Relationships of p16 Immunohistochemistry and Other Biomarkers With Diagnoses of Cervical Abnormalities: Implications for LAST Terminology

CONTEXT.—

Lower Anogenital Squamous Terminology (LAST) standardization recommended p16INK4a immunohistochemistry (p16 IHC) for biopsies diagnosed morphologically as cervical intraepithelial neoplasia (CIN) grade 2 (CIN2) to classify them as low-grade or high-grade squamous intraepithelial lesions (HSILs).

OBJECTIVE.—

To describe the relationships of p16 IHC and other biomarkers associated with cervical cancer risk with biopsy diagnoses.

DESIGN.—

A statewide, stratified sample of cervical biopsies diagnosed by community pathologists (CPs), including 1512 CIN2, underwent a consensus, expert pathologist panel (EP) review (without p16 IHC results), p16 IHC interpretation by a third pathology group, and human papillomavirus (HPV) genotyping, results of which were grouped hierarchically according to cancer risk. Antecedent cytologic interpretations were also available.

RESULTS.—

Biopsies were more likely to test p16 IHC positive with increasing severity of CP diagnoses, overall (Ptrend ≤ .001) and within each HPV risk group (Ptrend ≤ .001 except for low-risk HPV [Ptrend < .010]). All abnormal grades of CP-diagnosed biopsies were more likely to test p16 IHC positive with a higher HPV risk group (Ptrend < .001), and testing p16 IHC positive was associated with higher HPV risk group than testing p16 IHC negative for each grade of CP-diagnosed biopsies (P < .001). p16 IHC-positive, CP-diagnosed CIN2 biopsies were less likely than CP-diagnosed CIN3 biopsies to test HPV16 positive, have an antecedent HSIL+ cytology, or to be diagnosed as CIN3+ by the EP (P < .001 for all). p16 IHC-positive, CP-diagnosed CIN1 biopsies had lower HPV risk groups than p16 IHC-negative, CP-diagnosed CIN2 biopsies (P < .001).

CONCLUSIONS.—

p16 IHC-positive, CP-diagnosed CIN2 appears to be lower cancer risk than CP-diagnosed CIN3. LAST classification of "HSIL" diagnosis, which includes p16 IHC-positive CIN2, should annotate the morphologic diagnosis (CIN2 or CIN3) to inform all management decisions, which is especially important for young (<30 years) women diagnosed with CIN2 for whom surveillance rather than treatment is recommended.

Role of HPV Genotype, Multiple Infections, and Viral Load on the Risk of High-Grade Cervical Neoplasia

BACKGROUND

Human papillomavirus (HPV) testing provides a much more sensitive method of detection for high-grade lesions than cytology, but specificity is low. Here, we explore the extent to which full HPV genotyping, viral load, and multiplicity of types can be used to improve specificity.

METHODS

A population-based sample of 47,120 women undergoing cervical screening was tested for 13 high-risk HPV genotypes. Positive predictive values (PPV) for cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+; N = 3,449) and CIN3 or worse (CIN3+; N = 1,475) over 3 years of follow-up were estimated for HPV genotype and viral load. Weighted multivariate logistic regression models were used to estimate the odds of CIN2+ or CIN3+ according to genotype, multiplicity of types, and viral load.

RESULTS

High-risk HPV was detected in 15.4% of women. A hierarchy of HPV genotypes based on sequentially maximizing PPVs for CIN3+ found HPV16>33>31 to be the most predictive, followed sequentially by HPV18>35>58>45>52>59>51>39>56>68. After adjusting for higher ranked genotypes, the inclusion of multiple HPV infections added little to risk prediction. High viral loads for HPV18, 35, 52, and 58 carried more risk than low viral loads for HPV16, 31, and 33. High viral load for HPV16 was significantly more associated with CIN3+ than low viral load.

CONCLUSIONS

HPV genotype and viral load, but not multiplicity of HPV infections, are important predictors of CIN2+ and CIN3+.

IMPACT

The ability to identify women at higher risk of CIN2+ and CIN3+ based on both HPV genotype and viral load could be important for individualizing triage plans, particularly as HPV becomes the primary screening test.

Outcomes in Women With Cytology Showing Atypical Squamous Cells of Undetermined Significance With vs Without Human Papillomavirus Testing

IMPORTANCE

Little is known about the long-term yield of high-grade cervical intraepithelial neoplasia (CIN) and the influence on biopsy and treatment rates of human papillomavirus (HPV) triage of cytology showing atypical squamous cells of undetermined significance (hereafter ASC-US cytology).

OBJECTIVE

To examine 5-year outcomes after ASC-US cytology with vs without HPV testing.

DESIGN, SETTING, AND PARTICIPANTS

In this observational study, all cervical cytology and HPV testing reports from January 1, 2007, to December 31, 2012, were obtained for women throughout New Mexico and linked to pathology reports. The dates of the analysis were May 4, 2015, to January 13, 2017.

MAIN OUTCOMES AND MEASURES

Influence of HPV testing on disease yield, time to histologically confirmed disease, and biopsy or loop electrosurgical excision procedure rates.

RESULTS

A total of 457 317 women (mean [SD] age, 39.8 [12.5] years) with a screening test were recorded between 2008 and 2012, and 20 677 (4.5%) of the first cytology results per woman were reported as ASC-US. CIN grade 3 or more severe (CIN3+) lesions were detected in 2.49% of women with HPV testing vs 2.15% of women without HPV testing (P = .23). Time to CIN3+ detection was much shorter in those with HPV testing vs those without testing (median, 103 vs 393 days; P < .001). CIN grade 1 was detected in 11.6% of women with HPV testing vs 6.6% without testing (relative risk, 1.76; 95% CI, 1.56-2.00; P < .001). Loop electrosurgical excision procedure rates within 5 years were 20.0% higher in those who underwent HPV testing, resulting in more CIN2+ and CIN3+ detection.

CONCLUSIONS AND RELEVANCE

Human papillomavirus testing led to faster and more complete diagnosis of cervical disease, but 55.8% more biopsies and 20.0% more loop electrosurgical excision procedures were performed. In those tested, virtually all high-grade disease occurred in the 43.1% of women who were HPV positive, allowing clinical resources to be focused on women who need them most. These data provide essential information for cervical screening guidelines and public health policy.

Population-Based Incidence Rates of Cervical Intraepithelial Neoplasia in the Human Papillomavirus Vaccine Era

IMPORTANCE

A substantial effect of human papillomavirus (HPV) vaccines on reducing HPV-related cervical disease is essential before modifying clinical practice guidelines in partially vaccinated populations.

OBJECTIVE

To determine the population-based cervical intraepithelial neoplasia (CIN) trends when adjusting for changes in cervical screening practices that overlapped with HPV vaccination implementation.

DESIGN, SETTING, AND PARTICIPANTS

The New Mexico HPV Pap Registry, which captures population-based estimates of both cervical screening prevalence and CIN, was used to compute CIN trends from January 1, 2007, to December 31, 2014. Under New Mexico Administrative Code, the New Mexico HPV Pap Registry, a statewide public health surveillance program, receives mandatory reporting of all cervical screening (cytologic and HPV testing) and any cervical, vulvar, and vaginal histopathological findings for all women residing in New Mexico irrespective of outcome.

MAIN OUTCOME MEASURES

Prespecified outcome measures included low-grade CIN (grade 1 [CIN1]) and high-grade CIN (grade 2 [CIN2] and grade 3 [CIN3]).

RESULTS

From 2007 to 2014, a total of 13 520 CIN1, 4296 CIN2, and 2823 CIN3 lesions were diagnosed among female individuals 15 to 29 years old. After adjustment for changes in cervical screening across the period, reductions in the CIN incidence per 100 000 women screened were significant for all grades of CIN among female individuals 15 to 19 years old, dropping from 3468.3 to 1590.6 for CIN1 (annual percentage change [APC], -9.0; 95% CI, -12.0 to -5.8; P < .001), from 896.4 to 414.9 for CIN2 (APC, -10.5; 95% CI, -18.8 to -1.2; P = .03), and from 240.2 to 0 for CIN3 (APC, -41.3; 95% CI, -65.7 to 0.3; P = .05). Reductions in the CIN2 incidence were also significant for women 20 to 24 years old, dropping from 1027.7 to 627.1 (APC, -6.3; 95% CI, -10.9 to -1.4; P = .02).

CONCLUSIONS AND RELEVANCE

Population-level decreases in CIN among cohorts partially vaccinated for HPV may be considered when clinical practice guidelines for cervical cancer screening are reassessed. Evidence is rapidly growing to suggest that further increases in raising the age to start screening are imminent, one step toward integrating screening and vaccination.

Similar Risk Patterns After Cervical Screening in Two Large U.S. Populations: Implications for Clinical Guidelines

OBJECTIVE

To compare the risks of histologic high-grade cervical intraepithelial neoplasia (CIN) or worse after different cervical cancer screening test results between two of the largest U.S. clinical practice research data sets.

METHODS

The New Mexico Human Papillomavirus (HPV) Pap Registry is a statewide registry representing a diverse population experiencing varied clinical practice delivery. Kaiser Permanente Northern California is a large integrated health care delivery system practicing routine HPV cotesting since 2003. In this retrospective cohort study, a logistic-Weibull survival model was used to estimate and compare the cumulative 3- and 5-year risks of histologic CIN 3 or worse among women aged 21-64 years screened in 2007-2011 in the New Mexico HPV Pap Registry and 2003-2013 in Kaiser Permanente Northern California. Results were stratified by age and baseline screening result: negative cytology, atypical squamous cells of undetermined significance (ASC-US) (with or without HPV triage), low-grade squamous intraepithelial lesion, and high-grade squamous intraepithelial lesion.

