Research spotlight: CervixCheck

Cervical cancer screening using the pap test remains critical for this preventable disease. In BC, provincial screening rates have remained the same over the last decade where approximately 30% of the population are under or never screened. Despite this, few interventions have been implemented to increase screening, where rates are lowest among priority populations who face barriers to clinic-based screening.

CervixCheck is a website developed by the BC Centre for Disease Control (BCCDC) and the BC Cancer Cervix Screening Program. Using CervixCheck, women who are overdue for cervical cancer screening can order a kit to perform cervical cancer screening at home. This is a pilot research project where women will be recruited from collaborating family medical clinics in Surrey, an urban centre with some of the lowest regional screening rates in the province and large South Asian population.

CervixCheck was modelled off of the successful BCCDC “virtual clinic” for sexually transmitted and blood-borne infections (STBBI) called GetCheckedOnline.com (GCO), using existing code-base, infrastructure and safeguards. Evaluations of GCO have demonstrated:

  • high diagnosis rates;
  • high satisfaction because of the privacy and convenience of the online service;
  • users reported barriers to accessing testing prior to the service, compared to clinic clients;
  • despite common assumptions GCO users were not more likely to be youth or have higher digital literacy;
  • the service reached previously untested individuals.

Online services for self-collection at home, and clinician-collected screening for HPV testing are available commercially in Canada, however CervixCheck will be the first service of its kind administered in the publicly funded health system. To verify our assumptions in the development stages of the project, we administered a digital health survey to assess South Asian womens’ willingness to use the service and digital literacy. Women were recruited from the family practice clinics where CervixCheck will be piloted, and included 51 women between 30-65 years. Among the findings from this survey we found that

  • 30% of women reported being under/never-screened
  • Over 86% of women self-rated their general Internet skills as average or better
  • 80% of women responded somewhat likely to very likely to participate in CervixCheck
  • 70% of women responded somewhat likely to very likely to collecting their own vaginal specimen
  • Over 90% of women feel comfortable reading and understanding English

CervixCheck is planning to launch in January 2019 and will be available in English for the pilot, however the print and instructional materials associated with the screening project will also be offered in Punjabi. The lessons from this pilot project will be used to inform possible implementation within the BC Cervix Screening Program, as well as other under-screened populations, particularly in Northern BC where our team had engaged stakeholders and secured funding for an additional pilot.

BC Women’s Research Rounds

Title: The patient experience roadmap: implications for the research community
Presenter: Dr. Julie Robillard

Date: Friday, November 16, 2018
Time: 8:00am – 9:00 am
Location: Room D308 – Shaughnessy Building

Goals/Learning Objectives

1. Identify traditional and novel methods of capturing patient experience data
2. Understand the limitations in collecting and interpreting patient experience data
3. Describe the goals of the Patient Experience Roadmap

“The BC Women’s Research Rounds is a self-approved group learning activity (Section1) as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada”.

Information on remote and off-campus attendance.

Member Spotlight: Dr. Paula Gordon

Last month Minister of Health Adrian Dix announced that BC would become the first province to share breast density results with all women and their healthcare providers with their mammography screening. Dr. Paula Gordon, Medical Director of the Sadie Diamond Breast Program at BC Women’s Hospital, along with the organization Dense Breasts Canada, was instrumental in advocating for this policy change.

In honour of Breast Cancer Awareness month, we spoke to Dr. Gordon about this change and its impact on women throughout the province.

 

  1. What was your involvement in the push toward communicating breast density results in BC?

I’m a volunteer advisor to Dense Breasts Canada, a non-profit group of breast cancer survivors and medical professionals striving to educate women and physicians about the risks associated with having dense breasts.

  1. How is breast density related to breast health?

It’s normal and common to have dense breasts. But having dense breast tissue puts a woman at increased risk for getting breast cancer. Having the highest category of breast density is a greater risk factor than having a mother or sister with breast cancer. And when a woman’s breast tissue is dense, it makes it harder to see a cancer on a mammogram. Cancers and normal dense tissue both appear white on a mammogram, so looking for a cancer “is like looking for a snow ball in a snowstorm.” Women with fatty breasts are at lower risk AND it’s easier to see cancer in a fatty breast.

