The association of caregiver attitudes, information sources, and trust with HPV vaccine initiation among adolescents

This study described caregiver attitudes and the information sources they access about HPV vaccination for adolescents and determined their influence on human papillomavirus (HPV) vaccination initiation. An online survey was administered to 1,016 adults in July 2021. Participants were eligible if they were the caregiver of a child aged 9-17 residing in Mississippi, Arkansas, Tennessee, Missouri, and select counties in Southern Illinois. Multivariate logistic regression was used to estimate the association of caregiver attitudes and information sources with HPV vaccination. Information from doctors or healthcare providers (87.4%) and internet sources other than social media (31.0%) were the most used sources for HPV vaccine information. The highest proportion of caregivers trusted their doctor or healthcare providers (92.4%) and family or friends (68.5%) as sources of information. The HPV vaccine series was more likely to be initiated in children whose caregivers agreed that the vaccine is beneficial (AOR = 4.39, 95% CI = 2.05, 9.39), but less likely with caregivers who were concerned about side effects (AOR = 0.61, 95% CI = 0.42, 0.88) and who received HPV vaccination information from family or friends (AOR = 0.57, 95% CI = 0.35, 0.93). This study found that caregivers' attitudes, information sources, and trust in those sources were associated with their adolescent's HPV vaccination status. These findings highlight the need to address attitudes and information sources and suggest that tailored interventions considering these factors could increase HPV vaccination rates.

Assessing Management of Abnormal Cervical Cancer Screening Results and Concordance with Guideline Recommendations in Three US Healthcare Settings

BACKGROUND

Follow-up of abnormal results is essential to cervical cancer screening, but data on adherence to follow-up are limited. We describe patterns of follow-up after screening abnormalities and identify predictors of guideline-concordant follow-up.

METHODS

We identified the index screening abnormality (positive human papillomavirus [HPV] test or atypical squamous cells of undetermined significance [ASC-US] or more severe cytology) among women 25-65 years old at three U.S. healthcare systems during 2010-2019. We estimated the cumulative incidence of surveillance testing, colposcopy, or treatment after the index abnormality and initial colposcopy. Logistic regressions were fit to identify predictors of guideline-concordant follow-up according to contemporaneous guidelines.

RESULTS

Among 43,007 patients with an index abnormality, the cumulative incidence of any follow-up was 49.6% by 4 years for those with ASC-US/HPV-negative and higher for abnormalities warranting immediate colposcopy. The 1-year cumulative incidence of any follow-up after colposcopy was 70% for patients with normal results or cervical intraepithelial neoplasia (CIN) I and 90% for patients with CIN II+. Rates of concordant follow-up after screening and colposcopy were 52% and 47%. Discordant follow-up was associated with factors including age, race/ethnicity, overweight/obese BMI, and specific types of public payor coverage or being uninsured.

CONCLUSIONS

Adherence to recommended follow-up of cytologic and histopathologic abnormalities is inconsistent in clinical practice. Concordance was poor for mild abnormalities and improved, though suboptimal, for more severe abnormalities.

IMPACT

There remain gaps in the cervical cancer screening process in clinical practice. Further work is needed to understand barriers to appropriate management of cervical abnormalities.

Characteristics of Clinicians Caring for Transgender Men and Nonbinary Individuals and Guideline Concordance of Clinicians' Cervical Cancer Screening Counseling for Cisgender Individuals Versus Transgender Men and Nonbinary Individuals with a Cervix

Purpose: We examined characteristics of clinicians caring for transgender men and nonbinary (TMNB) individuals and guideline concordance of clinicians' cervical cancer screening recommendations. Methods: Using a survey of clinicians who performed ≥10 cervical cancer screenings in 2019, we studied characteristics of clinicians who do versus do not report caring for TMNB individuals and guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women. Results: In our sample (N = 492), 49.2% reported caring for TMNB individuals, and 25.4% reported performing cervical cancer screening for TMNB individuals with a cervix. Differences in guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women (45.8% vs. 50% concordant) were not statistically significant. Conclusion: Sizable proportions of clinicians cared for and performed cervical cancer screening for TMNB individuals. Research is needed to better understand clinicians' identified knowledge deficits to develop interventions (e.g., clinician trainings) to improve gender-affirming cervical cancer prevention.

Associations of geographic-based socioeconomic factors and HPV vaccination among male and female children in five US states

BACKGROUND

We assessed whether five geographic-based socioeconomic factors (medically underserved area (MUA); healthcare provider shortage area (HPSA); persistent poverty; persistent child poverty; and social vulnerability index (SVI)) were associated with the odds of HPV vaccination initiation, series completion, and parental vaccine hesitancy, and whether the observed relationships varied by gender of the child.

METHODS

An online panel service, administered through Qualtrics®, was used to recruit parents of adolescents 9-17 years of age to complete a one-time survey in 2021. Coverage of the panel included five US states: Arkansas, Mississippi, Missouri, Tennessee, and Southern Illinois. Generalized estimating equation (GEE) models were used to assess population-level associations between five geographic-based socioeconomic factors (MUA; HPSA; persistent poverty; persistent child poverty; and SVI) and three HPV vaccination outcomes (initiation, series completion, and hesitancy). All GEE models were adjusted for age of child and clustering at the state level.

RESULTS

Analyses were conducted using responses from 926 parents about their oldest child in the target age range (9-17 years). The analytic sample consisted of 471 male children and 438 female children across the five states. In adjusted GEE models, persistent child poverty and HPSA were negatively associated with HPV vaccination initiation and series completion among female children, respectively. Among male children, high social vulnerability was negatively associated with HPV vaccine series completion. Additionally, persistent poverty and high social vulnerability were negatively associated with HPV vaccine hesitancy in male children.

