Incidence Trends and Burden of Human Papillomavirus-Associated Cancers Among Women in the United States, 2001-2017

Recent trends in cervical cancer incidence, stage at diagnosis, and mortality according to county-level income in the United States, 2000-2019

Early evidence suggests that declining cervical cancer incidence reversed in low-income regions in the United States in recent years; however, it is unclear whether there are distinct patterns by race/ethnicity and stage at diagnosis and if the increase has translated into rising mortality. Using Surveillance, Epidemiology, and End Results data, we evaluated trends in hysterectomy-corrected cervical cancer incidence rates (2000-2019) and mortality rates (2005-2019) by county-level income and race/ethnicity, with further stratification of incidence by stage at diagnosis. Following a period of decline, hysterectomy-corrected cervical cancer incidence increased 1.0%/year (95% CI = 0.1% to 4.5%) among Non-Hispanic White women in low-income counties. Particularly, a statistically significant 4.4%/year (95% CI = 1.7% to 7.5%) increase in distant-stage cancer occurred in this group. Additionally, recent increases in cervical cancer mortality (1.1%/year [95% CI = -1.4% to 3.7%]) were observed among this group and Non-Hispanic Black women in low-income counties (2.9%/year [95% CI = -2.3% to 18.2%]), but trends were not statistically significant. Among Hispanic women in low-income counties, distant-stage cervical cancer incidence increased 1.5%/year (95% CI = -0.6% to 4.1%), albeit not statistically significant. The increasing incidence of distant-stage cervical cancer and mortality in specific racial/ethnic groups suggests that the recent introduction of higher sensitivity screening tests may not explain increasing trends in low-income counties. Our findings suggest that the observed rise in cervical cancer incidence may reflect disruptions along the screening and treatment continuum. Future research to further comprehend these trends and continued enhancements in prevention are crucial to combat rising cervical cancer incidence and mortality in low-income counties in the United States.

Increasing Rates of Human Papillomavirus Catch-Up Vaccination at a Sexual and Reproductive Health Clinic: A Quality Improvement Project

INTRODUCTION

Catch-up human papillomavirus (HPV) vaccination of adults aged 19 to 26 who were not vaccinated as children or adolescents may decrease rates of HPV-associated cancer. The purpose of this project was to increase uptake of catch-up HPV vaccination at a sexual and reproductive health clinic through the implementation of a multicomponent, systems-based intervention.

PROCESS

Catch-up vaccination rates were recorded at an intervention health clinic and a comparison health clinic. A comparative, interrupted time series design was used to compare rates of catch-up vaccination pre- and postintervention. Electronic health record prompts, in-clinic education, and scheduling of a next visit at the current visit were implemented. Data were analyzed using descriptive statistics, t tests, and regression analysis.

OUTCOMES

The proportion of all patients aged 19 to 26 who received an HPV vaccination rose at the intervention health clinic from 0.76% preintervention to 4.42% postintervention. At the intervention clinic there was a nonsignificant increase (4.47 minutes) in average daily patient cycle times between the pre- and postintervention periods (t(13) = 1.895, P = .075).

DISCUSSION

Rates of catch-up HPV vaccination increased significantly following the multicomponent, systems-based intervention. Further iteration of the quality improvement process should examine the sustainability of the interventions and the effects of the intervention on vaccine series completion.

Comparing the Diagnostic Performance of Quantitative PCR, Digital Droplet PCR, and Next-Generation Sequencing Liquid Biopsies for Human Papillomavirus-Associated Cancers

Human papillomavirus (HPV)-associated cancers, including oropharyngeal squamous cell carcinoma (HPV + OPSCC), cervical cancer, and squamous cell carcinoma of the anus (HPV + SCCA), release circulating tumor HPV DNA (ctHPVDNA) into the blood. The diagnostic performance of ctHPVDNA detection depends on the approaches used and the individual assay metrics. A comparison of these approaches has not been systematically performed to inform expected performance, which in turn affects clinical interpretation. A meta-analysis was performed using Ovid MEDLINE, Embase, and Web of Science Core Collection databases to assess the diagnostic accuracy of ctHPVDNA detection across cancer anatomic sites, detection platforms, and blood components. The population included patients with HPV + OPSCC, HPV-associated cervical cancer, and HPV + SCCA with pretreatment samples analyzed by quantitative PCR (qPCR), digital droplet PCR (ddPCR), or next-generation sequencing (NGS). Thirty-six studies involving 2986 patients met the inclusion criteria. The sensitivity, specificity, and quality of each study were assessed and pooled for each analysis. The sensitivity of ctHPVDNA detection was greatest with NGS, followed by ddPCR and then qPCR when pooling all studies, whereas specificity was similar (sensitivity: ddPCR > qPCR, P < 0.001; NGS > ddPCR, P = 0.014). ctHPVDNA from OPSCC was more easily detected compared with cervical cancer and SCCA, overall (P = 0.044). In conclusion, detection platform, anatomic site of the cancer, and blood component used affects ctHPVDNA detection and must be considered when interpreting results. Plasma NGS-based testing may be the most sensitive approach for ctHPVDNA overall.

Autoimmune disease and the risk of anal cancer in the US population aged 66 years and over

BACKGROUND

In the United States, anal squamous cell carcinoma rates have increased rapidly, particularly among women 50 or older than 66 years of age. As immunosuppression is associated with increased risk, autoimmune conditions may be associated with greater risk of anal squamous cell carcinoma.

