Disparity in the persistence of high-risk human papillomavirus genotypes between African American and European American women of college age

Does the Vaginal Microbiome Operate Differently by Race to Influence Risk of Precervical Cancer?

Background: The vaginal microbiome (VMB) plays an important role in the persistence of human papillomavirus (HPV) infection and differs by race and among women with cervical intraepithelial neoplasia (CIN). Materials and Methods: We explored these relationships using 16S rRNA VMB taxonomic profiles of 3050 predominantly Black women. VMB profiles were assigned to three subgroups based on taxonomic markers indicative of vaginal wellness: optimal (Lactobacillus crispatus, L. gasseri, and L. jensenii), moderate (L. iners), and suboptimal (Gardnerella vaginalis, Atopobium vaginae, Ca. Lachnocurva vaginae, and others). Multivariable Firth logistic regression models were adjusted for age, smoking, VMB, HPV, and pregnancy status. Results: VMB prevalence by subgroup was 18%, 30%, and 51% for the optimal, moderate, and suboptimal groups, respectively. In fully adjusted models, the risk of CIN grade 3 (CIN3) among non-Latina (nL) Blacks was twice that of nL Whites (odds ratio [OR] = 2.0, 95% confidence interval [CI]: 1.1, 3.9, p = 0.02). The VMB modified this association (p = 0.04) such that the risk of CIN3 was significantly higher for nL Blacks than for nL Whites only among women with optimal VMBs (OR = 7.8, 95% CI: 1.7, 74.5, p = 0.007). Within racial groups, the risk of CIN3 was only elevated among nL White women with suboptimal VMBs (OR = 6.0, 95% CI: 1.3, 56.9, p = 0.02) compared with their racial counterparts with optimal VMBs. Conclusions: Our findings suggest that race is a modifier of the VMB in HPV carcinogenesis. An optimal VMB does not appear to be protective for nL Black women compared with nL White women.

Disparities in awareness of the HPV vaccine and HPV-associated cancers among racial/ethnic minority populations: 2018 HINTS

OBJECTIVES

Human papillomavirus (HPV) is a common virus that currently infects nearly 80 million people in the United States (U.S.) and can lead to cancer. HPV vaccination provides safe, effective, and lasting protection against HPV infections. Nevertheless, vaccination rates remain suboptimal. The purpose of this study was to examine the relationship between sociodemographic characteristics, HPV and HPV vaccine awareness, and knowledge of HPV-associated cancers among U.S. adults.

DESIGN

Using responses from 3504 U.S. adults (aged 18 years and older) from the Health Information National Trends Survey 5 Cycle 2 (January-May 2018), we performed descriptive analysis to assess the level of awareness of HPV and HPV vaccines and knowledge of HPV-associated cancer. Multivariable regression analysis (including race, gender, age, level of education, marital status, number of children younger than 18) was conducted with weighted analysis.

RESULTS

About 62% of respondents had heard of HPV and HPV vaccine. Asians had a lower level of awareness than non-Hispanic Whites of HPV (36.4% vs. 66.1%) and HPV vaccine (48.7% vs. 67.1%). Multivariable analysis showed that race/ethnicity was associated with outcomes, with Asians being less likely to have heard about HPV (aOR = 0.17, 95% CI: 0.07-0.38) and non-Hispanic Blacks (aOR = 0.57, 95% CI: 0.35-0.91) and Hispanics (aOR = 0.54, 95% CI: 0.36-0.80) being less likely to have heard of the HPV vaccine than non-Hispanic Whites. In addition, gender, age, marital status, and education were associated with awareness of HPV and the HPV vaccine; in particular, individuals who were female, younger (18-45), married, and more highly educated were more likely to have heard of HPV and HPV vaccine.

CONCLUSION

Results highlight disparities in HPV and HPV vaccine awareness among racial/ethnic minority populations. Future interventions and legislation should target racial/ethnic minority populations to foster improvements in HPV vaccine uptake and reduce disparities in HPV-associated cancers.

Human papillomavirus 16/18/45 are not the most frequent genotypes in African American women: analysis in cervical Papanicolaou smears of women in an inner-city hospital

INTRODUCTION

Cervical cancer is considered the most common human papillomavirus (HPV)-associated disease in women. Primary and secondary prevention methods have been established through Pap tests, HPV molecular testing, and vaccines. Although the most common high-risk HPV (HR-HPV) genotypes in the United States are 16, 18, and 45, there is reported ethnic disparity in the distribution of these genotypes.

MATERIALS AND METHODS

Data analysis of HPV genotype results on cervical pap tests in our institution between late 2018 and early 2020 was performed. The distribution of HPV genotypes in each Bethesda category was evaluated.

RESULTS

A total of 13,160 smears were evaluated; 75.5% were from African American women. Of those tested for HR-HPV (10,060), 1412 (14%) were HR-HPV positive. In all diagnostic categories of the Bethesda classification system, non-16/18/45 HR-HPV genotypes were more prevalent, ranging from 60.8% even in high-grade squamous intraepithelial lesion to 90.4% in negative for intraepithelial lesion or malignancy.

CONCLUSIONS

In this study with a predominantly African American population, non-16/18/45 HR-HPV genotypes were prevalent in the majority (60.8%) of high-grade squamous intraepithelial lesion cases. Ethnic variability should be considered when deciding which HPV genotypes to integrate into the HPV vaccine.

Factors associated with HPV vaccine acceptability and hesitancy among Black mothers with young daughters in the United States

Introduction

Compared to other-race peers, Black women are disproportionately impacted by human papillomavirus [HPV] infection, related health outcomes, and cervical cancer mortality as a result of suboptimal HPV vaccine uptake during adolescence. Few studies in the United States have examined psychosocial determinants of HPV vaccine acceptability and hesitancy among Black parents. The current study integrated the health belief model and the theory of planned behavior to evaluate the extent to which psychosocial factors are associated with pediatric HPV vaccination intentions among this population.