  1. Why is it important that women are informed about their breast density?

Mammograms miss 50% of cancers in women with dense tissue. So, women with dense breasts need to know that they can’t have the same trust in the accuracy of their mammogram, than women can if they have fatty breasts. They should still have mammograms, but should also do breast self-examination, and should discuss the option of additional screening with ultrasound, with their family doctor. BC Cancer will initiate a program to educate physicians about dense breasts in 2019.

  1. How will this decision impact women in BC?

Hopefully, women who learn that they have dense breasts will be in a position to make informed decisions about their health. ALL women would ideally improve their lifestyle to reduce their risk of getting breast cancer.

Changes include:

  • Maintaining a healthy body weight, especially after menopause
  • Doing regular, moderately-intense exercise
  • Reducing the use of hormone therapy after menopause (use the lowest possible dose for the shortest possible time, avoiding oral estrogen, and balancing the risks with the benefits to their quality of life
  • Minimizing their alcohol consumption: there’s a linear relationship between alcohol use and breast cancer risk. So enjoy, but in moderation
  • Have routine screening mammography.

Women with dense breasts should discuss the option for supplemental screening with their family physician. Currently, there is evidence to show that ultrasound finds an additional 3-4 cancers per thousand women. But like any screening test (like mammograms and pap smears) ultrasound can create false alarms, which can necessitate additional testing to determine whether cancer is present, or not. But when ultrasound finds these cancers, they are usually small, and not yet spread to lymph nodes. So these women are good candidates for less aggressive surgery and often do not require chemotherapy. When not found early, women are more likely to need mastectomies and chemotherapy.


Read more about the announcement here.

Meet the Researcher: Dr. Cheryl Krasnick Warsh

Dr. Cheryl Krasnick Warsh, FRSC is a historian at Vancouver Island University, who also served as Executive Director of the Western Association of Women’s Historians, and Editor-in-Chief of the Canadian Bulletin of Medical History. She presently is co-editor of the international journal Gender and History. Her work focuses on the history of healthcare and health research, and within those fields, the inequalities women have faced in accessing care and inclusion within the healthcare system.

Dr. Warsh started her career as a historian of healthcare nearly 35 years ago.  Studying this history, she explains, adds greater dimension and context to our current healthcare concerns and advances in medicine. The history of gender inequalities in the healthcare system is rich with examples of women’s concerns being treated as psychological, related purely to their reproductive systems, or simply ignored.

“It goes right back to Greek medicine and the first physicians, Galen and Hippocrates,” says Dr. Warsh. “Galen postulated that the centre of a woman’s life was the womb, and the woman was built up around it. Women’s reproductive organs really guided everything about her health from puberty to menopause and beyond.”

She describes that when doctors had no clear cut answer for the cause of a woman’s ailment, they defaulted to the ‘theory of the wandering womb’. If a woman was suffering from a migraine, for instance, they might put sweet smelling herbs near her pelvis and garlic and other bad smelling things near her head to “entice her womb from her head and put it back where it belongs.”

This association between a woman’s wellbeing and her reproductive organs carried on well into the 20th century. Dr. Warsh’s first research was on the London Psychiatric Hospital  during the last decades of the 19th century, where asylum superintendent Richard Maurice Bucke had a theory that “much of a woman’s mental illness related to her ovaries. If she couldn’t be treated, then maybe they needed to be taken out.”

Over the past hundred years or so, the fate of women’s healthcare and health research largely shifted toward the assumption that their care is interchangeable with men’s. She explains that medical science primarily experimented on men, and women’s unique concerns have been downplayed.

“Women were expected from a young age to take care of reproductive health in ways that may not be healthy,” she says. “When the first birth control pill was tested through the FDA in the late 1950s the FDA didn’t yet have scientists there. They had a woman employee whom they sent to get a Master’s degree in science so that she would be ‘qualified’ to test the birth control pill. The early pill had severe side effects.”

