Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement

Integrating HPV self-collect into primary care to address cervical cancer screening disparities

Human papillomavirus (HPV) self-collect shows promise to increase cervical cancer screening rates in underscreened populations, such as Somali patients, but little is known about how to integrate such an approach in primary care. In this study, primary care providers and staff who provide primary care services to Somali women were asked for their views on integrating HPV self-collect into routine care to address cervical cancer screening disparities. Thirty primary care providers and staff participated in semi-structured interviews exploring their views on HPV self-collect and their anticipated needs or barriers to implementing this approach into the clinic generally and with specific patient populations, such as Somali women. A thematic analysis using the constructivist version of grounded theory was undertaken. Providers and staff anticipate positive patient reaction to the option of HPV self-collect, and were interested in using this approach both for Somali patients and for all patients in general. HPV self-collect was viewed as straightforward to integrate into existing clinic workflows. Providers largely lacked awareness of the evidence supporting primary HPV testing and HPV self-collect specifically, sharing concerns about effectiveness of self-collect and the lack of a physical exam. Providers felt clinic-wide staff education and patient education, along with strategies to address disparities, such as cultural and linguistic tailoring would be needed for successful implementation. Integrating HPV self-collect as an option in the cervical cancer screening process in a primary care clinical encounter offers considerable opportunity to address health disparities and may benefit all patients.

The Effect of Disability and Social Determinants of Health on Breast and Cervical Cancer Screenings During the COVID-19 Pandemic

Introduction

The objective of this study was to examine the effect of disability status and social determinants of health (SDOH) on adherence to breast and cervical cancer screening recommendations during the COVID-19 pandemic.

Methods

We conducted a secondary analysis of the 2018 and 2020 Behavioral Risk Factor Surveillance System (BRFSS) data sets. We defined adherence to screenings according to the US Preventive Services Task Force guidelines for breast and cervical cancer screening. The analysis included respondents assigned female at birth, aged 50 to 74 years (breast cancer screening) or aged 21 to 65 years (cervical cancer screening). We performed logistic regression to evaluate breast and cervical cancer screening adherence, by disability status and SDOH (health insurance coverage, marital status, and urban residency), independently and simultaneously.

Results

Our analysis included 27,526 BRFSS respondents in 2018 and 2020. In 2018, women with disabilities had lower adjusted odds than women without disabilities of being up to date with mammograms (adjusted odds ratio [AOR] = 0.76, 95% CI, 0.63-0.93) and Pap (Papanicolaou) tests (AOR = 0.73; 95% CI, 0.59-0.89). In 2020, among women with disabilities, the adjusted odds of mammogram and Pap test adherence decreased (AOR = 0.69; 95% CI, 0.54-0.89; AOR = 0.59; 95% CI, 0.47-0.75, respectively). In 2018, the adjusted odds of mammogram adherence among rural residents with and without disabilities were 0.83 (95% CI, 0.70-0.98), which decreased to 0.76 (95% CI, 0.62-0.93) in 2020.

Conclusion

The findings of this study highlight the effect of disability status and SDOH on breast and cervical cancer screening rates during the COVID-19 pandemic. Public health strategies that acknowledge and address these disparities are crucial in preparing for future public health crises.

Helping patients understand multi-cancer early detection tests: a scoping review

Multi-cancer early detection tests are emerging as a revolutionary technology for the early detection of dozens of cancers from a single blood sample, including cancers without proven screening methods. However, they also come with challenges, including false-positive and false-negative results. To help patients make informed decisions, patient education materials are crucial. A review of available materials reveals that, while some materials provide understandable and actionable information, most lack a balanced presentation of the current benefits and risks of multi-cancer early detection testing. The dynamic nature of this field necessitates continuous updates to educational materials, incorporating current evidence and uncertainties.

Exploring preventive care practices among unvaccinated individuals in the United States during the COVID-19 pandemic

INTRODUCTION

Building on a Canadian study associating unvaccinated individuals to increased car accidents, we examined the relationship between COVID-19 vaccination status and US preventive care practices.

METHODS

We queried the 2021 National Health Interview Survey. First, we fitted a model to identify respondent-level factors associated with receipt of at least one COVID-19 vaccination. Second, we fitted a survey-weighted logistic regression model adjusted for respondent-level characteristics to examine whether the receipt of at least one COVID-19 vaccination predicted the receipt of preventive care services. Preventive care services assessed included serum cholesterol, glucose, and blood pressure measurements, as well as guideline-concordant cancer screening including breast, cervical, colorectal, and prostate cancer screening.

RESULTS

Factors predicting receipt of COVID-19 vaccination were age (adjusted Odds Ratio (aOR) 1.03; 95 % confidence interval (CI) [1.03-1.03]), Hispanic (aOR 1.25; 95 % CI [1.08-1.44]), and non-Hispanic Asian (aOR 3.52; 95 % CI [2.74-4.52]) ethnicity/race, and history of cancer (aOR 1.61; 95 % CI [1.13-2.30]). Unvaccinated respondents were less likely to have received serum cholesterol (aOR 0.69; 95 % CI [0.50-0.70), serum glucose (aOR 0.65; 95 % CI [0.56-0.75]), or blood pressure measurements (aOR 0.47; 95 % CI [0.33-0.66]); and were less likely to have received breast cancer (aOR 0.35; 95 % CI [0.25-0.48]), colorectal cancer (aOR 0.52; 95 % CI [0.46-0.60]) and prostate cancer screening (aOR 0.61; 95 % CI [0.48-0.76]). There was no significant association between unvaccinated respondents receiving cervical cancer screening (aOR 0.96; 95 % CI [0.81-1.13]; p = 0.616).

CONCLUSION

Non-receipt of COVID-19 vaccination was associated with non-receipt of preventive care services including cancer screening. Further studies are needed to assess if this association is due to system-level factors or reflects a general distrust of medical preventive care amongst this population.

Optimising cervical cancer screening during pregnancy: a study of liquid-based cytology and HPV DNA co-test

This study assessed the efficacy of ThinPrep cytologic test and human papillomavirus (HPV) co-test in cervical cancer screening during pregnancy. A cohort of 8,712 pregnant women from Ren Ji Hospital participated in the study. Among them, 601 (6.90%) tested positive for high-risk HPV (HR-HPV) and 38 (0.44%) exhibited abnormal cytology results (ASCUS+). Following positive HR-HPV findings, 423 patients underwent colposcopy, and 114 individuals suspected of having high-grade squamous intraepithelial lesion and cervical cancer (HSIL+) underwent cervical biopsy. Histological examination revealed 60 cases of normal pathology (52.63%), 35 cases of low-grade squamous intraepithelial lesion (30.70%), 17 cases of HSIL (14.91%), and 2 cases of cervical cancer (1.75%). The incidence of HSIL+ in HPV 16/18 group was significantly higher than that in non-HPV16/18 group (10.53% vs. 6.14%, P < 0.05). Subsequent evaluation of the clinical performance of cytology alone, primary HPV screening, and co-testing for HSIL+ detection revealed that the HSIL+ detection rate was lowest with cytology alone. These findings suggest that HPV testing, either alone or combined with cytology, presents an efficient screening strategy for pregnant women, underscoring the potential for improved sensitivity in cervical cancer screening during pregnancy. The significantly higher incidence of HSIL+ in the HPV16/18 group emphasizes the importance of genotype-specific considerations.

Prevalence and predictors of cancer screening in transgender and gender nonbinary individuals

Background

Current cancer screening guidelines for transgender individuals are guided primarily by expert opinion, and are extrapolated from guidelines for cisgender populations, despite the additional unique risks that transgender populations face in cancer risk and cancer care.

Aims

We examined adherence to current recommended screening guidelines as well as drivers of cancer screening in 192 transgender and gender-nonbinary (TGNB) individuals participating in Project AFFIRM, a multi-site longitudinal cohort study of TGNB individuals.

Methods

We used a chi-squared analysis to look for significant associations between predictors and adherence to breast, cervical, prostate and colon cancer screening. We analyzed predictors by 3 different categories: sex/gender identity, healthcare access, and socioeconomic status.

Results

Screening rates were low for breast, cervical, prostate and colon cancer in TGNB populations compared to national rates for cisgender populations. Among several significant predictors, gender-affirming surgery (hysterectomy) (p-value = <0.0001) and telling others they are transgender at a younger age (< 18) (p-value = 0.0344) were associated with increased screening adherence, while having HIV was associated with decreased screening adherence (p-value = 0.0045).

Discussion

Our results suggest that interacting with the healthcare system to obtain comprehensive cancer screening can be difficult to navigate among the other healthcare needs of TGNB individuals both on an individual and systems level. Future efforts to mitigate the barriers to screening adherence should be targeted at the healthcare system level.

