Cervical cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study

Racial iniquity in mortality from cervical cancer in Brazil: a time trend study from 2002 to 2021

This ecological study examined time series, from 2002 to 20121, of age-adjusted coefficients of cervical cancer mortality, in Brazil, in women aged 20 years or more, by race. The information sources were Brazil's mortality information system (Sistema de Informação sobre Mortalidade - SIM) and the official bureau of statistics (Instituto Brasileiro de Geografia e Estatística - IBGE). Annual changes in age-adjusted mortality rates were calculated using the Prais-Winsten linear regression method. Black women die more and the rate is decreasing less. Racial inequality has increased over the years. In 2002, there were 0.08 more deaths per 100,000 women in the black population than among white women; in 2021, the number was one death. Health policymaking should consider racial differences in the implementation of strategies and goals.

The global burden of cervical cancer requiring surgery: database estimates

BACKGROUND

Scaling up surgical services for cervical cancer in low and middle income countries requires quantification of the need for those services. The aim of this study was to estimate the global burden of cervical cancer for which access to surgery is required.

METHODS

This was a retrospective analysis of publicly available data. Cervical cancer incidence was extracted for each country from the World Health Organization, International Agency for Research, Global Cancer Observatory. The proportion of cases requiring surgery was extrapolated from the United States Surveillance, Epidemiology and End-Result database. The need for cervical cancer surgery was tested against development indicators.

RESULTS

Data were available for 175 countries, representing 2.9 billion females aged 15 and over. There were approximately 566,911 women diagnosed with cervical cancer (95% CI 565,462-568,360). An estimated 56.9% of these women (322,686) would require surgery for diagnosis, treatment or palliation (95% CI 321,955 - 323,417). Cervical cancers for which surgery is required represent less than 1% of cancers in high income countries, and nearly 10% of cancers in low income countries.

CONCLUSIONS

At least 300,000 cervical cancer cases worldwide require access to surgical services annually. Gathering data on available cervical cancer surgery services in LMIC are a critical next step.

Family physicians' moral distress when caring for patients experiencing social inequities: a critical narrative inquiry in primary care

BACKGROUND

Family physicians (GPs) working with patients experiencing social inequities have witnessed patients' healthcare needs proliferate. Alongside increased workload demands fostered within current remuneration structures, this has generated concerning reports of family physician attrition and possible experiences of moral distress.

AIM

To explore stories of moral distress shared by family physicians caring for patients experiencing health needs related to social inequities.

DESIGN AND SETTING

A critical narrative inquiry, informed by the analytic lens of moral distress, conducted in Ontario, Canada.

METHOD

Twenty family physicians were recruited through purposive and snowball sampling via word of mouth and email mailing lists relevant to addictions and mental health care. Physicians participated in two narrative interviews and had the opportunity to review the interview transcripts.

RESULTS

Family physicians' accounts of moral distress were linked to policies governing physician remuneration, scope of practice, and the availability of social welfare programmes. These structural elements left physicians unable to get patients much needed support and resources.

CONCLUSION

This study provides evidence that physicians experience moral distress when unable to offer crucial resources to improve the health of patients with complex social needs resulting from structural features of the Canadian health and social welfare system. Further research is needed to critically interrogate how health and social welfare systems around the world can be reformed to improve the health of patients and increase family physicians' professional quality of life, potentially improving retention.

CT-based radiomics nomogram for overall survival prediction in patients with cervical cancer treated with concurrent chemoradiotherapy

Background and purpose

To establish and validate a hybrid radiomics model to predict overall survival in cervical cancer patients receiving concurrent chemoradiotherapy (CCRT).

Methods

We retrospectively collected 367 cervical cancer patients receiving chemoradiotherapy from the First Affiliated Hospital of Soochow University in China and divided them into a training set and a test set in a ratio of 7:3. Handcrafted and deep learning (DL)-based radiomics features were extracted from the contrast-enhanced computed tomography (CT), and the two types of radiomics signatures were calculated based on the features selected using the least absolute shrinkage and selection operator (LASSO) Cox regression. A hybrid radiomics nomogram was constructed by integrating independent clinical risk factors, handcrafted radiomics signature, and DL-based radiomics signature in the training set and was validated in the test set.

Results

The hybrid radiomics nomogram exhibited favorable performance in predicting overall survival, with areas under the receiver operating characteristic curve (AUCs) for 1, 3, and 5 years in the training set of 0.833, 0.777, and 0.871, respectively, and in the test set of 0.811, 0.713, and 0.730, respectively. Furthermore, the hybrid radiomics nomogram outperformed the single clinical model, handcrafted radiomics signature, and DL-based radiomics signature in both the training (C-index: 0.793) and test sets (C-index: 0.721). The calibration curves and decision curve analysis (DCA) indicated that our hybrid nomogram had good calibration and clinical benefits. Finally, our hybrid nomogram demonstrated value in stratifying patients into high- and low-risk groups (cutoff value: 5.6).

Conclusion

A high-performance hybrid radiomics model based on pre-radiotherapy CT was established, presenting strengths in risk stratification.

Enhancing prognostic accuracy: a SEER-based analysis for overall and cancer-specific survival prediction in cervical adenocarcinoma patients

BACKGROUND

Cervical adenocarcinoma (CA) is the second most prevalent histological subtype of cervical cancer, following cervical squamous cell carcinoma (CSCC). As stated in the guidelines provided by the National Comprehensive Cancer Network, they are staged and treated similarly. However, compared with CSCC patients, CA patients are more prone to lymph node metastasis and recurrence with a poorer prognosis. The objective of this research was to discover prognostic indicators and develop nomograms that can be utilized to anticipate the overall survival (OS) and cancer-specific survival (CSS) of patients diagnosed with CA.

METHODS

Using the Surveillance, Epidemiology, and End Result (SEER) database, individuals with CA who received their diagnosis between 2004 and 2015 were identified. A total cohort (n = 4485) was randomly classified into two separate groups in a 3:2 ratio, to form a training cohort (n = 2679) and a testing cohort (n = 1806). Overall survival (OS) was the primary outcome measure and cancer-specific survival (CSS) was the secondary outcome measure. Univariate and multivariate Cox analyses were employed to select significant independent factors and Least Absolute Shrinkage and Selection Operator (LASSO) Cox regression analysis was utilized to develop predictive nomogram models. The predictive accuracy and discriminatory ability of the nomogram were assessed by employing metrics such as the calibration curve, receiver operating characteristic (ROC) curve, and the concordance index (C-index).

RESULTS

Age, Tumor Node Metastasis stages (T, N, and M), SEER stage, grade, and tumor size were assessed as common independent predictors of both OS and CSS. The C-index value of the nomograms for predicting OS was 0.832 (95% CI 0.817-0.847) in the training cohort and 0.823 (95% CI 0.805-0.841) in the testing cohort.

CONCLUSION

We developed and verified nomogram models for predicting 1-, 3- and 5-year OS and CSS among patients with cervical adenocarcinoma. These models exhibited excellent performance in prognostic prediction, providing support and assisting clinicians in assessing survival prognosis and devising personalized treatments for CA patients.

Survival differences by race and surgical approach in early-stage operable cervical Cancer

OBJECTIVE

To evaluate if the higher rate of open radical hysterectomy in Black patients, prior to the widespread return to open surgical techniques, mitigated survival disparities and to identify other actionable factors to target for systemic change.

METHODS

This is a retrospective cohort study including patients from the National Cancer Database with cervical cancer who underwent radical hysterectomy from 2010 to 2018. Patient demographics, clinical characteristics and survival were compared by race and surgical route. Kaplan-Meier plots were constructed. Cox proportional hazards modeling was used to adjust for covariates.

RESULTS

7201 patients were eligible for inclusion, 687 (9.5%) Black and 4870 (68%) White. We found that 51% of Black patients and 39% of White patients underwent open surgery. Black patients were 10% less likely to receive Guideline Concordant Care (GCC). Those with publicly-funded insurance had a 40% higher hazard of death compared to private insurance (CI 1.19-1.73 p < 0.001). Black patients who had open surgery had similar 5-year survival compared to White patients who had MIS surgery (0.90 vs 0.91, NS). After adjusting for potential confounders including age, insurance, nodal status, and lymphovascular space invasion, Black patients who had surgery had a 40% higher hazard for death (HR 1.40 95% CI 1.10-1.79, p = 0.007) compared to White patients.

CONCLUSIONS

A lower 5 and 10-year survival was seen in Black patients, regardless of surgical approach. Adjustment for significant covariates did not resolve this disparity, confirming that these factors do not fully account racial disparities.

