016c).  In California, the economic burden of cervical cancer was estimated at $1.3 billion per year, of which $10,436 per person was attributed to direct cost of care (County of San Diego, 2010).  Chapter 2 contains an in-depth literature review regarding hypothesized risk factor for cervical cancer.

Problem Statement

Gap exists in knowledge related to alcohol consumption and cervical cancer incidence among women in Los Angeles, California (Burd, 2003; CDC, 2014a). In 2016, 173,200 new cases of cancer and 59,060 death cancer related were estimated to occur this year (California Department of Public Health (CDPH), 2016).   In 2013, about 6,703 new cases of cervical and n=1,484 deaths, including 105,500 (13%) existing cases of cervical of cancer (CDPH, 2016). About n=1,400 women were diagnosed and 400 cervical cancers death-related was projected to occur yearly (Brenda et al., 2008). In California, alcohol consumption resulted in 10,572 deaths and 304,472 years of potential life lost between 2006 and 2010. In 2010, excessive alcohol intake cost $35 billion, (approximately $2.05 per drink) as a result of healthcare expenses, and lost workplace productivity (CDC, 2016a; CDC, 2015). In 2001, approximately 3,596 deaths occurred from alcohol related in California (Lund, 2004).  Burd (2003), argued that the degree of the association between HPV and cervical cancer was higher compared to the association between smoking and lung cancer. Yearly, in the US, an estimated 11,771 HPV-associated cervical cancer new cases were diagnosed (CDC, 2016b). HPV alone does not explain the cause of cervical cancer. Most female diagnosed with HPV are not diagnosed with cervical cancer, other risk factors such as alcohol consumption, smoking, HIV infection, age and sexual activity, abnormal pap smears determine which women get exposed to HPV and more likely to be diagnosed with cervical cancer (ASC, 2016c). However, several studies have shown the association of human papillomavirus infection (HPV) and cervical cancer. Women who consumed alcohol were more likely to have multiple sex partners and practice unprotected sex. These activities increased the risks of unintended pregnancy and sexually transmitted diseases such as HPV leading to cervical cancer (CDC, 2016b). The research problem in this study is that the role in which alcohol consumption is associated with cervical cancer is unknown, although in recent years, few studies have created an awareness program that showed the effect of alcohol consumption among women with cervical cancer.

Purpose of the Study and Nature of Study

This cross-sectional study utilized secondary data to investigate the association of alcohol consumption as a potential risk factor for developing cervical cancer among women in Los Angeles California.  Pre-existing data was used to investigate the association.  No empirical evidence has been found to support the consumption of alcohol as a potential risk factor for developing cervical cancer; however, researchers have identified several other potential risk factors as associates as, such as human papilloma virus (HPV), smoking, Chlamydia infection, Being overweight, and Human immunodeficiency virus (HIV) etc. (ACS, 2016). The Independent variable is alcohol consumption, and the dependent variable is cervical cancer. This study has two hypotheses put forth to answer the research questions below.

Research Questions

This study was a retrospective cross-sectional study that is observational in nature and posed two main research questions with its associated hypotheses:

Research Question 1:  Did you consume alcoholic drink 30 days prior to ever told you had cervical cancer?

Research Question 2: Prior to ever told you had cervical cancer how many alcoholic drinks did you consume per day?

 

 

Hypotheses

The null hypothesis and alternative hypothesis associated with research question one and two are:

Null Hypothesis1: There is no association between consuming alcoholic drink 30 days prior and cervical cancer incidence among women in Los Angeles, California.

Alternate Hypothesis1: There is an association between consuming alcoholic drink 30 days prior and cervical cancer incidence among women in Los Angeles, California.

Null Hypothesis 2: There is no significant association between the number of alcoholic drinks consumed and cervical cancer incidence among women in Los Angeles, CA.

Alternate Hypothesis 2: There is a significant association between the number of alcoholic drinks consumed per day and cervical cancer incidence among women in Los Angeles, CA.