Blood-Based Multi-Cancer Early Detection Tests (MCEDs) as a Potential Approach to Address Current Gaps in Cancer Screening

Screening and early detection is one of the most effective approaches to reduce the population-level impact of cancer. Novel approaches to screening such as multi-cancer early detection tests (MCEDs) may further reduce cancer incidence and mortality. Many MCEDs detect fragments of circulating DNA containing mutations that originated from tumour cells, thereby informing both the presence of cancer and the cell-type of origin. In this review, we examine the current evidence of MCEDs as a potential tool to improve population-based cancer outcomes. We review the role of MCEDs to address low participation rates, disparities among underserved populations, changing epidemiology of common cancers, and the absence of screening tests for many cancer types. MCEDs have the potential to increase participation in cancer screening programs, as they may be less invasive than other procedures, and can screen for multiple cancer types in one appointment. Additionally, due to the lack of specialized collection equipment needed for these tests, underscreened populations and targeted populations could gain greater access to screening. Finally, because MCEDs can detect cancer types without screening tests that are moderately common and increasing in western populations, efficacious tests for these sites could alleviate the cancer burden and improve patient outcomes. While these tests offer great promise, considerable limitations and evidence gaps must be addressed. Notable limitations include scenarios where early detection does not improve survival outcomes, the costs and impact on health care resources for false positives, and false reassurance with subsequent lack of adherence to existing screening protocols.

Primary Human Papillomavirus Test Uptake and Cervical Cancer Screening Trends in the Midwest, United States

INTRODUCTION/OBJECTIVES

Despite U.S. Preventive Services Task Force and American Cancer Society endorsement of primary HPV screening, limited published data shows low uptake.

PRIMARY AIM

Assess cervical cancer screening rates over time, particularly primary HPV test uptake, among patients in a midwestern practice.

SECONDARY AIM

Evaluate associations between sociodemographics and screening adherence.

METHODS

Cross-sectional study. Qualifying subjects and type of screening test used were identified by applying ICD-9, ICD-10, lab test, and CPT codes to the Unified Data Platform. Sociodemographics were found through the electronic health record.

RESULTS

Primary HPV uptake represented <1% of annual screening from 1/2017 to 1/2022. On 1/1/2022, only 55% of 21 to 29 year old and 63% of 30 to 65 year old were up to date with screening among the studied population. For 21 to 29 year old, compared with White women, Black women were 28% less likely to be screened [RR = 0.72 (0.66-0.79)]. Compared with never-smokers, current smokers were 9% less likely to be screened [RR = 0.91 (0.87-0.96)], past smokers were 14% more likely [RR = 1.14 (1.09-1.2)]. Among 30 to 65 year old, compared with White women, Black women were 14% less likely to be screened [RR = 0.86 (0.81-0.9)]. Compared with never-smokers, current smokers were 21% less likely to be screened [RR = 0.79 (0.77-0.81)], past smokers were 6% less likely [RR = 0.94 (0.92-0.95)]. Jointly considering race, ethnicity, smoking status, Charlson score, and rurality, findings were similar for 21 to 29 year old; Black women were screened less than White women [RR = 0.73 (0.67-0.79)]; current smokers [RR = 0.9 (0.85-0.94)] and past smokers [RR = 1.12 (1.06-1.17)] were screened less than never smokers. For 30 to 65 year old, Black women were screened less than White women [RR = 0.83 (0.79-0.88)]; current smokers [RR = 0.8 (0.78-0.81)] and past smokers [RR = 0.95 (0.93-0.96)] were screened less than never smokers.

CONCLUSIONS

Screening rates remained below the Healthy People 2030 goal of 79.2% over time, particularly for younger Black women and current smokers, with minimal use of primary HPV screening.

HPV self-sampling among women in the United States: preferences for implementation

PURPOSE

With the inclusion of primary HPV testing in 2018 U.S. Preventive Services Taskforce guidelines, at-home HPV self-sampling may provide a future option for cervical cancer screening, especially among hard-to-reach populations in the U.S. This study evaluated the association of implementation preferences with the willingness of at-home HPV self-sampling.

METHODS

We conducted a cross-sectional study in 2018 among U.S. women ages 30-65 years, without a hysterectomy (n = 812). The outcome was willingness to have at-home HPV self-sampling (yes/no). Primary predictor variables (i.e., information source, methods of payment, methods of sending or receiving self-sampling kits) measured self-sampling implementation preferences. Adjusted logistic regression identified associations with willingness to have at-home HPV self-sampling.

RESULTS

Participants who preferred receiving information from healthcare providers (OR = 2.64; 95% CI 1.54,4.52) or from media or other sources (OR = 2.30; 95% CI 1.51,3.48) had higher HPV self-sampling willingness than participants who did not prefer those sources. Participants who did not want to pay for self-sampling (OR = 0.21; 95% CI 0.14,0.32) or did not know if they would pay for self-sampling (OR = 0.35; 95% CI 0.22,0.54) had lower odds of HPV self-sampling willingness compared to participants willing to pay. Participants who did not know which method they preferred for receiving a self-sampling kit (OR = 0.15, 95% CI 0.07,0.31) or preferred delivering the sample to the lab themselves (OR = 0.59; 95% CI 0.36,0.96) had lower odds for self-sampling willingness compared to participants who preferred the mail.

CONCLUSION

Understanding the preferences of women regarding the implementation of HPV self-sampling can improve uptake in cervical cancer screening, especially among hard-to-reach populations.

An automated cervical cancer diagnosis using genetic algorithm and CANFIS approaches

BACKGROUND

Cervical malignancy is considered among the most perilous cancers affecting women in numerous East African and South Asian nations, both in terms of its prevalence and fatality rates.

OBJECTIVE

This research aims to propose an efficient automated system for the segmentation of cancerous regions in cervical images.

METHODS

The proposed techniques encompass preprocessing, feature extraction with an optimized feature set, classification, and segmentation. The original cervical image undergoes smoothing using the Gaussian Filter technique, followed by the extraction of Local Binary Pattern (LBP) and Grey Level Co-occurrence Matrix (GLCM) features from the enhanced cervical images. LBP features capture pixel relationships within a mask window, while GLCM features quantify energy metrics across all pixels in the images. These features serve to distinguish normal cervical images from abnormal ones. The extracted features are optimized using Genetic Algorithm (GA) as an optimization method, and the optimized sets of features are classified using the Co-Active Adaptive Neuro-Fuzzy Inference System (CANFIS) classification method. Subsequently, a morphological segmentation technique is employed to categorize irregular cervical images, identifying and segmenting malignant regions within them.

RESULTS

The proposed approach achieved a sensitivity of 99.09%, specificity of 99.39%, and accuracy of 99.36%.

CONCLUSION

The proposed approach demonstrated superior performance compared to state-of-the-art techniques, and the results have been validated by expert radiologists.

The evolution of cervical cancer screening

There are few medical success stories in history as significant as the reduction in cervical cancer incidence. Through the collaborative efforts of dedicated scientific pioneers, the past century has witnessed remarkable advancement that began with the detection of exfoliated cancer cells through cytologic examination to widespread implementation of cervical cancer screening programs to the discovery of the link between cervical cancer and human papillomavirus (HPV). Current screening methods apply HPV-based testing, and artificial intelligence-based screening systems utilizing digitalized cytology images are being used in a continuous effort to optimize the accuracy and efficiency of the Papanicolaou test. This review summarizes the major milestones in cervical cancer screening history to emphasize its evolution as the World Health Organization aims for the global elimination of cervical cancer.

"Black Women Don't Always Put Our Healthcare First": Facilitators and Barriers to Cervical Cancer Screening and Perceptions of Human Papillomavirus Self-Testing Among Church-Affiliated African American Women

Background: African American women are at greater risk for cervical cancer incidence and mortality than White women. Up to 90% of cervical cancers are caused by human papillomavirus (HPVs) infections. The National Institutes of Health (NIH) co-developed HPV self-test kits to increase access to screening, which may be critical for underserved populations. Purpose/Research Design: This mixed methods study used the Theory of Planned Behavior to examine attitudes, barriers, facilitators, and intentions related to receipt of cervical cancer screening and perceptions of HPV self-testing among church-affiliated African American women. Study Sample/Data Collection: Participants (N = 35) aged 25-53 participated in focus groups and completed a survey. Results: Seventy-four percent of participants reported receipt of cervical cancer screening in the past 3 years. Healthcare providers and the church were supportive referents of screening. Past trauma and prioritizing children's healthcare needs were screening barriers. Concerns about HPV self-testing included proper test administration and result accuracy. Conclusions: Strategies to mitigate these concerns (e.g., delivering HPV self-test kits to the health department) are discussed.

Post-transplant malignancy: Focusing on virus-associated etiologies, pathogenesis, evidence-based management algorithms, present status of adoptive immunotherapy and future directions

Modern immunosuppression has led to a decrease in rejection rates and improved survival rates after solid organ transplantation. Increasing the potency of immunosuppression promotes post-transplant viral infections and associated cancers by impairing immune response against viruses and cancer immunoediting. This review reflects the magnitude, etiology and immunological characteristics of various virus-related post-transplant malignancies, emphasizing the need for future research. A multidisciplinary and strategic approach may serve best but overall literature evidence targeting it is sparse. However, the authors attempted to provide a more detailed update of the literature consensus for the prevention, diagnosis, management and surveillance of post-transplant viral infections and associated malignancies, with a focus on the current role of adoptive immunotherapy and the way forward. In order to achieve long-term patient and graft survival as well as superior post-transplant outcomes, collaborative research on holistic care of organ recipients is imperative.