Uptake of Cervical Cancer Screening Among Female Patients Using a Mobile Medical Clinic

INTRODUCTION

Although cervical cancer causes morbidity, it can be prevented if diagnosed early; previous research has shown lower rates of screening in patients with health-related social needs by self-report data. This study assessed cervical cancer screening uptake among female patients with health-related social needs who access care through a community-based mobile medical clinic.

METHODS

A retrospective cohort was developed of all cis-female patients aged 21-65 years who sought care at the mobile medical clinic between January 1, 2016 and December 31, 2019, and their medical data were captured from the electronic health record. Bivariate and multivariate logistic regression (performed in 2022/2023) were used to investigate correlates of ever having received cervical cancer screening and of being up to date with cervical cancer screening.

RESULTS

Less than half of the 1,455 patient cohort had ever undergone Pap testing. In the multivariate model, ever having received cervical cancer screening was directly associated with being Hispanic or Black, living with HIV, and having received human papillomavirus vaccination. People who currently smoke showed significantly lower odds of ever having had cervical cancer screening than people who have never smoked. Patients who were single or had other marital status had lower adjusted odds of being up to date as well as those with a substance use history and those with unstable housing.

CONCLUSIONS

Cervical cancer screening rates in this community-based mobile medical clinic model were low, highlighting a need for increased attention to screening in this high-risk population. Mobile medical clinics have increased screening uptake internationally, and this model could be adopted domestically to promote screening to patients who access health care in various settings.

Recent Advances and Adaptive Strategies in Image Guidance for Cervical Cancer Radiotherapy

The standard of care for locally advanced cervical cancer is external beam radiotherapy (EBRT) with simultaneous chemotherapy followed by an internal radiation boost. New imaging methods such as positron-emission tomography and magnetic resonance imaging have been implemented into daily practice for better tumor delineation in radiotherapy planning. The method of delivering radiation has changed with technical advances in qualitative imaging and treatment delivery. Image-guided radiotherapy (IGRT) plays an important role in minimizing treatment toxicity of pelvic radiation and provides a superior conformality for sparing the organs at risk (OARs) such as bone marrow, bowel, rectum, and bladder. Similarly, three-dimensional image-guided adaptive brachytherapy (3D-IGABT) with computed tomography (CT) or magnetic resonance imaging (MRI) has been reported to improve target coverage and reduce the dose to normal tissues. Brachytherapy is a complementary part of radiotherapy treatment for cervical cancer and, over the past 20 years, 3D-image-based brachytherapy has rapidly evolved and established itself as the gold standard. With new techniques and adaptive treatment in cervical cancer, the concept of personalized medicine is introduced with an enhanced comprehension of the therapeutic index not only in terms of volume (three-dimensional) but during treatment too (four-dimensional). Current data show promising results with integrated IGRT and IGABT in clinical practice and, therefore, better local control and overall survival while reducing treatment-related morbidity. This review gives an overview of the substantial impact that occurred in the progress of image-guided adaptive external beam radiotherapy and brachytherapy.

Effect Modification of Race on the Associated Tumor Size at Diagnosis and 10-Year Cancer Survival Rates in Women with Cervical Squamous Cell Carcinoma in the United States

BACKGROUND

While there may be an association between race, tumor size, and survival in patients with cervical squamous cell carcinoma (SCC), evidence on the effect of race on the association between tumor size at diagnosis and survival is limited. Our study evaluated whether race modifies the association between tumor size and 10-year survival in cervical SCC.

METHODS

This non-concurrent cohort study with the Surveillance, Epidemiology, and End Results (SEER) database included women diagnosed with cervical SCC between 2004-2018. The independent variable was diagnosis tumor size, where 2-4 cm was classified as high risk, and <2 cm was considered low risk. The dependent variable was 10-year cancer-specific survival rates, and race was our effect modifier. Unadjusted and adjusted Cox regression analysis were conducted to calculate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

While a higher proportion of Black/Asian/Pacific Islander patients presented with tumor sizes of 2-4 cm compared to <2 cm (32.8% vs. 22.3%; p = 0.007) and having a tumor size of 2-4 cm had a significantly decreased 10-year survival (HR: 2.7; 95% CI: 1.3-5.8), the interaction between race and 10-year cancer-specific survival was not significant.

CONCLUSION

Although race did not modify the interaction between tumor size and 10-year survival, emphasis needs to be placed on screening and proper data collection, especially for minority races, and studies with larger sample sizes should be conducted in order to better implement future recommendations to improve health and survival.

Trends in Adolescent Human Papillomavirus Vaccination and Parental Hesitancy in the United States

BACKGROUND

Human papillomavirus (HPV) vaccination coverage remains suboptimal in the United States, underscoring the importance of monitoring trends in vaccine hesitancy.

METHODS

Cross-sectional data from the 2011-2020 National Immunization Survey-Teen were used to assess trends in HPV vaccination initiation among 13-17-year-olds, parental intent to initiate vaccination, and primary reasons for parental hesitancy.

RESULTS

Among all sex and race and ethnicity groups, the prevalence of HPV vaccination initiation increased over time, but parental intent to vaccinate against HPV for unvaccinated teens remained consistently low (≤45%). Among hesitant parents, "safety concerns" increased in nearly all demographic groups, with the greatest increases observed for non-Hispanic white female and male teens and no change for non-Hispanic black female teens. In 2019-2020, parents of unvaccinated non-Hispanic white teens were least likely to intend on vaccinating their teens, and the most common reason for hesitancy varied by sex and race and ethnicity (eg, "safety concerns" for white teens and "not necessary" for black female teens).

CONCLUSIONS

Although HPV vaccination initiation increased over time, a substantial fraction of parents remain hesitant, and trends in their reason varied by sex and race and ethnicity. Health campaigns and clinicians should address vaccine safety and necessity.

Age-Specific Trends of Invasive Cervical Cancer Incidence in British Columbia, Canada, 1971-2017

This study examined invasive cervical cancer (ICC) incidence trends in British Columbia (BC) by age and stage-at-diagnosis relative to World Health Organization ICC elimination targets (4 per 100,000 persons). Incident ICC cases (1971-2017) were obtained from the BC Cancer Registry. Annual age-standardized incidence rates (ASIRs) per 100,000 persons were generated using the direct method. ASIRs were examined among all ages 15+ years and eight age groups using Joinpoint Regression with the Canadian 2011 standard population. Standardized rate ratios (SRRs) compared stage II-IV (late) versus stage I (early) ASIRs by age (2010-2017). ICC ASIRs did not reach the elimination target. ASIRs declined from 18.88 to 7.08 per 100,000 persons (1971-2017). Stronger declines were observed among ages 45+ years, with the largest decline among ages 70-79 years (AAPC = -3.2%, 95% CI = -3.9% to -2.6%). Among ages 25-69 years, varying levels of attenuation in declining trends and stabilization were observed since the 1980s. SRRs indicated higher rates of late-stage ICC among ages 55+ years (SRR-55-69 years = 1.34, 95% CI = 1.08-1.71). Overall, ICC incidence declined in BC since 1971 but did not reach the elimination target. The pace of decline varied across age groups and increased with age. Continued efforts are needed to progress cervical cancer elimination among all age groups.

Connecting the dots in the associations between diet, obesity, cancer, and microRNAs

The prevalence of obesity has reached pandemic levels worldwide, leading to a lower quality of life and higher health costs. Obesity is a major risk factor for noncommunicable diseases, including cancer, although obesity is one of the major preventable causes of cancer. Lifestyle factors, such as dietary quality and patterns, are also closely related to the onset and development of obesity and cancer. However, the mechanisms underlying the complex association between diet, obesity, and cancer remain unclear. In the past few decades, microRNAs (miRNAs), a class of small non-coding RNAs, have been demonstrated to play critical roles in biological processes such as cell differentiation, proliferation, and metabolism, highlighting their importance in disease development and suppression and as therapeutic targets. miRNA expression levels can be modulated by diet and are involved in cancer and obesity-related diseases. Circulating miRNAs can also mediate cell-to-cell communications. These multiple aspects of miRNAs present challenges in understanding and integrating their mechanism of action. Here, we introduce a general consideration of the associations between diet, obesity, and cancer and review the current knowledge of the molecular functions of miRNA in each context. A comprehensive understanding of the interplay between diet, obesity, and cancer could be valuable for the development of effective preventive and therapeutic strategies in future.

Construction of a prognostic signature of RFC5 immune-related genes in patients with cervical cancer

BACKGROUND

Cervical cancer (CC) is a malignant tumor threatening women's health. Replication factor C (RFC) 5 is significantly highly expressed in CC tissues, and the immune microenvironment plays a crucial role in tumor initiation, progression, and metastasis.

OBJECTIVE

To determine the prognostic role of RFC5 in CC, analyze the immune genes significantly associated with RFC5, and establish a nomogram to evaluate the prognosis of patients with CC.