CONCLUSIONS

The results of this cross-sectional study suggest that geographic-based socioeconomic factors, particularly, HPSA, persistent poverty, and SVI, should be considered when implementing efforts to increase HPV vaccine coverage for adolescents. The approaches to targeting these geographic factors should also be evaluated in future studies to determine if they need to be tailored for male and female children.

Racial and Ethnic Disparities in Cervical Cancer Screening From Three U.S. Healthcare Settings

INTRODUCTION

This study sought to characterize racial and ethnic disparities in cervical cancer screening and follow-up of abnormal findings across 3 U.S. healthcare settings.

METHODS

Data were from 2016 to 2019 and were analyzed in 2022, reflecting sites within the Multi-level Optimization of the Cervical Cancer Screening Process in Diverse Settings & Populations Research Center, part of the Population-based Research to Optimize the Screening Process consortium, including a safety-net system in the southwestern U.S., a northwestern mixed-model system, and a northeastern integrated healthcare system. Screening uptake was evaluated among average-risk patients (i.e., no previous abnormalities) by race and ethnicity as captured in the electronic health record, using chi-square tests. Among patients with abnormal findings requiring follow-up, the proportion receiving colposcopy or biopsy within 6 months was reported. Multivariable regression was conducted to assess how clinical, socioeconomic, and structural characteristics mediate observed differences.

RESULTS

Among 188,415 eligible patients, 62.8% received cervical cancer screening during the 3-year study period. Screening use was lower among non-Hispanic Black patients (53.2%) and higher among Hispanic (65.4%,) and Asian/Pacific Islander (66.5%) than among non-Hispanic White patients (63.5%, all p<0.001). Most differences were explained by the distribution of patients across sites and differences in insurance. Hispanic patients remained more likely to screen after controlling for a variety of clinical and sociodemographic factors (risk ratio=1.14, CI=1.12, 1.16). Among those receiving any screening test, Black and Hispanic patients were more likely to receive Pap-only testing (versus receiving co-testing). Follow-up from abnormal results was low for all groups (72.5%) but highest among Hispanic participants (78.8%, p<0.001).

CONCLUSIONS

In a large cohort receiving care across 3 diverse healthcare settings, cervical cancer screening and follow-up were below 80% coverage targets. Lower screening for Black patients was attenuated by controlling for insurance and site of care, underscoring the role of systemic inequity. In addition, it is crucial to improve follow-up after abnormalities are identified, which was low for all populations.

Factors associated with shorter-interval cervical cancer screening for young women in three United States healthcare systems

Frequently changing cervical cancer screening guidelines over the past two decades have been inconsistently adopted in the United States. Current guidelines set the recommended screening interval to three years for average-risk women aged 21-29 years. Few studies have evaluated how patient and provider factors are associated with implementation of cervical cancer screening intervals among younger women. This study evaluated multilevel factors associated with screening interval length among 69,939 women aged 21-29 years with an initial negative Pap screen between 2010 and 2015 across three large health systems in the U.S. Shorter-interval screening was defined as a second screening Pap within 2.5 years of an initial negative Pap. Mixed-effects logistic regression was performed for each site to identify provider and patient characteristics associated with shorter-interval screening. The odds of shorter-interval screening decreased over the study period across all sites, though the proportion of patients screened within 2.5 years remained between 7.5% and 20.7% across sites in 2014-2015. Patient factors including insurance, race/ethnicity, and pregnancy were associated with shorter-interval screening, though the patterns differed across sites. At one site, the variation in shorter-interval screening explained by the provider was 10.6%, whereas at the other two sites, the provider accounted for < 2% of the variation in shorter-interval screening. Our results highlight the heterogeneity in factors driving cervical cancer screening interval across health systems and point to the need for tailored approaches targeted to both providers and patients to improve guideline-concordant screening.

Influences of sociodemographic characteristics and parental HPV vaccination hesitancy on HPV vaccination coverage in five US states

BACKGROUND

In the United States (US), half of new human papillomavirus (HPV) infections occur among young people aged 15-24 years. Despite the effectiveness of HPV vaccination in protecting against HPV-associated cancers, its coverage among adolescents remains suboptimal. This study examined the association of sociodemographic characteristics and HPV vaccination hesitancy with HPV vaccination coverage in five US states with disproportionately low adolescent coverage rates compared to the national average.

METHODS

Responses to an online Qualtrics survey from 926 parents of children aged 9-17 years in Arkansas, Mississippi, Missouri, Tennessee, and Southern Illinois in July 2021 were analyzed using multivariate logistic regression to estimate the association of sociodemographic characteristics and HPV vaccination hesitancy with HPV vaccination coverage.

RESULTS

Of the parents, 78 % were female, 76 % were non-Hispanic White, 61.9 % lived in rural areas, 22 % were classified as HPV vaccine hesitant, and 42 % had vaccinated their oldest child between the ages of 9-17 years against HPV. Children of vaccine hesitant parents were less likely to have received any doses of the HPV vaccine than children of non-vaccine hesitant parents (AOR: 0.17, 95 % CI:0.11-0.27). Male children were less likely to have initiated the HPV vaccine series than female children (AOR: 0.70, 95 % CI:0.50-0.97). Older children (13-17 vs 9-12 years), receiving the meningococcal conjugate or most recent seasonal influenza vaccine were all associated with higher likelihoods of receiving any doses of the HPV vaccine (AOR: 6.01, 95 % CI:3.98-9.08; AOR: 2.24, 95 % CI:1.27-3.95; AOR: 2.41, 95 % CI:1.73-3.36, respectively).

CONCLUSIONS

Adolescent HPV vaccination coverage remains low in our targeted states. Children's age, sex, and parental vaccine hesitancy were significantly associated with likelihood of HPV vaccination. These findings offer the opportunity for targeted interventions among parents in regions with low vaccine uptake and underscore the importance of developing and implementing strategies to address parental HPV vaccination hesitancy to improve uptake in the US.