RESULTS

There were 453,618 women in the New Mexico HPV Pap Registry and 1,307,528 women at Kaiser Permanente Northern California. The 5-year CIN 3 or worse risks were similar within screening results across populations: cytology negative (0.52% and 0.30%, respectively, P<.001), HPV-negative and ASC-US (0.72% and 0.49%, respectively, P=.5), ASC-US (3.4% and 3.4%, respectively, P=.8), HPV-positive and ASC-US (7.7% and 7.1%, respectively, P=.3), low-grade squamous intraepithelial lesion (6.5% and 5.4%, respectively, P=.009), and high-grade squamous intraepithelial lesion (53.1% and 50.4%, respectively, P=.2). Cervical intraepithelial neoplasia grade 2 or worse risks and 3-year risks had similar trends across populations. Age-stratified analyses showed more variability, especially among women aged younger than 30 years, but patterns of risk stratification were comparable.

CONCLUSION

Current U.S. cervical screening and management recommendations are based on comparative risks of histologic high-grade CIN after screening test results. The similar results from these two large cohorts from different real-life clinical practice settings support risk-based management thresholds across U.S. clinical populations and practice settings.

Risk Stratification Using Human Papillomavirus Testing among Women with Equivocally Abnormal Cytology: Results from a State-Wide Surveillance Program

BACKGROUND

Clinical guidelines for cervical cancer screening have incorporated comparative risks of cervical intraepithelial neoplasia grade 3 or cancer (CIN3(+)) for various screening outcomes to determine management. Few cohorts are large enough to distinguish CIN3(+) risks among women with minor abnormalities versus negative cytology because of low incidence. The New Mexico Human Papillomavirus (HPV) Pap Registry offers a unique opportunity to evaluate cervical cancer screening in a diverse population across a broad-spectrum of health service delivery.

METHODS

Kaplan-Meier and logistic-Weibull survival models were used to estimate cumulative risks of CIN3(+) among women ages 21 to 64 who were screened in New Mexico between 2007 and 2011 with negative, equivocal or mildly abnormal cytology, that is, atypical squamous cells of undetermined significance (ASC-US; with or without HPV triage), or low-grade squamous intraepithelial lesions (LSIL).

RESULTS

We identified 452,045 women meeting the selection criteria. The 3-year CIN3(+) risks for women with negative, ASC-US, and LSIL cytology were 0.30%, 2.6%, and 5.2%, respectively. HPV triage of ASC-US stratified 3-year CIN3(+) risks were 0.72% for HPV-negative and 7.7% for HPV-positive. Risks tended to decline after age 30 for all screening results.

CONCLUSIONS

In this state-wide population-based cohort, cytology and HPV triage of ASC-US stratified women's CIN3(+) risk into similar patterns observed previously, suggesting the validity of screening guidelines for diverse populations in the United States. Absolute risk estimates should be compared across other large populations.

IMPACT

Strategies for HPV triage of ASC-US derived from clinical trials are upheld in large clinical practice settings and across diverse screening populations in the United States.

Inefficiencies and High-Value Improvements in U.S. Cervical Cancer Screening Practice: A Cost-Effectiveness Analysis

BACKGROUND

Studies suggest that cervical cancer screening practice in the United States is inefficient. The cost and health implications of nonadherence in the screening process compared with recommended guidelines are uncertain.

OBJECTIVE

To estimate the benefits, costs, and cost-effectiveness of current cervical cancer screening practice and assess the value of screening improvements.

DESIGN

Model-based cost-effectiveness analysis.

DATA SOURCES

New Mexico HPV Pap Registry; medical literature.

TARGET POPULATION

Cohort of women eligible for routine screening.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

Current cervical cancer screening practice; improved adherence to guidelines-based screening interval, triage testing, diagnostic referrals, and precancer treatment referrals.

OUTCOME MEASURES

Reductions in lifetime cervical cancer risk, quality-adjusted life-years (QALYs), lifetime costs, incremental cost-effectiveness ratios, and incremental net monetary benefits (INMBs).

RESULTS OF BASE-CASE ANALYSIS

Current screening practice was associated with lower health benefit and was not cost-effective relative to guidelines-based strategies. Improvements in the screening process were associated with higher QALYs and small changes in costs. Perfect adherence to screening every 3 years with cytologic testing and adherence to colposcopy/biopsy referrals were associated with the highest INMBs ($759 and $741, respectively, at a willingness-to-pay threshold of $100,000 per QALY gained); together, the INMB increased to $1645.

RESULTS OF SENSITIVITY ANALYSIS

Current screening practice was inefficient in 100% of simulations. The rank ordering of screening improvements according to INMBs was stable over a range of screening inputs and willingness-to-pay thresholds.

LIMITATION

The effect of human papillomavirus vaccination was not considered.

CONCLUSIONS

The added health benefit of improving adherence to guidelines, especially the 3-year interval for cytologic screening and diagnostic follow-up, may justify additional investments in interventions to improve U.S. cervical cancer screening practice.

PRIMARY FUNDING SOURCE

U.S. National Cancer Institute.

Relationship of missed and shortened hemodialysis treatments to hospitalization and mortality: observations from a US dialysis network

Background

The relationship of missed and shortened hemodialysis (HD) to clinical outcomes has not been well characterized in HD patients in the USA. Here we explored the frequency of missed and shortened treatments and their impact on mortality and hospitalization.

Methods

A retrospective review of data from a cohort of 15 340 HD patients treated in facilities operated by Dialysis Clinics, Inc. We compared the frequency of missed and shortened treatments by gender, race, age and treatment schedules [Mondays, Wednesdays, Fridays (MWF) versus Tuesdays, Thursdays, Saturdays (TTS)].

Results

Of the 15 340 patients, 48% were non-Hispanic whites (NHWs), 41% African Americans (AAs), 6% Hispanics, 2% Native American (NA), 2% Asians and 1% other races. The median number of years on HD was 1.8 years and the median follow-up was 12.4 months. The odds of missing at least one treatment in a month were higher in: patients aged <55 years, odds ratio (OR) 1.33 (P<0.0001); in AAs, OR 1.51 (P < 0.0001); in NAs, OR 1.50 (P = 0.0003); and in Hispanics, OR 1.33 (P = 0.0003) compared with NHWs and in patients who dialyzed on TTS compared with MWF, OR 1.33 (P < 0.0001). Similar findings were observed for treatments shortened by at least 10 min per month. Missed and shortened treatments were most prevalent on Saturdays and were also associated with progressive increases in hospitalization and mortality.

Conclusion

Missed and shortened HD treatments pose a challenge to providers. Improved adherence to prescribed dialysis may decrease the morbidity and mortality.

Human papillomavirus testing 2007-2012: co-testing and triage utilization and impact on subsequent clinical management

In the United States, high-risk human papillomavirus (HPV) testing is recommended for women with atypical squamous cells of unknown significance (ASC-US) cytology, and co-testing with cytology and HPV is a recommended option for screening women aged ≥ 30 years. No population-based data are available to examine utilization of HPV testing in the United States. Using the New Mexico HPV Pap Registry data resource, we describe population trends (2007-2012) in utilization and positivity rates for HPV testing as a routine co-testing screening procedure and for triage of ASC-US and other cytologic outcomes. For women aged 30-65 years co-testing increased from 5.2% in 2007 to 19.1% in 2012 (p < 0.001). Overall 82% of women with ASC-US cytology who did not receive co-testing also had an HPV test. HPV positivity was age and cytology result dependent but did not show time trends. For women with negative cytology, 64% received an additional screening test within 3 years if no co-test was done or if it was positive, but this was reduced to 47% with a negative co-test. Reflex HPV testing for ASC-US cytology is well established and occurs in most women. Evidence for reflex testing is also observed following other abnormal cytology outcomes. Co-testing in women aged 30-65 years has more than tripled from 2007 to 2012, but was still only used in 19.1% of women aged 30-65 years attending for screening in 2012. Women receiving co-testing had longer repeat screening intervals, but rescreening within 3 years is still very common even with co-testing.

Concurrence of multiple human papillomavirus infections in a large US population-based cohort

We examined the concurrence of multiple human papillomavirus (HPV) infections in 47,617 women who underwent cervical screening in New Mexico between December 2007 and April 2009 using the LINEAR ARRAY HPV Genotyping Test (Roche Diagnostics, Indianapolis, Indiana), which detects 37 different types of HPV. Our primary goal was to examine the distributions of multiple HPV types with a special interest in negative interactions, which could signal the possibility of type replacement associated with a common niche if some HPV types were prevented by vaccination. Multiple infections were found to be more common than expected under independence, but this could largely be accounted for by a woman-specific latent heterogeneity parameter which was found to be dependent on age and cytological grade. While multiple infections were more common in young women and in those with abnormal cytology, greater heterogeneity was seen in older women and in those with normal cytology, possibly reflecting greater variability in exposure due to current or past HPV exposure or due to heterogeneity in related HPV reactivation or in immune responses to HPV infection or persistence. A negative interaction was found between HPV 16 and several other HPV types for women with abnormal cytology but not for those with normal cytology, suggesting that type replacement in women vaccinated against HPV 16 is unlikely to be an issue for the general population.

Human papillomavirus genotype-specific prevalence across the continuum of cervical neoplasia and cancer

BACKGROUND

The New Mexico HPV Pap Registry was established to measure the impact of cervical cancer prevention strategies in the United States. Before widespread human papillomavirus (HPV) vaccine implementation, we established the baseline prevalence for a broad spectrum of HPV genotypes across the continuum of cervical intraepithelial neoplasia (CIN) and cancer.