Receipt, uptake, and satisfaction with tailored DVD and patient navigation interventions to promote cancer screening among rural women

Process evaluation is essential to understanding and interpreting the results of randomized trials testing the effects of behavioral interventions. A process evaluation was conducted as part of a comparative effectiveness trial testing a mailed, tailored interactive digital video disc (DVD) with and without telephone-based patient navigation (PN) to promote breast, cervical and colorectal cancer screening among rural women who were not up-to-date (UTD) for at least one screening test. Data on receipt, uptake, and satisfaction with the interventions were collected via telephone interviews from 542 participants who received the tailored interactive DVD (n = 266) or the DVD plus telephone-based PN (n = 276). All participants reported receiving the DVD and 93.0% viewed it. The most viewed sections of the DVD were about colorectal, followed by breast, then cervical cancer screening. Most participants agreed the DVD was easy to understand, helpful, provided trustworthy information, and gave information needed to make a decision about screening. Most women in the DVD+PN group, 98.2% (n = 268), reported talking with the navigator. The most frequently discussed cancer screenings were colorectal (86.8%) and breast (71.3%); 57.5% discussed cervical cancer screening. The average combined length of PN encounters was 22.2 minutes with 21.7 additional minutes spent on coordinating activities. Barriers were similar across screening tests with the common ones related to the provider/health care system, lack of knowledge, forgetfulness/too much bother, and personal issues. This evaluation provided information about the implementation and delivery of behavioral interventions as well as challenges encountered that may impact trial results.

A novel human papillomavirus and host DNA methylation score and detection of cervical adenocarcinoma

BACKGROUND

The widespread introduction of Pap testing in the 1960s was followed by substantial reductions in the incidence of cervical squamous cell cancer (SCC). However, the incidence of cervical adenocarcinoma (ADC) did not decrease, likely because of low Pap test sensitivity for ADC and adenocarcinoma in situ (AIS). This study assessed a novel human papillomavirus (HPV) and host DNA Methylation Score for AIS and ADC screening.

METHODS

We measured methylation levels at CpG sites in the L2/L1 open reading frames of HPV16, HPV18, and HPV45-as well as 2 human loci, DCC and HS3ST2. Specifically, we tested exfoliated cervicovaginal cells from women in the HPV Persistence and Progression (PaP) cohort who were positive for 1 of HPV16, 18, or 45, including: 1) 176 with AIS/ADC, 2) 353 with cervical intraepithelial neoplasia-3 (CIN3) or SCC, and 3) controls who either cleared (HPV-Clearers; n = 579) or had persistent HPV16, 18, or 45 infection (HPV-Persisters; n = 292). CpG site-specific methylation percentages were measured using our reported next-generation methods. The Methylation Score was the average methylation percentage across all 35 CpG sites tested.

RESULTS

Each individual CpG site had higher methylation percentages in exfoliated cervicovaginal cells collected from patients with AIS/ADC, and as well as those with CIN3/SCC, relative to either control group (weakest P  = .004). The Methylation Score for AIS/ADC had a sensitivity of 74% and specificity of 89%. The multivariate odds ratio (OR) between the Methylation Score (4th vs 1st quartile) for AIS/ADC was ORq4-q1 = 49.01 (PBenjamini-Hochberg = 4.64E-12), using HPV-Clearers as controls. CIN3/SCC had similar, albeit weaker, associations with the Methylation Score.

CONCLUSIONS

HPV16/18/45-infected women with Methylation Scores in the highest quartile had very high odds of AIS/ADC, suggesting they may warrant careful histologic evaluation of the cervical transition zone (eg, conization or loop electrosurgical excision procedure [LEEP]).

Addressing cervical cancer disparities in Texas: Expansion of a community-based prevention initiative for medically underserved populations

Although cervical cancer is preventable, significant disparities exist in access to screening and prevention services. In medically underserved areas (MUAs) of Texas, these rates are 55% higher compared to the remainder of the US. In 2019, we expanded a multicomponent, comprehensive program to improve cervical cancer prevention in partnership with 13 clinics and mobile vans in MUAs of Texas. Our multicomponent intervention program consists of community education and patient navigation coupled with a training/mentoring program for local medical providers to perform diagnostic procedures and treatment for patients with abnormal screening results. Hands-on training courses to learn these skills are coupled with biweekly telementoring conferences using Project ECHO® (Extension for Community Healthcare Outcomes). This program was implemented in 2015 and expanded to other MUAs in Texas in 2019. From March 2019 to August 2022, 75,842 individuals were educated about cervical cancer screening and HPV vaccination. A total of 44,781 women underwent screening for cervical cancer, and 2,216 underwent colposcopy and 264 underwent LEEP. High-grade cervical dysplasia was diagnosed in 658 individuals and invasive cervical cancer in 33 individuals. We trained 22 providers to perform colposcopy and/or LEEP. In addition, 78 Project ECHO telementoring sessions were held with an average of 42 attendees per session, with 72 individual patient cases discussed. Our comprehensive community-based prevention initiative for medically underserved populations has led to a significant number of individuals undergoing cervical cancer screening in MUAs, as well as improved access to colposcopy and LEEP services.

Are HPV-negative lesions concerned for the introduction of primary HPV testing for cervical cancer screening in Japan?

AIM

In Japan, primary human papilloma virus (HPV) testing has not been introduced for cervical cancer screening due to concerns that HPV-negative lesions may be missed and a lack of Japanese data. The purpose of this study was to evaluate the validity of primary HPV testing in Japan by analyzing cervical intraepithelial neoplasia 2 (CIN2) or more/high-risk HPV- (CIN2+/hrHPV-) cases in cervical cancer screening.

METHODS

Data from 35 525 cervical cancer screenings with HPV testing and cervical cytology from 2011 to 2019 in Saga City, Japan, were reviewed. The cases with low-grade squamous intraepithelial lesion (LSIL+)/hrHPV- were analyzed in detail.

RESULTS

The results of the 35 525 examinees were as follows: 31 123 were negative for intraepithelial lesion or malignancy (NILM)/hrHPV-, 2612 were NILM/hrHPV+, 262 were atypical squamous cells of undetermined significance (ASC-US)/hrHPV-, 213 were ASC-US/hrHPV+, 291 were LSIL+/hrHPV-, and 1024 were LSIL+/hrHPV+. Of the 256 LSIL+/hrHPV- examinees for whom histology was available, CIN2+ were CIN2 9.4% (24/256), CIN3 3.9% (10/256), cervical adenocarcinoma 0.4% (1/256), uterine corpus cancer 1.2% (3/256), and uterine sarcoma 0.4% (1/256). Overall, the rate of LSIL+/hrHPV- was 0.82% (291/35.525), 0.1% (36/35525) of which were cervical lesions with CIN2+. Only one cervical adenocarcinoma was detected, but gastric-type adenocarcinoma was not included.

CONCLUSION

HPV-negative CIN2+ or cervical adenocarcinoma is not a concern for the introduction of primary HPV screening in Japan. Primary HPV testing in cervical cancer screening is considered a feasible method that can be used in Japan, although an algorithm suitable for Japan and a national-level management system need to be established.

A qualitative study of primary care clinician's approach to ending cervical cancer screening in older women in the United States

The United States Preventive Services Task Force (USPSTF) recommends that cervical cancer screening end in average-risk patients with a cervix at 65 years of age if adequate screening measures have been met, defined as having 1) at least three normal consecutive cytology (Pap) tests, or 2) two normal cytology tests and/or two negative high-risk human papillomavirus tests between ages 55-65; the last test should be performed within the prior 5 years. Up to 60 % of all women aged 65 years and older who are ending screening do not meet the criteria for adequate screening. The objective of this study was to understand the process and approach that healthcare clinicians use to determine eligibility to end cervical cancer screening. In 2021 we conducted semi-structured interviews in San Francisco, CA with twelve healthcare clinicians: two family medicine physicians, three general internal medicine physicians, two obstetrician/gynecologists and five nurse practitioners. Thematic analysis, using inductive and deductive coding, was utilized. Three major themes emerged: following guidelines, relying on self-reported data regarding prior screening, and considering sexual activity as a factor in the decision to end screening. All interviewees endorsed following the USPSTF guidelines and they utilized self-report to determine eligibility to end screening. Clinicians' approach was dependent in part on their judgement about the reliability of the patient to convey their screening history. Sexual activity of the patient was considered when making clinical recommendations. Shared decision-making was often utilized. Clinicians voiced a strong reliance on self-reported screening history to end cervical cancer screening.