Leveraging health infrastructure to optimize HPV vaccination for adolescents in Zambia: Protocol for an implementation study

BACKGROUND

Cervical cancer is the leading cause of cancer death in Zambia, where HIV prevalence is also high (11.3%). HIV heightens the risk of developing and dying from cervical cancer. The human papillomavirus (HPV) vaccine can prevent 90% of cervical cancers, and in Zambia is recommended for adolescent girls ages 14-15 years, including those with HIV. Currently they mainly deliver HPV vaccination via school-based campaigns, which may exclude the most vulnerable adolescents-those out-of-school or who irregularly attend. Adolescents living with HIV (ALHIV) are more likely to have these vulnerabilities. Further, school-based campaigns are not tailored to the WHO-recommended HPV vaccination schedule for ALHIV (3 versus 2 doses). Integrating HPV vaccination into routine care in adolescent HIV clinics may ensure that ALHIV have access to vaccine at the WHO-recommended schedule. Such integration requires a multilevel approach, stakeholder engagement, and diversified implementation strategies, given known challenges of providing the HPV vaccine in LMICs, including Zambia.

METHODS

Our study aims to integrate HPV vaccination into routine care in adolescent HIV clinics. To achieve success, we will co-design a package of implementation strategies using a previously successful implementation research approach developed for cervical cancer prevention in LMICs: the Integrative Systems Praxis for Implementation Research (INSPIRE). INSPIRE is a novel, comprehensive approach to develop, implement, and evaluate implementation science efforts. Following key elements of INSPIRE, our specific aims are to: 1) Identify the unique multilevel contextual factors (barriers and facilitators) across HIV settings (rural, urban, peri-urban) that influence HPV vaccine uptake; 2) Use Implementation Mapping to translate stakeholder feedback and findings from Aim 1 into a package of implementation strategies to integrate HPV vaccine into HIV clinics; 3) Conduct a Hybrid Type 3 effectiveness-implementation trial to evaluate the package of multilevel implementation strategies for integrating HPV vaccine into HIV clinics.

DISCUSSION

Our research team has strong support, technical expertise, and resources (e.g., vaccines) from the Zambian Ministry of Health; and political will for scale-up. This stakeholder-based implementation model has the potential to be transported to HIV clinics across Zambia and serve as a model to address cancer prevention priorities for those with HIV in other LMICs.

TRIAL REGISTRATION

To be registered prior to Aim 3, when implementation strategies finalized.

Provider beliefs in effectiveness and recommendations for primary HPV testing in 3 health-care systems

In 2018, the US Preventive Services Task Force endorsed primary human papillomavirus testing (pHPV) for cervical cancer screening. We aimed to describe providers' beliefs about pHPV testing effectiveness and which screening approach they regularly recommend. We invited providers who performed 10 or more cervical cancer screens in 2019 in 3 healthcare systems that had not adopted pHPV testing: Kaiser Permanente Washington, Mass General Brigham, and Parkland Health; 53.7% (501/933) completed the survey between October and December 2020. Response distributions varied across modalities (P < .001), with cytology alone or cotesting being more often viewed as somewhat or very effective for 30- to 65-year-olds compared with pHPV (cytology alone 94.1%, cotesting 96.1%, pHPV 66.0%). In 21- to 29-year-olds, the pattern was similar (cytology alone 92.2%, 64.7% cotesting, 50.8% pHPV). Most providers were either incorrect or unsure of the guideline-recommended screening interval for pHPV. Educational efforts are needed about the relative effectiveness and recommended use of pHPV to promote guideline-concordant care.

Estimating Cancer Screening Sensitivity and Specificity Using Healthcare Utilization Data: Defining the Accuracy Assessment Interval

The effectiveness and efficiency of cancer screening in real-world settings depend on many factors, including test sensitivity and specificity. Outside of select experimental studies, not everyone receives a gold standard test that can serve as a comparator in estimating screening test accuracy. Thus, many studies of screening test accuracy use the passage of time to infer whether or not cancer was present at the time of the screening test, particularly for patients with a negative screening test. We define the accuracy assessment interval as the period of time after a screening test that is used to estimate the test's accuracy. We describe how the length of this interval may bias sensitivity and specificity estimates. We call for future research to quantify bias and uncertainty in accuracy estimates and to provide guidance on setting accuracy assessment interval lengths for different cancers and screening modalities.

Variation in the receipt of human papilloma virus co-testing for cervical screening: Individual, provider, facility and healthcare system characteristics

Since 2012, cervical cancer screening guidelines allow for choice of screening test for women age 30-65 years (i.e., Pap every 3 years or Pap with human papillomavirus co-testing every 5 years). Intended to give patients and providers options, this flexibility reflects a trend in the growing complexity of screening guidelines. Our objective was to characterize variation in cervical screening at the individual, provider, clinic/facility, and healthcare system levels. The analysis included 296,924 individuals receiving screening from 3626 providers at 136 clinics/facilities in three healthcare systems, 2010 to 2017. Main outcome was receipt of co-testing vs. Pap alone. Co-testing was more common in one healthcare system before the 2012 guidelines (adjusted odds ratio (AOR) of co-testing at the other systems relative to this system 0.00 and 0.50) but was increasingly implemented over time in a second with declining uptake in the third (2017: AORs shifted to 7.32 and 0.01). Despite system-level differences, there was greater heterogeneity in receipt of co-testing associated with providers than clinics/facilities. In the three healthcare systems, providers in the highest quartile of co-testing use had an 8.35, 8.81, and 25.05-times greater odds of providing a co-test to women with the same characteristics relative to the lowest quartile. Similarly, clinics/ facilities in the highest quartile of co-testing use had a 4.20, 3.14, and 6.56-times greater odds of providing a co-test relative to the lowest quartile. Variation in screening test use is associated with health system, provider, and clinic/facility levels even after accounting for patient characteristics.