 

 

 

Theoretical framework

Theory of relationalism by Kaipayil’s (2009) was the theoretical framework for this study. Theory of relationalism refers to the theory of realism, which construes the existence, significance and temperament of things with regards to their relationality. It is a philosophical theory of reality that suggests that there is an interrelation between consuming alcohol and the risk of cervical cancer (Kaipayil, 2009). This theory showed the association of cervical cancer incidence as the dependent variable and the alcohol consumption as the independent variable. This cross-sectional study design added to the existing body of knowledge surrounding cervical cancer by measuring the association between alcohol consumption and incidence of cervical cancer.

Definition of Terms

Comprehension of the terminology related with cervical cancer was essential for understanding the nature of this disease. Histological terms were defined to elucidate the makeup of cervical cancer. Medical terms are defined to help in understanding the language commonly used to describe the signs and symptoms related with cervical cancer. Definitions for the independent variables were retrieved from CDC (2014b).  Listed below are fundamental terms used frequently includes:

AdenocarcinomaCervical cancer that originates in the mucus-producing cells of the inner or endocervix.

Carcinoma in situ: Cancer that is confined to the cells in which it originated and has not spread to other tissues.

Cervical intraepithelial neoplasia (CIN):  Abnormal cell growth on the surface of the cervix.

Cervix:  Narrow, lower end of the uterus forming the opening to the vagina.

Human papillomavirus (HPV): Virus that causes abnormal cell growth; some types can cause cervical cancer.

Pap smear testremoval of cervical cells to screen for cancer.

Squamous cells: Thin, flat cells on the surfaces of the skin and cervix and linings of various organs (ACS, 2016).

Squamous intraepithelial lesion (SIL):  Abnormal growth of squamous cells on the surface of the cervix (ACS, 2016).

Heavy alcohol consumption:  one or more drinks per day for women and more than two drinks per day for men

Risky drinking: It is defined by consumption for men consuming more than 1drinks per week, or more than four drinks on any occasion, and women consuming more than seven drinks per week or more than three drinks on any occasion (DeNoon, August 04, 2014).

Excessive alcohol consumption or binge drinking: men consuming 5 or more drinks; women consuming or more drinks, in about 2 hours (CDC, 2014c).

Significance of the study

The intend of this study was to close the gap in the knowledge on the effects of alcohol consumption as a potential risk factor for incidences of cervical cancer among women in Los Angeles, California. The purpose of this study was to investigate the relationship between alcohol consumption and the risk of cervical cancer among women in Los Angeles, California. Thus, the significance of this research study was to reduce alcohol intake among women in Los Angeles, California, since alcohol consumption was a modifiable behavior; the potential detrimental role of alcohol intake and its effect on the risk of cervical cancers is of a major concern for prevention (CDPH,2016).  Another significance was to understand the risk of cervical cancer in the population among those who never consumed alcohol. Providing answers to the questions above contributed further insight into the factors that contributed to alcohol-related health disparities among women in Los Angeles, California, also findings from this study could enable policy maker to reform the social policy that would potentially lead to a positive social change among women in Los Angeles, California (Gostin, 2008).

Implications for Social Change

Public health is a multilayered discipline, which consist of several fields in an effort to enhance the health and wellbeing of its community members. This study provided evidence for or against the association of alcohol consumption as a potential risk factor for the incidence of cervical cancer. The social change effect of this research study relates to creating awareness on the detrimental role of alcohol consumption as a potential risk factor for cervical cancer.  Findings from this study provided future researchers with information, which could enable them to create effective awareness programs that will meet the needs of persons with similar characteristics such as, information’s that are based on individual’s income level, racial and ethnic background, education level, age distribution, and occupation.

Summary and Transition

This chapter provided an introduction, which pertains to the overlapping epidemics of alcohol consumption and cervical cancer incidence; problem statement, nature and significance of the study, variables of interest, research questions and hypotheses, the theoretical framework, and important terms associated with the study. Chapter 2 focused on literature reviews that are related to alcohol consumption and cervical cancer among women in Los Angeles, California and the United States, and provided a review of the suggested risk factors. Chapter3 provided details on the study design, proposed hypothesis and the methodology content. Chapter 4 described the data collection and analysis of demographic information of all the study participants. Chapter 5 provided the interpretation of the findings, study limitations, an implication for social change and provided recommendations for future research.

