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.

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.

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

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.

Research spotlight: OVCARE

This Ovarian Cancer Awareness month we are recognizing the history of OVCARE and the strides they’ve made in the field of ovarian cancer research, impacting women’s health around the globe.

In December 2000 in the cafeteria at Vancouver General Hospital (VGH), Drs. David Huntsman, Dianne Miller, and Blake Gilks sat down to brainstorm how they might improve outcomes for women with ovarian cancer. 

Despite conventional research efforts in the field of ovarian cancer – both locally and internationally – there had not yet been a research breakthrough leading to significantly improved outcomes for women with the diagnosis. Most of these women died within five years of receiving the diagnosis, which motivated them to build a multidisciplinary team and core resources to facilitate research. At the time, it was unprecedented to have contrasting perspectives of a pathologist, geneticist, and clinically focused gynaecologic oncologist to tackle this disease.

They presented their plans to the BC Cancer Foundation and the VGH and UBC Hospital Foundation. From there, OVCARE was born.


Today this partnership has made OVCARE a global leader in ovarian cancer research. Their findings have had a profound impact not only in British Columbia, but throughout Canada and the world. Their achievements include discovering that ovarian cancer is not a single disease, but is made up of a number of subtypes of ovarian cancer; discovering driver mutations in several rare ovarian and uterine cancers which are now the diagnostic markers for these cancers; developing a prevention protocol adopted in numerous countries; and  leading Vancouver Coastal Health to become the first region in the world to offer patients presenting with ovarian cancer molecular risk assessment for the two common hereditary cancer syndromes.

Among their successes, their ovarian cancer educational campaign has had a huge impact on women’s health around the globe. The campaign was comprised of three key recommendations: 1) To remove the Fallopian tubes at the time of hysterectomy (opportunistic salpingectomy, a term coined by Dr. Dianne Miller); 2) For women who are undergoing tubal ligation for permanent contraception to undergo opportunistic salpingectomy; and 3) For any woman diagnosed with ovarian cancer to be tested for the BRCA mutations, and for her family members to be tested as well so they have the opportunity to undergo preventative surgery.

With these recommended changes in practice OVCARE predicts they can prevent ovarian cancer in up to 40% of cases. Dr. Gillian Hanley is currently using a population-based database in British Columbia to track the incidence of the disease, as well as to see how many women have undergone opportunistic salpingectomy based off of the recommendations. Preliminary findings show that the uptake of recommendations in 2014 rose 80% in British Columbia, which is the highest rate of growth in the country. While it is currently too early to tell if the incidence of ovarian cancer has been reduced, they anticipate that they may have enough data to analyze toward the end of 2019.

OVCARE encourages other researchers in fields outside of ovarian cancer research to take an interest in studying the disease by developing partnerships which provide access to their resources.  Since the start of OVCARE, the team has expanded and now has an active research program on endometrial cancer led by Drs. Jessica McAlpine and Aline Talhouk.

To learn more about OVCARE visit their site.

Further reading:

Study spotlight: “Pharmacokinetics and Safety of Commonly Used Drugs in Lactating Women and Breastfed Infants”

Dr. Wee-Shian Chan, Head of BC Women’s Department of Medicine, is leading a team based out of BC Women’s Hospital + Health Centre (BCWH) to further research on the transfer of commonly used drugs from mother to child via breastmilk.

The large-scale study, “Pharmacokinetics and Safety of Commonly Used Drugs in Lactating Women and Breastfed Infants”, is being funded by the National Institutes of Health (NIH) in the United States.

Dr. Chan, Site Principle Investigator, says that BCWH was contacted as a potential site for the study being led by the Pediatric Trials Network (PTN), and secured its position as one of four Canadian sites due to its adjacency to BC Children’s Hospital (BCCH), its impressive breastfeeding rate (72.4%), and the volume of pregnant women with medical disorders on medications who could be potentially eligible to participate.

“Often when women are pregnant and they have to be on medications for their medical conditions there’s this conflict [of] whether they should take it or not,” says Dr. Chan. “What [we’re] looking at specifically is more the breastfeeding piece, so that women can be better counselled with respect to those medications that they take for breastfeeding.”

When new medications are released to the market they are not tested in pregnant or breastfeeding women, despite the many medical conditions which require their use throughout pregnancy.  Currently safety information for these drugs’ use during pregnancy and breastfeeding is only obtained through observation of use across large cohorts.

This study will help to bridge this knowledge gap by looking at how much a drug is transferred from mother to child during breastfeeding to help assess the safety of a medication.  The team will begin focusing on ten drugs commonly used within the organization, including antihypertensives, antibiotics, commonly used antidepressants, diabetic medications, and drugs that are used to stop bleeding, and will continue to expand the list of drugs, so long as funding exists.

