Increase in postmenopausal women with distant stage breast cancer in the United States over the last 18 years: Who is the most at risk?

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Background: In the United States, Asian women have traditionally been considered at low risk for breast cancer; yet it is unknown how distant stage disease has trended by geographic, demographic, and modifiable risk factors since 2001. Methods: Data were obtained from the United States Cancer Statistics (USCS) program from 2001-2018, the Behavioral Risk Factor Surveillance System (BRFSS) from 2000-2018. SEER*Stat 8.3.9.2 and the Joinpoint regression program 4.9.0.0 were used to calculate the incidences and trends of distant stage breast cancer per 100,000 women. The trend was presented as average annual or biennial percent change (AAPC or ABPC). Results: Using the USCS program, the overall incidence of postmenopausal breast cancer decreased from 367.90 to 345.07 (per 100,000); however, the incidence of distant stage cancer increased from 16.75 to 19.77 (per 100,000) over 18 years. The incidence is the highest for Black, followed by White, Hispanic, and Asian women at 27.14, 19.86, 14.15, and 11.98 (per 100,000) in 2018, respectively. The annual increase is highest in Asian, followed by Black, White, and Hispanic women at 2.28%, 1.44%, 1.17%, and 0.87% (P < 0.001), respectively. On intersection analysis, postmenopausal Asian women living in the Northeast have the highest annual rise at 2.54% (P = 0.004). BRFSS data revealed that the proportion of women non-compliant with screening mammograms decreased from 36.03% in 2000 to 20.93% in 2018. In 2018, Asian women were the most non-compliant followed by Hispanic, Black, and White women at 40.99%, 40.06%, 21.67%, and 18.17%, respectively. Over time, White, Black, and Hispanic women improved on compliance by 3.43%, 3.32%, and 1.24% (p < 0.05) on screening rates biennially; however, Asian women have not made any improvement (ABPC 0.80%, p = 0.410). On intersectional analysis, the most non-compliant group in 2018 were Asian women in the Midwest at 54.48%. We then evaluated upstream social determinants of breast cancer, such as obesity. While the baseline incidence of obesity in Asian Americans is low compared to other racial groups, it has increased from 9.22 in 2001 to 13.67 (per 100,000) in 2016. Specifically, the incidence of obesity increased the most in postmenopausal Asian 65 to 74-year-olds at 3% compared to White, Hispanic, and Black Americans of the same age group at 2.5%, 2.2%, and 1.1% (p < 0.05), respectively. Conclusions: Although the incidence of breast cancer has decreased in the United States since 2001, the rate of distant stage breast cancer continues to rise. Postmenopausal Asian women with distant stage breast cancer are increasing at the highest rate compared to other racial groups. Further, Asian women are more non-compliant with screening mammograms and have an increased rate of obesity. Tailored interventions are warranted to enhance primary and secondary prevention and decrease distant stage cancer in this high-risk group.

Persistence and clearance of high-risk human papillomavirus and cervical dysplasia at 1 year in women living with human immunodeficiency virus: a prospective cohort study

OBJECTIVE

Evaluate 1-year outcomes of cervical cancer screening and treatment using primary high-risk human papillomavirus (HPV) testing in women living with human immunodeficiency virus (HIV).

DESIGN

Prospective cohort study.

SETTING

HIV treatment centre in Botswana.

POPULATION

Women living with HIV.

METHODS

Participants underwent cervical cancer screening with high-risk HPV testing and triage evaluation at baseline and 1-year follow up. Excisional treatment was offered as indicated. Histopathology was the reference standard.

MAIN OUTCOME MEASURES

Persistence, clearance and incidence of high-risk HPV infection; and persistence, progression, regression, cure and incidence of cervical dysplasia.

RESULTS

Among 300 women screened at baseline, 237 attended follow up (79%). High-risk HPV positivity significantly decreased from 28% at baseline to 20% at 1 year (P = 0.02). High-risk HPV persistence was 46% and clearance was 54%; incidence was high at 9%. Prevalence of cervical intraepithelial neoplasia Grade 2 (CIN2) or higher was most common in participants with incident high-risk HPV (53%). CIN2 or higher was also common in those with persistent high-risk HPV (32%) and even in those who cleared high-risk HPV (30%). Of the high-risk HPV-positive participants at baseline with <CIN2, 40% progressed to CIN2 or higher at follow up.

CONCLUSION

The high incidence of high-risk HPV and high-grade cervical dysplasia in women living with HIV after one round of high-risk HPV-based screening and treatment raises concern about the rate of progression of high-risk HPV infection to dysplasia. Persistent disease is common. Caution in spacing cervical cancer screening intervals using high-risk HPV testing in women living with HIV is warranted.

TWEETABLE ABSTRACT

High incidence and persistence of HPV and CIN2+ in women living with HIV 1 year after screening and treatment.