De-implementation of cervical cancer screening before age 21

In 2012, United States consensus guidelines were modified to recommend that cervical cancer screening not begin before age 21 and, since 2014, the Health Effectiveness Data and Information Set (HEDIS), a health plan quality measurement too, has included a measure for non-recommended cervical cancer screening among females ages 16-20. Our goal was to describe prevalence over time of cervical cancer screening before age 21 following the 2012 guideline change, and provide information to help understand how rapidly new guidelines may be disseminated and implemented into clinical practice. We used longitudinal clinical and administrative data from three diverse healthcare systems in the Population-based Research to Optimize the Screening Process (PROSPR II) consortium to examine annual trends in screening before age 21. We identified 55,316 average-risk, screening-eligible females ages 18-20 between 2011 and 2017. For each calendar year, we estimated the proportion of females who received a Papanicolaou (Pap) test. We observed a steady decline in the proportion of females under age 21 who received a Pap test, from an average of 8.3% in 2011 to <1% in 2017 across the sites. The observed steady decline suggests growing adherence to the 2012 consensus guidelines. This trend was consistent across diverse geographic regions, healthcare systems, and patient populations, strengthening the generalizability of the results; however, since we only had 1-2 years of study data prior to the consensus guidelines, we cannot discern whether screening under age 21 was already in decline. Nonetheless, these results provide data to compare with other guideline changes to de-implement non-recommended screening practices.

Achieving equity in cervical cancer screening in low- and middle-income countries (LMICs): Strengthening health systems using a systems thinking approach

The World Health Organization (WHO) is leading a call to action to eliminate cervical cancer by the end of the century through global implementation of two effective evidence-based preventive interventions: HPV vaccination and cervical screening and management (CSM). Models estimate that without intervention, over the next 50 years 12.2 million new cases of cervical cancer will occur, nearly 60% of which are preventable only through CSM. Given that more than 80% of the cervical cancer occurs in low- and middle-income countries (LMICs), scaling up sustainable CSM programs in these countries is a top priority for achieving the global elimination goals. Multiple technologies have been developed and validated to meet this need. Now it is critical to identify strategies to implement these technologies into complex, adaptive health care delivery systems. As part of the coordinated cervical cancer elimination effort, we applied a systems thinking lens to reflect on our experiences with implementation of HPV-based CSM programs using the WHO health systems framework. While many common health system barriers were identified, the effectiveness of implementation strategies to address them was context dependent; often reflecting differences in stakeholder's belief in the quality of the evidence supporting a CSM algorithm, the appropriateness of the evidence and algorithm to context, and the 'implementability' of the algorithm under realistic assessments of resource availability and constraints. A structured planning process, with early and broad stakeholder engagement, will ensure that shared-decisions in CSM implementation are appropriately aligned with the culture, values, and resource realities of the setting.

Rates of New Human Papillomavirus Detection and Loss of Detection in Middle-aged Women by Recent and Past Sexual Behavior

BACKGROUND

Understanding the source of newly detected human papillomavirus (HPV) in middle-aged women is important to inform preventive strategies, such as screening and HPV vaccination.

METHODS

We conducted a prospective cohort study in Baltimore, Maryland. Women aged 35-60 years underwent HPV testing and completed health and sexual behavior questionnaires every 6 months over a 2-year period. New detection/loss of detection rates were calculated and adjusted hazard ratios were used to identify risk factors for new detection.

RESULTS

The new and loss of detection analyses included 731 women, and 104 positive for high-risk HPV. The rate of new high-risk HPV detection was 5.0 per 1000 woman-months. Reporting a new sex partner was associated with higher detection rates (adjusted hazard ratio, 8.1; 95% confidence interval, 3.5-18.6), but accounted only for 19.4% of all new detections. Among monogamous and sexually abstinent women, new detection was higher in women reporting ≥5 lifetime sexual partners than in those reporting <5 (adjusted hazard ratio, 2.2; 95% confidence interval, 1.2-4.2).

CONCLUSION

Although women remain at risk of HPV acquisition from new sex partners as they age, our results suggest that most new detections in middle-aged women reflect recurrence of previously acquired HPV.

Accuracy of Self-reported Colonic Polyps: Results from the Prostate, Lung, Colorectal, and Ovarian Screening Trial Study of Colonoscopy Utilization

BACKGROUND

Colonoscopy follow-up recommendations depend on the presence or absence of polyps, and if found, their number, size, and histology. Patients may be responsible for conveying results between primary and specialty care or providing medical information to family members; thus, accurate reporting is critical. This analysis assessed the accuracy of self-reported colonoscopy findings.

METHODS

3,986 participants from the Study of Colonoscopy Utilization, an ancillary study nested within the Prostate, Lung, Colorectal, and Ovarian Screening Trial, were included. Self-reports of polyp and adenoma were compared to medical records, and measures of sensitivity and specificity were calculated. Correlates of accurate self-report of polyp were assessed using logistic regression and weighted to account for study sampling.

RESULTS

The sensitivity and specificity of self-reported polyp findings were 88% and 85%, respectively, and for adenoma 11% and 99%, respectively. Among participants with a polyp, older age was associated with lower likelihood while polyp severity and non-white race were associated with increased likelihood of accurate recall. Among participants without a polyp, having multiple colonoscopies was associated with lower likelihood while family history of colorectal cancer was associated with increased likelihood of accurate recall. Among both groups, longer time since colonoscopy was associated with lower likelihood of accurate recall.

CONCLUSIONS

Participants recalled with reasonable accuracy whether they had a prior polyp; however, recall of histology, specifically adenoma, was much less accurate.

IMPACT

Identification of strategies to increase accurate self-report of colonic polyps are needed, particularly for patient-provider communications and patient reporting of results to family members.

Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy

OBJECTIVE

The vaginal microbiota helps protect the female genital tract from disease. We sought to describe the composition of the vaginal microbiota in premenopausal, perimenopausal, and postmenopausal women and to explore the association between the microbiota and vulvovaginal atrophy (VVA).