 

 

 

 

 

Chapter 2

Introduction

 

Cervical cancer is a major cause of cancer death found among women both in the United States(US) and around world. It is the second most common type of cancer among women in less developed countries (Burd, 2003, World Health Organization [WHO], 2016).  In the US, cervical cancer is rated as the third common cause of cancer among women, this is preceded by the breast cancer as the second common cause of cancer among women. Although, in developing countries, cervical cancer is normally the most common cause of cancer in women, which constituted  approximately 25% of female cancers (Burd, 2003).  In 2012, about 530 000 new cases of cervical cancer were estimated globally, and 270,000 deaths attributed to cervical cancer occurred each year (WHO, 2016; Beaulieu et al., 2009). With the implementation of cervical cancer screening program and Papanicolaou (pap) test in the US, the incidences of cervical cancer have reduced significantly over the past 40 years (Centers for Disease Control and Prevention [CDC], 2016). In 2010, American Cancer Society estimated 12,200 new cases of cervical cancer diagnoses and 4,210 deaths in the US.  In 2011, about 12,710 women were diagnosed with cervical and 4,290 cervical cancer deaths occurred (Glick et al., 2012).  In 2013, there was slight decrease shown among women (n=11,955) diagnosed with cervical cancer and (n=4,217) deaths related to cervical cancer in the US alone in 2013 (CDC, 2016).  This trend increased in 2016 with an estimated 12,990 new cases of cervical cancer diagnoses while the projected death decreased slightly to 4,120 (ACS, 2016). However, with HPV screening, cervical cancer is preventable and treatable with early detection, though some women still are diagnosed with serious outcome. The association between HPV and cervical has been well established, Burd (2003), argued that the degree of the association between HPV and cervical cancer is higher compared to the association between smoking and lung cancer. However, the overall evidence from epidemiologic research has not found sufficient evidence to consider alcohol consumption to be causally related to the risk of HPV associated to cervical cancer.

Literature Search Strategy

 

This chapter presented a discussion of findings from peer reviewed research on the topic of alcohol consumption and cervical cancer incidence. I reviewed peer reviewed articles published between 2000 –2016.  With some few exceptions of studies that were published in the 1990s that contained relevant information that is still useful when addressing the overlapping epidemics of alcohol consumption and cervical cancer incidence. This literature review focused on the association of alcohol consumption and risk of cervical cancer among women in Los Angeles California. Primary sources of information were collected thru Walden University library’s databases. The specific database included in this search was: PubMed, Medscape, and Medline. The following search engines were also used: Google Scholar, PROQUEST, and EBSCO. Additional information was gathered thru the following authoritative sources: Centers for Disease Control and Prevention (CDC), CDC Data & Statistics, American Cancer Society, National Cancer Institute. California Department of Public Health, California Health Interview Survey, California cancer registry.

Keywords used included:  alcohol consumption and cervical cancer,  squamous-cell carcinoma, Adenocarcinoma and HPV.

 

Histology Types of Cervical Cancer

Cervical cancer is the uncontrollable growth and the spread of abnormal cells in the cervix. Squamous carcinoma (85%), and adenocarcinoma in situ (10% to 15%), are the most common type of cervical cancer (Lax, 2011, Mosby, 2009). When the cancer growth is limited to the surface of cervix it is referred to as adenocarcinoma in situ (AIS). At that stage, the cancer can be cured. However, when the cancer has grown outside of the cervix, the cancer is referred as invasive cancer. Invasive cervical cancer is divided into three different stages; they include: local stage, regional stage and distant stage. These stages are divided into how far the cancer has spread. At the local stage, the cancer is confined to the cervix. At the regional stage, the cancer has spread beyond the cervix to nearby lymph nodes or into surrounding tissues. At the distant stage, the cancer has spread to other parts of the body. Cervical cancer is very difficult to treat once it has spread beyond the cervix. Tumorigenesis of cervical cancer is HPV-related. High risk HPV (such as type 16 and 18) is incorporated into the genome and advances to tumor progression. About 50% of cervical cancer is caused by HPV-16 strain. A 5-year survival rate for in situ cancer is usually about 73% to 92% (Mosby, 2009). 5-year relative survival rate for invasive cancer by stage are: 91.3% at the local stage, 57.4% at the regional stage and 16.8% at the distant stage respectively (Surveillance Epidemiology and Result Program [SEER], 2012; American Society of Clinical Oncology (ASCO), 2016). There are different treatment options for cervical cancer depending on the stage of the cancer. Treatment for squamous carcinoma includes some of the following: laser surgery, cryosurgery and cold knife conization etc. (ASC, 2016b). Hysterectomy is normally recommended for adenocarcinoma in situ treatment, however women who are of child-bearing age and wish to still have children, cone biopsy could be recommended, once they have finished having their children, hysterectomy would be recommended (ASC, 2016b).