METHODS

We conducted a population-based, case-control study using Surveillance, Epidemiology, and End Results-Medicare data (2000-2017). Anal squamous cell carcinoma cases (n = 4505) were matched to 200 000 cancer-free controls. Using multivariable logistic regression, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) for associations between 47 autoimmune conditions diagnosed before selection, identified using Medicare claims, and anal squamous cell carcinoma. The Bonferroni threshold was used to correct for multiple comparisons. Population attributable fractions were calculated for conditions nominally associated with anal squamous cell carcinoma.

RESULTS

In total, 18% of anal squamous cell carcinoma cases and 15% of cancer-free controls had a diagnosed autoimmune condition. Any autoimmune condition was associated with an increased risk of anal squamous cell carcinoma (OR = 1.11, 95% CI = 1.02 to 1.21; population attributable fraction = 1.8%). Anal squamous cell carcinoma was associated with systemic lupus erythematosus (OR = 1.79, 95% CI = 1.32 to 2.42; population attributable fraction = 0.4%) and nominally associated (P < .05) with sarcoidosis (OR = 2.09, 95% CI = 1.30 to 3.37; population-attributable fraction = 0.2%) and psoriasis (OR = 1.28, 95% CI = 1.06 to 1.56; population attributable fraction = 0.5%). Stratified by sex, only women showed statistically significant associations for systemic lupus erythematosus (OR = 1.97, 95% CI = 1.46 to 2.68). Statistically significant interaction was observed by sex for psoriasis (men vs women: OR = 1.68 [95% CI = 1.03 to 4.28] vs OR = 1.12 [95% CI = 0.88 to 1.43]) and polymyalgia rheumatica (OR = 0.33 [95% CI = 0.12 to 0.89] vs OR = 0.99 [95% CI = 0.75 to 1.30]).

CONCLUSION

Systemic lupus erythematosus, sarcoidosis, and psoriasis were associated with a moderately increased risk of anal squamous cell carcinoma. Given these conditions' rarity and moderate associations with anal squamous cell carcinoma, autoimmune diseases cannot explain the rising trend in this disease.

Consumption of Health-Related Videos and Human Papillomavirus Awareness: Cross-Sectional Analyses of a US National Survey and YouTube From the Urban-Rural Context

BACKGROUND

Nearly 70% of Americans use the internet as their first source of information for health-related questions. Contemporary data on the consumption of web-based videos containing health information among American adults by urbanity or rurality is currently unavailable, and its link with health topic awareness, particularly for human papillomavirus (HPV), is not known.

OBJECTIVE

We aim to describe trends and patterns in the consumption of health-related videos on social media from an urban-rural context, examine the association between exposure to health-related videos on social media and awareness of health topics (ie, HPV and HPV vaccine), and understand public interest in HPV-related video content through search terms and engagement analytics.

METHODS

We conducted a cross-sectional analysis of the US Health Information National Trends Survey 6, a nationally representative survey that collects data from civilian, noninstitutionalized adults aged 18 years or older residing in the United States. Bivariable analyses were used to estimate the prevalence of consumption of health-related videos on social media among US adults overall and by urbanity or rurality. Multivariable logistic regression models were used to examine the association between the consumption of health-related videos and HPV awareness among urban and rural adults. To provide additional context on the public's interest in HPV-specific video content, we examined search volumes (quantitative) and related query searches (qualitative) for the terms "HPV" and "HPV vaccine" on YouTube.

RESULTS

In 2022, 59.6% of US adults (152.3 million) consumed health-related videos on social media, an increase of nearly 100% from 2017 to 2022. Prevalence increased among adults living in both urban (from 31.4% in 2017 to 59.8% in 2022; P<.001) and rural (from 22.4% in 2017 to 58% in 2022; P<.001) regions. Within the urban and rural groups, consumption of health-related videos on social media was most prevalent among adults aged between 18 and 40 years and college graduates or higher-educated adults. Among both urban and rural groups, adults who consumed health-related videos had a significantly higher probability of being aware of HPV and the HPV vaccine compared with those who did not watch health videos on the internet. The term "HPV" was more frequently searched on YouTube compared with "HPV vaccine." Individuals were most commonly searching for videos that covered content about the HPV vaccine, HPV in males, and side effects of the HPV vaccine.

CONCLUSIONS

The consumption of health-related videos on social media in the United States increased dramatically between 2017 and 2022. The rise was prominent among both urban and rural adults. Watching a health-related video on social media was associated with a greater probability of being aware of HPV and the HPV vaccine. Additional research on designing and developing social media strategies is needed to increase public awareness of health topics.