METHODS

Eighty-seven women (aged 35-60 y) were classified as premenopausal (n = 30), perimenopausal (n = 29), or postmenopausal (n = 28) according to Stages of Reproductive Aging Workshop guidelines. Midvaginal bacterial community composition was characterized by 16S ribosomal RNA gene analysis.

RESULTS

Bacterial communities clustered into six community state types (CSTs), of which four were dominated by Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus iners, or Lactobacillus jensenii, and two (CST IV-A and CST IV-B) had low relative abundance of Lactobacillus. CST IV-A was characterized by Streptococcus and Prevotella, whereas CST IV-B was characterized by Atopobium. There were significant associations between menopause stage and CST (P = 0.004) and between VVA and CST (P = 0.002). Perimenopausal women were more likely to be classified as CST IV-A or L. gasseri CST, whereas postmenopausal women were often classified as CST IV-A. CSTs dominated by L. crispatus and L. iners were more prevalent in premenopausal women. Nineteen participants had signs of mild or moderate VVA. Compared with women with no VVA, the vaginal microbiota of women with mild or moderate atrophy had 25-fold greater odds of being classified as CST IV-A versus L. crispatus CST (adjusted odds ratio, 25.89; 95% credible interval, 2.98-406.79).

CONCLUSIONS

A distinct bacterial community state (CST IV-A) with a low relative abundance of Lactobacillus is associated with VVA. Future studies recruiting a larger number of women are needed to replicate the findings. This study provides an impetus for future longitudinal studies designed to manage, modulate, and restore vaginal microbiota homeostasis, which would provide stronger evidence for a causal relationship with VVA and ultimately improve the treatment and prevention of atrophic vaginitis in menopause.

Differences in Family Health History Knowledge Among Bisexual and Lesbian Women

PURPOSE

We aimed to determine whether there are differences between sexual minority women and heterosexual women in family health history knowledge.

METHODS

We used data from Dr. Susan Love Research Foundation's The Health of Women Study^®. We included women who completed two of six online surveys between 2012 and 2015 (n = 22,410).

RESULTS

Compared with heterosexual women, bisexual and lesbian women had consistently greater odds of not knowing their family health history (e.g., odds ratios of 2.59 and 1.56 for breast cancer, respectively).

CONCLUSION

To avoid exacerbating existing health disparities, in the era of precision medicine, we must address gaps in knowledge of family health history.

Abstract A62: Differences in sexual dysfunction between lesbian, bisexual, and heterosexual female breast cancer survivors

Purpose: The purpose of this study was to examine (1) differences in sexual dysfunction between lesbian, bisexual, and heterosexual female breast cancer survivors including (2) patient-provider communication regarding sexual problems, and (3) receipt of treatment for sexual complaints.

Methods: Dr. Susan Love Research Foundation's The Health of Women (HOW) Study™ is a cohort study of approximately 40,000 women with and without breast cancer who have responded to one or more online, self-administered surveys. This study includes data from women who completed the baseline and quality-of-life surveys. Women were included if they had a previous diagnosis of breast cancer and if they self-identified as lesbian, bisexual, or heterosexual (N=3,833). Sexual dysfunction was defined as “ever [having] significant problems with change in sexual interest.” We also examined whether women (1) thought that their cancer/cancer treatment was “the primary cause of [her] most significant problems with changes in sexual interest”, (2) “talked to [her] doctor about [her] problems with change in sexual interest”, and (3) “received treatment for [her] problems with change in sexual interest.” Analyses included chi-square test of independence and bivariate logistic regression. Differences were considered significant at p&lt;0.10.

Results: Distribution of sexual orientation was as follows: heterosexual (96%), lesbian (3%), and bisexual (1%). Over a third of women reported sexual dysfunction (34%); 78% of them attributed these changes in sexual interest to their breast cancer treatment. Bisexual women were most likely to report changes in sexual interest (48%) when compared to lesbian (34%) and heterosexual (34%) women. Bisexual women were 77% more likely to report changes in sexual interest compared to heterosexual women (OR=1.77; 95%CI: 0.99-3.17, p&lt;0.10); however, bisexual women were less likely than heterosexual women to talk to their doctor about this (OR=0.40; 95% CI: 0.16-0.94, p&lt;0.10). All women reported similar levels of bother from changes in sexual interest (62% reporting being bothered by changes in sexual interest “quite a bit” or “very much”). Irrespective of sexual orientation, less than 20% of women received treatment for changes in sexual interest.

Conclusion: Sexual dysfunction was a common issue identified by women breast cancer survivors, particularly among bisexual women who were also less likely to report sexual dysfunction to their provider. Overall, treatment for sexual dysfunction was low for all women, suggesting a potential gap in survivorship care more broadly. These findings suggest that experiencing problematic changes in sexual interest was more common among bisexual breast cancer survivors, who may face unique challenges in receiving needed survivorship care. Targeted interventions for these women may be warranted to increase patient-provider communication about sexual dysfunction and to improve the burden of sexual dysfunction among bisexual women.

Citation Format: Christopher W. Wheldon, Megan C. Roberts, Michelle I. Silver, Ulrike Boehmer. Differences in sexual dysfunction between lesbian, bisexual, and heterosexual female breast cancer survivors [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A62.