 

Alcohol Consumption in the United States

Alcohol consumption is increasing in several countries, including the US and is a compelling cause of cancer worldwide (Boffetta, and Hashibe, 2006). Approximately, 88, 000 alcohol related-deaths and 2.5 million years of potential life lost is attributed to excessive alcohol consumption each year in the US. In 2006, the economic cost of alcohol consumption was estimated at $223.5 billion (CDC, 2014a; CDC, 2014b; Bloom et al, 2011). Intake of alcohol has a substantial negative effect on mental, physical and social health. Older adults, especially women who consume alcohol have greater health risk that is related with the use of alcohol because of gender-related metabolic variances and age-related physiological differences, which increases sensitivity to alcohol (Moore et al. 2005). In a study that compared historical data from two national alcohols, epidemiology surveys revealed that alcohol consumption (risky drinking) declined very slightly between 1991-1992 and 2001-2002 (Borders and Booth, 2007). Moore et al. (2005) suggested that even though alcohol consumption declined among their study participant as they grew older but negative health effect of alcohol still increases as they grow older. Consequently, as the quantity of alcohol consumed among men increased, the cancer mortality risk increased with risk ratio 1.53. Thus, average alcohol consumption has been shown to be associated with cancer mortality; this increase is seen on average of three to five alcoholic drinks per day for men, while women drinking two or more alcoholic beverages increases their risk of cancer mortality with risk ratio 1.23 (Breslow and Graubard 2008; CDC, 2014b).  US adult binge drinking in 2012, accounted for over 38 million, equivalent to four times per month, thus the largest number of alcoholic drink per binge averages about eight drinks each month. Binge drinking has been reported to increase the risk of cancer and cancer mortality (CDC, 2014b).  Adults between the ages 18 and 34 years were found to be most binge drinkers, with the prevalence and intensity of 28.2% and 9.3 drinks, respectively. Individuals above 65year of age (5.5 episodes per month) and over were also found to binge drink most often. Research showed that individuals in the income group that is over $75,000 were noted to have the highest binge drinking prevalence, while individuals earning less than $25,000 were reported to have the highest binge drinking prevalence (5.0 episodes per month) and intensity (8.5 drinks on occasions) (CDC, 2014b).