Cancer screening in China: a steep road from evidence to implementation

Cancer screening has the potential to decrease mortality from several common cancer types. The first cancer screening programme in China was initiated in 1958 and the Cancer High Incidence Fields established in the 1970s have provided an extensive source of information for national cancer screening programmes. From 2012 onwards, four ongoing national cancer screening programmes have targeted eight cancer types: cervical, breast, colorectal, lung, oesophageal, stomach, liver, and nasopharyngeal cancers. By synthesising evidence from pilot screening programmes and population-based studies for various screening tests, China has developed a series of cancer screening guidelines. Nevertheless, challenges remain for the implementation of a fully successful population-based programme. The aim of this Review is to highlight the key milestones and the current status of cancer screening in China, describe what has been achieved to date, and identify the barriers in transitioning from evidence to implementation. We also make a set of implementation recommendations on the basis of the Chinese experience, which might be useful in the establishment of cancer screening programmes in other countries.

Primary Care Provider Receptivity to Multi-Cancer Early Detection Test Use in Cancer Screening

Multi-cancer early detection tests (MCEDs) are blood-based tests that detect biomarkers released or induced by cancer cells. If MCED tests are shown to be safe and effective in cancer screening, they are likely to be ordered and managed in primary care. To understand primary care providers' support for and concerns about the implementation and management of MCED testing, the research team developed a cross-sectional survey that was sent to 939 primary care providers (physicians, residents/fellows, and advanced practice providers) in a large academic health system in the greater Philadelphia area. The survey included standard items used to assess provider background characteristics and to measure provider awareness of challenges related to MCED test use (7 items), perceived competence in MCED testing (5 items), and receptivity to MCED test use in the future (4 items). A total of 351 (37.4%) primary care providers completed the survey. Among respondents, the awareness of challenges in MCED testing (mean = 3.95, sd = 0.64), perceived competence (3.67, sd = 0.85), and receptivity to MCED use in practice (mean = 3.62, 0.75) were moderately high. Multiple regression was performed to identify factors associated with receptivity to MCED testing. We found that provider number of years in practice (DATA), awareness of challenges related to MCED testing (DATA), and perceived competence in MCED test use (DATA) were positively and significantly associated with receptivity to MCED test use in practice. An exploratory factor analysis extracted two components: receptivity to MCEDs and awareness of challenges. Surprisingly, these factors had a positive correlation (r = 0.124, p = 0.024). Providers' perceived competence in using MCED tests and providers' experience level were significantly associated with receptivity to MCED testing. While there was strong agreement with potential challenges to implementing MCEDs, PCPs were generally receptive to using MCEDs in cancer screening. Keeping PCPs updated on the evolving knowledge of MCEDs is likely critical to building receptivity to MCED testing.

Strategies to Increase Cervical Cancer Screening With Mailed Human Papillomavirus Self-Sampling Kits: A Randomized Clinical Trial

Importance

Optimal strategies for increasing cervical cancer screening may differ by patient screening history and health care setting. Mailing human papillomavirus (HPV) self-sampling kits to individuals who are overdue for screening increases adherence; however, offering self-sampling kits to screening-adherent individuals has not been evaluated in the US.

Objective

To evaluate the effectiveness of direct-mail and opt-in approaches for offering HPV self-sampling kits to individuals by cervical cancer screening history (screening-adherent and currently due, overdue, or unknown).

Design, Setting, and Participants

Randomized clinical trial conducted in Kaiser Permanente Washington, a US integrated health care delivery system. Individuals aged 30 to 64 years with female sex, a primary care clinician, and no hysterectomy were identified through electronic health records (EHRs) and enrolled between November 20, 2020, and January 28, 2022, with follow-up through July 29, 2022.

Interventions

Individuals stratified as due (eg, at the time of randomization, these individuals have been previously screened and are due for their next screening in ≤3 months) were randomized to receive usual care (patient reminders and clinician EHR alerts [n = 3671]), education (usual care plus educational materials about screening [n = 3960]), direct mail (usual care plus educational materials and a mailed self-sampling kit [n = 1482]), or to opt in (usual care plus educational materials and the option to request a kit [n = 3956]). Individuals who were overdue for screening were randomized to receive usual care (n = 5488), education (n = 1408), or direct mail (n = 1415). Individuals with unknown history for screening were randomized to receive usual care (n = 2983), education (n = 3486), or to opt in (n = 3506).

Main Outcomes and Measures

The primary outcome was screening completion within 6 months. Primary analyses compared direct-mail or opt-in participants with individuals randomized to the education group.

Results

The intention-to-treat analyses included 31 355 randomized individuals (mean [SD] age, 45.9 [10.4] years). Among those who were due for screening, compared with receiving education alone (1885 [47.6%]), screening completion was 14.1% (95% CI, 11.2%-16.9%) higher in the direct-mail group (914 [61.7%]) and 3.5% (95% CI, 1.2%-5.7%) higher in the opt-in group (2020 [51.1%]). Among individuals who were overdue, screening completion was 16.9% (95% CI, 13.8%-20.0%) higher in the direct-mail group (505 [35.7%]) compared with education alone (264 [18.8%]). Among those with unknown history, screening was 2.2% (95% CI, 0.5%-3.9%) higher in the opt-in group (634 [18.1%]) compared with education alone (555 [15.9%]).

Conclusions and Relevance

Within a US health care system, direct-mail self-sampling increased cervical cancer screening by more than 14% in individuals who were due or overdue for cervical cancer screening. The opt-in approach minimally increased screening. To increase screening adherence, systems implementing HPV self-sampling should prioritize direct-mail outreach for individuals who are due or overdue for screening. For individuals with unknown screening history, testing alternative outreach approaches and additional efforts to document screening history are warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT04679675.

Surgical Treatment for Early Cervical Cancer in the HPV Era: State of the Art

Cervical cancer (CC) is the fourth most common cancer among women worldwide. The aim of this study is to focus on the state of the art of CC prevention, early diagnosis, and treatment and, within the latter, the role of surgery in the various stages of the disease with a focus on the impact of the LACC study (Laparoscopic Approach to Cervical Cancer trial) on the scientific debate and clinical practice. We have discussed the controversial application of minimally invasive surgery (MIS) for tumors < 2 cm and the possibility of fertility-sparing surgery on young women desirous of pregnancy. This analysis provides support for surgeons in the choice of better management, including patients with a desire for offspring and the need for sentinel node biopsy (SNB) rather than pelvic lymphadenectomy for tumors < 4 cm, and without suspicious lymph nodes' involvement on imaging. Vaccines and early diagnosis of pre-cancerous lesions are the most effective public health tool to tackle cervical cancer worldwide.

Epigenome-wide methylation and progression to high-grade cervical intraepithelial neoplasia (CIN2+): a prospective cohort study in the United States

BACKGROUND

Methylation levels may be associated with and serve as markers to predict risk of progression of precancerous cervical lesions. We conducted an epigenome-wide association study (EWAS) of CpG methylation and progression to high-grade cervical intraepithelial neoplasia (CIN2 +) following an abnormal screening test.

METHODS

A prospective US cohort of 289 colposcopy patients with normal or CIN1 enrollment histology was assessed. Baseline cervical sample DNA was analyzed using Illumina HumanMethylation 450K (n = 76) or EPIC 850K (n = 213) arrays. Participants returned at provider-recommended intervals and were followed up to 5 years via medical records. We assessed continuous CpG M values for 9 cervical cancer-associated genes and time-to-progression to CIN2+. We estimated CpG-specific time-to-event ratios (TTER) and hazard ratios using adjusted, interval-censored Weibull accelerated failure time models. We also conducted an exploratory EWAS to identify novel CpGs with false discovery rate (FDR) < 0.05.

RESULTS

At enrollment, median age was 29.2 years; 64.0% were high-risk HPV-positive, and 54.3% were non-white. During follow-up (median 24.4 months), 15 participants progressed to CIN2+. Greater methylation levels were associated with a shorter time-to-CIN2+ for CADM1 cg03505501 (TTER = 0.28; 95%CI 0.12, 0.63; FDR = 0.03) and RARB Cluster 1 (TTER = 0.46; 95% CI 0.29, 0.71; FDR = 0.01). There was evidence of similar trends for DAPK1 cg14286732, PAX1 cg07213060, and PAX1 Cluster 1. The EWAS detected 336 novel progression-associated CpGs, including those located in CpG islands associated with genes FGF22, TOX, COL18A1, GPM6A, XAB2, TIMP2, GSPT1, NR4A2, and APBB1IP.

CONCLUSIONS

Using prospective time-to-event data, we detected associations between CADM1-, DAPK1-, PAX1-, and RARB-related CpGs and cervical disease progression, and we identified novel progression-associated CpGs.

IMPACT

Methylation levels at novel CpG sites may help identify individuals with ≤CIN1 histology at higher risk of progression to CIN2+ and inform risk-based cervical cancer screening guidelines.

A non-invasive method for concurrent detection of multiple early-stage cancers in women

Untargeted serum metabolomics was combined with machine learning-powered data analytics to develop a test for the concurrent detection of multiple cancers in women. A total of fifteen cancers were tested where the resulting metabolome data was sequentially analysed using two separate algorithms. The first algorithm successfully identified all the cancer-positive samples with an overall accuracy of > 99%. This result was particularly significant given that the samples tested were predominantly from early-stage cancers. Samples identified as cancer-positive were next analysed using a multi-class algorithm, which then enabled accurate discernment of the tissue of origin for the individual samples. Integration of serum metabolomics with appropriate data analytical tools, therefore, provides a powerful screening platform for early-stage cancers.