CNKSR2 expression is correlated with immune infiltrates in Cervical Cancer as a favorable prognostic factor

Connector enhancer of kinase suppressor of Ras 2 (CNKSR2) is a scaffold protein that mediates mitogen-activated protein kinase pathways. However, the molecular function of CNKSR2 in cervical squamous cell carcinoma (CESC) remains unknown. This study aimed to characterize the role of CNKSR2 in patients with CESC. Immunohistochemistry revealed that the expression of CNKSR2 in CESCs is relatively low compared with that in normal cells. We also explored the gene expression profile of high- and low-CNKSR2 expression in patients with cervical cancer. Furthermore, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis showed that the expression of CNKSR2 was upregulated in synapse assembly, which was coordinately regulated using the cAMP signaling pathway and calcium signaling pathway. The correlation between CNKSR2 and cancer immune cell infiltration was investigated via single-sample gene set enrichment analysis (ssGSEA). High CNKSR2 expression was associated with better overall survival (OS) and disease-free survival (DFS). Interestingly, high CNKSR2 expression was a good predictor of the survival outcome in cervical cancer patients. Additionally, CNKSR2 expression was strongly correlated with diverse immune cells in CESCs, including NK cells and T cells. These findings suggest that CNKSR2 is correlated with prognosis and immune infiltration, laying the foundation for future studies on the functional role of CNKSR2 in CESC.

Urban and rural healthcare providers' perspectives on HPV vaccination in Minnesota

Human papillomavirus (HPV) vaccination can dramatically reduce the incidence of HPV-associated cancers. However, HPV vaccination coverage in rural areas is lower than in urban areas, and overall HPV vaccination coverage in the United States remains lower than other adolescent vaccines. We conducted 20 qualitative interviews with adolescent healthcare providers and clinic staff in urban and rural Minnesota and assessed their perspectives on HPV vaccination. Guiding interview topics included: strategies to persuade families to vaccinate their children, the impact of the patient-provider relationship and the clinical environment on vaccination uptake, and provider perceptions of parents' vaccine attitudes. In thematic analysis, all participants reported using common vaccination strategies, such as framing the HPV vaccine in terms of cancer prevention. The analysis also revealed three themes described as occurring uniquely or more intensely in rural communities than urban communities: the rural value of choice or independence, the spread of misinformation, and close-knit, multifaceted patient-provider relationships in clinical practice. Interventions aimed at increasing HPV vaccination should consider the distinctive circumstances of rural healthcare providers and patients.

The association between YouTube use and knowledge of human papillomavirus-related cancers

Objective

To examine the association between YouTube usage and HPV-related cancer knowledge (cervical, anal, oral and penile).

Study design

Cross-sectional study using data from the Health Information National Trends survey conducted between 2017 and 2020 (N = 16,092). Logistic regression was used to analyze the independent effect of YouTube use on cancer knowledge, controlling for sociodemographic characteristics.

Results

Respondents' knowledge of HPV-related cancers varied: 49.9% about cervical, 18% anal, 20.1% oral and 20.4% penile cancers. YouTube use was associated with increased knowledge for all cancers (cervical: OR 2.66, 95% CI 2.04, 3.46; anal: OR 1.83, 95% CI 1.32, 2.53; oral: OR 1.89, 95% CI 1.37, 2.61; penile OR 2.00, 95% CI 1.44, 2.77) in models adjusted for all covariates. Other independent predictors of HPV-related cancer knowledge included female gender, younger age, a higher income, and higher education.

Conclusions

YouTube could play an important role in educating people about HPV-related cancers and should also target other populations, such as males and those with less formal education.

Innovation

The study provides novel insights into the potential of YouTube as an educational tool for promoting cancer knowledge with the goal of cancer prevention.

Nomograms constructed for predicting diagnosis and prognosis in cervical cancer patients with second primary malignancies: a SEER database analysis

PURPOSE

Cervical cancer (CC) patients are more likely to develop second primary malignancies (SPMs) than general population. With the advancement in cancer therapy, CC patients are achieving long-term survival, leading SPMs to our attention. Our study aims to establish diagnostic and prognostic nomograms for CC patients with second primary malignancies (CCSPMs) to help make personalized follow-up plans and treatments.

METHODS

Data of CCSPMs between 2000 and 2019 was extracted from SEER. The proportions and the median interval time of CCSPM onset were calculated. 11 related clinical characteristics, including age, race, marital status, grade, FIGO stage, radiotherapy, chemotherapy, and surgery, were further explore. Logistic and Cox regressions were employed to predict risk factors for CCSPMs diagnosis. Finally, two nomograms were developed to predict the probability occurrence and prognosis of CCSPMs, respectively.

RESULTS

For diagnostic nomogram construction, 59,178 CC patients were randomly divided into training (n = 41,426) and validation cohorts (n = 17,752). For prognostic nomogram construction, 3527 CCSPMs patients were randomly divided into training (n = 2469) and validation cohorts (n = 1058). The diagnostic nomogram consisting of above 11 independent risk factors (all P < 0.05), had high accuracy (AUCtraining = 0.851 and AUCvalidating = 0.845). The prognostic nomogram integrated with eight independent prognostic factors such as treatments, FIGO stage and TNM stage performed well in predicting 5-year OS (AUCtraining = 0.835 and AUCvalidating = 0.837).

CONCLUSION

Our diagnostic and prognostic nomograms could facilitate clinicians to quantify individual SPMs risk and survival probabilities and optimize the surveillance recommendations and personalized clinical decision-making.