METHODS

High RFC5 expression in patients with CC was analyzed and verified through TCGA GEO, TIMER2.0, and HPA databases. A risk score model was constructed using RFC5-related immune genes identified using R packages. Combining the risk score model and clinical information of patients with CC, a nomogram was constructed to evaluate the prognosis of patients with CC.

RESULTS

Comprehensive analysis showed that the risk score was a prognostic factor for CC. The nomogram could predict the 3-year overall survival of patients with CC.

CONCLUSIONS

RFC5 was validated as a biomarker for CC. The RFC5 related immune genes were used to establish a new prognostic model of CC.

Patient, disease, and survival outcomes for stage IB to stage IV cervical cancer-A population study

BACKGROUND

Factors that impact recurrence in stages IB to IV include larger tumor, high-risk histology, older age, and lymphovascular invasion (LVI); however, local studies on risk factors for recurrence in British Columbia and our local recurrence patterns have not been well studied. Furthermore, the efficacy of treatment modalities including surgery and chemoradiation in the different stages of cervical cancer have not been clarified in this population.

OBJECTIVES

The purpose of this study is to determine the disease and treatment characteristics of stages IB to IV cervical cancer which are associated with survival differences within British Columbia.

METHODS/DESIGN

We performed a retrospective population study. A chart review on cervical cancer patients in British Columbia between 1 January 2010 and 31 December 2017 was done. Demographic data and treatment details were collected. Data were analyzed using multivariate Cox regressions, pairwise comparison using the Log-Rank test, and chi-square tests.

RESULTS

We included 780 patients (stage I: 31.5%, II: 20.0%, III: 34.5%, and IV: 3.3%). LVI and p16 negativity were associated with decreased overall survival (OS), and multivariate analyses show them to be independent risk factors for poorer survival. Surgical resection in stage I was associated with improved survival, but not with stages II-IV. The use of radical radiation therapy (RT), brachytherapy, and concurrent chemotherapy were independently associated with improved survival in stages II-IV. Peri-RT chemotherapy was not associated with survival benefit in adeno/adenosquamous carcinoma. There were 180 recurrences (23.1%), mostly distant metastases (42.8%). There were fewer recurrences after resection of tumors <2 cm compared to tumors 2 cm or larger (6.49% vs 31.3%, p = 0.00011). Only 37.7% of recurrence/metastases were treated with first-line carboplatin/paclitaxel/bevacizumab, but it was associated with better OS compared to other regimens (median OS 40.1 vs 24.8 months, p = 0.03).

CONCLUSION

A significant portion of patients with localized cervical cancer relapse despite radical therapy, with LVI and p16 negativity associated with poorer survival. Surgical resection may still play a role in stage IB disease, while RT, brachytherapy, and concurrent chemotherapy should be considered first-line therapy in stage II-IV diseases. First-line carboplatin, paclitaxel, and bevacizumab for recurrence shows improved survival.

Epidemiology and survival of cervical cancer in Iran based on national cancer registry data (2008-2014)

Background

Cervical cancer (CC) is the third most commonly diagnosed cancer and the fourth leading cause of cancer death in females worldwide, associated with the incidence of human papillomavirus (HPV) infection. The CC incidence is low in Iran, ranking 11th among cancers. This study aimed to estimate the survival rate of CC and the reasons for its low survival rate based on the data retrieved from the Iranian National Cancer Registry System.

Methods

In this retrospective cohort study, data for patients diagnosed with CC from 2008 to 2014 were collected and analyzed. The Kaplan-Meier method was used for survival analysis based on epidemiological and clinical factors.

Results

A total of 5,304 women were diagnosed from March 10, 2008 to March 9, 2014 and 2,423 patients were followed. The mean age of the cases was 51.91 years, and 65.91% were alive. The 5- and 10-year survival rates were 58% and 50%, respectively, with no difference between younger cases with SCC or AC but better survival rates for older patients with SCC.

Conclusions

As a preventable disease, CC is related to biological factors and geographical and sociodemographic indices. Geographical, cultural, and religious behaviors affect the CC incidence and survival. In Iran, the 5-year survival rate ranges from 34% to 70% among different geographic regions. Hence, effective screening based on cultural and sociodemographic issues is recommended.

PLAU is associated with cell migration and invasion and is regulated by transcription factor YY1 in cervical cancer

Cervical cancer, one of the most common malignancies, has a poor survival rate. The identification of more biomarkers for cervical cancer diagnosis and therapy is urgently needed. Plasminogen activator urokinase (PLAU) exerts multiple biological effects in various physiological and pathological processes; however the role of PLAU in cervical cancer progression is not fully understood. In the present study, the involvement and transcriptional regulation of PLAU in cervical cancer were explored. The expression of PLAU in cervical cancer was first analyzed, and PLAU was found to be overexpressed. In vitro experiments demonstrated that the migration and invasion of HeLa and HT3 cells were significantly suppressed by PLAU knockdown. Additionally, the core promoter of PLAU was confirmed, and the transcription factor YinYang 1 (YY1) was found to regulate PLAU mRNA expression. Overall, the present study elucidated the direct association between PLAU and cervical cancer, suggesting the YY1/PLAU axis as a potential novel therapeutic target for cervical cancer.

Molecular Heterogeneity of Cervical Cancer Among Different Ethnic/Racial Populations

The study aimed to find differential gene mutation profile and gene expression status among different ethnic/racial human populations relevant for cervical cancer pathogenesis. The study was based on freely available datasets of The Cancer Genome Atlas (TCGA) of cervical cancer samples in Genomic Data Commons (GDC) data portal. We identified that choline metabolism in cancer and Ras signaling pathways were significantly associated with the Hispanic and Latino group of cervical cancer patients. In these pathways, mutations in the PIK3CA gene, especially E545K, were significantly associated with the Hispanic and LATINO group. We found that AFF3 gene mutation was associated with downregulation of its expression only among the White racial category of cervical cancer cases. Additionally, hypomethylation of the CpG position in the S shore region of the PM20D1 gene was associated with overexpression among the Asian category of cervical cancer cases. Heterogeneity of the molecular profile of AFF3 and PM20D1 gene among racial groups reflects the potential of differential targeted therapy of cervical cancer.

Differences in Cancer Screening Responses to State Medicaid Expansions by Race and Ethnicity, 2011‒2019

Objectives. To estimate whether state Medicaid expansions' relationships to breast, cervical, and colorectal cancer screening differ by race/ethnicity. Methods. Analyses conducted in 2021 used 2011-2016 and 2018-2019 Behavioral Risk Factor Surveillance System data on adults aged 40 to 64 years with household incomes below 400% of the federal poverty guideline (FPG; n = 537 250). Triple-difference analyses compared cancer screening in Medicaid expansion versus nonexpansion states, before versus after expansion, among people with incomes above versus below the eligibility cutoff (138% FPG). Race/ethnicity and ethnicity-by-language interaction terms tested for effect modification. Results. Associations between Medicaid expansions and cancer screening were significant for past-2-year mammograms and past-5-year colorectal screening. Effect modification analyses showed elevated mammography among non-Hispanic Asian women (+9.0 percentage points; 95% confidence interval [CI] = 3.2, 14.8) and Hispanic women (+6.0 percentage points; 95% CI = 2.0, 10.1), and Papanicolaou tests among Hispanic women (+4.2 percentage points; 95% CI = 0.1, 8.2). Findings were not limited to English- or Spanish-speaking respondents and were robust to insurance status controls. Conclusions. Medicaid expansions yielded statistically significant increases in income-eligible Asian and Hispanic women's mammography and Hispanic women's Pap testing relative to non-Hispanic White women. Neither language proficiency nor insurance status explained these findings. (Am J Public Health. 2022;112(11):1630-1639. https://doi.org/10.2105/AJPH.2022.307027).

Current gaps and opportunities in screening, prevention, and treatment of cervical cancer

In their fiscal year 2021 reports, the US House and Senate Appropriations Committees requested that the National Institutes of Health (NIH) evaluate current research related to women's health and topics that include stagnant cervical cancer survival. In response, the NIH Office of Research on Women's Health, with input from women's health experts; members of the public; representatives from NIH institutes, centers, and offices; and members of the NIH Advisory Committee on Research on Women's Health, reviewed the public health needs and current NIH activities on cervical cancer. The Advancing NIH Research on the Health of Women: A 2021 Conference held in October 2021 reviewed these findings and allowed the identification of opportunities to strengthen research. In this review, the authors summarize public health needs related to cervical cancer and NIH activities in this realm. Cervical cancer has become a rare disease in the United States, yet significant portions of the US population remain under screened or unscreened for cervical cancer, human papillomavirus vaccination rates remain low, access to high-quality treatment remains a challenge for many, and large inequities by race and ethnicity persist. Novel, inclusive, and intentional research is needed to produce improvements in cervical cancer survival within the United States.

