Understanding Sexual and Gender Minority Populations and Organ-Based Screening Recommendations for Human Papillomavirus-Related Cancers

OBJECTIVES

Sexual gender minority (SGM) populations are at risk for human papillomavirus (HPV)-related cancers of the anogenital tract and oropharynx and often face barriers to health care. The goals of this document are to clarify language to provide inclusive care for SGM populations and to provide recommendations for screening and prevention of HPV-related cancers in SGM populations.

MATERIALS AND METHODS

An expert committee convened by the American Society for Colposcopy and Cervical Pathology performed a narrative review of the literature through February 2023. A comprehensive MEDLINE database search was performed for relevant studies. The literature review was divided into categories by organ/topic and by SGM population. Given the variability in available data for several of the categories, recommendations were made based on national guidelines where appropriate or expert opinion where there were less data to support risk-based guidelines.

RESULTS

Definitions and terminology relevant to SGM populations are presented. The authors advocate the adoption of sexual orientation gender identity data collection and an organ-based screening approach, which is possible with knowledge of patient anatomy, sexual behaviors, and clinical history. This includes screening for cervical cancer per national recommendations, as well as screening for anal, vulvar, vaginal, penile, and oral cancers based on risk factors and shared clinical decision making. The authors recommend consideration of HPV vaccination in all SGM individuals up to age 45 years old who are at risk.

CONCLUSIONS

An organ-based screening approach is part of a global strategy to create an inclusive care environment and mitigate barriers to screening and prevention of HPV-mediated cancers in SGM populations.

Abstract A85: Receipt of adjuvant endometrial carcinoma treatment according to race: An NRG Oncology/Gynecologic Oncology Group 210 Study

Background: Black women diagnosed with endometrial cancer (EC) experience worse outcomes compared with white women. Differences in receipt of treatment are postulated to contribute to this disparity. While underuse of surgical treatment among black women is well documented, we know less about racial differences in adjuvant treatment. We therefore examined receipt of adjuvant treatment among black and white women in the NRG Oncology/Gynecology Oncology Group (GOG) 210 Study, a large prospective cohort of women with EC who received uniform surgical treatment but varying adjuvant therapy regimens.

Methods: Our analysis included 615 black and 4,283 white women with EC who underwent either an abdominal hysterectomy or laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy and lymph node dissection. At study enrollment, women completed a questionnaire that assessed race as well as risk factors for EC. Tumor characteristics were available from surgical pathology reports and a centralized review by pathologists with expertise in gynecologic cancers. Adjuvant treatment was documented at the time of the postoperative clinical visits and was categorized as none (54.3%), radiotherapy only (16.5%), chemotherapy only (n=15.2%), and radiotherapy and chemotherapy (14.0%). We used polytomous logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between race and receipt of adjuvant therapy in the overall study population and stratified by tumor subtype (combination of histology and grade) adjusted for age, income, education, and stage.

Results: Black compared with white women had higher odds of receiving combination radiotherapy and chemotherapy compared to no adjuvant therapy (OR=1.35, 95% CI=1.01-1.79) but no difference in receipt of radiotherapy only (OR=0.95, 95% CI=0.72-1.25) or chemotherapy only (OR=0.88 (0.64-1.20) was observed. In tumor-subtype stratified models, black women diagnosed with low-grade endometrioid (OR=2.04, 95% CI=1.06-3.93) or serous tumors (OR=1.81, 95% CI=1.07-3.08) had higher odds of receiving radiotherapy and chemotherapy than white women, but race was not associated with receipt of radiotherapy and chemotherapy for women with high-grade endometrioid, carcinosarcoma, mixed-cell, or clear-cell tumors. Moreover, the tumor-subtype stratified analyses revealed no racial differences in receipt of radiotherapy-only or chemotherapy-only regimens.

Conclusions: In this study of women with EC who received uniform surgical treatment, we observed racial differences in receipt of some adjuvant treatment regimens but not others. Among women with indolent (i.e., low-grade endometrioid) or aggressive (i.e., serous) tumors, black women had higher odds of receiving radiotherapy and chemotherapy compared to white women. Radiotherapy and chemotherapy treatment is potentially contraindicated for women with indolent tumors, which suggests a need to understand the reasons why clinicians might overprescribe these therapies for black women. Overall, our results suggest racial differences in receipt of radiotherapy and chemotherapy, but not for other regimens.