Top advances of the year: Cervical cancer

Cervical cancer continues to affect women in the United States and throughout the world despite an effective vaccine against human papillomavirus and cancer screening programs. For the women who develop cervical cancer, surgery, radiation, and chemotherapy have been the mainstays of treatment for years. Recently, novel therapeutics have been developed that offer new treatment opportunities for women living with advanced and/or recurrent disease. Immunotherapy has become an important tool against cervical cancer with the approval of pembrolizumab in the second line for advanced or recurrent disease. Checkpoint inhibitors have recently been approved in the front line for advanced and/or recurrent disease in combination with chemotherapy, and they are being studied in the front line in combination with chemoradiation. Antibody-drug conjugates-specifically tisotumab vedotin (TV)-also have recently received Food and Drug Administration (FDA) approval, and TV is currently being studied in combination with checkpoint inhibitors and with carboplatin. Tumor-infiltrating lymphocytes have been studied in early-phase trials and have shown promise in small patient series. Despite these new therapies, there continue to be racial, ethnic, and socioeconomic inequities with respect to access to care, access to and participation in clinical trials, and survival in the United States as well as globally. New FDA guidance requires researchers to work to reduce disparities by including women of more diverse backgrounds in clinical trials. Finally, as progress continues to be made in the treatment of established disease, prevention through vaccination and screening remains paramount. PLAIN LANGUAGE SUMMARY: The treatment of cervical cancer remains a significant problem in the United States and especially worldwide. Although early cases can be cured, cervical cancer that has spread remains difficult to treat. The past few years have seen significant advances in new therapies and combinations of therapies for women with advanced or recurrent disease. Although this is excellent news for these women, cervical cancer is a preventable disease through screening with Papanicolaou smears and vaccination with the human papillomavirus vaccine. By improving access to and acceptance of screening and vaccination, we can eradicate cervical cancer in the United States and the world.

State Variation in Squamous Cell Carcinoma of the Anus Incidence and Mortality, and Association With HIV/AIDS and Smoking in the United States

PURPOSE

Squamous cell carcinoma of the anus (SCCA) incidence and mortality rates are rising in the United States. Understanding state-level incidence and mortality patterns and associations with smoking and AIDS prevalence (key risk factors) could help unravel disparities and provide etiologic clues.

METHODS

Using the US Cancer Statistics and the National Center for Health Statistics data sets, we estimated state-level SCCA incidence and mortality rates. Rate ratios (RRs) were calculated to compare incidence and mortality in 2014-2018 versus 2001-2005. The correlations between SCCA incidence with current smoking (from the Behavioral Risk Factor Surveillance System) and AIDS (from the HIV Surveillance system) prevalence were evaluated using Spearman's rank correlation coefficient.

RESULTS

Nationally, SCCA incidence and mortality rates (per 100,000) increased among men (incidence, 2.29-3.36, mortality, 0.46-0.74) and women (incidence, 3.88-6.30, mortality, 0.65-1.02) age ≥ 50 years, but decreased among men age < 50 years and were stable among similar-aged women. In state-level analysis, a marked increase in incidence (≥ 1.5-fold for men and ≥ two-fold for women) and mortality (≥ two-fold) for persons age ≥ 50 years was largely concentrated in the Midwestern and Southeastern states. State-level SCCA incidence rates in recent years (2014-2018) among men were correlated (r = 0.47, P < .001) with state-level AIDS prevalence patterns. For women, a correlation was observed between state-level SCCA incidence rates and smoking prevalence (r = 0.49, P < .001).

CONCLUSION

During 2001-2005 to 2014-2018, SCCA incidence and mortality nearly doubled among men and women age ≥ 50 years living in Midwest and Southeast. State variation in AIDS and smoking patterns may explain variation in SCCA incidence. Improved and targeted prevention is needed to combat the rise in SCCA incidence and mitigate magnifying geographic disparities.

Global burden of HPV-attributable squamous cell carcinoma of the anus in 2020, according to sex and HIV status: A worldwide analysis

Squamous cell carcinoma of the anus (SCCA) is caused by HPV, and is elevated in persons living with HIV (PLWHIV). We aimed to estimate sex- and HIV-stratified SCCA burden at a country, regional and global level. Using anal cancer incidence estimates from 185 countries available through GLOBOCAN 2020, and region/country-specific proportions of SCCA vs non-SCCA from the Cancer Incidence in Five Continents (CI5) Volume XI database, we estimated country- and sex-specific SCCA incidence. Proportions of SCCA diagnosed in PLWHIV, and attributable to HIV, were calculated using estimates of HIV prevalence (UNAIDS 2019) and relative risk applied to SCCA incidence. Of 30 416 SCCA estimated globally in 2020, two-thirds occurred in women (19 792) and one-third among men (10 624). Fifty-three percent of male SCCA and 65% of female SCCA occurred in countries with a very high Human Development Index (HDI). Twenty-one percent of the global male SCCA burden occurred in PLWHIV (n = 2203), largely concentrated in North America, Europe and Africa. While, only 3% of global female SCCA burden (n = 561) occurred in PLWHIV, mainly in Africa. The global age-standardized incidence rate of HIV-negative SCCA was higher in women (0.55 cases per 100 000) than men (0.28), whereas HIV-positive SCCA was higher in men (0.07) than women (0.02). HIV prevalence reached >40% in 22 countries for male SCCA and in 10 countries for female SCCA, mostly in Africa. Understanding global SCCA burden by HIV status can inform SCCA prevention programs (through HPV vaccination, screening and HIV control) and help raise awareness to combat the disease.