The increasing incidence of stage IV cervical cancer in the USA: what factors are related?

OBJECTIVE

Cervical cancer (International Federation of Gynecology and Obstetrics (FIGO)) stage IVA-B (distant stage) is a rare diagnosis with an approximate 5 year survival rate of 17% and with limited treatment options. The objective of this study was to determine the trends in distant stage cervical cancer in the USA and identify possible factors related to these trends.

METHODS

Data were obtained from the United States Cancer Statistics program from 2001 to 2018. Rates of cervical cancer screening and vaccination were evaluated using the Behavioral Risk Factor Surveillance System and TeenVaxView. SEER*Stat 8.3.8.9.2 and Joinpoint regression program 4.9.0.0 were used to calculate incidence trends.

RESULTS

Over the last 18 years, 29 715 women were diagnosed with distant stage cervical carcinoma. Black women have disproportionately higher rates at 1.55/100 000 versus 0.92/100 000 in White women (p<0.001). When examining the trends over time, there has been an annual increase in distant stage cervical cancer at a rate of 1.3% per year (p<0.001). The largest increase is seen in cervical adenocarcinoma with an average annual percent change of 2.9% (p<0.001). When performing an intersection analysis of race, region and age, White women in the South aged 40-44 have the highest rise in distant cervical cancer at a rate of 4.5% annually (p<0.001). Using the Behavioral Risk Factor Surveillance System and TeenVax data, compared with Black women, we found that White women have a nearly two-fold higher rate of missed or lack of guideline screening, 26.6% vs 13.8%. White teenagers (13-17 years) have the lowest human papillomavirus vaccination rate at 66.1% compared with others at 75.3%.

CONCLUSIONS

Black women have a higher incidence of distant stage disease compared with White women. However, White women have a greater annual increase, particularly in adenocarcinomas. Compared with Black women, White women also have lower rates of guideline screening and vaccination.

Advances in Radiation Oncology for the Treatment of Cervical Cancer

Background: Over the past two decades, there has been significant advancement in the management of cervical cancer, particularly in the domain of definitive chemoradiotherapy for locally advanced cervical cancer (LACC). Indeed, radiation treatment paradigms have shifted from a two-dimensional (2D) approach solely based on anatomical bony landmarks, to an image-guided three-dimensional (3D) approach, with the goal of delivering doses more precisely to clinical targets with an increased sparing of organs-at-risk. Methods: This is a narrative review on the advances in radiation technologies for the treatment of cervical cancer. Using the PubMed database, we identified articles published in English up until November 18, 2021 on the treatment of LACC with external beam radiotherapy (EBRT) and brachytherapy. A search of the Clinicaltrials.gov and Clinicaltrialsregister.eu retrieved information on ongoing clinical trials on the topic of combined immunotherapy and radiotherapy in cervical cancer. Results: We highlight the historical evolution from the use of 2D radiotherapy to 3D-conformal radiotherapy, and then intensity modulated radiotherapy (IMRT) for the delivery of EBRT. We also discuss advances in brachytherapy, notably the transition to 3D image-guided adaptive brachytherapy (3D-IGABT). In this context, we highlight large cohort studies that were recently constructed and have shown significant improvement in local control and treatment-related toxicities with 3D-IGABT. Finally, we discuss other advances in the field, notably the use of stereotactic body radiotherapy (SBRT) as a substitute to brachytherapy, and the addition of immunotherapy to chemoradiation. Conclusions: The use of IG-IMRT and 3D-IGABT have considerably improved treatment outcomes and toxicity profiles for patients with LACC, and are now considered the gold standard in many countries. The use of SBRT boost as a replacement for brachytherapy has been associated with increased toxicity and decreased efficacy and should be used with caution in the context of clinical trials. New experimental approaches include the addition of immunotherapy to chemoradiation regimens.

A descriptive study of cervical cancer survivors' persistent smoking behavior and perceived barriers to quitting

OBJECTIVE

Cervical cancer survivors (CCS) tend to smoke cigarettes at rates much higher than other cancer survivors and women in the general population. However, few studies take a deep dive into the smoking behavior of cervical cancer survivors and none focus on the barriers they experience related to smoking cessation. This study aimed to describe CCS' tobacco use characteristics, quit attempts, and barriers to quit success.

METHOD

In a concurrent mixed-method design, 50 CCS (94% White nonHispanic) who were diagnosed in the past 5 years and were current smokers at diagnosis provided data via standardized questionnaire and semi-structured interview.

RESULTS

More than three-quarters of participants were current smokers at the time of study participation, 25.6% of whom also reported noncigarette tobacco use (e.g., electronic cigarette, cigar, snus). Seventy percent of participants reported making at least one 24 hr quit attempt postdiagnosis, with 61.5% of current smokers preferring to quit without professional advice or counseling and 51.3% preferring to quit without medication assistance. Four themes emerged regarding barriers to smoking cessation: motivation and readiness; confidence and uncertainty; triggers; and social and environmental factors.

CONCLUSIONS

The rate of smoking in CCS is remarkably high, which may partly be explained by negative attitudes toward and low use of evidence-based treatment as well as multi-level barriers to smoking cessation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Bioinformatic Analysis for the Prognostic Implication of Genes Encoding Epithelial Sodium Channel in Cervical Cancer

Background

Cervical cancer is one of the leading causes of death in women. Among the sodium ion channels associated with cancer development, voltage gated sodium channel plays an important role in pathophysiology of cervical cancer; however, the clinicopathological implication of epithelial sodium channel (ENaC) has not been explored.

Purpose

This study focused on identifying dysregulation of ENaC encoding genes, including SCNN1A, SCNN1B, and SCNN1G, and their relationship with clinicopathologic features in cervical cancer patients.

Materials and Methods

RNA sequencing data of ENaC-encoding genes, clinicopathologic data, and survival data of cervical cancer patients were obtained from The Cancer Genome Atlas cohort. Microarray data of ENaC-encoding genes were obtained from Gene Expression Omnibus datasets: GSE6791 and GSE63514.

Results

The expression levels of SCNN1A, SCNN1B, and SCNN1G were positively correlated with each other. SCNN1A, SCNN1B, and SCNN1G are significantly overexpressed in normal tissues than in tumor tissues. Survival analysis showed that simultaneous overexpression of all three genes associated with better overall survival (OS). Each overexpression of SCNN1B and SCNN1G was significantly associated with better OS. Moreover, each expression level of SCNN1A, SCNN1B, and SCNN1G was negatively correlated with histologic grade of tumor.

Conclusion

ENaC-encoding genes might be potential biological markers to better predict survival outcomes in cervical cancer patients.

To what extent do age, stage and treatment influence survival after invasive cervical cancer: a French population-based study

PURPOSE

In an attempt to understand why cervical cancer (CC) survival is decreasing with diagnosis period among older women in France, this study aimed to estimate the effects of main prognostic factors on net survival in CC according to age.

METHODS

French cancer registries databases were used to retrospectively analyze women diagnosed with CC in 2011-2012. Net survival was estimated with the Pohar-Perme method and prognostic factors (socio-demographic, clinical variables, stage at diagnosis, therapeutic management) were analyzed with Lambert and Royston's flexible parametric model.

RESULTS

One thousand one hundred fifty three women with CC were identified. 30.4% were < 45, 41.4% 45-64, and 28.3% ≥ 65 years. Older women were diagnosed at a more advanced stage than younger women: 54.8% regional (FIGO IB2-IVA), 33.0% distant (IVB) in women ≥ 65 years vs 33.7% and 8.0%, respectively in women < 45 years. Half of women with regional stage of CC received recommended treatment; this rate decreased with increasing age (< 45: 66.1%, 45-64: 62.7%, ≥ 65: 29.2%). Older age was significantly associated with increased risk of death: hazard ratio 1.89 for age ≥ 65, as were regional stage (2.81), distant stage (15.99), and not receiving recommended treatment (2.26).

CONCLUSION

Older women with CC diagnosed at advanced stage who do not receive standard of care are at markedly increased risk of death. Special attention to the management of older women is warranted in France, not only to diagnose cancer at an earlier stage (via gynecological follow-up in these menopaused women who remain at risk of CC), but also to ensure they receive standard of care, taking into account their overall state of health.

