Economic Value of Lost Productivity Attributable to Human Papillomavirus Cancer Mortality in the United States

Prevalence and risk factors associated with high-risk human papillomavirus infection among women living with HIV (WLWH) at a tertiary health facility in Accra, Ghana

BACKGROUND

Women living with HIV (WLWH) have high risk of developing cervical cancer. High- risk Human papillomavirus (hrHPV) is the single most important cause of cervical cancer. Vaccination for and early detection of pre-malignant cervical changes, through cervical cancer screening contributes to prevention of cervical cancer. This study sought to determine the prevalence of HPV among WLWH, genotypes present and the risk factors associated with cervical cancer development.

METHODS AND FINDINGS

An analytical cross-sectional study of 250 sexually active women aged 18 years and above, attending HIV clinic at a tertiary health facility in Accra. Demographic data collection and risk factor assessments were done using interviewer-administered questionnaire, and patient records. Cervical swabs were collected and tested for HPV using real-time PCR assays. Genotype analysis was performed on 92 samples. Descriptive statistics and logistic regression analysis were used to establish associations between hrHPV and risk factors among WLWH. Approximately 60% of study participants tested positive for HPV. The prevalence of hr-HPV among WLH was 44.4%. Factors identified to be protective of hrHPV were employment (AOR = 0.19, 95% CI = 0.06, 0.56, p = 0.003) and highly active antiretroviral therapy (HAART) Tenofovir-Lamivudine-Ritonavir-Lopinavir (TLRL) (AOR = 0.30, 95% CI = 0.09, 0.95, p = 0.04). Women with HIV diagnosis within 6 to10 years (AOR = 4.89, 95% CI = 1.05, 22.70, p = 0.043) and diagnosis >10 years (AOR = 8.25, 95% CI = 1.24, 54.84, p = 0.029) had higher odds of hrHPV. Approximately 25% of samples analysed tested positive for hr-HPV group 1 (genotypes 16, 18, 31, 33, 35, 39, 45,51, 52, 56, 58, 69) and 46.8% for multiple HPV genotypes.

CONCLUSION

A high prevalence of genotypes that include high risk genotypes 16 and 18 and multiple HPV infections was found among WLWH. Almost half of the women screened had high-risk HPV and were prone to cervical cancer without their knowledge. Regular HPV screening is recommended for high-risk patient groups.

Immunogenicity of 2 or 3 Doses of 9vHPV Vaccine in U.S. Female Individuals 15 to 26 Years of Age

BACKGROUND: Within the United States, a 9-valent human papillomavirus (9vHPV) vaccine (HPV-6/11/16/18/31/33/45/52/58) is recommended as a two-dose series among individuals 9 to 14 years of age and a three-dose series among those 15 to 26 years of age. Data comparing two versus three doses of 9vHPV vaccine among individuals 15 to 26 years of age are limited. METHODS: We report on an ongoing, single-blinded, randomized noninferiority trial of the 9vHPV vaccine among individuals 15 to 26 years of age in the United States. Participants were randomly assigned to a two-dose (0 and 6 months) or three-dose (0, 2, and 6 months) schedule. Blood draws to assess antibody titers were planned before the first vaccination and at 1 and 6 months after the final vaccination. The primary outcome was the rate of seroconversion at 1 month after final vaccination. The secondary outcome was the two-dose versus three-dose ratio of antibody geometric mean titers (GMTs) for each of the 9vHPV genotypes at 1 and 6 months after final vaccination. This interim analysis reports results of female participants at 1 month after final vaccination. RESULTS: Of 860 participants screened, 438 were enrolled and randomly assigned to the two-dose (n=217) or three-dose (n=221) group. At 1 month after the final vaccine dose, the seroconversion rate for each of the nine HPV genotypes in the vaccine was 100% among participants in the two-dose group and 99% in the three-dose group. The point estimates of the two-dose versus three-dose ratios of antibody GMTs for eight of the nine HPV genotypes were above unity; the ratio for HPV-45 was 0.86 (95% confidence interval [CI], 0.66 to 1.13). This was also the smallest value for the lower bound of the 95% CI for all nine ratios (ratios above 1 favor the two-dose schedule). No serious adverse events were observed. CONCLUSIONS: In this unplanned interim analysis of U.S. female participants 15 to 26 years of age, two doses of 9vHPV vaccine appear to elicit responses similar to three doses at 1 month postvaccination. We await final results at 6 months following the last vaccine dose. (ClinicalTrials.gov number, NCT03943875.)