Citation Format: Ashley Felix, David Cohn, Theodore Brasky, David Mutch, William Creasman, Premal Thaker, Joan Walker, Richard Moore, Shashikant Lele, Saketh Guntupalli, Levi Downs, Christa Nagel, John Boggess, Michael Pearl, Olga Ioffe, Wei Deng, Marcus Randall, Louise Brinton. Receipt of adjuvant endometrial carcinoma treatment according to race: An NRG Oncology/Gynecologic Oncology Group 210 Study [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 A85.

Abstract C44: Endometrial carcinoma recurrence in black and white women in the NRG Oncology/Gynecologic Oncology Group 210 trial

BACKGROUND: Black women diagnosed with endometrial carcinoma have a higher risk of recurrence compared with white women. Higher recurrence risk among black women is due, in part, to a greater frequency of aggressive tumor characteristics including non-endometrioid histologies and advanced stage tumors. The risk of recurrence for black and white women within distinct tumor groupings has not been well-examined due to low numbers of black women and under-representation of aggressive histologic subtypes in single institution studies. Therefore, we examined the association between self-reported race and recurrence risk stratified by histologic subtype in the NRG Oncology/Gynecology Oncology Group (GOG) 210, a prospective observational study that enrolled 6,124 newly diagnosed endometrial carcinoma patients between 2003 and 2011.

METHODS: We restricted this analysis to 618 black and 4,316 white women with endometrial carcinoma. At study enrollment, women completed a questionnaire that assessed risk factors for gynecologic cancers. Recurrence, defined as evidence of disease following complete response to primary therapy, was abstracted from medical records. Tumor characteristics were available from surgical pathology reports and a centralized review by pathologists with expertise in gynecologic cancers. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between race (black vs. white) and recurrence risk in models stratified by histologic subtype (low-grade endometrioid, high-grade endometrioid, serous, mixed epithelial, carcinosarcoma, clear cell) and adjusted for stage (I, II, III, IV), age at diagnosis (continuous), and adjuvant therapy (none, chemotherapy, radiation, chemotherapy and radiation, unknown). We also examined income ($20,000-$39,999, $40,000-$69,999, ≥$70,000) and education (high school/GED, some college/technical school, college graduate/beyond) as potential mediators of the association between race and endometrial carcinoma recurrence risk using the Baron-Kenny method. Median follow-up time was 5 years.

RESULTS: Black women were more frequently diagnosed with non-endometrioid (52.9% vs. 31.8%) and advanced stage (Stage III or IV: 29.0% vs. 21.1%) tumors compared with white women. Recurrence was documented in 26% of black and 17% of white endometrial carcinoma patients. In histologic subtype-stratified models adjusted for stage, age, and adjuvant therapy, a higher risk of recurrence was noted in black women with low-grade endometrioid (HR=1.65, 95% CI=1.07-2.54), mixed epithelial (HR=1.75, 95% CI=1.13-2.71), or carcinosarcomas (HR=1.55, 95% CI=1.03-2.31) compared with white women. No significant race-recurrence relationships were observed among women diagnosed with high-grade endometrioid, serous, or clear cell tumors. After adjustment for income and education, the association of black race and recurrence risk remained elevated, but was not statistically significant: low-grade endometrioid (HR=1.52, 95% CI=0.97-2.38), mixed epithelial (HR=1.56, 95% CI=0.98-2.50), and carcinosarcoma (HR=1.48, 95% CI=0.98-2.25). Further, neither income nor education were significantly associated with recurrence risk in the multivariable models.

CONCLUSIONS: Our study provides evidence that racial disparities in endometrial carcinoma recurrence risk vary by histologic subtype. Socioeconomic factors do not explain black-white differences in endometrial carcinoma recurrence risk. Future studies exploring the role of biological factors and post-diagnosis surveillance contributing to racial differences in endometrial carcinoma recurrence are warranted.