METHODS

A population-based sample of 6,272 tissue specimens was tested for 37 HPV genotypes. The number of specimens tested within each diagnostic category was: 541 negative, 1,411 CIN grade 1 (CIN1), 2,226 CIN grade 2 (CIN2), and 2,094 CIN grade 3 (CIN3) or greater. Age-specific HPV prevalence was estimated within categories for HPV genotypes targeted by HPV vaccines.

RESULTS

The combined prevalence of HPV genotypes included in the quadrivalent and nonavalent vaccines increased from 15.3% and 29.3% in CIN1 to 58.4% and 83.7% in CIN3, respectively. Prevalence of HPV types included in both vaccines tended to decrease with increasing age for CIN1, CIN2, CIN3, and squamous cell carcinoma (SCC), most notably for CIN3 and SCC. The six most common HPV types in descending order of prevalence were HPV-16, -31, -52, -58, -33, and -39 for CIN3 and HPV-16, -18, -31, -45, -52, and -33 for invasive cancers.

CONCLUSIONS

Health economic modeling of HPV vaccine impact should consider age-specific differences in HPV prevalence.

IMPACT

Population-based HPV prevalence in CIN is not well described, but is requisite for longitudinal assessment of vaccine impact and to understand the effectiveness and performance of various cervical screening strategies in vaccinated and unvaccinated women.

The influence of type-specific human papillomavirus infections on the detection of cervical precancer and cancer: A population-based study of opportunistic cervical screening in the United States

There are limited data on the prospective risks of detecting cervical precancer and cancer in United States (US) populations specifically where the delivery of opportunistic cervical screening takes place outside managed care and in the absence of organized national programs. Such data will inform the management of women with positive screening results before and after widespread human papillomavirus (HPV) vaccination and establishes a baseline preceding recent changes in US cervical cancer screening guidelines. Using data reported to the statewide passive surveillance systems of the New Mexico HPV Pap Registry, we measured the 3-year HPV type-specific cumulative incidence of cervical intraepithelial neoplasia grade 2 or more severe (CIN2+) and grade 3 or more severe (CIN3+) detected during real-world health care delivery across a diversity of organizations, payers, clinical settings, providers and patients. A stratified sample of 47,541 cervical cytology specimens from a screening population of 379,000 women underwent HPV genotyping. Three-year risks for different combinations of cytologic interpretation and HPV risk group ranged from <1% (for several combinations) to approximately 70% for CIN2+ and 55% for CIN3+ in women with high-grade (HSIL) cytology and HPV16 infection. A substantial proportion of CIN2+ (35.7%) and CIN3+ (30.9%) were diagnosed following negative cytology, of which 62.3 and 78.2%, respectively, were high-risk HPV positive. HPV16 had the greatest 3-year risks (10.9% for CIN2+,8.0% for CIN3+) followed by HPV33, HPV31, and HPV18. Positive results for high-risk HPV, especially HPV16, the severity of cytologic interpretation, and age contribute independently to the risks of CIN2+ and CIN3+.

Cervical excisional treatment of young women: a population-based study

OBJECTIVE

Assessment of cytology and biopsy results preceding cervical excisional treatment and their association with excisional histology, to evaluate compliance with treatment recommendations and the potential effect of revisions in cervical histology terminology and usage.

METHOD

Data from a unique statewide population-based screening registry was used to describe the use and histologic outcomes of cervical excisional procedures in the year following an abnormal cervical screening cytology.

RESULTS

From 2007 to 2011, LEEP rates decreased 87%, 45%, and 16% for women aged 15-20, 21-24, and 25-29 years, respectively. Reductions were attributable to an overall decline in cervical screening and colposcopy, and a decrease in LEEP following a diagnosis of less than cervical intraepithelial neoplasia grade 2 (0.7) for women aged 30-39 years. Irrespective of age, CIN2 was the most common histologic antecedent of excisional treatment (42%), with most (80%) preceded by

CONCLUSION

Cervical excisions are an unavoidable consequence of cervical screening. Adherence to treatment guidelines stipulating conservative follow-up of young women with biopsies ≤CIN2 could significantly decrease the number of excisional procedures and associated harms. This opportunity will be lost if cervical intraepithelial neoplasia grade 3 (CIN3) and some or all of CIN2 are merged into a single histologic category, as has been recently recommended in the United States.

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Key Words

• Adherence to cervical treatment guidelines
• Cervical intraepithelial neoplasia grades 2 and 3 (CIN2 and CIN3)
• Cervical screening
• Colposcopy
• Effectiveness and harms of cervical screening
• Loop electrosurgical excision procedure (LEEP)

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MESH Headings

• Adolescent
• Adult
• Biopsy/methods
• Biopsy/statistics & numerical data
• Conization/methods
• Conization/statistics & numerical data
• Electrosurgery/methods
• Electrosurgery/statistics & numerical data
• Female
• Humans
• New Mexico/epidemiology
• Registries
• Uterine Cervical Neoplasms/classification
• Uterine Cervical Neoplasms/epidemiology
• Uterine Cervical Neoplasms/pathology
• Uterine Cervical Neoplasms/surgery
• Young Adult
• Uterine Cervical Dysplasia/classification
• Uterine Cervical Dysplasia/epidemiology
• Uterine Cervical Dysplasia/pathology
• Uterine Cervical Dysplasia/surgery

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Grants

• U19 AI084081 NIAID NIH HHS
• U54 CA164336 NCI NIH HHS
• U19AI084081 NIAID NIH HHS
• U54CA164336 NCI NIH HHS

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A population-based evaluation of cervical screening in the United States: 2008-2011

BACKGROUND

Cervical screening consumes substantial resources, but little is known about utilization in the United States or compliance with guideline recommendations.

METHODS

To describe population screening coverage, utilization, and outcomes and examine time trends from 2008 to 2011, cervical cytology reports from women residing in New Mexico (981,063 tests from 511,381 women) were evaluated.

RESULTS

From 2008 to 2011 cervical screening utilization decreased at all ages, but especially in younger women, with a two-third reduction at ages 15 to 20 years. Ninety-four percent of women ages 25 to 29 years were screened within 48 months but coverage decreased at older ages to 69% at 45 to 49 years and 55% at 60 to 64 years. Intervals between screening tests were significantly longer in 2011 compared with 2008 [HR = 1.23; 95% confidence intervals (CI), 1.22-1.24], although the commonest rescreening interval was 13 months. In 2011, 91.9% of screening tests for women ages 21 to 65 years were negative, 6.6% showed minor abnormalities, and 1.0% high-grade abnormalities. High-grade abnormality rates were relatively constant over time, but minor abnormalities and atypical cells cannot rule out high-grade (ASC-H) were increasing.

CONCLUSIONS

This population-based evaluation of cervical screening shows high coverage under the age of 40 years, but lower levels in older women. Screening under age 21 years is becoming less common and screening intervals are lengthening, reflecting updates in national screening guidelines.

IMPACT

Assessment of cervical screening intervals and population outcomes is essential for accurately estimating the impact and effectiveness of changing recommendations and vaccination against human papilloma virus infections.

A comparison of cervical histopathology variability using whole slide digitized images versus glass slides: experience with a statewide registry

Whole slide imaging is increasingly used for primary and consultative diagnoses, teaching, telepathology, slide sharing, and archiving. We compared pathologist evaluations of glass slides and corresponding digitized images within the context of a statewide surveillance effort. Cervical specimens collected by the New Mexico HPV Pap Registry research program targeted cases diagnosed between 2006 and 2010. Two samples of 250 slides each were digitized with the ScanScope XT (Aperio, Vista, CA) microscope and reviewed with Aperio ImageScope reader. (1) A "random set" had a distribution of community diagnoses: 70% from cases of cervical intraepithelial neoplasia grade 2 or higher, 20% from cases of cervical intraepithelial neoplasia grade 1 and 10% from negative cases. (2) A "discrepant set" was represented by difficult cases where 2 study pathologists initially disagreed. Within the regular workflow of the New Mexico HPV Pap Registry, 3 pathologists read the slides 2 to 3 times each without knowledge of clinical history, previous readings or sampling scheme. Pathologists also read each corresponding image twice. For within- and between-reader comparisons we calculated unweighted κ statistics and asymmetry χ(2) tests. Across all comparisons, slides and images yielded similar results. For the random set, almost all within-reader and between-reader Kappa values ranged between 0.7 and 0.8 and 0.6 and 0.7, respectively. For the discrepant set, most within- and between-reader κ values were 0.4 to 0.6. As cervical intraepithelial neoplasia diagnostic terminology changes, pathologists may need to re-read histopathology slides to compare disease trends over time, eg, before/after introduction of human papillomavirus vaccination. Diagnosis of cervical intraepithelial neoplasia differed little between slides and corresponding digitized images.

No evidence for synergy between human papillomavirus genotypes for the risk of high-grade squamous intraepithelial lesions in a large population-based study

BACKGROUND

Multiple human papillomavirus (HPV) genotypes may be independently or synergistically associated with risk of high-grade squamous intraepithelial lesions (HSILs). We evaluated the risk of HSIL in women concomitantly infected with multiple HPV genotypes.

METHODS

A population-based stratified sample of 59 664 cervical cytology specimens from women residing in New Mexico were evaluated for cytologic abnormalities and HPV genotypes. We calculated the risk of HSIL in women infected with a single HPV genotype and the risk in those infected with multiple HPV genotypes.