Cost effectiveness of pembrolizumab plus lenvatinib compared with chemotherapy for treating previously treated advanced endometrial cancer in Sweden

OBJECTIVE

Pembrolizumab plus lenvatinib was recently approved for the treatment of advanced or recurrent endometrial carcinoma in women with disease progression on or following prior treatment with a platinum‑containing therapy in any setting, and who are not candidates for curative surgery or radiation (KEYNOTE-775/Study-309; NCT03517449). The objective was to assess the cost effectiveness of pembrolizumab plus lenvatinib compared with chemotherapy from a Swedish healthcare perspective.

MATERIALS AND METHODS

A lifetime partitioned-survival model with three health states (progression free, progressed disease, death) was constructed. Chemotherapy was represented by paclitaxel or doxorubicin. Overall survival, progression-free survival, time on treatment, and utility data were obtained from KEYNOTE-775 (database lock: March 1, 2022). Costs (in 2020 Swedish Krona [SEK]) included drug acquisition and administration, health state, end of life, adverse event management, subsequent treatment, and societal (scenario analysis). Outcomes were calculated as quality-adjusted life-years (QALY) and life-years. Model results were presented as incremental cost-effectiveness ratios for all-comers, patients with proficient mismatch repair tumors, and deficient mismatch repair tumors. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

Pembrolizumab plus lenvatinib is a cost-effective treatment when compared with chemotherapy, with estimated deterministic and probabilistic incremental cost-effectiveness ratios of SEK 795,712 and 819,757 per QALY gained. Pembrolizumab plus lenvatinib was associated with a large incremental QALY and life-year gain per person versus chemotherapy over the model time horizon (1.49 and 1.76).

LIMITATIONS

Time-to-event data were incomplete and semiparametric and parametric curves were utilized for lifetime extrapolation. Willingness-to-pay thresholds, costs, and utility weights vary by country, which would vary the treatment's cost effectiveness in different countries.

CONCLUSIONS

This partitioned survival analysis suggests that pembrolizumab plus lenvatinib is cost effective compared with chemotherapy in Sweden for women with advanced or recurrent endometrial carcinoma following previous systemic therapy. Results were robust to mismatch repair status and to changes in parameters/assumptions.

Digital Storytelling Intervention to Promote Human Papillomavirus Vaccination Among At-Risk Asian Immigrant Populations: Pilot Intervention Study

BACKGROUND

The high morbidity, mortality, and economic burden attributed to cancer-causing human papillomavirus (HPV) calls for researchers to address this public health concern through HPV vaccination. Despite disparities in HPV-associated cancers in Korean Americans and Vietnamese Americans, their vaccination rates remain low. Evidence points to the importance of developing culturally and linguistically congruent interventions to improve HPV vaccination rates. Digital storytelling (a specific form of cultural narrative) shows promise as an effective culture-centric health promotion strategy.

OBJECTIVE

The aim of this quasi-experimental single-group study was to assess the feasibility, acceptability, and preliminary effects of a culturally and linguistically congruent digital storytelling intervention on Korean American and Vietnamese American mothers' attitudes and intention in vaccinating their children against HPV. We also examined if the association between attitudes and intention differed by their child's sex (boy vs girl) and by ethnicity (Korean American vs Vietnamese American).