Second primary malignancies associated with radiation therapy in cervical cancer patients diagnosed between 1975 and 2011: a population-based competing-risk study

Background

Cervical cancer is a major health threat for women. Radiotherapy plays an important role in the treatment of cervical cancer. However, its overall benefit has been questioned due to the risk of second primary malignancies.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was used to search for cervical cancer patients diagnosed between January 1975 and November 2011. Factors that could possibly affect the occurrence of second primary malignancies included the year of diagnosis, gender, ethnicity, histologic type, SEER cancer stage, histology, grade, and whether surgery, chemotherapy, or radiotherapy were used. Age-adjusted and propensity scoring matching (PSM)-adjusted competing-risk analysis was applied for analysis.

Results

Of the 23,112 patients identified through SEER, 14,800 (64.0%) received radiotherapy. Second malignancies were diagnosed in 2,545 (11.0%) cases. PSM-adjusted competing analysis revealed that patients receiving radiotherapy had a significantly higher risk of developing a second cancer in the colon, rectum and anus [hazard ratio (HR): 1.43; 95% confidence interval (CI): 1.09-1.87; P=0.01], lung and bronchus (HR: 1.41; 95% CI: 1.13-1.76; P=0.002), corpus uteri (HR: 3.71; 95% CI: 1.71-8.06; P<0.001), ovary (HR: 2.79; 95% CI: 1.38-5.64; P=0.004), and urinary bladder (HR: 2.18; 95% CI: 1.35-3.54; P=0.002). However, radiotherapy significantly lowered the risk of second cancers in the female breast (HR: 0.67; 95% CI: 0.52-0.86; P=0.002). Age-adjusted competing-risk analysis showed generally consistent results.

Conclusions

Radiotherapy increased the risk of second cancers among cervical cancer patients. Those who underwent radiotherapy had a significantly higher risk of developing a second cancer in the colon, rectum and anus, lung and bronchus, corpus uteri, ovary, and urinary bladder.

Comprehensive bioinformatic analysis reveals oncogenic role of H2A.Z isoforms in cervical cancer progression

Objectives

Cervical cancer ranks as the fourth most common neoplasia in women worldwide in which epigenetic alterations play an important role. Several studies have reported pro-oncogenic role of the histone variant H2A.Z in different types of cancer; however, the role of H2A.Z in cervical cancer remains poorly studied. This study aimed to determine the potential role of H2A.Z in cervical cancer through a bioinformatic approach.

Materials and Methods

H2A.Z expression was analyzed in The Human Protein Atlas, The Cancer Genome Atlas, and Gene Expression Omnibus datasets. The promoter regions of H2AZ1 and H2AZ2 genes were downloaded from Expasy, and the prediction of transcription factor binding motifs was performed using CONSITE, Alibaba, and ALGGEN. ChIP-seq and RNA-seq data from HeLa-S3 cells were downloaded from ENCODE. The discovery motif was investigated using MEME-ChIP. The functional annotation was examined in Enrich.

Results

The expression of H2A.Z is elevated in cervical cancer. Interestingly, DNA methylation, copy number, and transcription factors AP2α and ELK1 are involved in H2A.Z overexpression. Additionally, H2A.Z is enriched on promoter and enhancer regions of genes involved in pathways associated with cancer development. In these regions, H2A.Z enables the recruitment of transcription factors such as NRF1, NFYA, and RNA Pol II. Finally, H2A.Z allows the expression of genes associated with proliferation in patients with cervical cancer.

Conclusion

Our findings suggest that H2A.Z overexpression and its presence in promoters and enhancers could be regulating the transcription of genes involved in cervical carcinogenesis.

Disparities in cervical cancer survival in the United States by race and stage at diagnosis: An analysis of 138,883 women diagnosed between 2001 and 2014 (CONCORD-3)

OBJECTIVE

During 2000-2014, age-standardized five-year net survival for cervical cancer was 63-64% in the United States. Using data from CONCORD-3, we analyzed cervical cancer survival trends by race, stage and period of diagnosis.

METHODS

Data from 41 state-wide population-based cancer registries on 138,883 women diagnosed with cervical cancer during 2001-2014 were available. Vital status was followed up until December 31, 2014. We estimated age-standardized five-year net survival, by race (Black or White), stage and calendar period of diagnosis (2001-2003, 2004-2008, 2009-2014) in each state, and for all participating states combined.

RESULTS

White women were most commonly diagnosed with localized tumors (45-50%). However, for Black women, localized tumors were the most common stage (43.0%) only during 2001-2003. A smaller proportion of Black women received cancer-directed surgery than White women. For all stages combined, five-year survival decreased between 2001-2003 and 2009-2014 for both White (64.7% to 63.0%) and Black (56.7% to 55.8%) women. For localized and regional tumors, survival increased over the same period for both White (by 2-3%) and Black women (by 5%). Survival did not change for Black women diagnosed with distant tumors but increased by around 2% for White women.

CONCLUSIONS

Despite similar screening coverage for both Black and White women and improvements in stage-specific survival, Black women still have poorer survival than White women. This may be partially explained by inequities in access to optimal treatment. The results from this study highlight the continuing need to address the disparity in cervical cancer survival between White and Black women in the United States.

Comorbidity as a predictor of racial and ethnic disparities in cancer in the United States population

Aims

This study aims to examine the racial and ethnic disparity in cancer prevalence and determine if comorbidities can explain this disparity.

Study design

This was a cross-sectional study.

Methods

The study examined cancer prevalence among adults who self-identified as White, Black, and Other races in the US population according to data from the 2017 National Health Interview Survey.

Results

Cancer was 58.5% [OR = 0.415; 95% CI: 0.346–0.498] and 57.5% [OR = 0.425; 95%CI: 0.346–0.522] more likely to be found in the White compared to the Black adults and White compared to Other race adults, respectively. After adjusting for the comorbidities, the odds of cancer in White adults increased marginally compared to Black adults [OR = 0.407; 95%CI: 0.338–0.490] and decreased marginally compared to Other race adults [OR = 0.462; 95%CI: 0.374–0.569] even though the odds remained significant. Ever smoking, age of 50 years or more, Former and current alcohol consumption, overweight and obesity, being female and physical inactivity were found to be significantly associated with higher odds of cancer.

Conclusions

This study did identify a racial and ethnic disparity in cancer prevalence between White and Black adults and White and Other adult races. However, this racial and ethnic disparity could not be explained by comorbidities.

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Comorbidity in white and black disparity in a US population with cancer.

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Hypertension can predict cancer racial disparity.

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Comorbidity cancer prevalence in ethnic disparity.

Prevalence of HER2 overexpression and amplification in cervical cancer: A systematic review and meta-analysis

The reported rates of HER2 positivity in cervical cancer (CC) range from 0% to 87%. The importance of HER2 as an actionable target in CC would depend on HER2 positivity prevalence. Our aim was to provide precise estimates of HER2 overexpression and amplification in CC, globally and by relevant subgroups. We conducted a PRISMA compliant meta-analytic systematic review. We searched Medline, EMBASE, Cochrane database, and grey literature for articles reporting the proportion of HER2 positivity in CC. Studies assessing HER2 status by immunohistochemistry or in situ hybridization in invasive disease were eligible. We performed descriptive analyses of all 65 included studies. Out of these, we selected 26 studies that used standardized American Society of Clinical Oncology / College of American Pathologists (ASCO/CAP) Guidelines compliant methodology. We conducted several meta-analyses of proportions to estimate the pooled prevalence of HER2 positivity and subgroup analyses using geographic region, histology, tumor stage, primary antibody brand, study size, and publication year as moderators. The estimated pooled prevalence of HER2 overexpression was 5.7% (CI 95%: 1.5% to 11.7%) I2 = 87% in ASCO/CAP compliant studies and 27.0%, (CI 95%: 19.9% to 34.8%) I2 = 96% in ASCO/CAP non-compliant ones, p < 0.001. The estimated pooled prevalence of HER2 amplification was 1.2% (CI 95%: 0.0% to 5.8%) I2 = 0% and 24.9% (CI 95%: 12.6% to 39.6%) I2 = 86%, respectively, p = 0.004. No other factor was significantly associated with HER2 positivity rates. Our results suggest that a small, but still meaningful proportion of CC is expected to be HER2-positive. High heterogeneity was the main limitation of the study. Variations in previously reported HER2 positivity rates are mainly related to methodological issues.

Identification of a novel six-gene signature with potential prognostic and therapeutic value in cervical cancer

Introduction

Cervical cancer has high mortality, high recurrence and poor prognosis. Although prognostic biomarkers such as clinicopathological features have been proposed, their accuracy and precision are far from satisfactory. Therefore, novel biomarkers are urgently needed for disease surveillance, prognosis prediction and treatment selection.