“To successfully recruit and participate in this study really requires cooperation across the whole organization,” Dr. Chan says. “Participation in this study will move us closer to developing a teratogen information service in BC, where women can call for drug safety information during pregnancy and breastfeeding.”

This study will be unique because it will require collaboration across BCWH and BCCH between obstetric medicine, pharmacists, pediatricians and NICU physicians, as well as the on-site lab and pathology department.

Recruitment is expected to begin within the next two or three months.

Read more about Dr. Chan here.

Read more about the study here.

Researcher spotlight: Meet Dr. Sarah Munro

Dr. Munro is a WHRI researcher and implementation scientist doing work on access to contraception and informed, shared decision-making. She holds a joint post-doctoral position between the Contraception and Abortion Research Team (CART) and the Dartmouth Institute for Health Policy and Clinical Practice (TDI).

Dr. Sarah Munro headshotChoosing the right form of contraception is not always an easy task. Misinformation, high costs, or familiarity with a particular method are all reasons a patient may not consider different options for contraception. This gap is what led Dr. Munro, principal investigator Dr. Rachel Thompson, and the team at Dartmouth to develop and evaluate a set of tools called Right For Me, which supports patients to make informed, shared decisions for contraceptive methods. The tools are comprised of a collection of decision aid handouts, a video and prompt card outlining three key questions to ask during clinic visits, and training for healthcare providers. The tools aim to aid patients in selecting the form of contraception that best matches their values and needs.

The Right for Me study was conducted with funding from the Patient Centered Outcomes Research Institute (PCORI), which focuses on research that directly involves and benefits patients. Patient partners from diverse backgrounds collaborated throughout the research process – from identifying which outcomes to measure, to creating a video summary of the study protocol. Dr. Munro recently completed the qualitative evaluation of the implementation of Right for Me. Stay posted for her publication in the coming months!

Moving forward Dr. Munro will be adapting the Right For Me tools for a Canadian audience. She will continue working with Dr. Wendy Norman and other researchers at WHRI and across the province to implement these successful tools to support shared decision-making for patients and providers involved in maternal, sexual, and reproductive healthcare.

Learn more about RightForMe.org.

World Contraception Day 2018

This year World Contraception Day falls in the middle of the inaugural Gender Equality Week in Canada. In honour of both these awareness initiatives, we are featuring the CART program and its research, and highlighting the impact access to contraception has on gender equality. Read our Q&A with the team here!

    1. What is the CART program?

The Contraception and Abortion Research Team (CART) is a national, interdisciplinary, cross-sectoral collaboration performing research to support health services and policies to ensure equitable access to high-quality family planning knowledge, methods and services for people throughout Canada. The overarching goal of the team is to support Canadians to plan and space their pregnancies. The team was founded and led by Dr. Wendy Norman, an Associate Professor at UBC Department of Family Practice and the CIHR-PHAC Chair in Family Planning Public Health Research. 

    1. Why is it important to continue research around contraception?

In Canada, approximately half of all pregnancies are unintended. Access to highly effective contraception is important to Canadians who typically spend 3 or fewer years pregnant or attempting to become pregnant and more than 30 years attempting to avoid pregnancy. Improving access to contraception, especially long-acting reversible contraception, has been acknowledged to be one of the top public health advances that can lead to population-level gains, and yet there are still many obstacles, such as knowledge, access, and affordability of highly effective contraception, that need to be studied, addressed and mitigated. 

    1. What are some of the ways that access to contraception contributes to gender equality?

Disadvantaged and vulnerable populations, particularly youth, those of low socio-economic status or those subjected to Adverse Childhood Experiences (ACES) and/or intimate partner violence, those living with substance use and mental health disorders, residents in rural and remote communities, and immigrants are over-represented among those with unintended pregnancy. Lack of knowledge of highly effective contraception, unaffordability and limited access to services all contribute to the societal inequalities of access to contraception, which in turn impact the health of Canadians. 

    1. How might the CART research impact women and their families?

One major theme of the CART research program is Health Policy Research. We aim to effectively translate research evidence to support health policy that will improve access to family planning knowledge, methods and services. 

One example is the BC wide Safe Methods at the Right Time program (SMART Program) providing free contraception at the time of abortion implemented in 2016. This policy decision was directly based on research provided by Dr. Norman and the CART collaborators to the BC Ministry of Health. The proposal used data from two CART RCTs in rigorous simulation modelling to demonstrate that subsidy for highly effective contraception at the time of abortion can save government costs and improve health outcomes. 

Similar CART studies have been undertaken to support decision making on the cost-effectiveness of government subsidy to provide free contraception for all women.