Methods

Black mothers (N = 402; age range = 25 to 69 years, M = 37.45, SD = 7.88) of daughters ages 9 to 15 years completed an online survey assessing HPV infection and vaccine beliefs and attitudes across four domains: Mother's HPV Perceptions, Mother's Vaccine Attitudes, Cues to Action, and Perceived Barriers to HPV Vaccination. Participants indicated their willingness to vaccinate their daughter on a 5-level ordinal scale ("I will definitely not have my daughter get the vaccine" to "I will definitely have my daughter get the vaccine") which was dichotomously recoded for binomial logistic regressions.

Results

Half of the sample (48%) intended to vaccinate their daughter. Number of daughters, mother's HPV vaccine status, perceived HPV vaccine benefits, HPV vaccine safety concerns, pediatric HPV vaccine peer norms, and doctor recommendations emerged as independent factors of Black mothers' intentions to vaccinate their daughters against HPV when controlling for all other factors.

Discussion

In addition to medical training to increase doctor recommendation of the HPV vaccine for Black girls, population-tailored public health messaging aimed at promoting HPV vaccine acceptance among Black mothers is urgently needed. This messaging should engage community support and emphasize the benefits of vaccination for adolescent Black girls while also addressing parental concerns regarding the safety of pediatric HPV vaccination.

Cultural adaptation in HPV vaccine intervention among racial and ethical minority population: a systematic literature review

Racial and ethnic minorities in the United States face higher risks of human papillomavirus (HPV) and are less likely to benefit from HPV vaccines. Effective HPV vaccine promotion efforts need to acknowledge and adapt to the cultural characteristics of these minority groups. This systematic review examines and evaluates the cultural adaptations in the HPV vaccine intervention studies conducted in racial and ethnic minority communities in the United States. We searched five databases and identified 26 peer-reviewed English-language journal articles published between 2010 and 2019. These articles were analyzed using Healey et al.'s (2017) cultural adaptation framework for community health interventions. Almost all of these interventions involved some cultural adaptation. However, there is a lack of use of theories in guiding intervention design, lack of systematic, planned cultural adaptations and insufficient in-depth understanding of the targeted population's cultural characteristics associated with their HPV-related attitudes, beliefs and behaviors. Future intervention studies should identify specific cultural characteristics related to vaccine attitudes and behaviors to create more targeted cultural adaptations in HPV vaccine promotion.

Perceived Stress and Molecular Bacterial Vaginosis in the National Institutes of Health Longitudinal Study of Vaginal Flora

Vaginal microbiota provide the first line of defense against urogenital infections primarily through protective actions of Lactobacillus species Perceived stress increases susceptibility to infection through several mechanisms, including suppression of immune function. We investigated whether stress was associated with deleterious changes to vaginal bacterial composition in a subsample of 572 women in the Longitudinal Study of Vaginal Flora, sampled from 1999 through 2002. Using Cox proportional hazards models, both unadjusted and adjusted for sociodemographic factors and sexual behaviors, we found that participants who exhibited a 5-unit-increase in Cohen's Perceived Stress Scale had greater risk (adjusted hazard ratio (HR) = 1.40, 95% confidence interval (CI): 1.13, 1.74) of developing molecular bacterial vaginosis (BV), a state with low Lactobacillus abundance and diverse anaerobic bacteria. A 5-unit increase in stress score was also associated with greater risks of transitioning from the L. iners-dominated community state type (26% higher) to molecular-BV (adjusted HR = 1.26, 95% CI: 1.01, 1.56) or maintaining molecular-BV from baseline (adjusted HR = 1.23, 95% CI: 1.01, 1.47). Inversely, women with baseline molecular-BV reporting a 5-unit stress increase were less likely to transition to microbiota dominated by L. crispatus, L. gasseri, or L. jensenii (adjusted HR = 0.81, 95% CI: 0.68, 0.99). These findings suggest that psychosocial stress is associated with vaginal microbiota composition, inviting a more mechanistic exploration of the relationship between psychosocial stress and molecular-BV.

Prevalence of genital human papillomavirus by age and race/ ethnicity among males

BACKGROUND

Genital and oral cancers are often caused by human papillomavirus (HPV) types that can be prevented through HPV vaccination. Since HPV is sexually transmitted, knowledge of penile prevalence of vaccine-type HPV among US males can help predict potential disparities in these cancers. This study examines penile HPV prevalence by age and race/ethnicity among males.

METHODS

This study was a secondary analysis of publicly available data from the National Health and Nutrition Examination Survey (NHANES). Using data from penile swab samples collected from males between 2013 and 2016, the prevalence of 4vHPV and 9vHPV vaccine types was examined across age groups and by race/ethnicity. Logistic regression models adjusting for demographics, sexual behavior and circumcision were examined to determine whether associations remained after accounting for confounders.

RESULTS

Among 2,548 males evaluated, HPV infection prevalence differed by race/ethnicity with black males exhibiting a higher prevalence of HPV. Examination of 4vHPV type prevalence by age group showed that 18-26 year old males had a lower prevalence compared to older age groups. After controlling for confounders, 4vHPV prevalence was only significantly elevated among 27-34-year old males, those who were single, and males with 3+ lifetime sex partners. In adjusted models, 9vHPV type prevalence remained elevated among black males compared to white males.

CONCLUSION

Variations in 9vHPV type prevalence between blacks and whites indicate future disparities in HPV-related genital cancers may continue in the US during the next decade. Revaccinating certain populations with the 9vHPV vaccine may be appropriate to help mitigate this.