Materials

Differentially expressed genes (DEGs) between cervical cancer and normal tissues from three microarray datasets extracted from the Gene Expression Omnibus platform were identified and screened. Based on these DEGs, a six‐gene prognostic signature was constructed using cervical squamous cell carcinoma and endocervical adenocarcinoma data from The Cancer Genome Atlas. Next, the molecular functions and related pathways of the six genes were investigated through gene set enrichment analysis and co‐expression analysis. Additionally, immunophenoscore analysis and the QuartataWeb Server were employed to explore the therapeutic value of the six‐gene signature.

Results

We discovered 178 overlapping DEGs in three microarray datasets and established a six‐gene (APOC1, GLTP, ISG20, SPP1, SLC24A3 and UPP1) prognostic signature with stable and excellent performance in predicting overall survival in different subgroups. Intriguingly, the six‐gene signature was closely associated with the immune response and tumour immune microenvironment. The six‐gene signature might be used for predicting response to immune checkpoint inhibitors (ICIs) and the six genes may serve as new drug targets for cervical cancer.

Conclusion

Our study established a novel six‐gene (APOC1, GLTP, ISG20, SPP1, SLC24A3 and UPP1) signature that was closely associated with the immune response and tumour immune microenvironment. The six‐gene signature was indicative of aggressive features of cervical cancer and therefore might serve as a promising biomarker for predicting not only overall survival but also ICI treatment effectiveness. Moreover, three genes (UPP1, ISG20 and GLTP) within the six‐gene signature have the potential to become novel drug targets.

Black-White disparities in women's physical health: The role of socioeconomic status and racism-related stressors

Black women have elevated rates of multiple physical illnesses and conditions when compared to White women - disparities that are only partially explained by socioeconomic status (SES). Consequently, scholars have called for renewed attention to the significance of racism-related stress in explaining Black-White disparities in women's physical health. Drawing on the biopsychosocial model of racism as a stressor and the intersectionality perspective, this study examines the extent to which SES and racism-related stressors - i.e., discrimination, criminalization, and adverse neighborhood conditions - account for disparities in self-rated physical health and chronic health conditions between Black and White women. Results indicate that Black women have lower SES and report greater exposure to racism-related stressors across all domains. Moreover, I find that SES and racism-related stressors jointly account for more than 90% of the Black-White disparity in women's self-rated physical health and almost 50% of the Black-White disparity in chronic health conditions. Theoretical and policy implications of these findings are discussed.

CircRNA circ-ATAD1 Is Upregulated in Cervical Squamous Cell Carcinoma and Regulates Cell Proliferation and Apoptosis by Suppressing the Maturation of miR-218

The oncogenic function of circ-ATAD1 has been characterized in gastric cancer, while its role in cervical squamous cell carcinoma (CSCC) is unclear. This study explored the role of circ-ATAD1 in CSCC. To evaluate the differential expression of circ-ATAD1, mature miR-218, and premature miR-218 in CSCC, a total of 62 CSCC patients were subjected to biopsies to collect CSCC and paired normal tissues. Gene expression levels were quantified by RT-qPCRs. Nuclear fractionation assay was performed to analyze the subcellular location of circ-ATAD1. CSCC cells were used to perform cell transfections to explore the crosstalk between circ-ATAD1 and miR-218. The roles of circ-ATAD1 and miR-218 in CSCC cell behaviors were explored by BrdU assay, Transwell assay, cell apoptosis assay, and cell stemness assay. CSCC tissues exhibited upregulated expression of circ-ATAD1, which was localized to both nucleus and cytoplasm. Mature miR-218 was downregulated in CSCC tissues and was inversely correlated with circ-ATAD1, while premature miR-218 was not differentially expressed in CSCC. Upregulation of circ-ATAD1 in CSCC cells decreased the expression levels of mature miR-218, but not that of premature miR-218. In addition, overexpression of circ-ATAD1 increased cell proliferation and decreased cell apoptosis, while overexpression of miR-218 decreased cell proliferation and increased cell apoptosis, and it also attenuated the effects of overexpression of circ-ATAD1 on cell proliferation. However, CSCC cell invasion, migration, and stemness were not affected by circ-ATAD1 and miR-218. Circ-ATAD1 is upregulated in CSCC and may regulate cell proliferation and apoptosis by suppressing the maturation of miR-218.

Understanding the Role of Emerging Vitamin D Biomarkers on Short-term Persistence of High-Risk Human Papillomavirus Infection Among Mid-Adult Women

BACKGROUND

Associations between vitamin D biomarkers and persistent high-risk human papillomavirus (hrHPV) detection have not been evaluated.

METHODS

2011-2012 stored sera from 72 women aged 30-50 years with prevalent hrHPV (n = 116 type-specific infections) were tested for 5 vitamin D biomarkers: 25(OH)D and 4 emerging biomarkers, 1,25(OH)2D; 24,25(OH)2D; free vitamin D; and vitamin D binding protein (DBP). The hrHPV detection patterns (persistent vs transient/sporadic) were determined using cervicovaginal swabs collected monthly for 6 months. Associations between vitamin D and short-term type-specific hrHPV persistence were estimated using logistic regression. Our primary exposure was continuous 25(OH)D, with additional biomarkers evaluated as secondary exposures. Primary models were adjusted for age, race, body mass index, education, contraceptives, smoking, season, and calcium/phosphate levels. Sensitivity analyses were restricted from 19 hrHPV types to 14 used in cervical cancer screening.

RESULTS

In primary analyses, nonsignificant positive associations with hrHPV persistence were observed for measures of 25(OH)D and 24,25(OH)2D. Associations were stronger and significant when restricting to 14 hrHPV types (25(OH)D per 10 ng/mL increase: adjusted odds ratio [aOR], 1.82 [95% confidence interval {CI}, 1.15-2.88] and aOR, 4.19 [95% CI, 1.18-14.88] DBP-adjusted; 25(OH)D ≥30 vs <30 ng/mL: aOR, 8.85 [95% CI, 2.69-29.06]; 24,25(OH)2D: aOR, 1.85 [95% CI, 1.18-2.88]). 1,25(OH)2D was unassociated with persistence.

CONCLUSIONS

Serum vitamin D measured by multiple biomarkers showed positive associations with short-term hrHPV persistence that were significant only when restricting to 14 clinically relevant hrHPV types.

A population study of screening history and diagnostic outcomes of women with invasive cervical cancer

BACKGROUND

Despite advances to prevent and detect cervical cancer, national targets for screening have not been met in the United States. Previous studies suggested that approximately half of women who developed cervical cancer were not adequately screened. This study aimed to provide an updated examination of women's screening and diagnostic practices five years prior to an invasive cervical cancer diagnosis.

METHODS

The study included women age 21 years and older diagnosed with invasive cervical cancer in 2013-2016 from three population-based state cancer registries in the United States. Medical records abstraction identified screening history and diagnostic follow-up. A mailed survey provided sociodemographic data. Screening was a Pap or human papillomavirus (HPV) test between 6 months and 5 years before diagnosis. Adequate follow-up was defined per management guidelines.

RESULTS

Of the 376 women, 60% (n = 228) had not been screened. Among women who received an abnormal screening result (n = 122), 67% (n = 82) had adequate follow-up. Predictors of: (a) being screened were younger age, having a higher income, and having insurance; (b) adequate follow-up were having a higher income, and (c) stage 1 cervical cancer were being screened and younger age.

CONCLUSION

Unlike other cancer patterns of care studies, this study uses data obtained from medical records supplemented with self-report information to understand a woman's path to diagnosis, her follow-up care, and the stage of her cervical cancer diagnosis. This study provides findings that could be used to reach more unscreened or under screened women and to continue lowering cervical cancer incidence in the United States.

Prognostic Variables of Younger-Aged Cervical Carcinoma Patients: A Retrospective Study

Purpose

The prevalence of carcinoma of the cervix is increasing in younger women. This study aimed to evaluate the sociodemographic, pathological, and clinical features, prognosis, and treatment of women aged ≤35 years with carcinoma of the cervix (CC).

Methods and Materials

We retrospectively analysed the clinical information of 352 younger women with carcinoma of the cervix aged ≤35 years at the Gynaecological Oncology Department of Zhengzhou University People's Hospital from April 2000 to January 2018. The overall survival was evaluated with the Kaplan–Meier model, and the log-ranked analysis was compared with the univariate analysis to determine prognostic survival-related risk factors. Cox Proportional Hazards analysis was further used in analysing parameters correlated with survival after univariate analysis. A p value <0.05 was considered statistically significant. SPSS version 23.0 was used for the data analysis.