Abstract P4-06-01: Provider practice and compliance with NCCN clinical guidelines for BRCA1/2 testing: Findings from Dr. Susan Love Research Foundation's The Health of Women (HOW) StudyTM

BRCA1/2-attributable cancers disproportionately contribute to breast cancer mortality, but are relatively infrequent in the general population, making healthcare practices surrounding BRCA1/2 mutation carrier status difficult to study. This analysis leverages a large dataset of over 40,000 individuals with and without breast cancer from Dr. Susan Love Research Foundation's The Health of Women (HOW) StudyTM to evaluate factors associated with healthcare provider compliance with National Comprehensive Cancer Network (NCCN) guidelines for BRCA1/2 testing. Data from women ages 18 and older who completed baseline and family history questionnaires were included in our sample (n=22,410). We examined whether: (1) genetic testing receipt was aligned with NCCN guidelines for BRCA1/2 genetic testing, (2) guideline-consistent use of BRCA1/2 testing varied by race and education, (3) those who had genetic testing received pre-test genetic counseling, and (4) guideline-consistent BRCA1/2 testing differed among those who received pre-test genetic counseling. In this population, 4326 women (19.5%) reported BRCA1/2 testing. Of these women, 70.3% of women were eligible for testing based on NCCN guidelines (vs. 29.8% who did not qualify). Women with higher levels of education were less likely to be over-tested or under-tested than those with lower levels of education (p&lt;0.001); no differences were observed by Hispanic ethnicity (Hispanic vs. non-Hispanic, p=.71) or race (white vs. non-white, p=0.23). Among those tested for BRCA1/2, 65.6% (n=2976) received pre-test genetic counseling. Those who received pretest counseling were more likely to receive genetic testing consistent with NCCN guidelines than those who did not receive pretest counseling (73.8% vs 63.6%, p&lt;0.001). 58% received post-test counseling by a genetics provider (n=2515) compared to 33.9% who received genetic results from their primary care provider or another provider (n=1465). Those who received genetic test results from a genetics provider were more likely to have received BRCA1/2 testing that was compliant with NCCN guidelines than those who received their genetic test results from another type of provider, though by a modest amount (74.2% vs 70.6%, p=0.01). In this population, we found that pretest-genetic counseling was associated with higher rates of NCCN guideline-consistent recommendations for BRCA1/2 genetic testing, and a woman's educational level appears to be associated with higher rates of guideline concordant use of BRCA1/2 testing. Overall, these findings showed higher rates of BRCA1/2 testing and receipt of counseling than previously reported, which may be partially reflective of this unique study population of motivated volunteers. As genetics is increasingly incorporated into cancer prevention, there is an urgent need to examine adherence to genetic testing guidelines to ensure appropriate use.

Citation Format: Roberts MC, Loud J, Klein WMP, Silver MI. Provider practice and compliance with NCCN clinical guidelines for BRCA1/2 testing: Findings from Dr. Susan Love Research Foundation's The Health of Women (HOW) StudyTM [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-06-01.

Clinical Outcomes after Conservative Management of Cervical Intraepithelial Neoplasia Grade 2 (CIN2) in Women Ages 21-39 Years

Cervical intraepithelial neoplasia grade 2 (CIN2) frequently regresses, is typically slow-growing, and rarely progresses to cancer. Some women forgo immediate treatment, opting for conservative management (heightened surveillance with cytology and colposcopy), to minimize overtreatment and increased risk of obstetric complications; however, there are limited data examining clinical outcomes in these women. We performed a retrospective cohort analysis of younger women diagnosed with initially untreated CIN1/2, CIN2 and CIN2/3 lesions at Kaiser Permanente Northern California between 2003 and 2015. Clinical outcomes were categorized into five mutually exclusive hierarchical groups: cancer, treated, returned to routine screening, persistent high-grade lesion, or persistent low-grade lesion. Median follow-up for the 2,417 women was 48 months. Six women were diagnosed with cancer (0.2%), all with history of high-grade cytology, and none after a negative cotest. Thirty percent of women were treated, and only 20% returned to routine screening; 50% remained in continued intensive follow-up, of which 86% had either low-grade cytology/histology or high-risk human papillomavirus (HPV) positivity, but not necessarily persistence of a single HPV type. No cancers were detected after a single negative cotest in follow-up. Almost half of initially untreated women did not undergo treatment, but remained by protocol in colposcopy clinic for 2 or more years in the absence of persisting CIN2⁺ Their incomplete return to total negativity was possibly due to sequential new and unrelated low-grade abnormalities. The prolonged colposcopic surveillance currently required to return to routine screening in the absence of persisting CIN2⁺ might not be necessary after a negative cotest.Significance: Many younger women under conservative management following an initial CIN2 result remain in a clinical protocol of prolonged intensified surveillance without a subsequent diagnosis of CIN2 or more severe diagnoses. More research is needed to determine whether such prolonged management might be unnecessary following a negative cotest for those women with an initial CIN2 but otherwise only low-grade findings. Cancer Prev Res; 11(3); 165-70. ©2018 AACR.

Uptake of HPV testing and extended cervical cancer screening intervals following cytology alone and Pap/HPV cotesting in women aged 30-65 years

OBJECTIVE

To evaluate the adoption of HPV testing and recommended extended cervical cancer screening intervals in clinical practice, we described yearly uptake of Pap/HPV cotesting and estimated length of time between normal screens by patient characteristics.

METHODS

We examined 55,575 Pap/HPV records from 27,035 women aged 30-65 years from the Johns Hopkins Hospital Pathology Data System between 2006 and 2013. Cotest uptake and median times to next screening test for cotests and cytology only were calculated. Adjusted hazard ratios were estimated using Cox proportional hazards models, with random effects adjustment for clustering within clinic.

RESULTS

Cotest usage increased from < 10% in 2006 to 78% in 2013. The median time to next screening test following normal cytology alone remained constant around 1.5 years. Screening intervals following a dual-negative cotest increased from 1.5 years in 2006/2007 to 2.5 years in 2010, coincident with increases in the proportion of women cotested. Intervals following a dual negative cotest were longer among Medicare patients (3 years) compared with privately insured women (2.5 years), and shorter among black (2 years) compared with white women (2.8 years).

CONCLUSION

By mid-2013 we observed broad adoption of Pap/HPV cotesting in routine screening in a large academic medical center. Increased screening intervals were observed only among cotested women, while those screened by cytology alone continued to be screened almost annually. The influence of different combinations of race and insurance on screening intervals should be further evaluated to ensure balance of screening risks and benefits in the U.S.