These are only a few examples of the long history of inequalities in healthcare, and understanding where we came from can be helpful for understanding where our system stands today.

“When you do a little bit of history on anything, you find out a lot more than you expected,” says Dr. Warsh.


Read more about Dr. Warsh here.

Research Spotlight: The TMIST Trial

The Tomosynthesis Mammographic Imaging Screening Trial (TMIST) is a randomized, breast cancer screening trial that will help researchers learn about the best ways to find breast cancer in women who have no symptoms.

It compares two approved types of digital mammography: standard digital mammography (2-D) with a newer technology called tomosynthesis mammography (3-D). 2-D mammography takes pictures from two angles of the breast to create a flat image. 3-D mammography images are taken from multiple angles around the breast and then reconstructed into a 3-D-like image.

The goal of breast cancer screening is to find breast cancer early when it may be easier to treat. The TMIST trial aims to find out whether the newer technology is more effective than conventional 2-D mammography at reducing life-threatening (advanced) breast cancers.

The TMIST Lead-In study, led by Dr. Paula Gordon at the Breast Health Centre at C&W and Dr. Linda Warren at X-Ray 505, is now in its follow up stages with one-third of the 306 study participants completing their final screen to date. This Lead-In study has been funded by The Diamond Family.

Another important aspect of the trial is to build a tissue bank for future research. All women who joined the trial have been asked to submit tissue samples, such as blood and cheek swabs.  Researchers hope that the information from these tissue samples will help decide the best ways to screen for breast cancer in the future by taking a person’s genetics and other personal risk factors into account. Currently we have collected bio-specimens from approximately 25% of the participants.

With the success of the Lead-In study, we are nearly ready to begin recruitment on the main TMIST study. Women ages 45 to 74 who are planning to get a routine screening mammogram are eligible for this trial. The main study will be funded by the NIH.

If you would like to participate, or would like further information on participating, please contact the research team at TMIST@cw.bc.ca

Dr. Gina Ogilvie is featured in the news!

Dr. Gina Ogilvie is the lead study author on a publication in the Canadian Medical Association Journal about the sexual health practices of teen girls after the introduction of the HPV vaccine in BC public schools. The publication has been featured in the Vancouver Sun, Newsweek, and more!

The study found that teen girls’ sexual behaviour generally stayed the same or became less risky after HPV vaccines were introduced into BC public schools.

Read the UBC press release here.

Read the full publication in the Canadian Medical Association Journal here.

News publications:

CBC

The Vancouver Sun

Science Daily

Newsweek

The Abbotsford News

Newstral

Yahoo News

Meet the Researcher: Catriona Hippman

In honour of World Mental Health Day we talked to Catriona Hippman, a WHRI researcher, genetic counselor, and Clinical Assistant Professor in the Department of Psychiatry at the University of British Columbia. Check out this Q&A to learn more about psychiatric genetic counselling, and her research on reproductive mental health!

Catriona Hippman headshotWhat is psychiatric genetic counselling, and what does a counsellor in this field do?

Genetic counselling is a growing field, and is defined as “the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease.” Psychiatric genetic counselling entails helping people make personal meaning of the research that has been conducted in the area of psychiatric illness. People might see a psychiatric genetic counsellor if they have a family member with a mental illness (such as a child or parent), and they want to understand more about how they can help to protect their child’s – and their own – mental health. Someone who has a mental illness themselves might see a genetic counsellor to discuss what’s known about the causes of mental illness and what has contributed to their experience of mental illness. Psychiatric genetic counsellors can also talk to women and their partners about how to protect their mental health during and after pregnancy, discuss options in terms of how to manage mental health during pregnancy and the postpartum period, and answer questions about chances for their child to develop a mental illness. An important part of a psychiatric genetic counsellor’s role – regardless of the reason for an appointment – is to address feelings of guilt or shame that often impact families affected by mental illness.

How do genetics play a role in mental health?