METHODS

Participants were recruited via multiple avenues (eg, ethnic minority community organizations, social media, and flyers posted in local Asian supermarkets and nail salons). Web-based, valid, and reliable measures were administered to collect data preintervention and postintervention. Descriptive statistics, paired and independent sample t tests, the chi-square test, and the McNemar test were used to describe the distributions of variables and to examine the differences between subgroups and changes in key variables over time. Logistic regression models were used to examine associations of mothers' HPV- and vaccine-related attitudes with vaccination intention and to explore if the association between attitudes and vaccination intention differed by the target children's sex or ethnicity.

RESULTS

In our sample of 50 Korean American mothers (mean age 42.8, SD 4.8 years) and 114 Vietnamese American mothers (mean age 41.5, SD 5.4 years), 36% (18/50) of Korean American and 51% (58/114) of Vietnamese American mothers reported that their children received free or reduced-price lunches at school. After the intervention, mothers' attitudes toward HPV and the vaccine (t163=2.49, P=.01) and intention to vaccinate their children improved significantly (X21=18.38, P<.001). The measure of mothers' negative attitudes toward HPV and the vaccine was significantly associated with higher vaccination intention (odds ratio 0.27, 95% CI 0.14-0.51; P<.001), adjusting for background variables (sociodemographic characteristics) and other HPV-related variables (family cancer history, prior HPV education, and HPV communication with health care providers). Findings did not suggest that a child's sex or ethnicity moderated the association between attitudes and vaccination intention.

CONCLUSIONS

This remotely delivered intervention using digital stories was feasible and acceptable, and showed preliminary effects on promoting Korean American and Vietnamese American mothers' intention to vaccinate their children against HPV. Future research that uses a randomized controlled trial design with a larger and more diverse sample and includes children's vaccination status will help understand the effect of the intervention.

Barriers and determinants of consistent offering of HPV vaccination by healthcare facilities

Expanding access to HPV vaccination is critical to increasing HPV vaccine uptake. We assessed the determinants and barriers to consistent offering of HPV vaccine among healthcare facilities. This was a cross-sectional survey of healthcare providers (HCPs) in Texas. Prevalence of the reasons healthcare practices do not consistently offer HPV vaccination was estimated. Multivariable regression analyses were conducted. Of 1169 HCPs included in the study, 47.5% (95% CI: 44.6-50.3%) reported their practices do not provide HPV vaccination or do not offer it consistently. Compared to physicians, nurses had 77% lower odds (Adjusted Odds Ratio (AOR): 0.23, 95% CI: 0.16-0.32, p-value: < .001), and physician assistants had 89% lower odds (AOR: 0.11, 95% CI: 0.07-0.16, p-value: < .001) of their healthcare practices consistently offering HPV vaccination. Compared to university/teaching hospitals, the odds of healthcare practices consistently offering HPV vaccination were 44% lower (AOR: 0.56, 95% CI: 0.35-0.91, p-value: 0.019) in solo practices but 266% higher (AOR: 3.66, 95% CI: 2.04-6.58, p-value: < .001) in FQHC/public facilities. The common reasons healthcare practices do not consistently offer HPV vaccination were; HPV vaccination is not within the scope of the practice (48.1%), referrals to other clinics (27.7%), and limited personnel (11.4%). Non-physicians were more likely to report that HPV vaccination was not in their scope and to refer patients than physicians. Moreover, solo practices were more likely to report challenges with acquisition and storage of the vaccine and referral of patients as reasons for not consistently offering HPV vaccination than university/teaching hospitals, FQHC/public facilities, or group practices. System-level interventions including training of non-physicians and expansion of practice enrollment in programs that support HPV vaccine acquisition and storage are needed.

Imagine beyond: recent breakthroughs and next challenges in mammary gland biology and breast cancer research

On 8 December 2022 the organizing committee of the European Network for Breast Development and Cancer labs (ENBDC) held its fifth annual Think Tank meeting in Amsterdam, the Netherlands. Here, we embraced the opportunity to look back to identify the most prominent breakthroughs of the past ten years and to reflect on the main challenges that lie ahead for our field in the years to come. The outcomes of these discussions are presented in this position paper, in the hope that it will serve as a summary of the current state of affairs in mammary gland biology and breast cancer research for early career researchers and other newcomers in the field, and as inspiration for scientists and clinicians to move the field forward.