Alcohol Consumption in California

In California, alcohol consumption resulted in 10,572 deaths and 304,472 years of potential life lost between 2006 and 2010. In 2010, excessive alcohol intake cost $35 billion, (approximately $2.05 per drink) because of healthcare expenses, and lost workplace productivity (CDC, 2016a; CDC, 2015). In 2001, approximately 3,596 deaths occurred from alcohol related in California (Lund, 2004). Over 54 percent of Los Angeles men and women reported alcohol consumption during the past month in 1999 as compared to 60 percent for California.   Almost 950 (40%) death attributed to alcohol consumption was due to chronic causes (such as, cancer), 440(18%) death to other acute causes (CDC, 2014b).  In 2005, report revealed that in the last 30 days n =1,974 women (47.5) and n = 1,641 men (65.2) in California residents claimed to have used alcohol.  Among these numbers 55% males and 40% females consumed alcohol (CDC, 2015).  Same year n = 671 adults in California participated in binge drinking (approximately four or five drinks per occasion). Binge drinking frequency was the highest among persons between the ages of 18 and 24 years (25.6%). Among these groups, males (22.5%) and female (5.7%) engaged in binge drinking (CDC, 2015).  Heavy alcohol consumption (one or more drinks per day for women and more than two drinks per day for men) has been shown to increase the risk of chronic diseases including cervical cancer. Roughly, 371 (6.2%) adults in California in 2005 were heavy alcohol consumers. Among these heavy alcohol users, 265 (6.9%) are whites, 73(6.4%) are Hispanic, 10 (4%) are blacks, 14 (3%) are other, non-Hispanic and 5.7 were multiracial, non-Hispanic groups.  Adults whose income ranged from $35,000 to $49,000 (about 8%) were noted to be among the heavy drinkers (CDC, 2015).  Between 2005 and 2010 there was a huge increase in the prevalence among adults who claimed to have consumed at least one alcoholic beverage in the past 30 days (n=3615 [56.2%] and n=9280 [53.3%]) respectively (CDC, 2015).  In addition, 77% young males and 23% females died from alcohol-related diseases each year (CDC, 2013b).  Reports showed that persons that start to consume alcohol before the age of 14, were five times more likely to become alcohol dependent compared to those who began after the age of 21years of age (CDC, 2013b).  However, between 2011 and 2014, there was a significant decrease shown in the prevalence among adults who claimed to have consumed at least one alcoholic beverage in the past 30 days (n=9162 [57.1%] and n=4206 [53.6%]) respectively. Among these decrease the prevalence was higher among women from (n=4911 [50.5]) to (n= 1982 [46.6%]) than men from (n=4251 [63.7]) to (n= 2224 [ 60.9]) (CDC, 2015).

Cervical Cancer in the United States

Cervical cancer is one of the most common cause cancer among women in the United States.  it is rated as the third common cause of cancer among women, this is preceded by the breast cancer as the second common cause of cancer among women (Beaulieu et al., 2009; Bloom et al., 2011). Although, in developing countries, cervical cancer is normally the most common cause of cancer in women, which constitute approximately 25% of female cancers (Burd, 2003). In 2010, American Cancer Society estimated 12,200 new cases of cervical cancer diagnoses and 4,210 deaths reported in the US. Approximately, 11,955 women were diagnosed with cervical cancer and 4,217 deaths related to cervical cancer occurred in the US alone in 2013 (CDC, 2016). This trend increased in 2016 with an estimated 12,990 new cases of cervical cancer diagnoses while the projected death decreased slightly to 4,120 (ACS, 2016; ASCO, 2016). However, with human papillomavirus (HPV) screening, cervical cancer is preventable and treatable with early detection, though some women still are diagnosed with serious outcome. The association between HPV and cervical has been well established as the primary cause of cervical cancer. Burd (2003), argued that the degree of the association between HPV and cervical cancer was higher compared to the association between smoking and lung cancer. Each year, in the US, an estimated 11,771 HPV-associated cervical cancer new cases are diagnosed (CDC, 2016b).