While we know that genetic factors play a part in developing a mental illness, we also know that genetic factors alone do not cause mental illness. Anyone who would like to understand more about the causes of mental illness and the role genetics plays in mental health can contact the psychiatric genetic counselling specialty clinic at BC Women’s Hospital – the Adapt clinic: http://www.bcmhsus.ca/our-services/genetic-counselling-(the-adapt-clinic).

What drew you to focus your research on reproductive mental health?

Like many, I was drawn to work in an area that is very personally relevant. Mental illness has ravaged the lives of many of my closest friends. I have seen repeatedly how much suffering is caused by mental illness, and – fortunately – how much people can thrive when they receive support for their mental health. As a feminist, I am particularly passionate about supporting women to care for their mental health at a time when they are most vulnerable – during and after pregnancy.

What impact do you hope to make with your research?

My vision is for all women to feel empowered to care for their mental health, and my mission is to improve women’s reproductive mental health through translational research.

What is the coolest thing about the work you do?

I cherish the connections that I make with women who participate in my research, and I deeply value hearing their stories and working with them to make meaning of their experiences. It is a privilege that women tell me about some of the most personal and private aspects of their lives, and I see it as my responsibility to promote change on a large scale, in whatever way I can, through my research.


Learn more about World Mental Health Day 2018 here.

World Heart Day 2018: An Interview with Dr. Karen Tran

September 29th is World Heart Day. Check out our Q&A with Dr. Karen Tran on her research on hypertensive disorders in pregnant women!

  1. What are hypertensive disorders? Do they affect pregnant women differently than non-pregnant women?

High blood pressure affects 1 in 4 Canadians and is the most common reason for Canadians to see their family doctors. Untreated high blood pressure is a major risk factor for heart attacks, strokes, heart failure, and kidney disease. Despite women being more likely than men to be treated for their high blood pressure, women are less likely to achieve blood pressure control.

In contrast, high blood pressure in pregnancy occurs in 5-10% of pregnant women, and accounts for a majority of maternal, fetal and neonatal morbidity and mortality. In BC alone, 1800 deliveries annually are complicated by hypertension and preeclampsia. Also, we know that pregnant women who having high blood pressure in their pregnancy are at increased risk of developing hypertension, cardiovascular disease, such as heart disease and stroke in the future.

2. In 2-3 sentences, could you briefly describe your research?

Together with Dr. Wee Shian Chan, we are interested in understanding how measuring blood pressure at home can improve how we care for pregnant women who develop hypertension during their pregnancies. We know that home blood pressure monitoring is more reliable than office blood pressure and associated with better outcomes in non-pregnant women, but we do not know if the same is true in pregnant women.

  1. What are some of the differences between how blood pressure is measured between pregnant women and non-pregnant women? Why are these processes different?

In non-pregnant women, home blood pressure monitoring leads to improved cardiovascular outcomes, adherence to medications, overall lower blood pressure, and increased patient satisfaction. There are also good recommendations on how often to measure blood pressure at home, as well as home blood pressure targets to achieve. This unfortunately is not the case for pregnant women. Currently, the diagnosis and management of high blood pressure in pregnant women rely on blood pressure measured in a doctor’s office, which can be inaccurate.

  1. How do these knowledge gaps currently impact pregnant women?

Even though, many doctors recommend that pregnant women measure their blood pressure at home, we are still not clear how often they should be doing this, what blood pressure they should achieve, how to use these blood pressure measurements to manage their care and whether or not this would reduce complications to mothers and their newborn babies.

  1. Why is this research important? How might it change clinical practice?

By measuring blood pressure at home, we hope to engage and empower women to take an active role in their health.  Many pregnant women already measure their blood pressure at home, but we require evidence to guide doctors on which home blood pressure thresholds to diagnose high blood pressure and what their home blood pressure targets should be to manage hypertension in pregnancy. Furthermore, we need to make sure that home blood pressures are measured accurately using validated blood pressure machines. In the future, we hope that clinicians will be able to rely on home blood pressure measurements to manage hypertension in pregnant women and improve the health of mothers and their new babies.