Significance of concurrent HPV testing with unsatisfactory Papanicolaou test for prediction of follow-up HPV, Papanicolaou test, and biopsy results

OBJECTIVES

Approximately 1% to 2% of routine cytologic specimens collected for Papanicolaou testing are unsatisfactory for evaluation. The American Society for Colposcopy and Cervical Pathology 2019 guidelines recommend repeat testing within 2 to 4 months of an unsatisfactory Papanicolaou test (UPT) result.

METHODS

We evaluated the utility of follow-up Papanicolaou testing, human papillomavirus (HPV) testing, and biopsy in 258 cases of UPTs.

RESULTS

High-risk HPV testing was positive in 17.4% (n = 45) and negative in 82.6% (n = 213) of cases at the time of initial UPT; 8.1% (n = 21) of cases had discordant HPV test results. Similarly, 3.8% (n = 8) of initially HPV-negative cases were reported to be HPV-positive on follow-up; 28.9% (n = 13) of initially HPV-positive cases were reported to be HPV negative on follow-up. In total, 27.1% (n = 70) of cases underwent biopsy. Biopsies with significant findings were present in 40% (n = 12) of HPV-positive cases and 7.5% (n = 3) of HPV-negative cases. Low-grade squamous intraepithelial lesion (LSIL) (low-grade cervical intraepithelial neoplasia [CIN-1]) was the most significant finding in all 3 HPV-negative biopsies; 58.3% (n = 7) of HPV-positive biopsies showed LSIL (CIN-1), 13.3% (n = 4) showed HSIL (high-grade CIN), and 3.3% (n = 1) showed invasive carcinoma. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of concurrent HPV testing at the time of UPT for predicting follow-up HPV test result within 1 year of initial UPT are 80.0%, 94.0%, 71.1%, and 96.2%, respectively. The sensitivity, specificity, PPV, and NPV of initial HPV test results for predicting follow-up Papanicolaou test results are 67.7%, 89.7%, 48.8%, and 95.0%, respectively.

RESULTS

Concurrent HPV testing in the setting of UPT can be a sensitive tool for predicting follow-up HPV status and significant findings of squamous intraepithelial lesions on follow-up Papanicolaou tests and biopsy.

Estimated US Cancer Deaths Prevented With Increased Use of Lung, Colorectal, Breast, and Cervical Cancer Screening

Importance

Increased use of recommended screening could help achieve the Cancer Moonshot goal of reducing US cancer deaths.

Objective

To estimate the number of cancer deaths that could be prevented with a 10-percentage point increase in the use of US Preventive Services Task Force (USPSTF)-recommended screening.

Design, Setting, and Participants

This decision analytical model study is an extension of previous studies conducted for the USPSTF from 2018 to 2023. This study simulated contemporary cohorts of US adults eligible for lung, colorectal, breast, and cervical cancer screening.

Exposures

Annual low-dose computed lung tomography among eligible adults aged 50 to 80 years; colonoscopy every 10 years among adults aged 45 to 75 years; biennial mammography among female adults aged 40 to 74 years; and triennial cervical cytology screening among female adults aged 21 to 29 years, followed by human papillomavirus testing every 5 years from ages 30 to 65 years.

Main Outcomes and Measures

Estimated number of cancer deaths prevented with a 10-percentage point increase in screening use, assuming screening commences at the USPSTF-recommended starting age and continues throughout the lifetime. Outcomes were presented 2 ways: (1) per 100 000 and (2) among US adults in 2021; and they were expressed among the target population at the age of screening initiation. For lung cancer, estimates were among those who will also meet the smoking eligibility criteria during their lifetime. Harms from increased uptake were also reported.

Results

A 10-percentage point increase in screening use at the age that USPSTF recommended screening commences was estimated to prevent 226 lung cancer deaths (range across models within the cancer site, 133-332 deaths), 283 (range, 263-313) colorectal cancer deaths, 82 (range, 61-106) breast cancer deaths, and 81 (1 model; no range available) cervical cancer deaths over the lifetimes of 100 000 persons eligible for screening. These rates corresponded with an estimated 1010 (range, 590-1480) lung cancer deaths prevented, 11 070 (range, 10 280-12 250) colorectal cancer deaths prevented, 1790 (range, 1330-2310) breast cancer deaths prevented, and 1710 (no range available) cervical cancer deaths prevented over the lifetimes of eligible US residents at the recommended age to initiate screening in 2021. Increased uptake was also estimated to generate harms, including 100 000 (range, 45 000-159 000) false-positive lung scans, 6000 (range, 6000-7000) colonoscopy complications, 300 000 (range, 295 000-302 000) false-positive mammograms, and 348 000 (no range available) colposcopies over the lifetime.

Conclusions and Relevance

In this decision analytical model study, a 10-percentage point increase in uptake of USPSTF-recommended lung, colorectal, breast, and cervical cancer screening at the recommended starting age was estimated to yield important reductions in cancer deaths. Achieving these reductions is predicated on ensuring equitable access to screening.

Disparities in cervical cancer screening among Arabic-speaking women refugees

OBJECTIVES

Cervical cancer remains one of the most common cancers among females and one of the top causes of cancer-related deaths worldwide. Minority women are disproportionately more vulnerable. This study addressed disparities in cervical cancer screening among Arabic-speaking women refugees.

DESIGN

We conducted a cross-sectional study using qualitative and quantitative research methods at a Federally Qualified Health Center (FQHC) in Cleveland, Ohio, in the United States of America (USA). A structured phone-based survey was developed and administered in Arabic. The study was conducted from 2018 to 2019 and involved 20 participants.

RESULTS

Inequity in cervical cancer screening exists among Arab women refugees (41% being up to date with their screening) compared to their English- and Spanish-speaking counterparts (51%). These women perceived that the top three barriers to cervical cancer screening were fear of cancer, language, and lack of knowledge. The top three perceived facilitators were the doctor's recommendation, reminders from the provider's office, and awareness of cervical cancer screening.

CONCLUSION

Our work brings unique insights into improving preventive care services for Arabic-speaking women. These findings add unique insight focused on improving preventive care in this group and can inform interventions to increase cancer screening amongst Arabic-speaking women.

Uptake of Cervical Cancer Screening Among Female Patients Using a Mobile Medical Clinic

INTRODUCTION

Although cervical cancer causes morbidity, it can be prevented if diagnosed early; previous research has shown lower rates of screening in patients with health-related social needs by self-report data. This study assessed cervical cancer screening uptake among female patients with health-related social needs who access care through a community-based mobile medical clinic.

METHODS

A retrospective cohort was developed of all cis-female patients aged 21-65 years who sought care at the mobile medical clinic between January 1, 2016 and December 31, 2019, and their medical data were captured from the electronic health record. Bivariate and multivariate logistic regression (performed in 2022/2023) were used to investigate correlates of ever having received cervical cancer screening and of being up to date with cervical cancer screening.

RESULTS

Less than half of the 1,455 patient cohort had ever undergone Pap testing. In the multivariate model, ever having received cervical cancer screening was directly associated with being Hispanic or Black, living with HIV, and having received human papillomavirus vaccination. People who currently smoke showed significantly lower odds of ever having had cervical cancer screening than people who have never smoked. Patients who were single or had other marital status had lower adjusted odds of being up to date as well as those with a substance use history and those with unstable housing.

CONCLUSIONS

Cervical cancer screening rates in this community-based mobile medical clinic model were low, highlighting a need for increased attention to screening in this high-risk population. Mobile medical clinics have increased screening uptake internationally, and this model could be adopted domestically to promote screening to patients who access health care in various settings.

Women's perceptions and preferences for cervical cancer screening in light of updated guidelines

BACKGROUND

Updated risk-based guidelines for cervical cancer screening (CCS) allow for individualized screening that minimizes unnecessary testing. However, these guidelines are complex and may not be easily understandable to patients.

PURPOSE

To describe women's perceptions and preferences about CCS in light of recent guideline changes.

METHODOLOGY

This qualitative study conducted in February 2020 used online, text-based focus groups with a sample of US women ( n = 49) ages 27-45. After participants completed a short demographic survey, an experienced moderator used a semistructured guide to solicit participants' perceptions of routine gynecologic care and CCS. We summarized survey data using descriptive statistics. Two authors analyzed transcripts using conventional content analysis and met with other team members to resolve discrepancies and determine final themes.

RESULTS

Most participants were non-Hispanic White (65%), had health insurance (90%), and reported having a routine gynecologic examination in the past year (70%). We identified four common themes: (1) low perceived risk of human papillomavirus (HPV) coupled with low knowledge about HPV as a causative factor for cervical cancer, (2) confusion about-and mistrust of-recent individual risk-based guidelines that determine the indicated timing and type of CCS test (Pap or HPV testing), (3) mixed opinions about performing a self-swab for HPV testing, and (4) conflicting perceptions of trust toward providers and the health care industry.

CONCLUSIONS

Findings highlight women's uncertainty and hesitancy about updated CCS guidelines.