In 2013, about 12, 340 new cases and 4,030 death-related to cervical cancer was estimated (ACS 2013).  According Viens et al., (2012), in their study, the result of their analysis reported 33,369 HPV-related cancer between 2004 and 2008, however an increase of about 38,793 HPV-related cancer diagnoses was shown between 2008 and 2012. They explained that this increase demonstrated an overall increase in HPV-related cancer incidence, from 10.8 per 100,000 persons from 2004 to 2008 to 11.7 per 100,000 persons from 2008 to 2012 (Viens et al., 2012).  Even though, cervical cancer incidence and mortality rates have declined significantly due to pap smear screening and HPV vaccination (Byrd et al., 2013), yet cervical cancer disparities still exist among different race and ethnic group. Black and Hispanic women get HPV-related cervical cancer compared to women of other races or ethnicities, this is likely due to decreased access to Pap testing or follow-up treatment (CDC, 2016b). Although Hispanic women have the highest cervical cancer incidence rate followed by black women, however, black women have the highest mortality rates (Coker et al. 2009). HPV alone does not explain the cause of cervical cancer. Most female diagnosed with HPV are not diagnosed with cervical cancer, other risk factors such as alcohol consumption, smoking, HIV infection, age and sexual activity, abnormal pap smears determine which women get exposed to HPV and are more likely to be diagnosed with cervical cancer (ASC, 2016c). Sexual activity and age increases the risk of HPV-related cancer (Burd, 2003; Byrd et al., 2013). HPV infection is the most common among sexually active women, ages 18 to 30 years.  After the age of 30 a significant decrease in cervical cancer prevalence is seen among women. Though, cervical cancer incidence is more common among women above 35 years, which suggest that HPV infection diagnosed at a younger age could lead to slow progression to cancer (Burd, 2003). HPV in general is assumed to be responsible for about 91% of cervical cancer incidences (CDC, 2016c).  Both the incidence and mortality rates of cervical cancer are twice higher among women; however, the cervical cancer incidence is steadily increasing among women (CDC, 2012).

 

Medical Care Cost of cervical Cancer in California vs. the United States

Medical care cost of cancer in California was estimated at $1.3 billion per year, of this direct cost of cancer care per person was $10,436 in 2007 (County of San Diego, 2010). In 2002, the National Institutes of Health estimated medical costs of cancer, including cervical cancer at $171.6 billion, in which $95.2 billion was attributed to indirect mortality costs, while $60.9 billion was attributed to direct medical costs and $15.5 billion attributed to indirect morbidity costs alone in the United States (Chang et al., 2004). In 2003, over 1.3 million people were diagnosed with cancer in the US; since then the incidence of cancer has continued to rise (Chang et al., 2004).

Between 2008 and 2011, annual medical cost for female cancer survivors was $8,400 and $4,000 attributed in loss productivity compared to women without cancer at $5,100 and $2,700 respectively (Ekwueme et al., 2014).   Research conducted by Kutikova et al., (2005), found that diagnosed individuals (n=2040) with cancer were found to have more monthly total medical costs of $ 6,520 compared with controls subjects not diagnosed with cancers of $339, and the overall costs for the duration of the study period (from diagnosis to death or maximum of two years) were $45,897 for cases and $2907 for controls. Yabroff et al., (2008) revealed a Medicare claims data from January 1, 1999 through December 31, 2003 that estimated the medical cost of cancer for different stages of cancer. Cost per-patient net care was applied to a 5year survival of cancer patients by stages of care to estimate 5years costs of care and generalized to the Medicare for the US elderly populations that were diagnosed with cancer in 2004, which was estimated to be almost $21. 1billion. The cost of cancer (including cervical cancer) care varies depending on the stage at diagnosis, site of tumor, survival rate and phase-specific costs for cervical cancer (Yabroff et al., 2008).  In 2010, a study reported mean monthly net costs in the care of elderly cancer was about $1923 to $5,074 in the initial phase of care. In the subsequent phase of care, it was between $184 and $678 that was reported in the mean monthly net cost. Mean monthly net cost in the last year of life among patients who died from cancer was between $5, 238 and $7,710 (Yabroff et al., 2011). An estimated cost of $124.5 billion was projected in the prevalence costs of cancer care in 2010 (Yabroff et al., 2011). Of which $6.6 billion (82.3%) was for cervical cancer screening routine and $1.0 billion (12.0%) was for cancer follow-up, of this $0.4 billion went for cervical cancer (Chesson et al., 2009). In another study, the prevalence of cancer cost was based on recent available data on cancer incidence, survival, and medical cost of care retrieved from 2003 and earlier. The prevalence of cancer was projected at the national cost of cancer care and estimated by phase of care (first year following diagnosis, and last year of life) tumor site between 13 cancers in men and 16 cancers in women through year 2020 (Mariotto et al., 2011).  Using the base case scenario, constant cancer incidence, survival and cost of care, was estimated at the national costs at $124.57 billion in 2010, and a projected to increase to $157.77 billion in the year 2020, thus a 27% increase (Yabroff et al., 2011). This increase in cost over time reflects in the base case model the growth and aging in the US population (Mariotto et al. 2011). If the costs of care (recent incidence and survival trends) continue to increase annually assuming a 2% increase in the initial and last year of life phases of care, then the total cost by year 2020 could be projected to be $173 billion, which represents an increase of 39% of cost from 2010. However, under the assumption of 5% increase, total cost of cancer care by 2020 would be estimated at $207 billion in the initial and last year phases of care, thus a 66% increase from 2010 (Mariotto et al. 2011; Yabroff et al., 2011). As the women population ages, the national medical cost of cervical cancer among other cancer types will continue to increase substantially.