The impact of socioeconomic status on HPV infection among young Brazilians in a nationwide multicenter study

The aim of this study is to evaluate genital human papillomavirus (HPV) infection according to socioeconomic categories in Brazil. This cross-sectional, nationwide study included 7,694 sexually active women and men aged 16-25 years. Individuals of all socioeconomic groups in all 26 Brazilian capitals and the Federal District were enrolled through public primary care units between September 2016 and November 2017. All participants answered a standardized interview administered by trained primary care health professionals. Socioeconomic class was analyzed using a pricing classification system for the Brazilian public that divides the market exclusively in terms of economic class based on the ownership of assets and the education level. Cervical samples were obtained using a Digene® HC2 DNA Collection, and penile/scrotum samples were obtained using a wet Dacron swab. HPV typing (overall and high-risk) was performed in a central lab. Of the 7,694 participants (47.85% women), 17.92% belonged to class A-B, 56.08% to class C, and 26.00% to class D-E. The prevalence of overall HPV was similar among the social classes: 51.16% for classes A-B, 53.39% for class C, and 55.47% for classes D-E (P = 0.479). Similar results were found for high-risk HPV. After adjustments, the presence of HPV in individuals with a brown skin color belonging to classes A-B was 57.00% higher [prevalence ratio 1.57 (95%: 1.23, 2.01)] than that in whites and had no impact on the other social classes. In conclusion, HPV infection affects all socioeconomic classes in Brazil, evidencing the importance of offering the HPV vaccine to the entire population.

Cervical Cancer Incidence and Mortality among Non-Hispanic African American and White Women, United States, 1999-2015

BACKGROUND

Cervical cancer, a preventable cancer, has disproportionately affected African American women. To better understand the burden of cervical cancer, we assessed incidence and mortality rates and analyzed trends among non-Hispanic (NH) African American and White women in the US from 1999 to 2015.

METHODS

From age-adjusted cervical cancer incidence and mortality rates, rate ratios (RR) and 95% confidence intervals (CI) were calculated for comparison between the two races. Trends were analyzed using joinpoint regression and expressed as annual percent change (APC) and average annual percent change (AAPC).

RESULTS

Cervical cancer incidence rates were significantly higher (RR: 1.46; 95% CI: 1.44, 1.47) among NH African Americans (10.8 per 100,000 females) than NH Whites (7.4 per 100,000 females). Similarly, mortality rates were significantly higher (RR: 2.05; 95% CI: 2.01, 2.09) in NH African Americans (4.4 per 100,000 females) compared to NH Whites (2.1 per 100,000 females). From 1999 to 2015, overall incidence and mortality trends decreased significantly for both races. Mortality rates steadily increased with age for both races, and incidence rates only increased with age in NH African American women.

CONCLUSION

NH African American women had significantly higher cervical cancer incidence and mortality rates than NH Whites. Even as incidence and mortality trends declined significantly, older NH African Americans had three times the rate of cervical cancer than NH Whites. Prevention and treatment programs need to be enhanced for African Americans as failure to do so may widen cancer disparities.

Health disparities in cervical cancer: Prevalence of high-risk HPV and cytologic diagnoses according to race

BACKGROUND

In the United States, the rate of cervical cancer is disproportionally higher in Hispanic and Black women compared with White women. In the current study, the authors compared human papillomavirus (HPV) testing and cytology results among Black and White women over a 24-month period. They then assessed the rates in young women in 2011 compared with 2017 according to race.

METHODS

The authors searched the gynecologic cytology case files for Black and White women treated at Johns Hopkins Hospital across all ages for a period of 24 months (2017-2019) and compared HPV results and cytologic interpretations. They then compared results among Black and White cohorts of young women (aged 21-29 years) in 2011 versus 2017.

RESULTS

A total of 26,302 specimens from January 2017 to January 2019, including 11,676 Black women and 14,626 White women, were reviewed. The most common HPV genotype(s) detected were non-HPV-16 and/or HPV-18 (non-16/18) high-risk HPV (hrHPV) (84% of positive results). Non-16/18 hrHPV was more common in Black women (1309 women; 15%) compared with White women (1075 women; 9%). Non-16/18 hrHPV was more commonly observed in association with atypical squamous cells, cannot rule out high-grade squamous intraepithelial lesion and/or high-grade squamous intraepithelial lesion (ASC-H/HSIL) in HPV-positive Black women compared with White women (P = .007). Black women were found to have higher rates of HPV-positive Papanicolaou results and high-grade lesions, including carcinoma (P < .01). In the 2011 cohort, young Black women were found to have a higher rate of ASC-H/HSIL (P = .003) compared with White women. However, the difference was not noted in the 2017 cohort. There was a decrease in ASC-H/HSIL in 2017 compared with 2011, with a lower incidence of ASC-H/HSIL noted among Black women in 2017.

CONCLUSIONS

Black women appear to have a higher incidence of higher grade lesions, but the difference between Black and White cohorts was not found to be significant in young women in more recent years.

Evaluation of PCR-Reverse Dot Blot Human Papillomavirus Genotyping Test in Predicting Residual/Recurrent CIN 2+ in Posttreatment Patients in China

Objective

To assess the clinical value of the PCR-reverse dot blot human papillomavirus genotyping test during follow-up of patients with CIN grade 2 or worse (CIN 2+).

Methods

Four hundred patients with CIN 2+ receiving treatment from January 2008 to January 2017 were included in our study. Postoperative follow-up procedures comprised HPV examination and cervical cytology every 3–6 months for the first 2 years and then followed up every 6–12 months. A pathology examination was performed when there was a positive funding for HPV 16/18 or an abnormal ThinPrep cytology test (TCT) with or without positive for HR-HPV according to the American Society for Coloscopy and Cervical Pathology (ASCCP) guidelines.