IMPLICATIONS

Provider-patient communication strategies should consider women's gaps in knowledge about HPV, include the rationale for guidelines and types of tests, and build trust between patients and providers.

Disparities in Gynecologic Cancers

ABSTRACT

Gynecologic cancer disparities have different trends by cancer type and by sociodemographic/economic factors. We highlight disparities in the United States arising due to poor delivery of cancer care across the continuum from primary prevention, detection, and diagnosis through treatment and identify opportunities to eliminate/reduce disparities to achieve cancer health equity. Our review documents the persistent racial and ethnic disparities in cervical, ovarian, and uterine cancer outcomes, with Black patients experiencing the worst outcomes, and notes literature investigating social determinants of health, particularly access to care. Although timely delivery of screening and diagnostic evaluation is of paramount importance for cervical cancer, efforts for ovarian and uterine cancer need to focus on timely recognition of symptoms, diagnostic evaluation, and delivery of guideline-concordant cancer treatment, including tumor biomarker and somatic/germline genetic testing.

Geographic Variation in Late-Stage Cervical Cancer Diagnosis

Importance

There are stark disparities in cervical cancer burden in the United States, notably by race and ethnicity and geography. Late-stage diagnosis is an indicator of inadequate access to and utilization of screening.

Objective

To identify geospatial clusters of late-stage cervical cancer at time of diagnosis in Texas.

Design, Setting, and Participants

This population-based cross-sectional study used incident cervical cancer data from the Texas Cancer Registry from 2014 to 2018 of female patients aged 18 years or older. Late-stage cervical cancer cases were geocoded at the census tract level (n = 5265) using their residential coordinates (latitude and longitude) at the time of diagnosis. Statistical analysis was performed from April to September 2023.

Exposures

Census tract of residence at diagnosis.

Main Outcome and Measures

Late-stage cervical cancer diagnosis (ie, cases classified by the National Cancer Institute Surveillance, Epidemiology and End Results summary stages 2 to 4 [regional spread] or 7 [distant metastasis]). A Poisson probability-based model of the SaTScan purely spatial scan statistics was applied at the census tract-level to identify geographic clusters of higher (hot spots) or lower (cold spots) proportions than expected of late-stage cervical cancer diagnosis and adjusted for age.

Results

Among a total of 6484 female patients with incident cervical cancer cases (mean [SD] age, 48.7 [14.7] years), 2300 (35.5%) were Hispanic, 798 (12.3%) were non-Hispanic Black, 3090 (47.6%) were non-Hispanic White, and 296 (4.6%) were other race or ethnicity. Of the 6484 patients, 2892 with late-stage diagnosis (mean [SD] age, 51.8 [14.4] years were analyzed. Among patients with late-stage diagnosis, 1069 (37.0%) were Hispanic, 417 (14.4%) were non-Hispanic Black, 1307 (45.2%) were non-Hispanic White, and 99 (3.4%) were other race or ethnicity. SaTScan spatial analysis identified 7 statistically significant clusters of late-stage cervical cancer diagnosis in Texas, of which 4 were hot spots and 3 were cold spots. Hot spots included 1128 census tracts, predominantly in the South Texas Plains, Gulf Coast, and Prairies and Lakes (North Texas) regions. Of the 2892 patients with late-stage cervical cancer, 880 (30.4%) were observed within hot spots. Census tract-level comparison of characteristics of clusters suggested that hot spots differed significantly from cold spots and the rest of Texas by proportions of racial and ethnic groups, non-US born persons, and socioeconomic status.

Conclusions and Relevance

In this cross-sectional study examining geospatial clusters of late-stage cervical cancer diagnosis, place-based disparities were found in late-stage cervical cancer diagnosis in Texas. These findings suggest that these communities may benefit from aggressive cervical cancer interventions.

Disparities Contributing to Late-Stage Diagnosis of Lung, Colorectal, Breast, and Cervical Cancers: Rural and Urban Poverty in Florida

Despite advances in cancer screening, late-stage cancer diagnosis is still a major cause of morbidity and mortality in the United States. In this study, we aim to understand demographic and geographic factors associated with receiving a late-stage diagnosis (LSD) of lung, colorectal, breast, or cervical cancer. (1) Methods: We analyzed data of patients with a cancer diagnosis between 2016 and 2020 from the Florida Cancer Data System (FCDS), a statewide population-based registry. To investigate correlates of LSD, we estimated multi-variable logistic regression models for each cancer while controlling for age, sex, race, insurance, and census tract rurality and poverty. (2) Results: Patients from high-poverty rural areas had higher odds for LSD of lung (OR = 1.23, 95% CI (1.10, 1.37)) and breast cancer (OR = 1.31, 95% CI (1.17,1.47)) than patients from low-poverty urban areas. Patients in high-poverty urban areas saw higher odds of LSD for lung (OR = 1.05 95% CI (1.00, 1.09)), breast (OR = 1.10, 95% CI (1.06, 1.14)), and cervical cancer (OR = 1.19, 95% CI (1.03, 1.37)). (3) Conclusions: Financial barriers contributing to decreased access to care likely drive LSD for cancer in rural and urban communities of Florida.

The cancer glycocode as a family of diagnostic biomarkers, exemplified by tumor-associated gangliosides

One unexploited family of cancer biomarkers comprise glycoproteins, carbohydrates, and glycolipids (the Tumor Glycocode).A class of glycolipid cancer biomarkers, the tumor-marker gangliosides (TMGs) are presented here as potential diagnostics for detecting cancer, especially at early stages, as the biological function of TMGs makes them etiological. We propose that a quantitative matrix of the Cancer Biomarker Glycocode and artificial intelligence-driven algorithms will expand the menu of validated cancer biomarkers as a step to resolve some of the challenges in cancer diagnosis, and yield a combination that can identify a specific cancer, in a tissue-agnostic manner especially at early stages, to enable early intervention. Diagnosis is critical to reducing cancer mortality but many cancers lack efficient and effective diagnostic tests, especially for early stage disease. Ideal diagnostic biomarkers are etiological, samples are preferably obtained via non-invasive methods (e.g. liquid biopsy of blood or urine), and are quantitated using assays that yield high diagnostic sensitivity and specificity for efficient diagnosis, prognosis, or predicting response to therapy. Validated biomarkers with these features are rare. While the advent of proteomics and genomics has led to the identification of a multitude of proteins and nucleic acid sequences as cancer biomarkers, relatively few have been approved for clinical use. The use of multiplex arrays and artificial intelligence-driven algorithms offer the option of combining data of known biomarkers; however, for most, the sensitivity and the specificity are below acceptable criteria, and clinical validation has proven difficult. One strategic solution to this problem is to expand the biomarker families beyond those currently exploited. One unexploited family of cancer biomarkers comprise glycoproteins, carbohydrates, and glycolipids (the Tumor Glycocode). Here, we focus on a family of glycolipid cancer biomarkers, the tumor-marker gangliosides (TMGs). We discuss the diagnostic potential of TMGs for detecting cancer, especially at early stages. We include prior studies from the literature to summarize findings for ganglioside quantification, expression, detection, and biological function and its role in various cancers. We highlight the examples of TMGs exhibiting ideal properties of cancer diagnostic biomarkers, and the application of GD2 and GD3 for diagnosis of early stage cancers with high sensitivity and specificity. We propose that a quantitative matrix of the Cancer Biomarker Glycocode and artificial intelligence-driven algorithms will expand the menu of validated cancer biomarkers as a step to resolve some of the challenges in cancer diagnosis, and yield a combination that can identify a specific cancer, in a tissue-agnostic manner especially at early stages, to enable early intervention.

Frequency of post-treatment disease after excisional procedure in stage IA1 squamous cervical carcinoma - a case series

Early stages of cervical cancer in young women need conservative treatments. Electrosurgical therapies (LLETZ, LEEP, SWETZ, NETZ) have been recommended for these women. However, there are recommendations to perform a second excision when the specimen margins are not free of disease. This can lead to some important complications. This article aims to verify the frequency of residual invasive or microinvasive disease after the excisional procedure in women with IA1CC. Data on women with IA1CC diagnosed between 1990 and 2022, were retrieved from medical records. Post-treatment disease was detected during a second surgical procedure or postoperative follow-up. Among the 69 included women, three (4.3 percent; CI95 percent 0-9.2) had residual microinvasive lesions, while none showed invasive disease during a second procedure or follow-up. Only the age of 37 years or more was significantly related to the presence of preinvasive or microinvasive residual lesions. Nearly 80 percent of the women who underwent a second procedure showed no residual lesions. The absence of invasive disease in a second procedure or during the follow-up of these women and the large proportion of women with no residual lesion questions the need for a new surgical procedure even when the surgical margins of the initial specimen are involved.

Self-Collection for Primary HPV Testing: Perspectives on Implementation From Federally Qualified Health Centers

INTRODUCTION

Primary testing for high-risk human papillomavirus (HPV) by self-collection could result in higher rates of cervical cancer screening. Federally qualified health centers (FQHCs) in the US serve a large proportion of women who have low income and no health insurance and are medically underserved - risk factors for being insufficiently screened for cervical cancer. Although the implementation of self-collection for HPV testing is not yet widespread, health care entities need to prepare for its eventual approval by the US Food and Drug Administration. We conducted focus groups and interviews among clinical and administrative staff and leadership to gather data on key logistical concerns that must be addressed before implementing self-collection for HPV testing in FQHCs.