RESULTS

The highest risk of HSIL was observed for HPV-16 (0.036), followed by HPV-33 (0.028), HPV-58 (0.024), and HPV-18 (0.022). For most types, we observed a greater risk of HSIL in women infected with multiple carcinogenic HPV types. In contrast, the risk of HSIL was similar in women infected with HPV-16 and other types, compared with women infected with HPV-16 only. We observed an increased but plateauing risk of HSIL in women infected with multiple types, compared with those infected with a single type, with risk ratios of 1.5 (95% confidence interval [CI], 1.2-1.8), 1.7 (95% CI, 1.3-2.4), and 1.4 (95% CI, 0.83-2.5) for women infected with 2, 3, and ≥4 genotypes, respectively.

CONCLUSIONS

In the largest population-based study of HPV genotypes and cytologic outcomes so far, we did not see more than additive effects of HPV types on the risk of HSIL in women infected with multiple types.

Age-specific occurrence of HPV16- and HPV18-related cervical cancer

The age-specific occurrence of cervical cancer related to human papillomavirus (HPV) genotypes HPV16 and HPV18, the two targeted by current HPV vaccines, is not well described. We therefore used data from two large, tissue-based HPV genotyping studies of cervical cancer, one conducted in New Mexico (n = 744) and an International study restricted to cancers (n = 1,729) from Europe, North America, and Australia to represent those regions with widely available cervical cancer screening facilities. HPV results were categorized as HPV16- or HPV18-positive (HPV16/18) versus other HPV genotype. We observed a decreasing proportion of HPV16/18-positive cancers with increasing age in the International study (Ptrend < 0.001) and New Mexico study (Ptrend < 0.001). There was no heterogeneity in the relationship between age of diagnosis and the proportion of HPV16/18-positive cancers between studies (P = 0.8). Combining results from the two studies (n = 2,473), the percentages of HPV16/18-positive cases were 77.0% [95% confidence interval (CI): 75.1%-78.9%] for women less than 65 years old and 62.7% [95% confidence interval (CI): 58.4%-66.9%] for women aged 65 and older (P < 0.001). In women who are under the age of 25 and have been vaccinated before becoming sexually active, the cervical cancer incidence is expected to be approximately 3.5 per million by 2020. HPV vaccination against HPV16/18 may have a greater impact on cervical cancers in women under 65 than in women aged 65 and older. These data will inform the age-specific impact of HPV vaccination and its integration with cervical cancer screening activities.

Cervical histopathology variability among laboratories: a population-based statewide investigation

To inform the proposed systematic adjudicative staining of cervical intraepithelial neoplasia grade 2 (CIN2) and equivocal diagnoses, we characterized diagnostic heterogeneity across 15 laboratories. Laboratory-specific distributions of 37,486 biopsy specimen diagnoses were compared after adjusting for preceding cytology. In a subset of preceding cytology specimens, HPV16 genotyping was considered an indicator of lesion severity. Distributions of normal and CIN1 diagnoses varied widely, with laboratories favoring either normal (5.5%-57.7%) or CIN1 diagnoses (23.3%-86.7%; P < .001 for normal:CIN1 variability). Excluding extreme values, 6.2% to 14.4% of diagnoses were CIN2 (P < .001). For CIN2 diagnoses, HPV16 positivity in the preceding cytology varied between 39.0% in the largest laboratory and 57.4% in others (P < .001), suggesting differential interpretation, not population differences, as a cause of variability. In conclusion, the frequency of diagnoses requiring special staining (p16(INK4a) immunostaining) to adjudicate equivocal CIN2 will be sizable and vary between laboratories, especially if extended to a fraction of CIN1 lesions.

A population-based study of human papillomavirus genotype prevalence in the United States: baseline measures prior to mass human papillomavirus vaccination

Currently, two prophylactic human papillomavirus (HPV) vaccines targeting HPV 16 and 18 have been shown to be highly efficacious for preventing precursor lesions although the effectiveness of these vaccines in real-world clinical settings must still be determined. Toward this end, an ongoing statewide surveillance program was established in New Mexico to assess all aspects of cervical cancer preventive care. Given that the reduction in cervical cancer incidence is expected to take several decades to manifest, a systematic population-based measurement of HPV type-specific prevalence employing an age- and cytology-stratified sample of 47,617 women attending for cervical screening was conducted prior to widespread HPV vaccination. A well-validated polymerase chain reaction (PCR) method for 37 HPV genotypes was used to test liquid-based cytology specimens. The prevalence for any of the 37 HPV types was 27.3% overall with a maximum of 52% at age of 20 years followed by a rapid decline at older ages. The HPV 16 prevalences in women aged ≤ 20 years, 21-29 years or ≥ 30 years were 9.6, 6.5 and 1.8%, respectively. The combined prevalences of HPV 16 and 18 in these age groups were 12.0, 8.3 and 2.4%, respectively. HPV 16 and/or HPV 18 were detected in 54.5% of high-grade squamous intraepithelial (cytologic) lesions (HSIL) and in 25.0% of those with low-grade SIL (LSIL). These baseline data enable estimates of maximum HPV vaccine impact across time and provide critical reference measurements important to assessing clinical benefits and potential harms of HPV vaccination including increases in nonvaccine HPV types (i.e., type replacement).

Anemia management and association of race with mortality and hospitalization in a large not-for-profit dialysis organization

BACKGROUND

The optimal hemoglobin target and possible toxicity of epoetin therapy in hemodialysis patients are controversial. Previous studies suggest that African American patients use higher doses of epoetin and have better survival compared with white hemodialysis patients.

STUDY DESIGN

Retrospective longitudinal cohort.

SETTING & PARTICIPANTS

Epoetin-exposed incident hemodialysis patients (N = 12,733; African Americans, n = 4,801; white, n = 7,386) treated in Dialysis Clinic Inc facilities during 2000 to 2006.

PREDICTORS

Hemoglobin, epoetin, iron.

OUTCOMES

Mortality, hospitalization.

MEASUREMENTS

Proportional hazards models with time-varying covariates.

RESULTS

Hemoglobin concentrations less than 10 g/dL in whites and less than 11 g/dL in African Americans were associated with increased mortality and hospitalization versus the referent hemoglobin level of 11 to 11.9 g/dL. Hemoglobin levels of 13 g/dL or greater in whites were associated with decreased noncardiovascular mortality. Six-month cumulative epoetin doses of 20,000 U/wk or greater were associated with increased mortality and hospitalization versus the referent group (8,000 to 12,499 U/wk). Epoetin doses less than 8,000 U/wk were associated with decreased risk. Higher epoetin doses were associated with increased mortality at hemoglobin concentrations of 10 to 12.9 g/dL and with increased hospitalization at all hemoglobin concentrations of 10 g/dL or greater. Higher epoetin doses were associated with increased mortality and hospitalization within each tertile of serum albumin concentration. These patterns did not differ by race.

LIMITATIONS

Treatment-by-indication bias and unidentified confounders cannot be excluded. Small sample sizes in the highest and lowest hemoglobin strata decrease statistical power.

CONCLUSIONS

Relationships between hemoglobin concentration and mortality differed between African Americans and whites. Additionally, the relationship of lower mortality with greater achieved hemoglobin concentration seen in white patients was observed for all-cause, but not cardiovascular, mortality. A higher cumulative epoetin dose was associated with worse outcomes, even in patients with albumin levels greater than 4 g/dL. There were no statistically significant interactions between race and epoetin dose. Further studies are needed to confirm and to define the mechanism of these findings.

Human papillomavirus genotype distributions: implications for vaccination and cancer screening in the United States

BACKGROUND

Limited data are available describing human papillomavirus (HPV) genotype distributions in cervical cancer in the United States. Such studies are needed to predict how HPV vaccination and HPV-based screening will influence cervical cancer prevention.

METHODS

We used the New Mexico Surveillance, Epidemiology, and End Results Registry to ascertain cases of in situ (n = 1213) and invasive (n = 808) cervical cancer diagnosed during 1985-1999 and 1980-1999, respectively, in the state of New Mexico. HPV genotyping was performed using two polymerase chain reaction-based methods on paraffin-embedded tissues from in situ and invasive cancers and on cervical Papanicolaou test specimen from control subjects (ie, women aged 18-40 years attending clinics for routine cervical screening [n = 4007]). Relative risks for cervical cancer were estimated, and factors associated with age at cancer diagnosis and the prevalence of HPV genotypes in cancers were examined.

RESULTS

The most common HPV genotypes detected in invasive cancers were HPV type 16 (HPV16, 53.2%), HPV18 (13.1%), and HPV45 (6.1%) and those in in situ cancers were HPV16 (56.3%), HPV31 (12.6%), and HPV33 (8.0%). Invasive cancer case subjects who were positive for HPV16 or 18 were diagnosed at younger ages than those who were positive for other carcinogenic HPV genotypes (mean age at diagnosis: 48.1 [95% confidence interval {CI} = 46.6 to 49.6 years], 45.9 [95% CI = 42.9 to 49.0 years], and 52.3 years [95% CI = 50.0 to 54.6 years], respectively). The proportion of HPV16-positive in situ and invasive cancers, but not of HPV18-positive cancers, declined with more recent calendar year of diagnosis, whereas the proportion positive for carcinogenic HPV genotypes other than HPV18 increased.

CONCLUSIONS

HPV16 and 18 caused the majority of invasive cervical cancer in this population sample of US women, but the proportion attributable to HPV16 declined over the last 20 years. The age at diagnosis of HPV16- and HPV18-related cancers was 5 years earlier than that of cancers caused by carcinogenic HPV genotypes other than HPV16 and 18, suggesting that the age at initiation of cervical screening could be delayed in HPV-vaccinated populations.