Anal Cancer in High-Risk Women: The Lost Tribe

In developed countries the incidence of anal squamous cell carcinoma (SCC) has been rising; especially in women over the age of 60 years who present with more advanced disease stage than men. Historically, anal SCC screening has focused on people living with Human Immunodeficiency Virus (HIV) (PLWH) who are considered to be at the highest risk of anal SCC, and its precancerous lesion, anal squamous intraepithelial lesion (SIL). Despite this, women with vulval high-grade squamous epithelial lesions (HSIL) and SCCs have been shown to be as affected by anal HSIL and SCC as some PLWH. Nevertheless, there are no guidelines for the management of anal HSIL in this patient group. The ANCHOR trial demonstrated that treating anal HSIL significantly reduces the risk of anal SCC in PLWH, there is therefore an unmet requirement to clarify whether the screening and treatment of HSIL in women with a prior genital HSIL is also beneficial. This review presents the current evidence supporting the screening, treatment, and surveillance of anal HSIL in high-risk women with a previous history of genital HSIL and/or SCC.

Human Papillomavirus Vaccine Administration Trends Among Commercially Insured US Adults Aged 27-45 Years Before and After Advisory Committee on Immunization Practices Recommendation Change, 2007-2020

Importance

In 2019, the Advisory Committee on Immunization Practices (ACIP) recommended patient-clinician shared decision-making for human papillomavirus (HPV) vaccination in adults aged 27 to 45 years. Less is known about the HPV vaccine administration trends in this age group before and after this recommendation update.

Objective

To examine the association between the ACIP recommendation update and the HPV vaccine administration among US adults aged 27 to 45 years.

Design, Setting, and Participants

This large commercial claim-based retrospective cohort study used the Optum Clinformatics database for validated claims from January 1, 2007, through December 31, 2020. A total of 22 600 520 US adults aged 27 to 45 years without previous HPV vaccination claims during the study and enrollment period were included.

Main Outcomes and Measures

The first-appearing HPV vaccination claim per individual was defined as a new HPV vaccine administration. Interrupted time-series analyses were conducted to assess the association between the ACIP update and the quarterly vaccine administration rate change. The annual rate trends across race and ethnicity groups and the proportions of vaccination cases by sub-age groups and valent types were also estimated. Vaccine administration trends were assessed by race and ethnicity in this age group because HPV vaccination trends were found to differ by race and ethnicity in the initially eligible population.

Results

Among 22 600 520 final study participants, the majority were men (50.9%) and non-Hispanic White (53.4%), and the mean (SD) age when first observed was 34.6 (5.8) years. In women, the ACIP update was associated with an immediate increase in vaccine administration rate (coefficient β2, 40.18 per 100 000 persons; P = .01) and an increased slope (coefficient β3, 9.62 per 100 000 persons per quarter; P = .03) over time postupdate. The ACIP update was only associated with an immediate increase in vaccine administration in men (coefficient β2, 27.54; P < .001). The annual rate trends were similar across race and ethnicity groups. Age at vaccine administration shifted over time (eg, women aged 40-45 years comprised only 4.9% of vaccinations in 2017, then 19.0% in 2019, and 22.7% in 2020). The most administered HPV vaccines in 2020 were 9 valent (women, 97.0%; men, 97.7%).

Conclusions and Relevance

In this population-based cohort study, there were statistically significant increases in HPV vaccine administration in adults aged 27 to 45 years after the ACIP recommendation update. Patient-clinician shared decision-making may have been the main associated factor for this increase. Further research is warranted to explore the decision-making process in receiving HPV vaccination and to develop effective decision aids to maximize the cancer prevention benefit in this age group.

Cervical Cancer Incidence Among US Women, 2001-2019

This study uses national cancer incidence data to evaluate calendar trends in cervical cancer incidence by age at diagnosis.

Tdap-HPV vaccination bundling in the USA: Trends, predictors, and implications for vaccine series completion

The Centers for Disease Control and Prevention (CDC) promotes taking a 'bundling approach' (i.e., administering Tetanus, diphtheria toxoids, and acellular pertussis [Tdap] and human papillomavirus [HPV] vaccines in the same way and on the same day) for adolescent vaccinations. Recent trends and patterns in Tdap-HPV vaccination bundling in the USA remain undocumented. In addition, the implications of bundling Tdap-HPV vaccination for HPV vaccine series completion remain unknown. To address these critical knowledge gaps, we performed a retrospective study using a nationwide sample of privately insured adolescents (Optum's de-identified Clinformatics® Data Mart Database). Tdap-HPV vaccination bundling (per 100 Tdap vaccination encounters) during 2014-2018 was estimated overall, for 50 states, and by adolescents' age, sex, and provider specialties. Survival model estimated the likelihood of series completion among 9-14-year-old adolescents. From 2014 to 2018, 560,806 adolescents received a Tdap vaccine of which 172,604 (30.8%) received the HPV vaccines on the same day. Tdap-HPV vaccination bundling (per 100 Tdap vaccinations) increased nationally, from 22.9 in 2014 to 39.1 in 2018 (Ptrend < 0.001); bundling was lowest in New York and New Jersey. The likelihood of receiving the Tdap and HPV vaccines bundled was higher for young and female adolescents. Adolescents who received their first HPV vaccine bundled with the Tdap vaccine were more likely to complete the series compared to those who received it alone (Hazards Ratio = 1.45; 1.43-1.48). HPV vaccination bundling has increased in recent years in the USA. The increased likelihood of HPV vaccine series completion provides important evidence supporting the adoption of same-day Tdap-HPV vaccine administration in clinical practice to boost HPV vaccination coverage.