METHODS

We identified focus group and interview participants from 6 FQHCs in North Carolina. We conducted focus groups with clinical and administrative staff (N = 45) and semistructured interviews with chief executive officers, senior-level administrators, chief medical officers, and clinical data managers (N = 24). Transcripts were coded by using codebooks derived from research questions and notes taken during data collection. Themes emerged on implementation of self-collection for HPV testing. We applied the constructs from the Consolidated Framework for Implementation Research (CFIR) to themes to identify domains of potential barriers and facilitators to implementation.

RESULTS

Clinical personnel reported that offering self-collection for HPV testing is acceptable and feasible and can increase cervical cancer screening rates. Uncertainties emerged about accuracy of results, workflow disruptions, financial implications, and effects on clinic quality measures.

CONCLUSION

Implementing self-collection for HPV testing was considered feasible and acceptable by participants. However, important health service delivery considerations, including financial implications, must be addressed before integrating self-collection for HPV testing into the standard of care.

The Role of p16/Ki67 Dual Staining in Cervical Cancer Screening

Cervical cancer screening has enabled a decrease in the incidence and mortality of cervical cancer. Various screening modalities have been studied to date. In many countries, screening is still based on cervical cytology, where cervical cells obtained either on glass or in a liquid medium are examined under a microscope. However, the fact that the vast majority of cervical cancers are a result of persistent infection with high-risk human papillomaviruses (hr-HPV) has led to the implementation of primary HPV screening in many countries. Taking into consideration the fact that the majority of HPV infections are transient and do not cause cervical precancer, effective triage methods are needed to prevent an increase in colposcopy referrals. Among these, the most extensively investigated are HPV genotyping, HPV methylation, and p16/Ki67 dual staining. In this manuscript, we briefly summarize the current knowledge regarding different screening strategies for the prevention of cervical cancer, with a focus on p16/Ki67 dual staining. In addition, we provide an explanation regarding the rationale for the use of various screening modalities based on the molecular biology of cervical cancer and cervical precancerous lesions.

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial

Importance

Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results.

Objective

To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results.

Design, Setting, and Participants

Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021.

Intervention

Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment.

Main Outcomes and Measures

The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk.

Results

Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result.

Conclusions and Relevance

A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT03979495.

Screening for cancer beyond recommended upper age limits: views and experiences of older people

BACKGROUND

Internationally, screening programmes and clinical practice guidelines recommend when older adults should stop cancer screening using upper age limits, but it is unknown how older adults view these recommendations.

OBJECTIVE

To examine older adults' views and experiences about continuing or stopping cancer screening beyond the recommended upper age limit for breast, cervical, prostate and bowel cancer.

DESIGN

Qualitative, semi-structured interviews.

SETTING

Australia, telephone.

SUBJECTS

A total of 29 community-dwelling older adults (≥70-years); recruited from organisation newsletters, mailing lists and Facebook advertisements.

METHODS

Interviews were audio-recorded, transcribed and analysed thematically using Framework Analysis.

RESULTS

Firstly, older adults were on a spectrum between trusting recommendations and actively deciding about cancer screening, with some who were uncertain. Secondly, participants reported limited in-depth discussions with health professionals about cancer screening. In primary care, discussions were focused on checking they were up to date with screening or going over results. Discussions mostly only occurred if older adults initiated themselves. Finally, participants had a socially- and self-constructed understanding of screening recommendations and potential outcomes. Perceived reasons for upper age limits were cost, reduced cancer risk or ageism. Risks of screening were understood in relation to their own social experiences (e.g. shared stories about friends with adverse outcomes of cancer treatment or conversations with friends/family about controversy around prostate screening).

CONCLUSIONS

Direct-to-patient information and clinician support may help improve communication about the changing benefit to harm ratio of cancer screening with increasing age and increase understanding about the rationale for an upper age limit for cancer screening programmes.

Opportunities Missed: Cervix Cancer Screening Failures in Women Aged 65 and Older

OBJECTIVES

This study aimed to determine the screening history and associated outcomes of women diagnosed with cervical cancer after age 65.

METHODS

All patients from 2012 to 2021 diagnosed with squamous, adenocarcinoma, neuroendocrine, or adenosquamous cervical cancer after age 65 in a single managed care organization (MCO) were included in this retrospective cohort study. Demographic, medical, screening, pathologic, follow-up, and treatment data were extracted. Statistical analysis was done using chi-square test and logistic regression. Cancer-specific survival was estimated using the Kaplan-Meier method.

RESULTS

Of 2,175 patients screened, 209 met inclusion criteria. Only 26.3% of patients had appropriate cervical cancer screening and 41% of patients died of their disease. Managed care organization membership duration of more than 5 years positively correlated with proper cervical cancer screening ( p < .001); however, 64% of the long-term members still did not meet criteria to end screening at age 65, with 42.6% of these patients having more than 25 physician visit opportunities to address screening. Increased physician visits correlated with earlier stage at diagnosis of cervical cancer ( p = .012). Median cancer-specific survival was significantly better in properly screened patients at 68 vs 30 months, respectively ( p = .03).

CONCLUSIONS

Most patients diagnosed with cervical cancer after age 65 did not have adequate previous screening, including those who were MCO members for more than 5 years. There were many missed opportunities for screening, despite multiple provider touchpoints. The authors' data suggest that adequate screening confers a survival benefit secondary to earlier stage at diagnosis. Further study in this age group is needed to redefine the criteria to end cervix cancer screening.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Late cervical and vaginal clear cell adenocarcinoma in women exposed in utero to diethylstilbestrol: Evaluation and screening

OBJECTIVES

We aimed to evaluate the risk of cervical and vaginal clear cell adenocarcinoma (CCA) in women, aged 50 years or more, exposed in utero to diethylstilbestrol (DES) and contribute to a reevaluation of the recommendations for cervical and vaginal cancer and pre-cancer screening for these women.

METHODS

We carried out a retrospective review for patients received in a cancer institute. Two cohorts were consecutively studied, the first from 1970 to 2003 and the second from 2004 to 2021, and then linked.

RESULTS

During the first period, we observed 61 CCA cases, with a mean age at diagnosis of 23 years (7-42), 36 (59%) following DES exposure in utero. During the second period, we found 27 cases, with one case of DES exposure (4%) for a women diagnosed at the age of 40 years. The mean age of the second cohort was 38 years (14-79). For the seven women aged 50 years or more at the time of CCA diagnosis, DES exposure was excluded for five and considered unlikely for the other two.

CONCLUSION

In total, 88 cases of cervical or vaginal CCA were observed over a period of 51 years in a cancer center. The 37 cases associated with DES exposure represented approximatively one third of the CCA related to DES expected in France. DES exposure was improbable for the seven cases of CCA for women aged 50 years or more. These results do not support the hypothesis of late cervical or vaginal CCA in women exposed to DES in utero and indicate the need for larger multicentric studies. For the present, we propose specific screening for women exposed to DES in utero in terms of : 1) methods: association of cytology and hrHPV testing, with cervical and vaginal sampling, 2) timing : annual, or without exceeding a three-year interval, continuing after 65 years of age and after hysterectomy.

Unamplified and Label-Free Detection of HPV16 DNA Using CRISPR-Cas12a-Functionalized Solution-Gated Graphene Transistors

The persistent infection of high-risk-human papillomavirus type 16 (HPV16) is considered an essential element for suffering cervical cancer. Despite polymerase chain reaction, loop-mediated amplification, and microfluidic chips are used to detect the HPV16, these methods still exist some drawbacks including time-consuming and false positive results. The CRISPR-Cas system is widely used in the region of biological detection due to its precise targeted recognition capability. In this contribution, the novel solution-gated graphene transistor sensor is designed to realize the unamplified and label-free detection of HPV16 DNA. Using the precise recognition of the CRISPR-Cas12a system and the gate functionalization, HPV16 DNA can be precisely identified without need the amplification and labeling. The limit of detection of the sensor can be up to 8.3 × 10-18  m and the detection can be within 20 min. Additionally, the heat-Inactivated clinical samples can be clearly distinguished by the sensor the diagnosis results have a high degree of agreement with q-PCR detection.