POPULATION

Trends in cervical cancer incidence in younger US women from 2000 to 2013

OBJECTIVE

This study aimed to assess the temporal trends in invasive cervical cancer (ICC) incidence rates among 21-25year-olds. US guidelines no longer recommend screening prior to age 21, and concerns have been raised that delayed screening initiation may increase ICC incidence among young women.

METHODS

This study utilized ICC incidence data from 18 US population-based cancer registries in SEER from 2000 to 2013 and Pap test prevalence data from the Behavioral Risk Factor Surveillance System from 1996 to 2012. Trends were evaluated with annual percent changes (APCs) using Joinpoint regression.

RESULTS

The prevalence of never having a Pap test before age 21 increased from 22.0% in 1996-2004 to 38.3% in 2006-2012 (APC=+5.48, 95%CI=+4.20, +7.50). Despite this decline in screening, ICC incidence among 21-23year olds significantly declined between 2000 and 13 (APC=-5.36, 95%CI=-7.83,-2.82), particularly from 2006 to 2013 (APC=-9.70, 95%CI=-15.79, -3.17). ICC incidence remained constant among 24-25year olds (APC=+0.45, 95%CI=-2.00, 2.97). Compared to women born in 1978-1985, women born in 1986-1991 had a higher prevalence of never receiving a Pap test prior to 21 (35.4% vs. 22.1%, p<0.001), but a lower ICC incidence at 21-23 (0.98 vs. 1.55 per 100,000, p<0.001).

CONCLUSION

While US females born in 1986-1991 were less likely to receive a Pap test before age 21, diagnoses of ICC in the early 20s were rare and lower than for those born in earlier years. This provides reassurance that the updated guidelines to delay screening until 21 has not resulted in a population-level increase in ICC rates among young women.

The population impact of human papillomavirus/cytology cervical cotesting at 3-year intervals: Reduced cervical cancer risk and decreased yield of precancer per screen

BACKGROUND

The objective of cervical screening is to detect and treat precancer to prevent cervical cancer mortality and morbidity while minimizing overtreatment of benign human papillomavirus (HPV) infections and related minor abnormalities. HPV/cytology cotesting at extended 5-year intervals currently is a recommended screening strategy in the United States, but the interval extension is controversial. In the current study, the authors examined the impact of a decade of an alternative, 3-year cotesting, on rates of precancer and cancer at Kaiser Permanente Northern California. The effect on screening efficiency, defined as numbers of cotests/colposcopy visits needed to detect a precancer, also was considered.

METHODS

Two cohorts were defined. The "open cohort" included all women screened at least once during the study period; > 1 million cotests were performed. In a fixed "long-term screening cohort," the authors considered the cumulative impact of repeated screening at 3-year intervals by restricting the cohort to women first cotested in 2003 through 2004 (ie, no women entering screening later were added to this group).

RESULTS

Detection of cervical intraepithelial neoplasia 3/adenocarcinoma in situ (CIN3/AIS) increased in the open cohort (2004-2006: 82.0/100,000 women screened; 2007-2009: 140.6/100,000 women screened; and 2010-2012: 126.0/100,000 women screened); cancer diagnoses were unchanged. In the long-term screening cohort, the detection of CIN3/AIS increased and then decreased to the original level (2004-2006: 80.5/100,000 women screened; 2007-2009: 118.6/100,000 women screened; and 2010-2012: 84.9./100,000 women screened). The number of cancer diagnoses was found to decrease. When viewed in terms of screening efficiency, the number of colposcopies performed to detect a single case of CIN3/AIS increased in the cohort with repeat screening.

CONCLUSIONS

Repeated cotesting at a 3-year interval eventually lowers population rates of precancer and cancer. However, a greater number of colposcopies are required to detect a single precancer. Cancer 2016;122:3682-6. © 2016 American Cancer Society.

Patient concerns about human papillomavirus testing and 5-year intervals in routine cervical cancer screening

OBJECTIVE

To explore attitudes toward new cervical cancer screening options and understand factors associated with those beliefs among women in routine gynecologic care.

METHODS

We used an interviewer-administered survey of 551 women aged 36-62 years enrolled in the HPV in Perimenopause Study. Poisson regression with robust error variance was used to estimate prevalence ratios and 95% confidence intervals (CIs) to compare women's preferences for cervical cancer screening methods and frequency.

RESULTS

A majority of women (55.6%, 95% CI 51.4-59.8%) were aware that screening recommendations had changed, yet 74.1% (95% CI 70.3-77.7%) still believed women should be screened annually. If recommended by their doctor, 68.4% (95% CI 64.4-72.2%) were willing to extend screening to every 3 years, but only 25.2% (95% CI 21.9-29.2%) would extend screening to 5 years. Most women (60.7%, 95% CI 56.5-65.7%) expressed a strong preference for Pap testing, and 41.4% (95% CI 37.4-45.6%) expressed at least moderate concern over having a human papillomavirus (HPV) test without a Pap test. A desire for more frequent care, higher degree of worry and perceived risk, and abnormal screening history were all associated with reduced willingness to accept HPV testing and longer screening intervals.

CONCLUSION

A majority of routinely screened women indicated a willingness to adopt a cervical cancer screening strategy of cytology alone or Pap-HPV cotesting every 3 years if recommended by their physician. However, they remain concerned about HPV testing and extension of screening intervals to once every 5 years. Our results suggest continued reticence to accepting newer HPV-based screening algorithms among routinely screened women older than age 35 years.

Cervical cancer screening in older women: new evidence and knowledge gaps

Anne Rositch and colleagues discuss the study by Peter Sasieni and colleagues on cervical cancer screening in older women and describe the further information needed to help inform decisions about whether to extend screening programs beyond 65 years for women with adequate negative screening. Please see later in the article for the Editors' Summary

Obesity and human papillomavirus infection in perimenopausal women

INTRODUCTION

Obesity is known to increase susceptibility to certain infections in men. It is unclear whether obesity increases women's risk for human papillomavirus (HPV) infection.