Human Papillomavirus Vaccine Impact and Effectiveness in Six High-Risk Populations: A Systematic Literature Review

Specific adult populations known to be at high risk for human papillomavirus (HPV)-related disease, such as men who have sex with men, are inconsistently included in national immunization programs. No compilation of the evidence on the real-world impact and effectiveness of HPV vaccines across these populations exists. This systematic literature review identifies and synthesizes the evidence of the real-world impact and effectiveness of the quadrivalent and nonavalent HPV vaccines in high-risk populations: women with prior/current HPV-related anogenital disease, men who have sex with men, immunocompromised/immunosuppressed individuals, female sex workers, transgender and non-binary individuals, and patients with recurrent respiratory papillomatosis (RRP). The outcomes included anogenital precancers/cancers, head and neck cancers, genital warts, and RRP recurrence. From the 2216 records identified, 30 studies (25 effectiveness and 5 impact studies) were included in this systematic literature review. The results, quantity, and quality of these studies were highly variable. The evidence for effectiveness was of high quality only in women with prior/current cervical disease and in individuals with RRP, the most frequently studied populations. No studies of transgender/non-binary individuals or female sex workers were identified. The real-world evidence supports HPV vaccination among women with prior cervical disease and individuals with RRP. Significant real-world data gaps remain in these high-risk populations.

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.

Anal Cancer Screening and Prevention: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Guidelines

In June 2019 the Centers for Disease Control and Prevention (CDC) convened an advisory group to assist in development of the 2021 CDC sexually transmitted infections (STI) guidelines. The advisory group on anal cancer screening and prevention met to formulate key questions in this field. The group examined published literature and abstracts to assess evidence and give recommendations for development of the CDC guidelines. This article summarizes key questions, evidence, recommendations, and areas for further research for the screening, diagnosis, and prevention of anal cancer.

Perceptions of Anal Cancer Risk Among HIV-Positive and High-Risk HIV-Negative Women

OBJECTIVES

Women living with HIV (WLWH) have a greater risk of anal cancer than women without HIV; however, there are limited studies that examine awareness of anal cancer risk among WLWH and "high-risk" HIV-negative women. This study examines risk factors for anal cancer, perceptions of risk for anal cancer, and perceptions of anal cancer screening among a cohort of WLWH and high-risk HIV-negative women.

MATERIALS AND METHODS

From the Atlanta, GA, and Bronx, NY, sites of the Women's Interagency HIV Study, 155 WLWH and HIV-negative women were enrolled and the Champion Health Belief Model Scale questionnaire measuring risk perceptions to anal cancer was administered to each participant.

RESULTS

The WLWH perceived anal cancer to be less serious and perceived facing fewer barriers to anal cancer screening than HIV-negative women (both p = .01). Older women (≥50 years) felt that they had less barriers to anal cancer screening (p = .047). Moreover, women who had less than a high school education felt more susceptible to anal cancer (p = .001), as did women who reported a history of anal intercourse (p = .017).

CONCLUSIONS

Despite being at an increased risk for anal cancer, perceptions of susceptibility to anal cancer and seriousness of anal cancer were low among WLWH. These findings highlight opportunities for provider and patient educational interventions to improve awareness of anal cancer risk among WLWH.

Long-term survival after treatment for primary anal cancer- results from the Swedish national ANCA cohort study

BACKGROUND

Squamous cell carcinoma of the anus is increasing in incidence but remains a rare disease with good 3- and 5-year recurrence free and overall survival rates of 63%-86%. The treatment includes chemoradiotherapy, mainly with 5-fluoruracil (5FU) and mitomycin. The aim of this study was to describe long-term (up to 9 years after treatment) oncological outcome and the types of treatments given, in a Swedish national cohort of patients diagnosed with anal cancer between 2011 and 2013.

METHOD

Patients were identified in the Swedish Cancer Registry. Patients still alive were contacted and asked for consent. Clinical data were retrieved from National Patient Register at the Swedish National Board of Health and Welfare and from medical records. Unadjusted and adjusted analyses were performed for overall survival.

RESULTS

Three hundred and eighty-eight patients were included in the study of which 338 patients (87%) received treatment with a curative intent. Follow up was 85 months (0-113 months) for patients treated with curative intent (information missing in one patient) 7.5 months (0-55) for patients with treated with a palliative intent. Curative treatment varied and consisted of both chemoradiotherapy and radiotherapy (46-64 Gy) alone. 5-FU, mitomycin and cisplatin were the most used chemotherapy agents. Five-year overall survival for patients treated with curative intent was 73%. In an adjusted analysis 5-FU and mitomycin is associated with a lower mortality than 5-FU and cisplatin but the association was weaker (HR 1.61 (95% CI: 0.904; 2.85) than in the unadjusted analysis.

CONCLUSIONS

In this national cohort overall five-year survival was 73% for patients treated with curative intent. As reported by others our results indicate that 5-FU and mitomycin C should be the preferred chemotherapy in treatment for cure.