Citation Format: Ashley S. Felix, Theodore Brasky, David Cohn, Scott McMeekin, David Mutch, Creasman William, Premal Thaker, Joan Walker, Richard Moore, Shashikant Lele, Saketh Guntupalli, Levi Downs, Christa Nagel, John Boggess, Michael Pearl, Olga Ioffe, Kay Park, Shamshad Ali, Louise Brinton. Endometrial carcinoma recurrence in black and white women in the NRG Oncology/Gynecologic Oncology Group 210 trial. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C44.

Propensity-Weighted Comparison of Long-Term Risk of Urinary Adverse Events in Elderly Women Treated For Cervical Cancer

PURPOSE

Cervical cancer treatment is associated with a risk of urinary adverse events (UAEs) such as ureteral stricture and vesicovaginal fistula. We sought to measure the long-term UAE risk after surgery and radiation therapy (RT), with confounding controlled through propensity-weighted models.

METHODS AND MATERIALS

From the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified women ≥66 years old with nonmetastatic cervical cancer treated with simple surgery (SS), radical hysterectomy (RH), external beam RT plus brachytherapy (EBRT+BT), or RT+surgery. We matched them to noncancer controls 1:3. Differences in demographic and cancer characteristics were balanced by propensity weighting. Grade 3 to 4 UAEs were identified by diagnosis codes plus treatment codes. Cumulative incidence was measured using Kaplan-Meier methods. The hazard associated with different cancer treatments was compared using Cox models.

RESULTS

UAEs occurred in 272 of 1808 cases (17%) and 222 of 5424 (4%) controls; most (62%) were ureteral strictures. The raw cumulative incidence of UAEs was highest in advanced cancers. UAEs occurred in 31% of patients after EBRT+BT, 25% of patients after RT+surgery, and 15% of patients after RH; however, after propensity weighting, the incidence was similar. In adjusted Cox models (reference = controls), the UAE risk was highest after RT+surgery (hazard ratio [HR], 5.07; 95% confidence interval [CI], 2.32-11.07), followed by EBRT+BT (HR, 3.33; 95% CI, 1.45-7.65), RH (HR, 3.65; 95% CI, 1.41-9.46) and SS (HR, 0.99; 95% CI, 0.32-3.01). The higher risk after RT+surgery versus EBRT+BT was statistically significant, whereas, EBRT+BT and RH were not significantly different from each other.

CONCLUSIONS

UAEs are common after cervical cancer treatment, particularly in patients with advanced cancers. UAEs are more common after RT, but these women tend to have the advanced cancers. After propensity weighting, the risk after RT was similar to that after surgery.

A phase I feasibility study of multi-modality imaging assessing rapid expansion of marrow fat and decreased bone mineral density in cancer patients

PURPOSE

Cancer survivors are at an increased risk for fractures, but lack of effective and economical biomarkers limits quantitative assessments of marrow fat (MF), bone mineral density (BMD) and their relation in response to cytotoxic cancer treatment. We report dual energy CT (DECT) imaging, commonly used for cancer diagnosis, treatment and surveillance, as a novel biomarker of MF and BMD.

METHODS

We validated DECT in pre-clinical and phase I clinical trials and verified with water-fat MRI (WF-MRI), quantitative CT (QCT) and dual-energy X-ray absorptiometry (DXA). Basis material composition framework was validated using water and small-chain alcohols simulating different components of bone marrow. Histologic validation was achieved by measuring percent adipocyte in the cadaver vertebrae and compared with DECT and WF-MRI. For a phase I trial, sixteen patients with gynecologic malignancies (treated with oophorectomy, radiotherapy or chemotherapy) underwent DECT, QCT, WF-MRI and DXA before and 12months after treatment. BMD and MF percent and distribution were quantified in the lumbar vertebrae and the right femoral neck.

RESULTS

Measured precision (3mg/cm(3)) was sufficient to distinguish test solutions. Adiposity in cadaver bone histology was highly correlated with MF measured using DECT and WF-MRI (r=0.80 and 0.77, respectively). In the clinical trial, DECT showed high overall correlation (r=0.77, 95% CI: 0.69, 0.83) with WF-MRI. MF increased significantly after treatment (p<0.002). Chemotherapy and radiation caused greater increases in MF than oophorectomy (p<0.032). L4 BMD decreased 14% by DECT, 20% by QCT, but only 5% by DXA (p<0.002 for all). At baseline, we observed a statistically significant inverse association between MF and BMD which was dramatically attenuated after treatment.