The Burden of Cervical Conization in Privately Insured Young and Mid-Adult Women in the United States

In 2019, the United States (US) Advisory Committee on Immunization Practices (ACIP) recommended that healthcare providers engage in shared clinical decision making for adults aged 27-45 who may benefit from HPV vaccination. However, it is difficult to assess these benefits as there is a lack of data on HPV burden on young and mid-adult women. This analysis estimates the incidence of conization and the burden associated with treating pre-cancerous states related to HPV with a loop electrosurgical excision procedure (LEEP) or a cold knife conization (CKC) among commercially insured women aged 18-45. This retrospective cohort study used the IBM MarketScan commercial claims encounter database for women aged 18-45 treated with conization. We assessed the annual incidence of conization (2016-2019) and adjusted the two-year health care costs post-conization using a multivariable Generalized Linear Model (GLM)-accounting for follow-up time and other characteristics-stratified by the age groups, namely 18-26 and 27-45. The inclusion criteria were met by 6735 women, with a mean age of 33.9 years (SD = 6.2). Conization incidence was lowest for women aged 18-26 (41/100,000 to 62/100,000 women-years) and highest for women aged 31-35 (243/100,000 to 269/100,000). The GLM-adjusted, all-cause healthcare costs per patient per year were USD 7279 and USD 9249 in the 18-26 and 27-45 age groups, respectively. The adjusted costs for disease-specific care were USD 3609 and USD 4557 for women ages 18-26 and 27-45, respectively. The burden of conization and the associated costs were significant, indicating a potential healthcare benefit of HPV vaccination among young and middle-aged women.

Raising the HPV Vaccination Rate in Rural Northern New England Using Local Opinion Leaders

The human papillomavirus is associated with a range of cancers. A vaccine introduced in 2006 has dramatically decreased the incidence of these cancers, but Americans still experience over 47,000 new cases of HPV-related cancers each year. The situation is worse in rural areas, where vaccination rates lag the national average, making HPV a significant health disparity issue. This article lays out an evidence-based HPV vaccine-promotion strategy that will serve as part of a campaign to improve health equity in rural northern New England in a process that is repeatable and sustainable. The campaign includes the following elements: partnerships with state departments of health and trusted community opinion leaders, evidence-based storytelling, local social media, traditional media, and school-based pop-up vaccination clinics. Borrowing from marketing and social marketing frameworks and guided by public health perspectives, we begin with psychographic and geodemographic information about our target audience, followed by a discussion about relevant models, frameworks, and research related to persuasive storytelling. We conclude with the outline of a guidebook to foster the creation of persuasive stories as part of a sustainable, replicable HPV vaccination campaign.

Is 2045 the best we can do? Mitigating the HPV-related oropharyngeal cancer epidemic

INTRODUCTION

Oropharyngeal cancer (OPC) will be among the most common cancers in men by 2045 due to a rapid rise in human papillomavirus (HPV)-related OPC. Those who survive their cancer often suffer life-long treatment effects and early death. HPV vaccination could prevent virtually all HPV-related cancers but is not an effective preventive strategy for those already exposed. Without a dramatic increase in vaccine uptake in the U.S., HPV vaccination will have a negligible effect on OPC incidence through 2045 and no substantial impact until 2060. Additionally, targeted screening for earlier diagnosis may soon be feasible for those inadequately protected by vaccination.

AREAS COVERED

PubMed search for English-language articles related to incidence, screening, and prevention of HPV-related malignancies, focused on OPC in the U.S.

EXPERT OPINION

HPV-related OPC incidence will continue to increase for the foreseeable future with prophylactic vaccination offering no substantial public health impact for decades. Consequently, we must rapidly increase vaccination rates and develop screening methods to identify high-risk individuals. Such individuals would be eligible for potential preventive treatments and screening to diagnose early-stage HPV-related OPC allowing less morbid treatments. These methods will bridge the population into an era of decreasing incidence after vaccination takes effect.