Current Management of Locally Advanced and Metastatic Cervical Cancer in the United States

Despite decreases in incidence in the twentieth century, cervical cancer continues to be a highly morbid disease in the United States. For those diagnosed with locally advanced disease, single-agent cisplatin-based chemotherapy concurrent with radiation remains the mainstay of treatment. For patients with metastatic, progressive, and recurrent disease, treatment typically consists of combination chemotherapy and incorporation of bevacizumab, and recent data show benefits with the addition of upfront immunotherapy in women whose cancer expresses programmed death ligand-1. The physical sequelae of locally advanced cervical cancer treatments stem largely from irradiation of the pelvis, and treatment of these is aimed at identifying reversible or treatable causes of symptoms and palliating those with irreversible causes. From a psychologic standpoint, patients with cervical cancer face the stigma of having a preventable cancer caused by a sexually transmitted infection and the ramifications of sexual dysfunction. Clinicians must invite honest dialogue to be able to address specific survivorship issues.

Trends in the Incidence of Human Papillomavirus-Associated Cancers by County-Level Income and Smoking Prevalence in the United States, 2000-2018

Human papillomavirus (HPV)-associated cancer burden is rising in the United States. Trends in the incidence by county-level income and smoking prevalence remain undescribed. We used the Surveillance, Epidemiology, and End Results 21 database to ascertain HPV-associated cancers during 2000-2018. Trends were estimated by county-level income and smoking prevalence quartiles. Anal and vulvar cancer incidence among women and anal cancer incidence among men increased markedly in the lowest-income counties, whereas the increases were slower in the highest-income counties (eg, for vulvar cancer, incidence increased 1.9% per year, 95% confidence interval [CI] = 0.9% to 2.9%, in the lowest-income counties vs 0.8% per year, 95% CI = 0.6% to 1.1%, in the highest-income counties). In recent years, cervical cancer incidence plateaued (0.0% per year [95% CI = -0.5% to 0.5%]) in the highest-income counties; in the lowest-income counties, the annual percentage change was 1.6% per year (95% CI = -0.7% to 4.0%). Counties with high smoking prevalence had marked increases in incidence compared with their counterparts (eg, anal cancer among men increased 4.4% per year [95% CI = 2.7% to 6.0%] for those living in counties with the highest smoking prevalence vs 1.2% per year [95% CI = 0.7% to 1.7%] for those living in counties with the lowest smoking prevalence). Improved and targeted prevention is needed to combat the widening disparities.

Design of the ANal Cancer/HSIL Outcomes Research study (ANCHOR study): A randomized study to prevent anal cancer among persons living with HIV

It is well established that persons living with HIV (PLWH) have highly elevated rates of anal HSIL and anal cancer compared with those who are not living with HIV. The 5-year risk of anal cancer following anal HSIL has been reported to be as high as 14.1% among PLWH compared with 3.2% among those who are not living with HIV. To address these concerns, the AIDS Malignancy Consortium completed a large-scale, randomized trial to compare strategies for the prevention of anal cancer among PLWH with anal HSIL. The objective of the study was to determine whether treating anal HSIL was effective in reducing the incidence of anal cancer in PLWH compared with active monitoring. This paper describes the design of the ANal Cancer/HSIL Outcomes Research Study (ANCHOR) with respect to estimating the anal cancer event rate in this high risk population.

Oropharyngeal Cancer Incidence and Mortality Trends in All 50 States in the US, 2001-2017

Importance

Oropharyngeal cancer (OPC) incidence is rising among men in the US. Comprehensive assessments of nationwide trends in OPC incidence and mortality by demographics, tumor characteristics at diagnosis, and geography are lacking.

Objective

We examined secular trends in OPC incidence and mortality rates in all 50 US states and the District of Columbia (DC).

Design, Setting, and Participants

In this cross-sectional study, we used the US Cancer Statistics data set to examine OPC incidence trends from 2001 through 2017. Observed and incidence-based mortality trends were evaluated using data from the National Center for Health Statistics and Surveillance Epidemiology and End Results program, respectively. Data analysis was conducted from January to April 2021.

Results

Nationwide, 260 182 OPC cases were identified; 209 297 (80%) occurred in men, 168 674 (65%) with regional stage, and 142 068 (55%) in the Southeast and Midwest regions, during 2001 to 2017. Incidence of OPC increased nationally 2.7% per year among men, with a notable (over 3% per year) rise among non-Hispanic White men and in men aged 65 years and older. Overall, among women, the annual percentage change was 0.5% (95% CI, -0.28% to 1.22%). Among men, with a 3.1% per year rise (95% CI, 2.4% to 3.8%), regional-stage OPC incidence increased nearly 2-fold. Among women, regional-stage OPC incidence increased 1.0% per year (95% CI, 0.3% to 1.7%). Among men, OPC incidence increased in all states and regions except Alaska, DC, and Wyoming. Among men, the most pronounced increases (more than 3.5% per year) were clustered in the Southeast and Midwest regions. Among women, a rise of more than 2% per year was also concentrated in the Southeast and Midwest regions. Among men, OPC incidence-based mortality increased 2.1% per year (95% CI, 1.0% to 3.2%) overall in recent years (from 2006 to 2017). In contrast, among women, the annual percentage change in OPC incidence-based mortality was -1.2% (95% CI, -2.5% to 0.1%).

Conclusion and Relevance

The findings of this cross-sectional study suggest that the incidence of OPC has continued to increase nationally among men in the US, with rapid increases among the elderly population. The notable rise in regional-stage OPC and the concurrent recent rise in mortality among men is troubling and calls for urgent improvements in prevention. Distinct geographic patterns with notable rises in the Midwest and Southeast regions imply the need for improved and targeted prevention as well as future studies to understand etiological reasons for geographic disparities.