Results

The median follow-up period was 27.10±12.47 months (ranging from 3 to 50 months). During follow-up, 12.00% (48/400) of the women developed residual/recurrent disease. The highest risk in CIN 2+ and CIN 3+ residual/recurrence was HPV-16/-18 (hazard ratio (HR)=12.898, 95% CI= 6.849–24.289; HR= 20.726, 95% CI= 9.64–44.562, respectively). Among the different follow-up methods, type-specific (TP) HR-HPV persistent infection showed the highest cumulative incidence risk (CIR) (84.62%, 95% CI=73.29–95.94) and HR (5.38, 95% CI= 2.596–11.149) during the 4-year follow-up period. At the CIN 2+ and CIN 3+ endpoints, TP-HPV testing had relatively high sensitivity (84.62%, 95% CI=73.29–95.94 and 89.28%, 95% CI= 77.83–100.00, respectively) and specificity (78.07%, 95% CI= 72.70–83.44 and 75.73%, 95% CI= 70.30–81.17, respectively). However, at the CIN 2+/CIN 3+ endpoint, TCT follow-up had a sensitivity of 60.42%/62.16% (95% CI=46.58–72.25/46.54–77.79) and specificity of 90.18%/88.72% (95% CI=86.95–93.41/85.35–92.10).

Conclusion

TP HR-HPV follow-up can provide a reliable and sensitive clinical reference for CIN 2+ postoperative patients.

Vaginal dysbiosis and the risk of human papillomavirus and cervical cancer: systematic review and meta-analysis

OBJECTIVE

The vaginal microbiota proposedly influence the association between human papillomavirus and cervical cancer. Our aim was to assess whether vaginal dysbiosis affects human papilloma virus acquisition, persistence, and progression to related cervical premalignancy.

DATA SORUCES

MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science (inception until June 2018) were used for this study. The study protocol was registered at PROSPERO (CRD42016035620).

STUDY ELIGIBILITY CRITERIA

This systematic review included all observational studies reporting on incident human papilloma virus, persistent human papilloma virus, and/or related cervical disease in women with or without vaginal dysbiosis prior to outcome assessment.

STUDY APPRAISAL AND SYNTHESIS METHODS

We used random-effects models for meta-analyses and report pooled relative risks with 95% confidence intervals. The risk for incident and/or persistent human papilloma virus or related cervical disease based on longitudinal results was determined.

RESULTS

Of 1645 unique articles, 15 mainly prospective cohort studies were included, published between 2003 and 2017, including a total of 101,049 women. Vaginal dysbiosis was associated with an increased risk of incident human papilloma virus (overall relative risk, 1.33, 1.18-1.50, I² = 0%; among young women relative risk, 1.43, 1.10-1.85, I² = 0%), human papilloma virus persistence (overall relative risk, 1.14, 1.01-1.28, I² = 44.2%; for oncogenic types relative risk, 1.18, 1.01-1.38, I² = 0%), and high-grade lesions and cancer (relative risk, 2.01, 1.40-3.01, I² = 0%), but women with lesions/cancer were compared with those without, regardless of their oncogenic human papilloma virus status. Overall, comparable results were found in the molecular vaginal microbiota studies.

CONCLUSION

This study supports a causal link between vaginal dysbiosis and cervical cancer along the oncogenic human papillomavirus acquisition, persistence, and cervicovaginal dysplasia development pathway.

Regional variations in human papillomavirus prevalence across time in NHANES (2003-2014)

INTRODUCTION

The consequences of low human papillomavirus (HPV) vaccination in Census regions with higher incidence of cervical cancer may contribute to continued disparities. Our purpose was to evaluate regional variations in HPV prevalence across time.

METHODS

Repeated cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), 2003-2014 were examined. Participants included females 14 to 34 years old who provided adequate vaginal samples for HPV DNA typing (N = 6387). Region of residence and HPV vaccination status associations with HPV prevalence were examined using chi-square and multivariable logistic regression. HPV types were grouped according to vaccine-type HPV (types 6, 11, 16, 18) and risk (high or low-risk). Time and vaccination status were included in subsequent models for post-licensure survey cycles (2007-2014) to assess their effects on observed associations.

RESULTS

No decreases in vaccine-type HPV prevalence were found between the prevaccine cycles (2003-2006) and early post-licensure cycles (2007-2010, p > 0.05). Vaccine-type HPV prevalence decreased in late post-licensure years (2011-2014) compared to prevaccine years (2003-2006, p = 0.001). The highest prevalence of vaccine-type HPV occurred in the South (8.6%) and Midwest (8.6%), followed by the West (4.8%), and the Northeast (3.5%) in late post-licensure years. Lower odds of vaccine-type HPV across time in post-licensure survey cycles were found to be attributable to time, and more strongly to HPV vaccination.

CONCLUSIONS

There were regional variations in vaccine-type HPV prevalence between prevaccine and post-licensure years. These decreases appeared to be at least partially attributable to HPV vaccination. Programs are needed to address geographical disparities in HPV vaccination.

High Rates of High-Grade Cervical Dysplasia in High-Risk Young Women With Low-Grade Cervical Cytology

OBJECTIVE

The aim of the study was to determine rates of cervical intraepithelial neoplasia (CIN) 2 or greater in high-risk, racially diverse, young women with low-grade cytology.

MATERIALS AND METHODS

After institutional review board approval, a cross-sectional study of 21- to 24-year-old women with low-grade cytology (atypical squamous cells of undetermined significance, high-risk human papillomavirus+, low-grade squamous intraepithelial lesion, or human papillomavirus+ only) managed with colposcopy at our university-based clinic between May 2011 and April 2013 were identified. Demographics and pathologic data were collected including age, race, parity, smoking status, screening history, and histology. Student t test and χ tests were used to compare women with and without CIN 2 or 3. Univariate analysis was performed with demographic data.