Potential renal sequelae in survivors of hantavirus cardiopulmonary syndrome

Although other hantaviruses are associated with renal manifestations, hantavirus cardiopulmonary syndrome (HCPS) has not been associated with such sequelae. The HCPS survivors were prospectively evaluated for renal complications. Subjects underwent yearly evaluation, laboratory studies, and 24-hour urine collection. Thirty subjects were evaluated after recovery from HCPS with the first follow-up at a median of 7.4 months after discharge. Subjects were a wide age range (18-51) but had an equal gender composition. Eighteen of 30 (60%) returned for > 1 evaluation. Half (15/30) had a 24-hour urine collection with > 150 mg of total protein and 6 had > 300 mg. Seven had a Cockcroft-Gault creatinine clearance (CrClCG) < 90 mL/min/1.73 m2 and 2 were < 60. Fifty-three percent met the definition of chronic kidney disease. Those treated with extracorporeal membrane oxygenation had less renal sequelae (P = 0.035). Our data suggest that renal sequelae may occur in HCPS. Further study of renal complications of New World hantavirus infections are needed.

Age-related blood pressure patterns and blood pressure variability among hemodialysis patients

BACKGROUND AND OBJECTIVES

Despite the high prevalence of cardiovascular disease among hemodialysis patients, the relationship between age and blood pressure (BP) is not well understood. It was postulated that the relationship of BP to age differs among hemodialysis patients versus the general population and that there is significant variability in dialysis unit BP measurements.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To explore this hypothesis, the patterns of systolic, diastolic, mean arterial, and pulse pressures in the general population using data from National Health and Nutrition Examination Survey participants (n = 9242) were compared with those in a cohort of hemodialysis patients (n = 9849).

RESULTS

In contrast to the increase in systolic BP with age in the general population, systolic BP was elevated in young hemodialysis patients and declined slightly among the elderly. The inverted "U"-shape relationship between age and diastolic BP in the general population was absent in hemodialysis patients. Diastolic BP was elevated among hemodialysis patients <50 yr of age and declined with advancing age. Mean arterial and pulse pressures were elevated among young hemodialysis patients and exhibited less age dependency than in the general population. Variability in BP within patients was similar to that between patients.

CONCLUSIONS

The relationship of BP to age differed from that in the general population. The variability in dialysis unit BP measurements may limit their use in managing hypertension and predicting outcomes. Nevertheless, dialysis unit BP measurements are necessary to minimize acute complications during the dialysis procedure.

Revised Norms for the Lollipop Test for Children Ages 42 to 65 Months

Lollipop Test scores were acquired for 1,402 preschoolers in southwestern Indiana. Means and standard deviations for both boys and girls by 6-mo. intervals from the ages of 42 through 65 months showed scores increased significantly across ages, with girls scoring significantly higher than boys in all age groups. Current mean scores are similar to those published in 1988 for boys and slightly higher for girls.

Prostate cancer testing following a negative prostate biopsy: over testing the elderly

BACKGROUND

Screening elderly men for prostate cancer is not recommended because definitive treatments are unlikely to extend life expectancy.

OBJECTIVE

Describe clinical outcomes after a negative prostate biopsy in a population-based cohort of men ages 65 and older.

DESIGN

Retrospective cohort study.

PARTICIPANTS

9,410 Medicare-eligible men who underwent a prostate biopsy in Los Angeles or New Mexico in 1992.

MEASUREMENTS

We used Medicare and SEER databases to identify a cohort with an initial negative biopsy (n = 7,119) and to ascertain survival, subsequent PSA testing, prostate biopsies, and prostate cancer detection and treatment through 1997.

RESULTS

The overall 5-year survival was 79.4% (95% CI 78.4-80.3), but only 74.6% (72.4-76.7) for men ages 75-79 at the time of the initial negative biopsy and 55.0% (51.9-57.9) for men ages 80+. During a median 4.5 years follow-up, a cumulative 75.0% (73.9-76.1) of the cohort underwent PSA testing. Among men ages 75-79 and 80+, the cumulative proportions that underwent PSA testing were 75.4% (73.0-77.8) and 74.3% (71.1-77.5), respectively. Additionally, 29.1% (26.7-31.6) of men ages 75-79 and 20.1% (17.6-23.1) of men ages 80+ underwent repeat prostate biopsy, and 10.9% (9.4-12.7) and 8.3% (6.6-10.4), respectively, were diagnosed with cancer. Among men ages 75+ with localized cancers, approximately 34% received definitive treatment.

CONCLUSIONS

High proportions of men ages 75+ underwent PSA testing and repeat prostate biopsies after an initial negative prostate biopsy. Given the known harms and uncertain benefits for finding and treating localized cancer in elderly men, most continued PSA testing after a negative biopsy is potentially inappropriate.

Which targets in clinical practice guidelines are associated with improved survival in a large dialysis organization?

Professional organizations have developed practice guidelines in the hope of improving clinical outcomes. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has set targets for dialysis dosage (single-pool Kt/V), hematocrit, serum albumin, calcium, phosphorus, parathyroid hormone, and BP for hemodialysis (HD) patients. Several guidelines are largely based on results from observational studies. In contrast to other parameters, BP values within the KDOQI guidelines have been associated with increased mortality. Therefore, it was postulated that having multiple parameters that satisfy the current guidelines, except those for BP, is associated with improved survival among HD patients. A retrospective analysis was conducted of incident HD patients who were treated at facilities operated by Dialysis Clinic Inc., a not-for-profit dialysis provider, between January 1, 1998, and December 31, 2004 (n = 13,792). Cox proportional hazards models were used to assess the association between satisfying guidelines and mortality. Values within guidelines for single-pool Kt/V, hematocrit, serum albumin, calcium, phosphorus, and parathyroid hormone were associated with decreased mortality (P < or = 0.0001). The largest survival benefit was found for serum albumin (hazard ratio [HR] 0.27; 95% confidence interval [CI] 0.24 to 0.31). Satisfying these six guidelines simultaneously was associated with an 89% reduction in mortality (HR 0.11; 95% CI 0.06 to 0.19]). Conversely, BP values satisfying the guideline were associated with increased mortality (HR 1.90; 95% CI 1.73 to 2.10). Because this target was largely extrapolated from the general population, a randomized, controlled trial is needed to identify the optimal BP for HD patients.

Human Papillomavirus Genotypes and the Cumulative 2‐Year Risk of Cervical Precancer

BACKGROUND

Prospective data on the risks of cervical precancer associated with specific human papillomavirus (HPV) genotypes are limited.

METHODS

In 5060 women participating in the Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesions Triage Study (ALTS), we determined the cumulative 2-year risks of cervical intraepithelial neoplasia (CIN) grade 2 or more severe (> or =CIN2) and of grade 3 or more severe (> or =CIN3) for 38 individual HPV genotypes, as detected by polymerase chain reaction.

RESULTS

The most common HPV genotypes detected at baseline, in descending order of prevalence, were 16, 52, 51, 31, 18, 53, 39, 56, 62, 59, and 58. When detected as a single-type HPV infection, HPV-16 had a 2-year cumulative risk of 50.6% (95% confidence interval [CI], 44.1%-57.2%) for > or =CIN2 and 39.1% (95% CI, 32.9%-45.7%) for > or =CIN3. For other singly detected carcinogenic HPV types, the risk of > or =CIN2 ranged from 4.7% (for HPV-59) to 29.5% (for HPV-31), and the risk of > or =CIN3 ranged from 0.0% (for HPV-59) to 14.8% (for HPV-31). Multiple infections with HPV genotypes of different risk classes resulted in a risk that was similar to, and not significantly different from, the risk observed for the HPV genotype of the highest risk class.

CONCLUSIONS

Genotype-specific HPV testing may be useful for identifying women with atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions who are at higher and lower risk of prevalent and incipient cervical precancer.

Mortality risk among hemodialysis patients receiving different vitamin D analogs

Intravenous vitamin D is standard therapy for secondary hyperparathyroidism in hemodialysis (HD) patients. In for-profit dialysis clinics, mortality was higher for patients on calcitriol compared to paricalcitol. Doxercalciferol, a second vitamin D2 analog, is currently available. We assessed mortality associated with each vitamin D analog and with lack of vitamin D therapy in patients who began HD at Dialysis Clinic Inc. (DCI), a not-for-profit dialysis provider. During the 1999-2004 study period we studied 7731 patients (calcitriol: n=3212; paricalcitol: n=2087; doxercalciferol: n=2432). Median follow-up was 37 weeks. Mortality rates (deaths/100 patient-years) were identical in patients on doxercalciferol (15.4, 95% confidence interval (13.6-17.1)) and paricalcitol (15.3 (13.6-16.9)) and higher in patients on calcitriol (19.6 (18.2-21.1)) (P<0.0001). In all models mortality was similar for paricalcitol versus doxercalciferol (hazard ratios=1.0). In unadjusted models, mortality was lower in patients on doxercalciferol (0.80 (0.66, 0.96)) and paricalcitol (0.79 (0.68, 0.92)) versus calcitriol (P<0.05). In adjusted models, this difference was not statistically significant. In all models mortality was higher for patients who did not receive vitamin D versus those who did (1.2 (1.1-1.3)). Mortality in doxercalciferol- and paricalcitol-treated patients was virtually identical. Differences in survival between vitamin D2 and D3 may be smaller than previously reported.