CONCLUSION

Our study demonstrated that DECT, similar to WF-MRI, can accurately measure marrow adiposity. Both imaging modalities show rapid increase in MF following cancer treatment. Our results suggest that MF and BMD cannot be used interchangeably to monitor skeletal health following cancer therapy.

Longitudinal assessment of bone loss from diagnostic computed tomography scans in gynecologic cancer patients treated with chemotherapy and radiation

OBJECTIVE

The objective of the study was to measure the volumetric bone mineral density (vBMD) using diagnostic computed tomography scans in gynecologic oncology patients.

STUDY DESIGN

In a retrospective study, spine and femoral neck (FN) vBMD was measured for 1 year in 40 patients receiving chemotherapy or radiation.

RESULTS

There is significant bone loss after chemotherapy, radiation, and a combination of radiation and chemotherapy (P = .0211). In 1 year, the percent reduction in vBMD (±SE) at L1-L2 spine and the FN was a 15.9% (±5.67) and 10.4% (±4.06) in chemotherapy; 11% (±5.68) and 15.8% (±2.56) in radiation; and 21.0% (±7.03) and 3.6% (±3.3.7) in the combined therapy group. Bone loss was evident immediately after treatment and persisted or worsened in most women.

CONCLUSION

Gynecologic cancer patients treated with chemotherapy or radiation experience immediate and prolonged bone loss; thus, pre- and posttreatment monitoring of bone loss is important in these patients.

Anal human papillomavirus infection and abnormal anal cytology in women with genital neoplasia

OBJECTIVES

Describe the type-specific prevalence of anal HPV infection in women with lower genital tract intraepithelial neoplasia and cancer. Describe the prevalence of abnormal anal cytology and identify risk factors for anal HPV infection and abnormal anal cytology in this population.

METHODS

We performed a cross-sectional study of women attending 2 university-based colposcopy clinics with high-grade lower genital tract intraepithelial neoplasia or cancer. Participants received anal HPV testing/typing, anal cytology and completed a questionnaire detailing medical history and sexual behavior.

RESULTS

Of the 102 women enrolled, 92 (90%) had adequate beta-globin for analysis of HPV DNA status, and 47/92 women (51%) had detectable anal HPV. Of the 15 HPV types identified, 9 (60%) were oncogenic types and 6 (40%) were non-oncogenic or undetermined risk types. Overall, 9 women (9%) had abnormal anal cytology, and 7 of those had corresponding anal intraepithelial neoplasia grade I (AIN I). Women with vulvar disease had the highest proportion of abnormal anal cytology (21%) compared to women with cervical disease alone (7%), but this difference was not statistically significant (p=0.10). Neither anal HPV infection nor abnormal cytology was significantly associated with anal sex practices, smoking or number of sexual partners.

CONCLUSIONS

Anal infection with high-risk HPV types is common in women with high-grade genital neoplasia, but was not associated with known risk factors for genital HPV infection. Other unidentified risk factors may play a role in the anal HPV infection in this population. Abnormal anal cytology was rare and larger studies are needed to identify risk factors associated with abnormal cytology and anal intraepithelial neoplasia in this population.

Measurement of N-methyl-2-pyridone-5-carboxamide in urine by high performance liquid chromatography

We have previously described a simple and reproducible method for the measurement of nicotinamide and its major metabolite N-methyl-2-pyridone-5-carboxamide (2-pyr) in human plasma. We now describe a low-cost high-throughput method for measurement of urinary 2-pyr, and demonstrate that Isolute C18 bulk can replace use of the column to clean up the samples prior to injection into the HPLC apparatus. Using a standard curve together with an internal standard for each sample, with mean recovery of 2-pyr greater than 95%, the assay has proved reproducible, with considerable savings in cost and time. The principal advantages of this method are the rapid column clean up of samples prior to injection and the simple but effective methodology.