Emerging Disparities in Prevention and Survival Outcomes for Patients with Head and Neck Cancer and Recommendations for Health Equity

Purpose of Review

The aim of this review is to describe less known and emerging disparities found in the prevention and survival outcomes for patients with head and neck cancer (HNC) that are likely to play an increasingly important role in HNC outcomes and health inequities.

Recent Findings

The following factors contribute to HNC incidence and outcomes: (1) the effect of rurality on prevention and treatment of HNC, (2) dietary behavior and nutritional factors influencing the development of and survival from HNC, and (3) barriers and benefits of telehealth for patients with HNC.

Summary

Rurality, nutrition and diet, and telehealth usage and access are significant contributors to the existing health disparities associated with HNC. Population and culturally specific interventions are urgently needed as well as more research to further define the issues and develop appropriate population and individual level solutions.

A Digital Storytelling Intervention for Vietnamese American Mothers to Promote Their Children's HPV Vaccination

Despite higher rates of human papillomavirus (HPV)-associated cancer in Vietnamese Americans (VAs), their vaccination rate remains low. Culturally grounded narratives incorporating culture-specific beliefs and practices may be a promising approach to promote HPV vaccination and potentially mitigate HPV-associated cancer disparities experienced by VAs. We co-developed personal, audiovisual digital stories about HPV vaccination with VA mothers of vaccinated children, and examined the effects of the digital storytelling (DST) intervention on vaccination intention among VA mothers of unvaccinated children aged 11-14. The stories (3 minutes each) were produced in both English and Vietnamese through a two-day workshop in collaboration with two VA first-generation immigrant mothers. A community sample of 114 VA mothers of unvaccinated children viewed the stories and filled out an anonymous survey before and after the intervention. Of these mothers (mean age = 41.5 years; SD = 5.4), 35.2% were immigrants, and about half (51%) reported having a child who received free or reduced-price lunch at school. After the intervention, changes in two items indicating mothers' positive attitudes toward HPV vaccination were significant. Mothers' intention to vaccinate their children increased from 53% to 74%; the difference was large (OR = 9.12; Cohen' g = .40) and statistically significant, X2(1, N = 114) = 17.63, p &lt; .001. Mothers' scores on the Narrative Quality Assessment scale were high, suggesting high levels of identification and engagement with the stories. This brief intervention using digital stories was feasible and showed preliminary effects on promoting VA mothers' intention to vaccinate their children against HPV.

Adjuvant HPV Vaccination to Prevent Recurrent Cervical Dysplasia after Surgical Treatment: A Meta-Analysis

Objective: The aim of this meta-analysis was to discuss evidence supporting the efficacy of adjuvant human papillomavirus (HPV) vaccination in reducing the risk of recurrent cervical intraepithelial neoplasia (CIN) 2 or greater after surgical treatment. Methods: A systematic literature search was performed for studies reporting the impact of HPV vaccination on reducing the risk of recurrence of CIN 2+ after surgical excision. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). Results: Eleven studies met the inclusion criteria and were selected for analysis. In total, 21,310 patients were included: 4039 (19%) received peri-operational adjuvant HPV vaccination while 17,271 (81%) received surgery alone. The recurrence of CIN 2+ after treatment was significantly lower in the vaccinated compared with the unvaccinated group (OR 0.35; 95% CI 0.21–0.56; p < 0.0001). The recurrence of CIN 1+ after treatment was significantly lower in the vaccinated compared with the unvaccinated group (OR 0.51; 95% CI 0.31–0.83; p = 0.006). A non-significant trend of reduction rate of HPV persistence was observed in the vaccinated compared with the unvaccinated cohorts (OR was 0.84; 95% CI 0.61–1.15; p = 0.28). Conclusions: HPV vaccination, in adjuvant setting, is associated with a reduced risk of recurrent CIN 1+ and CIN 2+ after surgical treatment.