Cervical Cancer in California

Cancer is a major health problem in California. In California, cancer is the second leading cause of death.  In 2016, 173,200 new cases of cancer and 59,060 death cancer related were estimated (California Department of Public Health (CDPH), 2016).   Even though there has been decrease in death related to cervical cancer across all major race, however, non-Hispanic black women and Hispanic’s rates are higher compared to Hispanic white and Asian Pacific Islander women (Brenda et al., 2008). In 2013, about 6,703 new cases of cervical and 1,484 deaths, including 105,500 (13%) existing cases of cervical of cancer was reported (CDPH, 2016). About 1,400 women were diagnosed and 400 cervical cancers death-related was projected yearly in 2008 (Brenda et al., 2008). California cancer registry (CCR), estimated in 2009, that over 140, 000 were diagnosed with some form of cancer that year, skin cancer not included. Same year about 24% death were attributed to cancer compared to heart disease (25%), which is the leading cause of death among Californians (CCR, 2009). Non-Hispanic white (7%), non-Hispanic black (8.7%), Hispanic (14.4%), and Asian pacific islander (8.3%) (Brenda et al., 2008; CCR, 2009).  Even though in California a declined in cervical cancer was shown in the overall incidence and death among women, though this decline has not been equally shared among women. Between 2000 and 2004.  Incidence rates of cervical cancer among Hispanic (14.4%) women are twice higher than non-Hispanic white women (7%), while death rates are higher among non-Hispanic black women compared among women of other races and ethnicities (Brenda et al., 2008).

Alcohol Consumption and Cervical Cancer

The association between alcohol consumption and cervical cancer has been found in limited research studies. However, several studies have shown the association of human papillomavirus infection (HPV) and cervical cancer. Women who consume alcohol are more likely to have multiple sex partners and practice unprotected sex. These activities increase the risks of unintended pregnancy and sexually transmitted diseases such as HPV leading to cervical cancer (CDC, 2016b). A population-based cohort study was conducted in Sweden between 1965 and 1995 among 36,856 women discharged from hospital diagnosed with alcoholism, to analyze the risk of developing cancer (cervical cancer, cancer of the vagina and vulva). The result of the study revealed a significant trend of increased risk of invasive cervical cancer associated with alcohol consumption (Weiderpass et al., 2001).  Several other evidences have shown alcohol consumption as a contributing factor of cancers of esophagus, oral cavity, breast and liver cancer. However, there has been limited evidence that links the association between alcohol consumption and cervical cancer risk. Women whom consume alcohol are likely to have smoked more compared to those who never consumed alcohol. In addition, women who consume alcohol could be at a higher risk for progression from HPV infection to cervical cancer from lifestyle-related behaviors, such as early initiation of sexual intercourse and promiscuity (Ylitalo et al., 2000). Several studies have established cigarette smoking as the most common risk factor, nevertheless, alcohol intake was found to be associated with an increased risk of cervical cancer (WHO, 2016).  Research have shown that HPV infection alone is not sufficient to cause cervical cancer, and other several possible cofactors have been proposed such as exposure to smoking-related carcinogens, dietary deficiencies and contraceptive hormones (Kjellberg et al., 2000).  In another study conducted among n=257 cervical cancer patients in Lesotho, Southern Africa to find out if there was any association between alcohol consumption, smoking and cervical cancer, the researchers used four binary variables in 16 different combinations to analyzed:  cigarettes smoking, pipe, or snuff, and indigenous alcohols consumption, European drink, and sour porridges made from fermented sorghum or corn. The result of the study revealed a significant association between indigenous alcohol consumption than tobacco use (Martin and Hill, 1984). Hy et al., (2015) also conducted a study that tested n= 9,230 Korean women for HPV and asked those women about their consumption of alcohol. The result revealed that at the beginning of the study and during a two year follow up, women who consumed alcohol were almost three times likely compared to non-alcohol consumers to test HPV positive. Their study suggested that women who has been drinking for over five years were at higher risk of persistent HPV than women who drank less than five years prior to their study.  Their study suggested that reducing consumption of alcohol could be an important measure to avert cervical cancer development among women with risk of persistent high-risk (HR) human papillomavirus (HPV) infection (HY et al., 2015).