RESULTS

One thousand fifty-eight women with a mean (SD) age of 22.5 (1.1) were included. Most patients (59.5%) were parous, 36.1% were smokers, and most (52.9%) were black. These patients were considered high risk because of their lower socioeconomic status, minority status, lack of insurance, or having Medicaid and therefore had limited access to preventative health care. Based on colposcopy, the prevalence of CIN 2+ was 19.1%: 13.9% (95% CI = 11.9-16.1) CIN 2 and 5.1% (95% CI = 3.9-6.6) CIN 3. There was an overall prevalence of 4.7% (95% CI = 3.7%-6.3%) of CIN 3 from excisional pathology from the 157 of 185 patients who returned for a recommended excisional procedure. Smoking (odds ratio = 1.64, 95% CI = 1.2-2.25) and a history of high-grade cytology (odds ratio = 2.06, 95% CI = 1.02-4.01) were associated with CIN 2/3.

CONCLUSIONS

High prevalence of CIN 2/3 in young women with low-grade cervical cytology in this population suggests that it may be prudent to consider alternative surveillance such as colposcopy in similar high-risk populations.

Disparities in HPV vaccination rates and HPV prevalence in the United States: a review of the literature

Human papillomavirus (HPV) is a common sexually transmitted infection which is the cause of several cancers, including cervical cancer, and genital warts. Although cervical cancer can be prevented through screening, this cancer persists in the US. More recently, HPV vaccination has the potential to decrease the burden of HPV-related disease among young HPV-unexposed adolescents. Several initiatives aimed to encourage HPV vaccination have been adopted. Unfortunately, uptake of the HPV vaccine remains modest, despite evidence that vaccine-type HPV prevalence is decreasing as a result of HPV vaccination. Further, geographic disparities in vaccination uptake across different US regions and by race/ethnicity may contribute to continuing disparities in HPV-related cancers. More data are needed to evaluate impact of HPV vaccination on HPV prevalence in smaller geographic areas. Further, more information is needed on the impact of individual vaccination programs and policy on population level vaccination and HPV prevalence.

Global Inequities in Precision Medicine and Molecular Cancer Research

Precision medicine based upon molecular testing is heralded as a revolution in how cancer is prevented, diagnosed, and treated. Large efforts across the world aim to conduct comprehensive molecular profiling of disease to inform preclinical models, translational research studies and clinical trials. However, most studies have only been performed in patients from high-income countries. As the burden on non-communicable diseases increases, cancer will become a pressing burden across the world, disproportionately affecting low-middle income settings. There is emerging evidence that the molecular landscape of disease differs geographically and by genetic ancestry, which cannot be explained by environmental factors alone. There is a lack of good quality evidence that characterises the molecular landscape of cancers found in low-middle income countries. As cancer medicine becomes increasingly driven by molecular alterations in high-income settings, low-income settings may become left behind. Further efforts on an international scale must be made by researchers, funders, and policymakers to ensure cancer research addresses disease across the world, so models are not limited to subtypes of disease found in high-income countries. In this review, we discuss differences found in the molecular profiles of tumours worldwide and the implication this has for the future of global cancer care. Finally, we identify several barriers currently limiting progress in this field and innovative solutions, which may address these shortcomings.

Barriers to HPV Vaccination Among Unvaccinated, Haitian American College Women

Background: Haitian women residing in the United States are disproportionately affected by cervical cancer. Human papillomavirus (HPV) vaccine has been licensed in the United States since 2006. Vaccination rates are less than optimal overall, and the rates are particularly low among young black women. We investigated barriers to HPV vaccination in a sample of Haitian American college women. Methods: Thirty self-identified Haitian American women, aged 17-26 years, were recruited from a large university campus in southeastern United States (n=30). They completed in-depth face-to-face interviews. The research team analyzed the transcripts using thematic analysis. Results: More than half of the participants (n=18) had not yet initiated the HPV vaccine series. Most of the unvaccinated participants stated that they had received a provider recommendation for the vaccine. Lack of provider recommendation, negative vaccine perception and attitudes, and side effect concerns constituted barriers to vaccination. Conclusions: Haitian American college women at high risk of cervical cancer have cited several barriers to HPV vaccination, with the most prominent being lack of physician recommendation. Healthcare providers should continue recommending the vaccine to college women as many of them may not have received a recommendation. When recommending the HPV vaccine, discussions should be framed with the intent to positively influence HPV vaccine perceptions and ultimately vaccine attitudes.

Racial/ethnic differences in HPV 16/18 genotypes and integration status among women with a history of cytological abnormalities

OBJECTIVE

HPV genotype distribution varies by race/ethnicity, but is unclear whether there are racial/ethnic variations in HPV 16/18 integration in the host genome. We describe HPV16/18 infection and integration status in a racially/ethnically diverse sample of women with a recent abnormal Pap test.

METHODS

Patients (n=640) represent a subset of women participating in a clinical trial. Cervical swabs were tested for HPV16/18 DNA using type-specific polymerase chain reaction assays. Viral integration status was assessed using type-specific integration assays and categorized as fully integrated, fully non-integrated, or mixed. Unconditional logistic regression was used to generate unadjusted (OR) and adjusted odds ratios (aOR) to assess the association between self-reported race/ethnicity and risk of these outcomes.

RESULTS

Hispanic and non-Hispanic black women had half the odds of prevalent HPV16 compared to non-Hispanic white women (aORs: 0.43 and 0.45, respectively). The prevalence odds of HPV18 was less than half among Hispanic women (aOR: 0.48), but not significantly different between black and white women (aOR: 0.72). Among women with prevalent HPV16, the odds of fully integrated viral DNA were significantly higher among black women (aORs: 2.78) and marginally higher among Hispanic women (aOR: 1.93). No racial/ethnic differences were observed for HPV18 DNA integration.

CONCLUSIONS

While HPV16 and 18 infections were less prevalent among Hispanic and black women compared to whites, their HPV16 DNA was more likely to be present in a fully integrated state. This could potentially contribute to the higher rates of abnormal cytology and cervical dysplasia observed among Hispanic and black women.