Ethnic differences in the use of complementary and alternative therapies among adults with osteoarthritis

INTRODUCTION

The use of complementary and alternative medicine (CAM) in the United States has been rising steadily, especially among people with chronic conditions such as osteoarthritis. It has been suggested that ethnicity and acculturation may influence use of CAM. The purpose of this study was to assess the influence of ethnicity and acculturation on patterns of CAM use among Hispanic and non-Hispanic white adults with osteoarthritis.

METHODS

We conducted interviews in person, in English or Spanish, using a 255-item survey. We randomly selected participants aged 18 to 84 years from patients at university-based primary care outpatient clinics who had been diagnosed with osteoarthritis during the previous year. Measures included prevalence and types of CAM use, sociodemographic factors, self-reported ethnicity, and degree of acculturation according to language use.

RESULTS

The Hispanic (n = 218) and non-Hispanic white (n = 204) populations showed similar rates of overall current CAM use (65.5% Hispanic vs 67.8% NHW) at time of interview. However, although more Hispanics used oral herbs (P = .03) and magnets or copper jewelry (P = .03), more non-Hispanic whites used nutritional supplements (P < .001). Hispanics speaking primarily English mirrored patterns of CAM use among non-Hispanic whites. These effects persisted after controlling for age, sex, income, education, degree of disability, and disease duration.

CONCLUSION

In this population, ethnicity was a significant influence on patterns of CAM use but did not affect overall rates of use. Some differences were more pronounced among Spanish-speaking Hispanics, reflecting the incorporation of folk or traditional remedies into their health care practices.

Telomere content correlates with stage and prognosis in breast cancer

PURPOSE

To evaluate the hypothesis that telomere DNA content (TC) in breast tumor tissue correlates with TNM staging and prognosis.

EXPERIMENTAL DESIGN

Slot blot assay was used to quantitate TC in 70 disease-free normal tissues from multiple organ sites, and two independent sets of breast tumors containing a total of 140 samples. Non-parametric Rank-Sums tests, logistic regression and Cox proportional hazards models were used to evaluate the relationships between TC and tumor size, nodal involvement, TNM stage, 5-year survival and disease-free interval.

RESULTS

TC in 95% of normal tissues was 75-143% of that in the placental DNA standard, whereas only 50% of tumors had TC values in this range. TC was associated with tumor size (p=0.02), nodal involvement (p<0.0001), TNM stage (p=0.004), 5-year overall survival (p=0.0001) and 5-year disease-free survival (p=0.0004). A multivariable Cox model was developed using age at diagnosis, TNM stage and TC as independent predictors of breast cancer-free survival. Relative to the high TC group (>123% of standard), low TC (<101% of standard) conferred an adjusted relative hazard of 4.43 (95% CI 1.4-13.6, p=0.009). Receiver operating characteristic curves using thresholds defined by the TC distribution in normal tissues predicted 5-year breast cancer-free survival with 50% sensitivity and 95% specificity, and predicted death due to breast cancer with 75% sensitivity and 70% specificity.

CONCLUSIONS

TC in breast cancer tissue is an independent predictor of clinical outcome and survival interval, and may discriminate by stage.

Health outcomes in older men with localized prostate cancer: results from the Prostate Cancer Outcomes Study

PURPOSE

We compared health-related quality-of-life (HRQOL) outcomes and survival of men with localized prostate cancer who received aggressive treatment with those receiving conservative management.

METHODS

We conducted a population-based cohort study of men aged 75 to 84 years when diagnosed with a clinically localized cancer in 1994 or 1995. We used medical record abstractions and patient surveys to obtain clinical and HRQOL data at diagnosis and 24-month follow-up. We used a propensity score method to adjust for baseline differences between men treated with radical prostatectomy or radiation therapy (n = 175) and men who received hormone therapy or no treatment (n = 290). Propensity scores were used in regression analyses comparing HRQOL outcomes between treatment groups. Overall and disease-specific survivals were estimated with multivariate proportional hazards models.

RESULTS

At 24 months following diagnosis, aggressively treated men were more likely to report daily urinary leakage (odds ratio [OR] = 2.9, 95% confidence interval [CI] 1.2-7.0) and to be bothered by urinary problems (OR = 5.1, 95% CI, 1.3-9.1) and sexual problems (OR = 2.8, 95% CI, 1.2-6.3). The adjusted disease-specific mortality hazard ratio was 0.43 (95% CI, 0.15, 1.28), favoring aggressive treatment. However, the absolute 5-year disease-specific survival difference was only 6% (98% vs 92%). Over 80% of all deaths were from other causes.

CONCLUSIONS

Aggressive treatment was associated with significant decreases in disease-specific HRQOL. However, men who were aggressively treated for localized cancer had a minimally reduced absolute risk of dying from prostate cancer. Physicians and older patients should consider these outcomes in making decisions about screening and treatment.

Changing relationship of blood pressure with mortality over time among hemodialysis patients

High BP is a major risk factor for atherosclerotic cardiovascular disease mortality in the general population. Surprising, studies that have been conducted among hemodialysis (HD) patients have yielded conflicting data on the relationship between BP and mortality. This study explores two hypotheses among HD patients: (1) The relationship between BP and mortality changes over time, and (2) mild to moderate hypertension is well tolerated. Incident HD patients who were treated at Dialysis Clinic Inc. facilities between 1993 and 2003 were studied. Primary end points were atherosclerotic cardiovascular disease and all-cause mortality. The relationship between BP and mortality was analyzed in two sets of Cox proportional hazards models. Model-B explored the relationship between baseline BP and mortality in sequential time periods. Model-TV assessed the relationship between BP, treated as time-varying, and mortality. The study sample (n = 16,959) was similar in characteristics to the United States Renal Data Systems population, although black patients were slightly overrepresented. Model-B demonstrated that the relationship between baseline BP and mortality changes over time. Low systolic BP (<120 mmHg) was associated with increased mortality in years 1 and 2. High systolic BP (> or =150 mmHg) was associated with increased mortality among patients who survived > or =3 yr. Low pulse pressure was associated with increased mortality. Model-TV demonstrated that mild to moderate systolic hypertension may be relatively well tolerated. In conclusion, the relationship between baseline BP and mortality changes over time. Mild to moderate systolic hypertension was associated with only modest increases in mortality.

A randomized trial assessing the utility of a test-dose program with taxanes

OBJECTIVE

Taxanes are commonly used anticancer agents with a potential of producing an allergic or hypersensitivity reaction (HSR). We performed a randomized study to evaluate the value of a test dose given prior to the full dose of either paclitaxel or docetaxel.

RESEARCH DESIGN AND METHODS

Patients were randomly assigned to either the administration of the full dose or to the prior administration of a 1 mg intravenous test dose of either paclitaxel or docetaxel. The primary endpoints were severity of the HSR and the cost of drug wastage due to a HSR.

RESULTS

Two hundred and eighteen patients were randomized from three different treatment sites. The overall incidence of HSR was 6.5% and there was no significant difference in the incidence of HSR in either group. The mean HSR severity grade was 2.8 for patients without a test dose and 2.3 for those receiving a test dose. There was, however, a reduction in the wastage of taxane in the test dose arm. Wastage avoided in the test dose arm was $1573 per patient who had a HSR and $104 per patient treated with a taxane.

CONCLUSION

Although a test dose may not reduce the severity of a HSR with the administration of a taxane, it does reduce the cost associated with drug wastage.

TNF‐αPromoter Polymorphisms and Susceptibility to Human Papillomavirus 16–Associated Cervical Cancer

BACKGROUND

Polymorphisms in the TNF-alpha promoter region have recently been shown to be associated with susceptibility to cervical cancer. Some polymorphisms have been reported to influence transcription for this cytokine. Altered local levels in the cervix may influence an individual's immune response, thereby affecting persistence of human papillomavirus (HPV) 16 infection, a primary etiological factor for cervical cancer.

METHODS AND RESULTS

The association of 11 TNF-alpha single-nucleotide polymorphisms (SNPs) with susceptibility to HPV16-associated cervical cancer was investigated. Sequencing of the TNF-alpha promoter region confirmed 10 SNPs, and 1 previously unreported SNP (161 bp upstream of the transcriptional start site) was discovered. Microsphere-array flow cytometry-based genotyping was performed on 787 samples from Hispanic and non-Hispanic white women (241 from randomly selected control subjects, 205 from HPV16-positive control subjects, and 341 from HPV16-positive subjects with cervical cancer). The genotype distribution of 3 SNPs (-572, -857, and -863) was significantly different between case subjects and control subjects. Analysis of haplotypes, which were computationally inferred from genotype data, also revealed statistically significant differences in haplotype distribution between case subjects and control subjects.

CONCLUSIONS

We report new associations between several TNF-alpha SNPs and susceptibility to cervical cancer that support the involvement of the TNF- alpha promoter region in development of cervical cancer.

Association between cancer-free survival and telomere DNA content in prostate tumors

PURPOSE

We evaluated the hypothesis that telomere DNA content (TC) in prostate tumor tissue is associated with time to prostate cancer recurrence.

MATERIALS AND METHODS

The cohort was comprised of 77 men who underwent prostatectomy between 1982 and 1995. Slot blot assay was used to measure TC in DNA extracted from paraffin embedded tumor and nearby, histologically normal prostate (NHN) tissues. Multivariate Cox proportional hazards analysis was done to relate TC, patient age at diagnosis, Gleason sum and pelvic node involvement to time of prostate cancer recurrence. Regression analysis was done to relate TC in paired tumor and NHN tissues. Nonparametric Kruskal-Wallis analysis was done to relate TC in tumor and NHN tissues with 72-month disease-free survival.