Results

The most frequent histopathological type observed in the selected 352 younger women was squamous cell carcinoma (SCC) (n = 221, 62.9%), adenocarcinoma (n = 125, 35.5%), and adenosquamous carcinoma (n = 6, 1.7%). The 5-year overall survival time was 80.5%. The prognostic risk factors discovered through univariate analysis were tumour stage (IA1-IIB vs. IIIA-IVA) (89.2% vs. 35.1%: p value = 0.002), histological type (SCC vs. non-SCC) (95.7% vs. 56.2%: p value = 0.001), surgical margin (negative vs. positive) (90.9% vs. 41.2%: p value = 0.001), and pelvic lymph node metastasis (no vs. yes) (93.4% vs. 39.2%: p value = .001). The Cox proportional hazards test demonstrated that lymph node metastases ([HR] = 2.924, 95% CI: 1.432–7.426; p=0.014), tumour stage IIIA-IVA ([HR] = 3.765, 95% CI: 1.398–9.765; p=0.016), and surgical margin ([HR] = 2.167, 95% CI: 1.987–9.554; p=0.019) were independent prognostic risk factors for overall survival in younger women with cervical carcinoma.

Conclusion

In conclusion, the status of lymph node metastases, tumour stage, and surgical margin and the type of histopathology substantially influence the rate of survival.

Factors Affecting Survival Outcome After Percutaneous Nephrostomy as Palliative Urinary Diversion in Obstructive Uropathy due to Advance Cervical Cancer Patients

Introduction:

Cervical cancer is the 3^rd most common cancer in women. In late stages, obstructive uropathy due to mass infiltration is common and the mainstay of treatment for this condition is palliative urinary diversion through percutaneous nephrostomy. Nevertheless, complications due to nephrostomy may have adverse effects on some patients. Further study is necessary to determine whether nephrostomy is suitable for all cervical cancer patients with obstructive uropathy. This study aims to identify the determinants of survival rate of cervical cancer patients undergoing nephrostomy for obstructive uropathy and determine the group of cervical cancer patients that would benefit the most from nephrostomy.

Methods:

Data were obtained from medical records of cervical cancer patients in Hasan Sadikin Central Public Hospital from January 2018 to December 2019. Log-rank analysis was performed to assess the survival rate of patients based on clinical conditions (age, metastasis, and ECOG performance status) and initial laboratory results (hemoglobin, leukocyte, thrombocyte and blood acidity).

Results:

A total of 163 cases were identified from the medical records, with a median survival of 5(1-17) months. The results of the analysis showed that the survival rates of cervical cancer patients undergoing nephrostomy were significantly affected by age (p = 0.0001), metastasis (p = 0.0001), and ECOG performance status (p = 0.0001), while laboratory findings were not significant factors affecting survival (pHb=0.501; pLeu=0.634; pTr=0.077; pBGA=0.687).

Conclusion:

The survival after nephrostomy in advanced cervical cancer patients is largely affected by age, metastasis, and performance status. The choices of doing nephrostomy in those patients should be considering those factors to maximize the benefit over the risk of complications.

Race- and Age-Related Disparities in Cervical Cancer Mortality

BACKGROUND

Although the incidence of cervical cancer among younger Black women is now equivalent to that of White women, it is unknown whether the reduced incidence has affected survival rates among younger Black women. The goal of this study was to assess differences in survival by age and race.

PATIENTS AND METHODS

A retrospective cohort study was performed using the National Cancer Database to analyze women with nonmetastatic cervical cancer diagnosed between 2004 and 2014. Women with unknown survival data and those who died within 3 months of diagnosis were excluded. Multivariable logistic regression models evaluated interactions between age and race (Black vs non-Black) for presentation with stage I disease and receipt of optimal treatment. A multivariable Cox regression model was used to evaluate survival differences by age and race.

RESULTS

Of 55,659 women included, 16.4% were Black. Compared with their non-Black counterparts, fewer Black women presented with stage I disease (37.8% vs 47.8%; P<.01) and received optimal treatment (46.2% vs 58.3%; P<.01). Fewer Black women had private insurance if they were aged <65 years (39.6% vs 55.7%; P<.01), but not if they were aged ≥65 years (11.7% vs 12.4%; P=.43). According to multivariable logistic regression, Black women aged ≤39 years were less likely to present with stage I disease, with a significant interaction term between age and race (P<.01 for interaction). Disparities in overall survival by race were greatest for Black women aged ≤39 years (adjusted hazard ratio, 1.32; 95% CI, 1.20-1.46; P<.01) but decreased with increasing age interval until no disparity was noted for women aged ≥65 years (P<.01 for interaction).

CONCLUSIONS

Younger Black women with cervical cancer are at risk for presenting with higher-stage disease and having worse overall survival. These findings may be related to insurance-related disparities and inadequate follow-up for abnormal Papanicolaou test results. Younger Black women with cervical cancer may be a particularly vulnerable population.

The role and utility of population-based cancer registries in cervical cancer surveillance and control

Population-based cancer registries (PBCR) are vital to the assessment of the cancer burden and in monitoring and evaluating national progress in cervical cancer surveillance and control. Yet the level of their development in countries exhibiting the highest cervical cancer incidence rates is suboptimal, and requires considerable investment if they are to document the impact of WHO global initiative to eliminate cervical cancer as a public health problem. As a starting point we propose a comprehensive cancer surveillance framework, positioning PBCR in relation to other health information systems that are required across the cancer control continuum. The key concepts of PBCR are revisited and their role in providing a situation analysis of the scale and profile of the cancer-specific incidence and survival, and their evolution over time is illustrated with specific examples. Linking cervical cancer data to screening and immunization information systems enables the development of a comprehensive set of measures capable of assessing the short- and long-term achievements and impact of the initiative. Such data form the basis of national and global estimates of the cancer burden and permit comparisons across countries, facilitating decision-making or triggering cancer control action. The initiation and sustainable development of PBCR must be an early step in the scale-up of cervical cancer control activities as a means to ensure progress is successfully monitored and appraised.

Cervical cancer screening in the United States: Challenges and potential solutions for underscreened groups

Cervical cancer screening rates in the United States are generally high, yet certain groups demonstrate disparities in screening and surveillance. Individuals at greatest risk for cervical cancer are often from marginalized or underserved groups who do not participate in regular screening for a variety of reasons. Using the Population-based Research to Optimize the Screening Process (PROSPR) Trans-Organ Conceptual Model, including concepts of individual-, provider-, facility-, system-, or policy-level factors, we provide a commentary to highlight reasons for low screening participation among subgroups in the U.S. These include racial and ethnic minorities, rural residents, sexual and gender minorities, those with limited English proficiency, those with particular religious beliefs, and various health conditions. We describe barriers and offer potential solutions for each group. In addition, we discuss cross-cutting barriers to screening including difficulty interacting with the healthcare system (limited knowledge and health literacy, lack of provider recommendation/contact), financial (cost, lack of insurance), and logistical barriers (e.g., lack of usual source of care, competing demands, scheduling issues). Solutions to address these barriers are needed to improve screening rates across all underscreened groups. Changes at state and national policy levels are needed to address health insurance coverage. Mobile screening, ensuring that interpreters are available for all visits, and targeted in reach at non-gynecological visits can further overcome barriers. Employing community outreach workers can increase community demand for screening, and patient navigators can improve adherence to both screening and follow-up diagnostic evaluation. HPV self-sampling can address multiple barriers to cervical cancer screening.

Screening for the prevention and early detection of cervical cancer: protocol for systematic reviews to inform Canadian recommendations

PURPOSE

To inform recommendations by the Canadian Task Force on Preventive Health Care on screening in primary care for the prevention and early detection of cervical cancer by systematically reviewing evidence of (a) effectiveness; (b) test accuracy; (c) individuals' values and preferences; and (d) strategies aimed at improving screening rates.

METHODS

De novo reviews will be conducted to evaluate effectiveness and to assess values and preferences. For test accuracy and strategies to improve screening rates, we will integrate studies from existing systematic reviews with search updates to the present. Two Cochrane reviews will provide evidence of adverse pregnancy outcomes from the conservative management of cervical intraepithelial neoplasia. We will search Medline, Embase, and Cochrane Central (except for individuals' values and preferences, where Medline, Scopus, and EconLit will be searched) via peer-reviewed search strategies and the reference lists of included studies and reviews. We will search ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. Two reviewers will screen potentially eligible studies and agree on those to include. Data will be extracted by one reviewer with verification by another. Two reviewers will independently assess risk of bias and reach consensus. Where possible and suitable, we will pool studies via meta-analysis. We will compare accuracy data per outcome and per comparison using the Rutter and Gatsonis hierarchical summary receiver operating characteristic model and report relative sensitivities and specificities. Findings on values and preferences will be synthesized using a narrative synthesis approach and thematic analysis, depending on study designs. Two reviewers will appraise the certainty of evidence for all outcomes using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and come to consensus.

DISCUSSION

The publication of guidance on screening in primary care for the prevention and early detection of cervical cancer by the Task Force in 2013 focused on cytology. Since 2013, new studies using human papillomavirus tests for cervical screening have been published that will improve our understanding of screening in primary care settings. This review will inform updated recommendations based on currently available studies and address key evidence gaps noted in our previous review.