Disentangling the effects of alcohol consumption and smoking has proven very difficult because the two exposures tend to be associated, but the possibility of an alcohol effect cannot be refuted because of this problem automatically (Bandera et al. 2001; Chao, 2007, and Neuenschwander et al. 2002). Specific tobacco carcinogens are found in the mucus of the female genital tract (Castle, 2008).  In a study conducted in 2006, a causative association was found between alcohol consumption and liver cancer, larynx, cancers of the oral cavity, rectum and breast cancer in women however, no association was found with cervical cancer (Boffetta and Hashibe, 2006, CDC, 2016b).  Evidence from their study suggested that the effect of alcohol was controlled by polymorphisms in genes, which encode enzymes for ethanol metabolism (such as; alcohol dehydrogenases, and cytochrome P450 2E1), folate metabolism, and DNA repair. However, the mechanisms by which alcohol consumption exerts its carcinogenic effect have not been fully defined, although plausible events include: a genotoxic effect of acetaldehyde, which is the main metabolite of ethanol; increased estrogen concentration is important for breast carcinogenesis; solvent role for tobacco carcinogens; production of reactive oxygen species and nitrogen species, and changes in folate metabolism (Boffetta and Hashibe, 2006). Alcohol consumption is a modifiable behavior thus; its role in cancer prevention should be of utmost importance (Bandera et al. 2001).

Summary and Conclusion

This literature review concentrated on two epidemics that are affecting women in Los Angeles, California: alcohol consumption and cervical cancer. Initial epidemiologic evidences pointed out that HPV is the most important risk factors associated with cervical cancer (Burd 2003). Yearly, in the US, an estimated 11,771 HPV-associated cervical cancer new cases are diagnosed (CDC, 2016b). HPV in general is assumed to be responsible for about 91% of cervical cancer incidences (CDC, 2016c).  Epidemiological data that relates to alcohol consumption and its contribution to the development of cervical cancer are still limited.  Thus, there continue to be a gap in the literature about creating the awareness of the danger of consumption of alcohol while diagnosed with cervical cancer.  This dissertation study   added latest information and data to the body of literature, which is currently lacking recent data that would address effective awareness program for alcohol consumers with cervical cancer.  This information could enable researchers, public health professional, and policy makers to create an awareness program that can reduce the current projected incidence rates of cervical cancer, and possibly tailor a program that could effectively meet the needs of different demographic characteristics during this twenty-first century among women in California.

In conclusion, different studies have called for more research on this topic, which involves the overlapping epidemic between alcohol consumption and cervical cancer incidence.  Several unanswered questions remain, to be answered on creating the awareness of the dangerous effect of consumption of alcohol and risk of developing cervical cancer. This dissertation study focused on investigating the association between alcohol consumption and its effect on developing cervical cancer. This research study added to the body of literature and could enhance public health efforts to collect, analyze, and share recent findings. Since nearly most of the data that are currently presented in prior literatures are outdated.  In addition, the findings from dissertation study, could enable public health institutes, healthcare participations, and scholars to create effective awareness programs that can meet the needs of persons with similar characteristics such as, information’s that are based on individual’s income level, racial and ethnic background, education level, age distribution. In Chapter 3, details of the selected study design, its rationale, and the methodology content were presented.



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