Racial Disparity in Gastrointestinal Cancer Risk

Cancer from the gastrointestinal tract and its associated excretory organs will occur in more than 300,000 Americans in 2017, with colorectal cancer responsible for >40% of that burden; there will be more than 150,000 deaths from this group of cancers in the same time period. Disparities among subgroups related to the incidence and mortality of these cancers exist. The epidemiology and risk factors associated with each cancer bear out differences for racial groups in the United States. Esophageal adenocarcinoma is more frequent in non-Hispanic whites, whereas esophageal squamous cell carcinoma with risk factors of tobacco and alcohol is more frequent among blacks. Liver cancer has been most frequent among Asian/Pacific Islanders, chiefly due to hepatitis B vertical transmission, but other racial groups show increasing rates due to hepatitis C and emergence of cirrhosis from non-alcoholic fatty liver disease. Gastric cancer incidence remains highest among Asian/Pacific Islanders likely due to gene-environment interaction. In addition to esophageal squamous cell carcinoma, cancers of the small bowel, pancreas, and colorectum show the highest rates among blacks, where the explanations for the disparity are not as obvious and are likely multifactorial, including socioeconomic and health care access, treatment, and prevention (vaccination and screening) differences, dietary and composition of the gut microbiome, as well as biologic and genetic influences. Cognizance of these disparities in gastrointestinal cancer risk, as well as approaches that apply precision medicine methods to populations with the increased risk, may reduce the observed disparities for digestive cancers.

Identification and characterization of HPV-independent cervical cancers

BACKGROUND

Human papillomavirus (HPV) initiates cervical cancer, and continuous expression of HPV oncogenes E6 and E7 is thought to be necessary to maintain malignant growth. Current therapies target proliferating cells, rather than specific pathways, and most experimental therapies specifically target E6/E7. We investigated the presence and expression of HPV in cervical cancer, to correlate HPV oncogene expression with clinical and molecular features of these tumors that may be relevant to new targeted therapies.

RESULTS

While virtually all cervical cancers contained HPV DNA, and most expressed E6/E7 (HPV-active), a subset (8%) of HPV DNA-positive cervical cancers did not express HPV transcripts (HPV-inactive). HPV-inactive tumors occurred in older women (median 54 vs. 45 years, p = 0.02) and were associated with poorer survival (median 715 vs 3046 days, p = 0.0003). Gene expression profiles of HPV-active and -inactive tumors were distinct. HPV-active tumors expressed E2F target genes and increased AKT/MTOR signaling. HPV-inactive tumors had increased WNT/β-catenin and Sonic Hedgehog signaling. Substantial genome-wide differences in DNA methylation were observed. HPV-inactive tumors had a global decrease in DNA methylation; however, many promoter-associated CpGs were hypermethylated. Many inflammatory response genes showed promoter methylation and decreased expression. The somatic mutation landscapes were significantly different. HPV-active tumors carried few somatic mutations in driver genes, whereas HPV-inactive tumors were enriched for non-synonymous somatic mutations (p-value < 0.0000001) specifically targeting TP53, ARID, WNT, and PI3K pathways.

MATERIALS AND METHODS

The Cancer Genome Atlas (TCGA) cervical cancer data were analyzed.

CONCLUSIONS

Many of the gene expression changes and somatic mutations found in HPV-inactive tumors alter pathways for which targeted therapeutics are available. Treatment strategies focused on WNT, PI3K, or TP53 mutations may be effective against HPV-inactive tumors and could improve survival for these cervical cancer patients.

Disparity in rates of HPV infection and cervical cancer in underserved US populations

There is a higher rate of HPV infection and cervical cancer incidence and mortality in underserved US population who reside in Appalachian mountain region compared to Northern Plains. Social and behavioral factors such as smoking and alcohol consumption are for such a high incidence. However, by and large, the reasons for these discrepancies lie in the reluctance of the underserved population to adopt preventive measures such as prophylactic Human papilloma virus (HPV) vaccines and Pap smear screening that have significantly reduced the incidence and mortality rate of cervical cancer in Caucasian women. Thus, it is clear that drastic change in social behavior and implementation of preventive measures is required to effectively reduce the incidence and mortality from cervical cancer in this underserved population.

High-risk human papillomavirus seroprevalence in men and women of six different ethnicities in Amsterdam, the Netherlands: The HELIUS study

Background

Ethnic variations in the (sero)prevalence of Human Papillomavirus (HPV) and HPV related diseases have been observed previously. We explored if high-risk HPV (hrHPV) seropositivity indeed differs among 6 ethnic groups in Amsterdam the Netherlands and assessed if hrHPV seroprevalence is higher among women than men within each ethnic group, both after adjustment for confounders.

Methods

From the multi-ethnic HEalthy Life In an Urban Setting (HELIUS) study in Amsterdam (the Netherlands) we randomly selected 4637 men and women aged 18–44 years with a Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Moroccan, or Turkish ethnicity. Blood samples were tested for HPV-16,−18,−31,−33,−45,−52, and −58 antibodies using a validated Luminex-based multiplex serology assay. We assessed the association of both ethnicity and gender with hrHPV seropositivity using logistic regression models with generalised estimating equations.

Results

The hrHPV seroprevalence in Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Moroccan, and Turkish participants was 18%, 12%, 23%, 19%, 17%, and 15% in men, and 30%, 22%, 34%, 31%, 14%, and 15% in women, respectively. HrHPV seroprevalence of non-Dutch men did not differ significantly from Dutch men. HrHPV seroprevalence was significantly higher among African Surinamese women, and significantly lower among Moroccan and Turkish women when compared to Dutch women. These differences were not significant anymore after adjustment for demographic, health, and sexual behavioural differences between ethnicities. HrHPV seroprevalence varied by age, age of sexual debut, and lifetime sexual partners among women but not among men. Seroprevalence of hrHPV was higher among women than among men, except in the Turkish group.

Conclusion

Among women hrHPV seroprevalence differed by ethnicity, yet among men no pronounced differences were observed across ethnicities.

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Women have a higher hrHPV seroprevalence than men, except in the Turkish group.