Prognostic Model for Predicting Overall and Cancer-Specific Survival Among Patients With Cervical Squamous Cell Carcinoma: A SEER Based Study

BACKGROUND

Cervical squamous cell carcinoma (CSCC) is the most common histological subtype of cervical cancer. The purpose of this study was to assess prognostic factors and establish personalized risk assessment nomograms to predict overall survival (OS) and cancer-specific survival (CSS) in CSCC patients.

METHODS

CSCC patients diagnosed between 1988 and 2015 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox proportional hazard regression models were applied to select meaningful independent predictors and construct predictive nomogram models for OS and CSS. The concordance index (C-index), calibration curve, and receiver operating characteristic (ROC) curve were used to determine the predictive accuracy and discriminability of the nomogram.

RESULTS

A total cohort (n=17962) was randomly divided into a training cohort (n=11974) and a validation cohort (n=5988). Age, race, histologic grade, clinical stage, tumor size, chemotherapy and historic stage were assessed as common independent predictors of OS and CSS. The C-index value of the nomograms for predicting OS and CSS was 0.771 (95% confidence interval 0.762-0.780) and 0.786 (95% confidence interval 0.777-0.795), respectively. Calibration curves of the nomograms indicated satisfactory consistency between nomogram prediction and actual survival for both 3-year and 5-year OS and CSS.

CONCLUSION

We constructed nomograms that could predict 3- and 5-year OS and CSS of CSCC patients. These nomograms showed good performance in prognostic prediction and can be used as an effective tool to evaluate the prognosis of CSCC patients, thus contributing to clinical decision making and individualized treatment planning.

The effect of distance from cancer facility on advanced clinical stage at diagnosis in patients with cervical cancer

PURPOSE/OBJECTIVES

In the United States, cervical cancer remains a significant cause of morbidity and mortality. The effect of distance has a complicated relationship with disease characteristics and outcomes in other cancers. The purpose of this study is to investigate the relationship between distance from cancer facility on clinical stage at diagnosis in women with cervical cancer.

MATERIALS/METHODS

Data were obtained from the National Cancer Database which include patient demographics, disease characteristics, and treatment details. Persons diagnosed with cervical cancer from 2004 to 2015 were included. Subjects were excluded if they had missing information, variant histology, or lived >1,000 miles from their facility resulting in 51,413 persons. Disease was classified as localized (stage 1a-2a) or advanced (stage 2b-4b). Univariate comparisons were performed using analysis of variance and chi-square test. Multivariable logistic regression was used to investigate the effect of distance quartiles on advanced stage while adjusting for other significant variables.

RESULTS

Mean age was 51.0 years, 16.9% of women were black, 14.7% were Hispanic, 45.0% had private insurance, and 10.7% were uninsured. Overall, 50.9% of women presented with advanced disease. In multivariable analysis, greater distance demonstrated a stepwise risk reduction of advanced disease where those in the farthest quartile had odds ratio of 0.73 (p<0.001) relative to the closest. Additionally, age, race, income, and insurance status significantly affected risk of advanced disease.

CONCLUSIONS

Distance from cancer facility resulted in lower risk of advanced stage disease at diagnosis. Additional research could elucidate the nuanced relationship between distance, disease characteristics and outcomes in cervical cancer.

Circulating Tumor Cells Counting Act as a Potential Prognostic Factor in Cervical Cancer

Background:

Circulating tumor cells (CTCs) hold huge potential for both clinical applications and basic research into the management of cancer, but the relationship between CTC count and cervical cancer prognosis remains unclear. Therefore, research on this topic is urgently required.

Objective:

This study investigated whether CTCs were detectable in patients with cervical cancer and whether CTC count was an indicator of prognosis.

Methods:

We enrolled 107 patients with pathologically confirmed cervical cancer. CTCs were detected after radiotherapy or concurrent cisplatin-containing chemotherapy in all patients. We evaluated all medical records and imaging data as well as follow-up information to calculate progression-free survival (PFS). PFS was defined as the time until first diagnosis of tumor progression or death. We also analyzed the relationship between CTC count and patient age, disease stage, histological differentiation, tumor size, and pathological type.

Results:

CTCs were identified in 86 of 107 patients (80%), and the CTC count ranged from 0 to 27 cells in 3.2 mL blood. The median progression-free survival (PFS) was 43.1 months. Patients in which CTCs were detected had a significantly shorter PFS than CTC-negative patients (P = 0.018). Multivariate analysis indicated that CTC count was an independent negative prognostic factor for survival. However, no correlation was observed between CTC count and patient age, disease stage, histological differentiation, tumor size, and pathological type.

Conclusion:

CTC count is an independent negative prognostic factor for cervical cancer.

Trends and survival outcomes of robotic, laparoscopic, and open surgery for stage II uterine cancer

INTRODUCTION

A recent randomized clinical trial showed that minimally invasive surgery led to poorer survival compared with open surgery in early stage cervical cancer. We determined the trends in adoption of minimally invasive surgery and 5-year overall survival outcomes after open, laparoscopic-assisted, and robotic-assisted hysterectomy for stage II uterine cancer with cervical stromal involvement.

METHODS

Data for patients with stage II uterine cancer were acquired from the National Cancer Database from 2010 to 2015. χ² testing, Kaplan-Meier methods, and Cox models were used for statistical analyses.

RESULTS

Of 2949 patients, 44.3% underwent open hysterectomy, 13.9% underwent laparoscopic hysterectomy, and 41.8% underwent robotic hysterectomy. The proportion of robotic cases increased from 26.8% in 2010 to 48.3% in 2015 (annual percent change 10.1%), with a decrease in open hysterectomy from 63.3% to 34.3% (annual percent change -12.5%). The overall 5-year survival was 77.6% in robotic, 76.8% in laparoscopic, and 72.5% in open hysterectomy (p=0.045); however, after adjusting for known prognostic factors, robotic (HR 1.00, 95% CI 0.82 to 1.21; p=0.97) and laparoscopic hysterectomy (HR 1.09, 95% CI 0.83 to 1.44; p=0.54) did not portend for improved survival compared with open hysterectomy. Black women (HR 1.59, 95% CI 1.25 to 2.02; p<0.001) and individuals with co-morbidities (HR 1.45, 95% CI 1.21 to 1.75, p<0.001) had worse adjusted survival and the highest rates of open hysterectomy.

CONCLUSION

The use of minimally invasive surgery for stage II uterine cancer has increased over time, with comparable adjusted 5-year survival after robotic or laparoscopic hysterectomy compared with open hysterectomy. Black women and those with co-morbidities had lowest rates of minimally invasive surgery and the poorest adjusted survival.

Single Radiotherapy Fraction with Local Anti-CD40 Therapy Generates Effective Abscopal Responses in Mouse Models of Cervical Cancer

Current treatment options for advanced cervical cancer are limited, especially for patients in poor-resource settings, with a 17% 5-year overall survival rate. Here, we report results in animal models of advanced cervical cancer, showing that anti-CD40 therapy can effectively boost the abscopal effect, whereby radiotherapy of a tumor at one site can engender therapeutically significant responses in tumors at distant untreated sites. In this study, two subcutaneous cervical cancer tumors representing one primary and one metastatic tumor were generated in each animal. Only the primary tumor was treated and the responses of both tumors were monitored. The study was repeated as a function of different treatment parameters, including radiotherapy dose and dosing schedule of immunoadjuvant anti-CD40. The results consistently suggest that one fraction dose of radiotherapy with a single dose of agonistic anti-CD40 can generate highly effective abscopal responses, with a significant increase in animal survival (p = 0.0004). Overall, 60% of the mice treated with this combination showed long term survival with complete tumor regression, where tumors of mice in other cohorts continued to grow. Moreover, re-challenged responders to the treatment developed vitiligo, suggesting developed immune memory for this cancer. The findings offer a potential new therapy approach, which could be further investigated and developed for the treatment of advanced cervical cancer, with major potential impact, especially in resource-poor settings.

Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program: Increasing Access to Screening

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast and cervical cancer screening and diagnostic services to low-income, uninsured, and underinsured women across the nation. Although the program has provided services to more than 5 million women since 1991, there remains a significant burden of breast and cervical cancer with inequities among certain populations. To reduce this burden and improve health equity, the NBCCEDP is expanding its scope to include population-based strategies to increase screening in health systems and communities through the implementation of patient and provider evidence-based interventions, connecting women in communities to clinical services, increasing opportunities to access screening, and enhancing the targeting of women in need of services. The goal is to reach more women and make sure women are getting the right screening test at the right time.