RESULTS

TC was a predictor of time to prostate cancer recurrence when controlling for age at diagnosis, Gleason sum and pelvic node involvement (RH = 5.02, 95% CI 1.40 to 17.96, p = 0.0132). TC in tumor tissue was associated with TC in NHN tissue (R = 0.601, p <0.0001). Median TC in tumor and NHN tissues from men in whom cancer recurred within 6 years was approximately half that in men who remained disease-free (p = 0.012 and 0.024, respectively).

CONCLUSIONS

Decreased TC in prostate tissues obtained by radical prostatectomy predicts prostate cancer recurrence independent of age at diagnosis, Gleason sum and pelvic node involvement. TC in tumor tissue is also associated with TC in NHN prostate tissue. Thus, mechanisms known to generate genomic instability are operative in fields of cells beyond the tumor margins prior to histological changes.

Association of body composition and weight history with breast cancer prognostic markers: divergent pattern for Hispanic and non-Hispanic White women

Body composition and weight gain are breast cancer risk factors that may influence prognosis. The Health, Eating, Activity, and Lifestyle Study was designed to evaluate the relations of body composition, weight history, hormones, and lifestyle factors to prognosis for women with breast cancer. In the cross-sectional analysis of this cohort study specific to 150 Hispanic and 466 non-Hispanic White women in New Mexico diagnosed between 1996 and 1999, the authors hypothesized that obesity measures are associated with baseline prognostic markers and that these associations are modified by ethnicity. Ethnic-stratified multiple logistic regression analyses showed divergent results for a tumor size of 1.0 cm or more and, to a lesser extent, positive lymph node status. Among Hispanics, the highest quartile for body mass index (29.5 vs. <22.5 kg/m2: odds ratio (OR) = 0.16, 95% confidence interval (CI): 0.03, 0.84) and for waist circumference (> or =95.0 vs. <78.5 cm: OR = 0.09, 95% CI: 0.01, 0.78) was significantly associated with a reduced tumor size. In contrast, for overweight and obese non-Hispanic White women, there was an increased association with obesity-related measures, particularly striking for the highest quartile of waist circumference (OR = 2.76, 95% CI: 1.45, 5.26). These findings suggest that Hispanics may have a different breast cancer phenotype than non-Hispanic Whites, which associates differently with body composition and weight history.

Cross-sectional and longitudinal comparisons of health-related quality of life between patients with prostate carcinoma and matched controls

BACKGROUND

Prostate carcinoma and treatments affect health-related quality of life (HRQOL). The authors prospectively compared prostate and general HRQOL between prostate carcinoma cases and an age-matched and ethnicity-matched control group.

METHODS

The case cohort consisted of 293 men with localized prostate carcinoma who were selected randomly from the population-based New Mexico Tumor Registry, and the control cohort consisted of 618 men who were selected randomly from administrative databases and matched for age and ethnicity. Subjects completed a baseline survey of demographics, socioeconomic status, comorbidity, and prostate and general HRQOL. Also, 210 cases (71.7%) and 421 controls (67.8%) completed a follow-up survey 5 years later. Multinomial logistic regression models compared baseline characteristics as well as 5-year general HRQOL outcomes measured by selected domains of the Medical Outcomes Study SF-36. The authors used a mixed-model repeated-measures analysis of variance and multinomial regression analyses to compare longitudinal changes in urinary, bowel, and sexual function between groups.

RESULTS

At baseline, patients with prostate carcinoma had better urinary control and sexual function than controls. Over 5 years, sexual function declined significantly among controls, although urinary function remained stable. However, patients with cancer subsequently reported significant declines in both domains and were left with much worse function and more bother than controls. Bowel function and general HRQOL were similar for both groups at follow-up.

CONCLUSIONS

Prostate carcinoma treatment led to significant 5-year declines in urinary and sexual function that far exceeded age-related changes in controls. Patients with cancer had significantly worse function and more bother than controls for these disease-specific domains of HRQOL. Bowel function and general HRQOL were not affected by cancer status.

Accuracy of alcohol diagnosis among DWI offenders referred for screening

BACKGROUND

Most US courts use screening programs to evaluate substance-abuse problems of convicted driving while impaired (DWI) offenders. Typically self-report information determines need for treatment. However, little is known about the accuracy of self-reports of alcohol-use problems in this population.

METHODS

DSM-III-R alcohol abuse and dependence diagnoses from an initial, court-ordered screening evaluation of 583 female and 495 male convicted DWI offenders were compared with diagnoses and other self-reported information from a voluntary, noncoerced interview 5 years after the screening referral.

RESULTS

At initial screening, 16.8% of offenders were diagnosed with alcohol abuse and 20.1% with alcohol dependence. At the 5-year interview, 19.9 and 60.1% received a retrospective diagnosis of alcohol abuse or dependence at the age at which they were screened. Significantly fewer of those with a retrospective alcohol diagnosis reported that their alcohol use self-reports at screening were "very accurate" compared to those with no retrospective diagnosis.

CONCLUSIONS

Although many DWI offenders undergoing screening have diagnosable alcohol-related problems, underreporting is common, leading to inaccurate diagnosis and, therefore, a missed treatment opportunity. The research community and policymakers should review and reform the current screening system for alcohol-impaired drivers to better address this serious public health problem.

Use of complementary therapies among primary care clinic patients with arthritis

INTRODUCTION

Use of complementary and alternative medicine (CAM) for chronic conditions has increased in recent years. There is little information, however, on CAM use among adults with clinic-confirmed diagnoses, including arthritis, who are treated by primary care physicians.

METHODS

To assess the frequency and types of CAM therapy used by Hispanic and non-Hispanic white women and men with osteoarthritis, rheumatoid arthritis, or fibromyalgia, we used stratified random selection to identify 612 participants aged 18-84 years and seen in university-based primary care clinics. Respondents completed an interviewer-administered survey in English or Spanish.

RESULTS

Nearly half (44.6%) of the study population was of Hispanic ethnicity, 71.4% were women, and 65.0% had annual incomes of less than 25,000 dollars. Most (90.2%) had ever used CAM for arthritis, and 69.2% were using CAM at the time of the interview. Current use was highest for oral supplements (mainly glucosamine and chondroitin) (34.1%), mind-body therapies (29.0%), and herbal topical ointments (25.1%). Fewer participants made current use of vitamins and minerals (16.6%), herbs taken orally (13.6%), a CAM therapist (12.7%), CAM movement therapies (10.6%), special diets (10.1%), or copper jewelry or magnets (9.2%). Those with fibromyalgia currently used an average of 3.9 CAM therapies versus 2.4 for those with rheumatoid arthritis and 2.1 for those with osteoarthritis. Current CAM use was significantly associated with being female, being under 55 years of age, and having some college education.

CONCLUSION

Hispanic and non-Hispanic white arthritis patients used CAM to supplement conventional treatments. Health care providers should be aware of the high use of CAM and incorporate questions about its use into routine assessments and treatment planning.

Psychiatric disorders of convicted DWI offenders: a comparison among Hispanics, American Indians and non-Hispanic whites

OBJECTIVE

Alcohol-impaired offenders have high prevalence rates of psychiatric disorders; however, differences in prevalence rates among ethnic minorities have not been investigated. This study compares lifetime prevalence estimates of DSM-III-R psychiatric disorders (alcohol and drug abuse and dependence, nicotine dependence, major depressive disorder [MDD], dysthymia, generalized anxiety disorder, posttraumatic stress disorder and antisocial personality disorder [ASPD]) among Hispanics, American Indians and non-Hispanic whites convicted of driving while alcohol-impaired.

METHOD

Offenders (758 women, 631 men) previously referred to a screening program in Bernalillo County, NM, were interviewed for this study using a structured diagnostic interview.

RESULTS

Adjusting for age, education, income and marital status, Hispanic women had significantly higher rates of alcohol abuse (odds ratio [OR] = 2.2) and lower rates of alcohol dependence (OR = 0.3), drug abuse (OR = 0.4) and nicotine dependence (OR = 0.3) than non-Hispanic white women. American-Indian women showed significantly lower rates of alcohol dependence (OR = 0.5), nicotine dependence (OR = 0.2) and MDD (OR = 0.3) than non-Hispanic white women. Hispanic men had significantly lower rates of alcohol dependence (OR = 0.6), drug dependence (OR = 0.5), nicotine dependence (OR = 0.2), MDD (OR = 0.5) and ASPD (OR = 0.4) than non-Hispanic white men. American-Indian men also reported significantly lower rates of drug dependence (OR = 0.5), nicotine dependence (OR = 0.2) and ASPD (OR = 0.3) than non-Hispanic white men.

CONCLUSIONS

After statistically adjusting for demographic differences, minority groups were in general less affected by substance abuse problems and had similar or lower rates of other psychiatric disorders when compared with non-Hispanic whites.

Racial differences in initial treatment for clinically localized prostate cancer. Results from the prostate cancer outcomes study

OBJECTIVE

We examined whether there were racial differences in initial treatment for clinically localized prostate cancer and investigated whether demographic, socioeconomic, clinical, or tumor characteristics could explain any racial differences.

DESIGN

Prospective cohort study.

SETTING

Population-based tumor registries in Connecticut, Los Angeles, and Atlanta.

PARTICIPANTS

We evaluated 1144 African-American and non-Hispanic white men, aged 50 to 74 years, with clinically localized cancer diagnosed between October 1994 and October 1995.