METHODS

In a prospective cohort of 696 perimenopausal women enrolled in 2008-2012, we sought to determine whether obesity predicted incident HPV detection or nondetection. Obesity was defined as body mass index (BMI) ≥ 30 kg/m(2).

RESULTS

Baseline any type HPV prevalence was comparable between obese and nonobese women (18.7% vs 19.1%; P > .05). Over a median follow-up period of 17.9 months (interquartile range: 12.1-24.5), 187 new HPV detections occurred among 123 women, 60 of whom subsequently lost 76 detectable infections. When compared with nonobese participants, obese women had a similar rate of new HPV detection (7.1 vs 7.8 infections per 1000 infection-years; P > .05) or loss of detection (100.3 vs 85.8 infections per 100 infection-years; P > .05). Similar results were found after adjusting for age, menopausal status, smoking habit, and sexual exposure history.

CONCLUSIONS

Results from the current analysis suggest little effect of obesity on HPV detection and loss of detection in mid-adult women. More research is needed to determine whether adipokines or cytokines better capture the potential immune modulating effects of obesity on HPV infection.

A cohort effect of the sexual revolution may be masking an increase in human papillomavirus detection at menopause in the United States

BACKGROUND

Cohort effects, new sex partnerships, and human papillomavirus (HPV) reactivation have been posited as explanations for the bimodal age-specific HPV prevalence observed in some populations; no studies have systematically evaluated the reasons for the lack of a second peak in the United States.

METHODS

A cohort of 843 women aged 35-60 years were enrolled into a 2-year, semiannual follow-up study. Age-specific HPV prevalence was estimated in strata defined by a lower risk of prior infection (<5 self-reported lifetime sex partners) and a higher risk of prior infection (≥ 5 lifetime sex partners). The interaction between age and lifetime sex partners was tested using likelihood ratio statistics. Population attributable risk (PAR) was estimated using Levin's formula.

RESULTS

The age-specific prevalence of 14 high-risk HPV genotypes (HR-HPV) declined with age among women with <5 lifetime sex partners but not among women with ≥ 5 lifetime sex partners (P = .01 for interaction). The PAR for HR-HPV due to ≥ 5 lifetime sex partners was higher among older women (87.2%), compared with younger women (28.0%). In contrast, the PAR associated with a new sex partner was 28% among women aged 35-49 years and 7.7% among women aged 50-60 years.

CONCLUSIONS

A lower cumulative probability of HPV infection among women with a sexual debut before the sexual revolution may be masking an age-related increase in HPV reactivation in the United States.

Contributions of recent and past sexual partnerships on incident human papillomavirus detection: acquisition and reactivation in older women

Understanding the fraction of newly detected human papillomavirus (HPV) infections due to acquisition and reactivation has important implications on screening strategies and prevention of HPV-associated neoplasia. Information on sexual activity and cervical samples for HPV DNA detection using Roche Linear Array were collected semiannually for two years from 700 women ages 35 to 60 years. Incidence and potential fraction of HPV associated with new and lifetime sexual partnerships were estimated using Poisson regression. Cox frailty models were used to estimate hazard ratios (HR) for potential risk factors of incident HPV detection. Recent and lifetime numbers of sexual partners were both strongly associated with incident HPV detection. However, only 13% of incident detections were attributed to new sexual partners, whereas 72% were attributed to 5 or more lifetime sexual partners. Furthermore, 155 of 183 (85%) incident HPV detections occurred during periods of sexual abstinence or monogamy, and were strongly associated with cumulative lifetime sexual exposure [HR: 4.1, 95% confidence interval (CI): 2.0-8.4). This association increased with increasing age. These data challenge the paradigm that incident HPV detection is driven by current sexual behavior and new viral acquisition in older women. Our observation that most incident HPV infection was attributable to past, not current, sexual behavior at older ages supports a natural history model of viral latency and reactivation. As the more highly exposed baby-boomer generation of women with sexual debut after the sexual revolution transition to menopause, the implications of HPV reactivation at older ages on cervical cancer risk and screening recommendations should be carefully evaluated.

Determinants of VIA (Visual Inspection of the Cervix After Acetic Acid Application) positivity in cervical cancer screening of women in a peri-urban area in Andhra Pradesh, India

OBJECTIVES

Visual inspection of the cervix after acetic acid application (VIA) is widely recommended as the method of choice in cervical cancer screening programs in resource-limited settings because of its simplicity and ability to link with immediate treatment. In testing the effectiveness of VIA, human papillomavirus DNA testing, and Pap cytology in a population-based study in a peri-urban area in Andhra Pradesh, India, we found the sensitivity of VIA for detection of cervical intraepithelial neoplasia grade 2 and worse (CIN2+) to be 26.3%, much lower than the 60% to 90% reported in the literature. We therefore investigated the determinants of VIA positivity in our study population.

METHODS

We evaluated VIA positivity by demographics and reproductive history, results of clinical examination, and results from the other screening methods.

RESULTS

Of the 19 women diagnosed with CIN2+, only 5 were positive by VIA (positive predictive value, 3.1%). In multivariate analysis, VIA positivity (12.74%) was associated with older age, positive Pap smear, visually apparent cervical inflammation, and interobserver variation. Cervical inflammation of unknown cause was present in 21.62% of women. In disease-negative women, cervical inflammation was associated with an increase in VIA positivity from 6.1% to 15.5% (P<0.001). Among the six gynecologists who performed VIA, the positivity rate varied from 4% to 31%.

CONCLUSIONS

The interpretation of VIA is subjective and its performance cannot be readily evaluated against objective standards.

IMPACT

VIA is not a robust screening test and we caution against its use as the primary screening test in resource-limited regions.