Endothelial dysfunction in Type 1 diabetes mellitus: relationship with LDL oxidation and the effects of vitamin E

AIMS

To examine the hypothesis that increased susceptibility of low density lipoproteins (LDL) to oxidation predisposes to endothelial dysfunction in patients with Type 1 diabetes mellitus.

METHODS

A cross-sectional study of 46 non-nephropathic diabetic and 39 control subjects and in the diabetic patients, a 3-month duration, randomized, placebo-controlled double-blind trial of vitamin E 500 U/day. Flow-mediated vasodilatation (FMD) was measured in the forearm by high resolution ultrasound. LDL oxidation by Cu2+ was measured in vitro.

RESULTS

Diabetic patients had greater basal and reactive forearm blood flow (geometric mean (SD%) flow (ml/min) 110.15 (19.19%) vs. 74.99 (23.17%); P=0.045, and 344.35 (20.84%) vs. 205.17 (21.48%); P=0.007), compared with controls, but there was no difference in FMD (median (interquartile range) 0.00 (-0.01-0.02) vs. 0.02 (-0.01-0.02) cm2; P=0.78). Diabetic LDL oxidation lag time correlated with postdilatation brachial artery area (r= 0.32; P=0.05) but not with FMD. Lag-times and total LDL oxidation by Cu2+, lipoprotein and vitamin E concentrations were similar in diabetic and control groups. Antibody titres to oxidized LDL (oxLDL) were higher in non-diabetic than diabetic subjects, and were unrelated to FMD. In diabetic patients, vitamin E increased mean (SD) plasma vitamin E levels (24.0 (6.5) to 47.5 (7.5) gmol/l; P=0.0006) and resulted in increased FMD (delta 0.00 (-0.02-0.01) vs. 0.01 (0.01-0.02)) cm2; P=0.0036), but no changes in LDL Cu2+ oxidation profiles were observed.

CONCLUSIONS

FMD is no different in Type 1 diabetic and non-diabetic subjects and nor are indices of lipid peroxidation and in vitro LDL oxidation although levels of antibody to oxLDL are lower in diabetes. Vitamin E supplementation increases plasma vitamin E levels and may enhance FMD in diabetes but, in the absence of changes in LDL oxidation, this may not be mediated by reduced oxidation of LDL.

The effect of arm exercise on regional cerebral blood flow in the subclavian steal syndrome

Reversed vertebral blood flow distal to a subclavian obstruction is not uncommon and rarely leads to stroke. A small subgroup of these patients have obstruction in other portions of the extracranial or intracranial circulation, however, and cerebrovascular symptoms are induced by arm exercise, which may decrease regional cerebral blood flow--at times to critical levels--indicating a true "steal" syndrome. We evaluated six patients with symptomatic subclavian steal syndrome using stable xenon with computed tomography cerebral blood flow mapping. A decrease in flow from 13% to 90% in one or more regional vascular territories was found after arm exercise. Patients with a true "steal" syndrome may be at higher risk for stroke. Measuring regional cerebral blood flow may be a means of detecting patients who have a critical loss of flow reserves and who will be symptomatically improved by cerebral revascularization.

Effect of reduced phytate wheat bran on zinc absorption

The rise in plasma zinc after the ingestion of 765 mumol (50 mg) elemental zinc was measured over 6 h in three groups of healthy subjects who, in a second test, also consumed a standard wheat bran, a reduced phytate, high fibre processed bran or rice-based, low phytate, low fibre breakfast cereal (Rice Krispies). Standard bran, reduced phytate bran and Rice Krispies all significantly decreased the area under the plasma zinc time curve (AUC) compared to the zinc alone test. The AUC obtained with standard bran was significantly lower than that after reduced phytate bran (mean +/- s.e.: -5.9 +/- 2.7 vs 18.5 +/- 4.2 mumol.h/l, P less than 0.001). The percentage reductions in AUC produced by the test meals were: standard bran 106.4 +/- 2.4, reduced phytate bran 75.9 +/- 4.8, Rice Krispies 46.3 +/- 10.4 per cent, P less than 0.01). Histidine, taken with standard bran in a small subgroup of subjects, tended to improve zinc absorption but the difference was not statistically significant.