Evaluation of Cervical Cancer Screening Uptake and Adherence Among Women Without Human Papillomavirus Vaccination in the US

This cross-sectional study compares uptake rates of cervical cancer screening and adherence among US women who were vaccinated for human papillomavirus vs those who were not vaccinated.

The Role of Demographics, Social Deprivation and Ethnicity on Anal Squamous Cell Carcinoma Incidence in England

Anal Squamous Cell Carcinoma (ASCC) is an HPV-related malignancy with increasing incidence in high-income economies. Although ethnicity and social deprivation are known to be risk factors in other malignancies, little is known about socioeconomic status and risk of ASCC. This is a cross-sectional study following the STROBE Statement. Demographic data from the English Clinical Outcomes and Services Dataset (COSD) were extracted for all patients diagnosed with ASCC in England between 2013 and 2018. Outcomes included ethnicity, social deprivation, staging and treatment. This study included 5457 patients. Incidence increased by 23.4% in 5 years, with female incidence increasing more rapidly than male incidence (28.6% vs. 13.5%). Men were more likely to present with early staging (p < 0.001) and have surgery as their only treatment (p < 0.001). The rate of incidence of Stage 1 tumours in men was 106.9%; however, women had the greatest increase in metastatic tumours (76.1%). Black Caribbean and Black African patients were more likely to present at an earlier age with later staging (p < 0.001) and social deprivation was associated with younger age (p < 0.001). ASCC incidence is rapidly increasing in patterns consistent with two separate populations: one male with early staging, the other female and related to social deprivation and ethnicity factors.

Assessing Human Papillomavirus Awareness and the Role of Oropharyngeal Squamous Cell Carcinoma Education on Improving Intention to Vaccinate

OBJECTIVES/HYPOTHESIS

The current state of the U.S. public's knowledge of the relationship between human papillomavirus (HPV) and HPV vaccinations to oropharyngeal squamous cell carcinoma (OPSCC) is unknown. Our objective was to 1) assess the general population's knowledge of human papillomavirus (HPV) and willingness to vaccinate, and 2) assess whether targeted education on HPV-related OPSCC can change intentions to vaccinate.

STUDY DESIGN

Online cross-sectional survey.

METHODS

An online, cross-sectional survey utilizing U.S. census-derived quotas to represent the U.S. population was distributed and analyzed to 517 adults in 2020.

RESULTS

Exactly 72.7% of participants stated that they had or would vaccinate their child against HPV and were designated as "vaccinators." In multivariate regression, Black individuals were less likely to be vaccinators (OR 0.51 [95% CI 0.27-0.94]), but those who were aware of HPV's role in OPSCC were more likely to vaccinate (OR 2.56 [95% CI 1.47-4.46]). Knowledge about vaccination side-effects, eligibility, and mechanisms of HPV spread was low. Only 30.6% of the sample reported understanding the role of HPV in OPSCC. Of these, 43.0% gained this knowledge exclusively from nonhealthcare professional sources, like television. When presented with four short HPV-OPSCC-centered facts (HPV's role in OPSCC etiology, prevalence of infection, clinically silent course, and vaccine preventative effects), 54.0% of "nonvaccinators" indicated a willingness to change their minds.

CONCLUSIONS

General knowledge about HPV, HPV's role in OPSCC, and the vaccine remains low in the general population. There are racial disparities in willingness to vaccinate within this sample, but these may be overcome by effective education on HPV-related OPSCC.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Human papillomavirus awareness among foreign- and US-born Hispanics, United States, 2017-2018

INTRODUCTION

Human papillomavirus (HPV) and HPV vaccine knowledge and awareness are known to be lower among Hispanics compared to non-Hispanic whites. However, Hispanics in the US are a non-homogenous population, with significant differences by nativity, particularly between the US-and foreign-born individuals. We examined HPV and HPV vaccine awareness among foreign-born Hispanics, US-born Hispanics, and US-born non-Hispanic whites.

METHODS

We analyzed data from the Health Information National Trends Survey (HINTS) 5, cycles 1 (2017) and 2 (2018), the most recent HINTS datasets including nativity information. We used descriptive statistics and multivariable regression to compare awareness of HPV and the HPV vaccine among ethnicity/nativity subgroups.

RESULTS

Over 50% of foreign-born Hispanics had not heard of HPV, compared to 32% of US-born Hispanics (P < 0.01) and 33% of non-Hispanic whites (p < 0.01). Lack of HPV vaccine awareness among foreign-born Hispanics was not significantly different from US-born Hispanics (52% vs. 44%, p = 0.12), but was significantly lower compared to non-Hispanic whites (52% vs. 32%, p < 0.01). In multivariable analyses, non-Hispanic whites had over twice the odds of having heard of HPV than foreign-born Hispanics (p < 0.05), while US-born Hispanics had 75% higher odds (p < 0.05). Regarding HPV awareness, non-Hispanic whites had 95% higher odds of having heard of the HPV vaccine than foreign-born Hispanics (p < 0.05), while differences between US and foreign-born Hispanics were not significant.

CONCLUSION

There are significant nativity-related differences in HPV and HPV vaccine awareness and knowledge among US-born Hispanics. Over 50% of foreign-born Hispanic adults are unaware of HPV and the HPV vaccine.