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Seroprevalence of hrHPV varies by ethnicity among women in Amsterdam.

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Among men no pronounced differences in hrHPV seroprevalence by ethnicity are observed.

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Differences by ethnicity in women are attributable to differences in sexual behaviour.

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HPV serology is not a useful indicator of sexual exposure among heterosexual men.

Race is Associated With Sexual Behaviors and Modifies the Effect of Age on Human Papillomavirus Serostatus Among Perimenopausal Women

BACKGROUND

Human papillomavirus (HPV) causes oropharyngeal and cervical cancers. Oropharyngeal cancer primarily affects whites, but cervical cancer is more common among blacks. Reasons for this distinct epidemiology are unclear.

METHODS

Serum was collected from women aged 35 to 60 years in the HPV in Perimenopause cohort and evaluated for antibodies to 8 HPV types. Demographic and behavioral data were collected by telephone questionnaire. Associations between sexual behaviors, race, age, HPV serostatus, and strength of serologic response to HPV were evaluated.

RESULTS

There were 781 women in this analysis, including 620 white (79%) and 161 (21%) black women. Whites were less likely to report 5+ vaginal sex partners (prevalence ratio [PR], 0.86; 95% confidence interval [CI], 0.77-0.97), but more likely to report 5+ oral sex partners (PR, 2.38; 95% CI, 1.62-3.49) compared with blacks. Seropositivity to most individual HPV types and at least 3 types was significantly lower in whites than in blacks (PR, 0.62; 95% CI, 0.47-0.80). Human papillomavirus seropositivity was independently associated with younger age among blacks, but with sexual exposures among whites. Furthermore, strength of serologic response to most HPV types significantly decreased with older age among blacks, but not among whites.

CONCLUSIONS

Racial differences in immune markers of HPV exposure and the epidemiology of HPV-related cancers may be linked to differences in patterns of sexual behaviors.

Racial/Ethnic Disparities in Cervical Cancer Screening and Outcomes

Invasive cervical cancer disproportionately affects women without sufficient access to care, with higher rates among minority groups in higher-income countries and women in low-resource regions of the world. Many elements contribute to racial/ethnic disparities in the cervical cancer continuum - from screening and diagnosis to treatment and outcome. Sociodemographic factors, access to healthcare, income and education level, and disease stage at diagnosis are closely linked to such inequities. Despite the identification of such elements, racial/ethnic disparities persist, and are widening in several minority subgroups, particularly in older women, who are ineligible for human papillomavirus (HPV) vaccination and are underscreened. Recent studies suggest that racial/ethnic differences in HPV infection exist and may also have a role in observed differences in cervical cancer. In this review, we provide an overview of the current literature on racial disparities in cervical cancer screening, incidence, treatment and outcome to inform future strategies to reduce persistent inequities.

Clinical Utility of Molecular Biomarkers in Cervical Squamous Intraepithelial Lesions in a Young Adult Population

OBJECTIVE

Although human papillomavirus (HPV) infection is necessary for cervical squamous intraepithelial lesion (SIL/CIN) and cancer to develop, exposure to HPV is not predictive of which women will develop SIL/CIN and cancer. This study examines mRNA expression of several potential biomarkers in exfoliated cervical cells collected from college-aged women.

MATERIALS AND METHODS

Freshman female students were recruited into the Carolina Women's Care Study, which was designed to prospectively evaluate factors that contribute to persistent HPV infections. One component of this study was to extract mRNA from exfoliated cervical cells. In this study, mRNA expression of Frizzled (FZD), growth differentiating factor 15, interleukin 1 beta (IL1β), and N-cadherin was assessed through real-time polymerase chain reaction. Statistical analysis was performed with a Student t test; all results were standardized with glyceraldehyde 3-phosphate dehydrogenase.

RESULTS

Fifty samples were selected that reflected the demographics of the Carolina Women's Care Study participants. IL1β mRNA expression was 9.4-fold higher in cervical cells from women with abnormal Pap tests (p = .0018); low-grade squamous intraepithelial lesion had 12.7-fold higher expression than negatives (p = .0011). The FZD mRNA expression was 5.7-fold higher in CIN 2 as compared with CIN 1 (p = .0041) and 8.5-fold higher compared with cytology/pathology negative (p = .0014). Other differences in mRNA expression showed trends but not reaching statistical significance for each condition.

CONCLUSIONS

It seems that several biomarkers involved in the cytokine/inflammatory pathway (IL1β), cell adhesion pathway (N-cadherin), growth factor (growth differentiating factor 15), and Wingless (WNT) signaling pathway (FZD) may be potential biomarkers in conjunction with the Pap test and HPV that help predict which women are at highest risk for developing CIN 3 and cervical cancer.

Human Papillomavirus Type 16 L2 DNA Methylation in Exfoliated Cervical Cells From College-Age Women

OBJECTIVES

The Carolina Women's Care Study (CWCS) at the University of South Carolina followed 467 young women with the goal of identifying biomarkers of human papillomavirus (HPV) persistence. In this study, we analyzed the methylation of HPV16 DNA.

METHODS

The aims of this study were to determine the methylation status of the HPV16 L2 gene in DNA isolated from exfoliated cervical cells collected longitudinally as part of the CWCS and to determine the prevalence of polymorphisms (single nucleotide polymorphisms [SNPs]) in folate metabolizing enzymes and DNA repair enzymes known to affect DNA methylation in blood-derived genomic DNA from CWCS participants. For methylation studies, DNA samples were bisulfite converted and amplified with the EpiTect Whole Bisulfitome kit. Polymerase chain reaction was performed for amplicons containing 5 CpG sites in L2. Pyrosequencing was carried out using EpigenDx and analyzed with PyroMark Software. Taqman genotyping assays were performed to determine selected SNP alleles in the CWCS cohort.