MEASUREMENTS AND MAIN RESULTS

We obtained demographic, socioeconomic, and clinical data from patient surveys and medical record abstractions. We reported adjusted percentages for receiving treatment derived from multinomial logistic regression. We found an interaction between race and tumor aggressiveness. Among men with more aggressive cancers (PSA > or = 20 ng/mL or Gleason score > or = 8), African Americans were less likely to undergo radical prostatectomy than non-Hispanic whites (35.2% vs 52.0%), but more likely to receive conservative management (38.9% vs 16.3%, P=.003). Among the 71% of subjects with less aggressive cancers, African Americans and non-Hispanic whites were equally likely to receive either radical prostatectomy or radiation therapy (80.0% vs 84.5%, P=.2).

CONCLUSIONS

African Americans with more aggressive cancers were less likely to undergo radical prostatectomy and more likely to be treated conservatively. These treatment differences may reflect African Americans' greater likelihood for presenting with pathologically advanced cancer for which surgery has limited effectiveness. Among men with less aggressive cancers-the majority of cases-there were no racial differences in undergoing radical prostatectomy or radiation therapy.

Changes in nonmelanoma skin cancer incidence between 1977-1978 and 1998-1999 in Northcentral New Mexico

Nonmelanoma skin cancer (NMSC) is a highly common form of malignant disease in light-skinned populations. In 1977-1978, the National Cancer Institute sponsored a population-based skin cancer survey that found marked geographic variability in the incidence of NMSC within the United States. Some of the highest rates were observed in the southwestern state of New Mexico within its non-Hispanic white population. We recently undertook a follow-up survey of NMSC in New Mexico and report here incidence rate data for non-Hispanic white residents of a three-county area in northcentral New Mexico for two 12-month time periods: June 1, 1977 to May 31, 1978 and July 1, 1998 to June 31, 1999. Our results show that incidence rates of basal cell carcinoma increased by 50% in males and 20% in females, whereas rates of squamous cell carcinoma roughly doubled in both males and females. Temporal analysis of rates according to major anatomical site showed the head and neck was consistently the most frequent site of occurrence, however, the greatest percentage increase in rates over time occurred at the upper and lower limbs. These findings are consistent with those reported for various other populations showing the incidence of NMSC has measurably increased since the 1970s.

Effects of misattribution in assigning cause of death on prostate cancer mortality rates

PURPOSE

Estimate the magnitude of misattribution in death certification and to determine whether misattribution could explain temporal trends in New Mexico prostate cancer mortality.

METHODS

Investigators retrospectively reviewed medical records to classify cause of death for men with prostate cancer who died in New Mexico in either 1985 or 1995. The investigator-assigned cause of death, either prostate cancer or another cause, was compared with the New Mexico Bureau of Vital Statistics' (BVS) assignment. Net misattribution was the difference between BVS and investigators in the number of deaths attributed to prostate cancer relative to the number attributed by investigators.

RESULTS

Concordance for death certification between BVS and investigators was higher in 1995 (95.8%) than 1985 (85.1%), p <0.01, but net misattribution was higher in 1995 (16.8% vs. 1.9%). During this time, the crude prostate cancer mortality rate in New Mexico increased 33.5%, from 18.5 to 24.7 per 100,000. However, after adjusting for misattribution, mortality increased only 15.9%, from 18.2 to 21.1 per 100,000.

CONCLUSIONS

Net misattribution in death certification was higher in 1995 than 1985. The adjusted increase in crude mortality rates was substantially less than the observed increase, suggesting that misattribution explained about half of the observed increase.

Patient satisfaction with treatment decisions for clinically localized prostate carcinoma. Results from the Prostate Cancer Outcomes Study

BACKGROUND

Men with early-stage prostate carcinoma can choose aggressive treatment or conservative management. The authors used data from a population-based cohort of men with clinically localized prostate carcinoma to describe satisfaction with treatment decisions 24 months after diagnosis and to examine the association of demographic, socioeconomic, and clinical characteristics with treatment satisfaction.

METHODS

The authors evaluated 2365 men with clinically localized prostate carcinoma, diagnosed between October 1994 and October 1995, in one of six Surveillance, Epidemiology, and End Results tumor registries and who were available for 24 month follow-up. Medical record review and patient-completed surveys provided demographic, socioeconomic, and clinical data and measured treatment satisfaction. Logistic regression analyses were used to identify factors associated with satisfaction.

RESULTS

Overall, 59.2% of subjects were delighted or very pleased with their treatment selection. The perception of being cancer free (66.4%), maintaining urinary (64.2%) and bowel (60.5%) control and normal erectile function (65.9%), having good general health (71.3%), and preserving social relationships (68.1%) were significantly associated with being satisfied (P < 0.05). Men receiving no active treatment were less satisfied (50.5%, P < 0.001) than actively treated men, and Hispanic men were less satisfied than non-Hispanic white men after undergoing radical prostatectomy (50.1% vs. 58.0%, P = 0.05) or androgen deprivation (29.7% vs. 71.8%, P < 0.02).

CONCLUSIONS

The majority of men were satisfied with their treatment selection for clinically localized prostate carcinoma. Receiving an active treatment, believing oneself to be free of cancer, avoiding treatment complications, and having good overall health and social support were positively associated with satisfaction.

Prostate-specific antigen testing accuracy in community practice

BACKGROUND

Most data on prostate-specific antigen (PSA) testing come from urologic cohorts comprised of volunteers for screening programs. We evaluated the diagnostic accuracy of PSA testing for detecting prostate cancer in community practice.

METHODS

PSA testing results were compared with a reference standard of prostate biopsy. Subjects were 2,620 men 40 years and older undergoing (PSA) testing and biopsy from 1/1/95 through 12/31/98 in the Albuquerque, New Mexico metropolitan area. Diagnostic measures included the area under the receiver-operating characteristic curve, sensitivity, specificity, and likelihood ratios.

RESULTS

Cancer was detected in 930 subjects (35%). The area under the ROC curve was 0.67 and the PSA cutpoint of 4 ng/ml had a sensitivity of 86% and a specificity of 33%. The likelihood ratio for a positive test (LR+) was 1.28 and 0.42 for a negative test (LR-). PSA testing was most sensitive (90%) but least specific (27%) in older men. Age-specific reference ranges improved specificity in older men (49%) but decreased sensitivity (70%), with an LR+ of 1.38. Lowering the PSA cutpoint to 2 ng/ml resulted in a sensitivity of 95%, a specificity of 20%, and an LR+ of 1.19.

CONCLUSIONS

PSA testing had fair discriminating power for detecting prostate cancer in community practice. The PSA cutpoint of 4 ng/ml was sensitive but relatively non-specific and associated likelihood ratios only moderately revised probabilities for cancer. Using age-specific reference ranges and a PSA cutpoint below 4 ng/ml improved test specificity and sensitivity, respectively, but did not improve the overall accuracy of PSA testing.

Priming of human papillomavirus type 11-specific humoral and cellular immune responses in college-aged women with a virus-like particle vaccine

In this study, we evaluated the potency of a human papillomavirus (HPV) virus-like particle (VLP)-based vaccine at generating HPV type 11 (HPV-11)-specific cellular and humoral immune responses in seronegative women. The vaccine was administered by intramuscular immunizations at months 0, 2, and 6. A fourth immunization was administered to approximately half of the women at month 12. All vaccine recipients had positive HPV-11 VLP-specific lymphoproliferative responses at month 3 following the second immunization (geometric mean lymphoproliferative stimulation index [SI] = 28.4; 95% confidence interval [CI] = 16.9 to 48.0) and HPV-11 VLP-specific antibody titers following the first immunization at month 1 (geometric mean antibody titer = 53.9 milli-Merck units/ml, 95% CI, 34.8 to 83.7). In contrast, lymphoproliferative and antibody titer responses were never detected in the participants who received placebo. Relatively homogeneous lymphoproliferative responses were observed in all vaccinated women. The mean lymphoproliferative SI of the vaccinated group over the first 12 months of the study was 7.6-fold greater than that of the placebo group following the initial immunization. The cellular immune responses generated by VLP immunization were both Th1 and Th2, since peripheral blood mononuclear cells from vaccinees, but not placebo recipients, secreted interleukin 2 (IL-2), IL-5, and gamma interferon (IFN-gamma) in response to in vitro stimulation with HPV-11 VLP. The proliferation-based SI was moderately correlated with IFN-gamma production and significantly correlated with IL-2 production after the third immunization (P = 0.078 and 0.002, respectively). The robust lymphoproliferative responses were specific for HPV-11, since SIs generated against bovine papillomavirus and HPV-16 VLPs were not generally observed and when detected were similar pre- and postimmunization.

Are drunk-driving offenders referred for screening accurately reporting their drug use?

Several studies report that a substantial percentage of offenders arrested for impaired driving test positive for drugs of abuse besides alcohol. Current guidelines recommend screening offenders for both alcohol and other drug use, yet little is known about the accuracy of self-reports of drug use in this population. We compared drug abuse and dependence DSM-III-R diagnoses from an initial, court-ordered screening evaluation of 583 female and 495 male convicted drunk-driving offenders with diagnoses obtained via a voluntary, non-coerced interview 5 years later. At initial screening, fewer than 6% of offenders were diagnosed with drug abuse or dependence. Among offenders who did not receive an initial drug diagnosis, 28% subsequently reported having experienced drug use problems consistent with a retrospective diagnosis of drug abuse or dependence by the age at which they were screened. Half of those with a retrospective diagnosis of drug dependence reported their initial screening responses were "very accurate". We conclude that, although many drunk-driving offenders undergoing screening have diagnosable drug problems, a high proportion under-report their drug use. We suggest that certain modifications to screening procedures, such as urine drug screening, reducing barriers to treatment, and training counselors in motivational interviewing techniques, may increase accurate identification of drug use problems in this population.