Maternal Microbiome Legacy Project Update

The Maternal Microbiome LEGACY Project team is excited to announce the launch of our second study site, being led by Dr. Sheona Mitchell-Foster at the University Hospital of Northern BC (UHNBC) in Prince George!

The goal of the Maternal Microbiome LEGACY Project, being led by Dr. Deborah Money, is to help clarify the link between the vaginal microbiome, mode of the delivery (vaginal or caesarean section delivery), and the development of the infant gut microbiome. Since its launch earlier this year at BC Women’s Hospital, the Maternal Microbiome LEGACY Project has recruited over 160 participants from the greater Vancouver area. The addition of our Prince George site will help in establishing a study population which is more representative of the British Columbia population.

This is a longitudinal study of women with term deliveries, with women and their infants being followed for 3 months after delivery. We are looking to recruit 920 women over the course of the study. To participate, women should be pregnant with a single or twin pregnancy, over 19 years of age, and be registered for hospital or home delivery at one of our study sites.

We thank the women who have participated so far and expressed interest in our study, and all of the nursing and clinical staff who have facilitated with in-hospital sample collection!

For more information, visit the study website, or follow MaternalLegacy on Facebook and Twitter.

If you would like to participate, or would like further information on participating, please fill out this survey.

For general study inquiries, please email the Study Manager, Zahra Pakzad at zahra.pakzad@cw.bc.ca.

Congratulations to Drs. Gina Ogilvie and Marette Lee, recipients of a MSFHR 2018 Implementation Science Team Project Grant!

Dr. Gina Ogilvie and Dr. Marette Lee have received the grant for the “At-Home Cervical Cancer Screening & Strategies To Enhance Engagement With The Care Pathway For Under-Screened Populations project”.

In this proposal we will use implementation science methodology to explore and address barriers to cervical cancer screening in BC to improve access to screening in under-served populations. Over the last decade in BC screening rates have remained at about 70%, which means there is a large proportion of the population who are under or never screened. Despite this, there are few interventions that have been successfully implemented to improve screening rates in priority populations.

Specifically we will use different implementation approaches for self-collected sampling for HPV (human papillomavirus) testing. This is a highly effective, validated tool for cervical screening that can be used to address many of the barriers women face to clinic-based pap testing, which is the current standard in BC. For example, embarrassment or discomfort with a pelvic exam, cultural taboos, or past trauma are reasons some women avoid screening, as well as inconvenient clinic hours, not having a family physician, or time and distance to travel for services. We anticipate that the use of self-screening can address many of these barriers. With this approach, women can collect their own sample in a simple and painless way, and it can be done in the privacy of women’s homes or wherever they are comfortable using it. 

To implement self-screening we are piloting two approaches, one being an online service called CervixCheck where women can order self-sampling kits for screening which are mailed to their home. After they have collected their sample the kit is mailed to the BC Public Health Laboratory for testing, and screening results become viewable online through their personal online account. In the second approach, self-collection based screening will be offered through community health centers.

Initially the program is being piloted in the urban clinics in Surrey with South Asian women, and in Northern BC with rural Indigenous communities. These populations are known to have some of the lowest screening rates in the province and face barriers to traditional screening approaches. This will also allow us to see how our interventions can be adapted to different contexts.

The program is embedded within the provincial health authority at BC Cancer, and will be examining health systems impact and cost-effectiveness to be used for future scale up planning of the program. The team is led by Dr Gina Ogilvie, Associate Director of the WHRI, UBC Professor, and Canada Research Chair in global control of HPV related diseases and cancer; Dr Marette Lee, Provincial Colposcopy Lead for the BC Cancer Cervix Screening Program; Dr Dirk van Niekerk, Medical Director of the BC Cancer Cervix Screening Program; along with an interdisciplinary team of researchers and research users in the Vancouver, Fraser, and Northern Regions of BC. Through health systems implementation research, our goal is that self-collection based screening and CervixCheck can be adopted within the BC Cancer Cervix Screening Program in the future, and serve as a model for other public health programs in BC.