RESULTS AND CONCLUSIONS

Methylation data were obtained for 82 samples from 27 participants. Of these, 22 participants were positive for HPV16 for 3 or more visits (≥12 months). Methylation in L2 was detectable, but methylation levels varied and were not associated with HPV16 persistence. No linearity of methylation levels over time was observed in participants for whom longitudinal data could be analyzed. Analysis of 9 selected SNPs did not reveal an association with persistence. We conclude that at early stages of infection methylation of HPV16 L2 DNA in Pap test samples is not a predictive biomarker of HPV persistence.

HPV16 variants distribution in invasive cancers of the cervix, vulva, vagina, penis, and anus

Human papillomavirus (HPV)16 is the most oncogenic human papillomavirus, responsible for most papillomavirus‐induced anogenital cancers. We have explored by sequencing and phylogenetic analysis the viral variant lineages present in 692 HPV16‐monoinfected invasive anogenital cancers from Europe, Asia, and Central/South America. We have assessed the contribution of geography and anatomy to the differential prevalence of HPV16 variants and to the nonsynonymous E6 T350G polymorphism. Most (68%) of the variance in the distribution of HPV16 variants was accounted for by the differential abundance of the different viral lineages. The most prevalent variant (above 70% prevalence) in all regions and in all locations was HPV16_A1‐3, except in Asia, where HPV16_A4 predominated in anal cancers. The differential prevalence of variants as a function of geographical origin explained 9% of the variance, and the differential prevalence of variants as a function of anatomical location accounted for less than 3% of the variance. Despite containing similar repertoires of HPV16 variants, we confirm the worldwide trend of cervical cancers being diagnosed significantly earlier than other anogenital cancers (early fifties vs. early sixties). Frequencies for alleles in the HPV16 E6 T350G polymorphism were similar across anogenital cancers from the same geographical origin. Interestingly, anogenital cancers from Central/South America displayed higher 350G allele frequencies also within HPV16_A1‐3 lineage compared with Europe. Our results demonstrate ample variation in HPV16 variants prevalence in anogenital cancers, which is partly explained by the geographical origin of the sample and only marginally explained by the anatomical location of the lesion, suggesting that tissue specialization is not essential evolutionary forces shaping HPV16 diversity in anogenital cancers.

Vaginal high-risk human papillomavirus infection in a cross-sectional study among women of six different ethnicities in Amsterdam, the Netherlands: the HELIUS study

OBJECTIVE

In the Netherlands the incidence of cervical cancer is higher among ethnic minority populations compared with the general Dutch population. We investigated the prevalence of, and risk factors associated with, vaginal high-risk human papillomavirus (hrHPV) infection in women of six different ethnicities living in Amsterdam.

METHODS

For this cross-sectional study we selected women aged 18-34 years old of six ethnicities from the large-scale multiethnic HEalthy LIfe in an Urban Setting study. Self-collected vaginal swabs were tested for HPV DNA and genotyped using a highly sensitive PCR and reverse line blot assay (short PCR fragment (SPF)10-PCR DNA enzyme immunoassay/LiPA25-system version-1, delft diagnostic laboratory (DDL)). Participants completed a questionnaire regarding demographics and sexual behaviour. Logistic regression using generalised estimating equations was used to assess risk factors of hrHPV, and to investigate whether prevalence of hrHPV differed among ethnicities.

RESULTS

The study population consisted of 592 women with a median age of 27 (IQR: 23-31) years. Dutch and African Surinamese women reported the highest sexual risk behaviour. HrHPV prevalence was highest in the Dutch (40%) followed by the African Surinamese (32%), Turkish (29%), Ghanaian (26%), Moroccan (26%) and South-Asian Surinamese (18%). When correcting for sexual risk behaviour, the odds to be hrHPV-positive were similar for all non-Dutch groups when compared with that of the Dutch group.

CONCLUSIONS

We found an overall higher hrHPV prevalence and higher sexual risk behaviour in the native Dutch population. Further research is needed to unravel the complex problem concerning cervical cancer disparities, such as differences in participation in the cervical cancer screening programme, or differences in clearance and persistence of hrHPV.

IL-10, IL-15, IL-17, and GMCSF levels in cervical cancer tissue of Tanzanian women infected with HPV16/18 vs. non-HPV16/18 genotypes

Background

Despite comparable screening rates for precancerous lesions, higher incidence and mortality related to cervical cancer in minority women persists. Recent evidence suggests that minority women with precancerous cervical lesions harbor a wider range of human papillomavirus (HPV) genotypes, many of these distinct from HPV16/18, those most commonly found in Caucasian women. The goal of the analysis was to determine if inflammatory cytokines and chemokines varied by HPV 16/18 versus other genotypes in cervical cancer tissues from Tanzanian women.

Methods

HPV genotypes and concentrations of chemokines and cytokines were measured from homogenized fresh tumor tissue of thirty-one women with invasive cervical cancer (ICC). Risk factors for cervical cancer including age, parity, hormonal contraceptive use and cigarette smoking were obtained by questionnaire. Generalized linear models were used to evaluate differences between chemokines/cytokine levels in women infected with HPV16/18 and those infected with other HPV genotypes.

Results

After adjusting for age, parity and hormonal contraceptives, IL-17 was found significantly more frequently in invasive cervical cancer samples of women infected with HPV16/18 compared to women infected with other HPV genotypes (p = 0.033). In contrast, higher levels for granular macrophage colony-stimulating factor (p = 0.004), IL-10 (p = 0.037), and IL-15 (p = 0.041) were found in ICC tissues of women infected with genotypes other than HPV16/18 when compared to those of women infected with HPV16/18.

Conclusions

While the small sample size limits inference, our data suggest that infection with different HPV genotypes is associated with distinct pro-inflammatory cytokine expression profiles; whether this explains some of the racial differences observed in cervical cancer is still unclear. Future studies are needed to confirm these findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s13027-015-0005-1) contains supplementary material, which is available to authorized users.