Concordance of Primary Human Papillomavirus Testing Among Clinicians and Patients: A Systematic Review

Objective: Primary high risk human papilloma virus (hrHPV) testing is recommended as first-line screening for cervical cancer. Testing involves either a clinician-collected or a self-collected cervicovaginal swab. This study examines concordance between methods of collection of primary HPV testing. Methods: Ovid MEDLINE, Ovid Embase, and Cochrane were searched for relevant studies on self-collected and clinician-collected primary HPV testing published before December 31, 2022. English-language studies for primary HPV testing of average-risk patients were included. Studies conducted in screening settings rather than colposcopy clinics, that used standard devices for HPV collection, and that directly compared methods of collection were included. Outcomes were concordance and kappa between paired samples, and rate of HPV detection in self-collected and clinician-collected samples. Results: A total of 2381 studies were screened, of which 228 were included for full-text evaluation. Thirty-six studies, including 23,328 individuals screened, met the inclusion criteria. The rate of HPV detection ranged from 4.7% to 63% for self-collection and from 3.7% to 62% for clinician-collection. The concordance ranged from 78.2% to 96.9%, and kappa had substantial agreement for 26 of the 36 studies and moderate agreement for 7 of the 36 studies. Conclusions: This study directly compares clinician-collected and self-collected primary HPV screening rates. Studies were conducted in methods which are widely reproducible in the primary care setting. Primary HPV self-collection is a reliable and accurate method for cervical cancer screening.

Triage Value of Cervical Exfoliated Cell DNA Ploidy Analysis in Cervical High-Risk Human Papillomavirus-Positive Women

OBJECTIVE

This study aimed to investigate the triage value obtained in DNA ploidy analysis of cervical exfoliated cells in women with high-risk human papillomavirus (HR-HPV)-positive status in the primary screening of cervical cancer.

METHODS

The authors selected 3,000 HR-HPV-positive women for cervical exfoliated cell sampling and conducted DNA ploidy analysis, liquid-based cytology (LBC), colposcopy, and cervical biopsy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of high-grade squamous intraepithelial lesion (HSIL)-positive detection between DNA ploidy analysis and LBC were compared according to histopathology diagnosis as the golden criteria, and the efficacy of predicting HSIL-positive immediate risk was evaluated.

RESULTS

A total of 2,892 HR-HPV-positive women were enrolled in the investigation. For HSIL+ women, the DNA ploidy group showed a significantly higher sensitivity (CIN2+: 79.21% vs 65.35%, p = .022; CIN3+: 81.48% vs 70.37%, p = .013), lower specificity (CIN2+: 85.00% vs 96.59%, p < .001; CIN3+: 84.14% vs 93.41%, p < .001), and lower PPV (CIN2+: 16.23% vs 29.33%, p = .001; CIN3+: 8.92% vs 16.89%, p = .002) compared with the LBC group, whereas the NPV showed no significant difference. Compared with LBC alone in diagnosing HSIL, DNA ploidy combined with LBC showed higher specificity (CIN2+: 99.21% vs 96.59%, p = .003; CIN3+: 96.48% vs 93.41%, p < .001) and higher PPV (CIN2+: 41.35% vs 29.33%, p = .022; CIN3+: 24.81% vs 16.89%, p = .028), whereas no significant difference was observed in the sensitivity (CIN2+: 54.46% vs 65.35%, p = .063; CIN3+: 61.11% vs 70.37%, p = .221) and NPV ( p > .05). Among the HR-HPV-positive women positive for DNA ploidy, the imminent risk of CIN2+ and CIN3+ were 15.62% and 8.92%, respectively, above the threshold for the colposcopy positive rate. Among the positive cases both for DNA ploidy and the LBC result of negative for intraepithelial lesion or malignancy, the immediate risk of CIN3+ was 3.31%, below the threshold for colposcopy positive rate. Besides, for women with LBC result of ASC-US and above, the immediate risk of CIN3+ was greater than 4%.

CONCLUSIONS

The DNA ploidy analysis can be used as an effective triage method for HR-HPV-positive women during the primary screening of cervical cancer, although it can provide higher specificity when combined with LBC and reduce the referral rate for colposcopy.

The Association Between Adverse Childhood Experiences and Human Papillomavirus Vaccination Coverage in US Young Adults: A Cross-Sectional Study

BACKGROUND

Adverse childhood experiences (ACEs) contribute to adverse health outcomes in adulthood. Access to preventive health care services, including genital human papillomavirus (HPV) vaccinations, may mitigate the impact of ACEs on adverse health outcomes. Our objective was to assess associations between ACEs and HPV vaccination coverage among young adults.

METHODS

We included 3415 respondents aged 18 to 29 years to the 2019-2020 Behavioral Risk Factor Surveillance System ACE and HPV vaccination modules. Adverse childhood experiences included emotional, physical, and sexual abuse; household intimate partner violence, substance abuse, and mental illness; and parental separation/divorce and incarcerated household member. We used log-binomial regression models to calculate prevalence ratios (PRs) with 95% confidence intervals (CI) for associations between ACEs and self-reported HPV vaccination and completion. Secondary outcomes included influenza vaccination uptake, time since routine checkup, HIV testing history, and HIV-related risk behavior.

RESULTS

Several ACEs were positively associated with HPV vaccination initiation, including emotional abuse (PR, 1.29; 95% CI, 1.17-1.43), intimate partner violence (PR, 1.14; 95% CI, 1.00-1.30), substance abuse (PR, 1.20; 95% CI, 1.08-1.33), and mental illness (PR, 1.35; 95% CI, 1.22-1.50). Similar associations were observed for completion. Conversely, most ACEs were negatively associated with influenza vaccination (PRs from 0.72 to 1.00) and with recent checkup (PRs from 0.92 to 1.00). Adverse childhood experiences were positively associated with having had an HIV test (PRs from 1.19 to 1.56) and HIV-related risk behavior (PRs from 1.19 to 2.07).

CONCLUSIONS

The unexpected positive associations between ACEs and HPV vaccination coverage could be due to opportunities to receive HPV vaccination in late adolescence or early adulthood while accessing STI/HIV prevention or treatment services. Future studies should evaluate associations between ACEs and timely HPV vaccination in early adolescence.

MicroRNA expression associated with low-grade cervical intraepithelial neoplasia outcomes

PURPOSE

Only a fraction of low-grade cervical intraepithelial neoplasia (CIN) progresses to high-grade CIN; however, the biological processes that differentiate progressive CIN from CIN that resolves naturally are poorly understood. MicroRNAs (miRNAs) are important epigenetic regulators of gene expression and thus, miRNA expression profiling can reveal the dysregulated biology underlying disease processes. The purpose of this case-control study was to reveal miRNA expression patterns and predict the underlying biological pathways that are associated with clinical outcomes of low-grade CIN.

METHODS

Women with low-grade CIN diagnosis and definitive clinical outcomes (n = 51) were identified retrospectively using electronic clinical records. Comprehensive miRNA expression profiling was performed on the low-grade CIN diagnostic cervical biopsies retrieved from pathology archives. Differential miRNA expression was analyzed by comparing women with CIN that progressed to women with CIN that resolved naturally.

RESULTS

Differential expression of 29 miRNAs was observed in low-grade CIN that progressed to high-grade compared to low-grade CIN that resolved. Of these, 24 were significantly downregulated in progressive CIN, including miR-638, miR-3196, miR-4488, and miR-4508, while 5 miRNAs, including miR-1206a, were significantly upregulated. Computational gene ontology analysis based on the discovered miRNAs and their putative mRNA targets revealed biological processes associated with oncogenic phenotypes.

CONCLUSION

Distinct miRNA expression profiles are associated with clinical outcomes of low-grade CIN. The functional effects of the differentially expressed miRNAs may be biological determinants of CIN progression or resolution.

Colposcopy referral rates post-introduction of primary screening with human papillomavirus testing: evidence from a large British Columbia cohort study

Background

Shifting from cytology to human papillomavirus (HPV)-based cervical cancer screening will initially increase colposcopy referrals. The anticipated impact on health systems has been raised as a concern for implementation. It is unclear if the higher rate of colposcopy referrals is sustained after initial HPV-based screens or reverts to new lower baselines due to earlier detection and treatment of precancer. This study aimed to investigate long-term rates of colposcopy referrals after participation in HPV-based screening.

Methods

Participants of HPV for Cervical Cancer Screening trial (HPV FOCAL) received one (HPV1, N = 6204) or two (HPV2, N = 9540) HPV-based screens. After exit, they returned to British Columbia's (BC) cytology screening program. A comparison cohort from the BC screening population (BCS, N = 1,140,745) was identified, mirroring trial inclusion criteria. All participants were followed for 10-14 years through the provincial screening registry. Colposcopy referral rates per 1000 screens were calculated for each group. Trial colposcopy referrals for HPV1 and HPV2 were calculated under two referral scenarios: (1) all HPV positive referred to colposcopy; (2) cytology triage with ASCUS or greater referred to colposcopy. Colposcopy referrals from post-trial screens in HPV1 an HPV2 and all screens in BCS were based on actual recommendations from the screening program. A multivariable flexible survival regression model compared hazard ratios (HR) throughout follow-up.

Findings

Scenario 2 referral rates were higher during initial HPV screen(s) vs cytology screen (HPV1: 28 per 1000 screens (95% CI: 24, 33), HPV2: 32 per 1000 screens (95% CI: 29, 36), BCS: 8 per 1000 screens (95% CI: 8.9)). However, post-trial rates in HPV1 and HPV2 were significantly lower than in BCS. Cumulative rates in HPV1 and HPV2 approached the cumulative rate in BCS 11-12 years after HPV-based screening (HPV1: 11 per 1000 screens (95% CI: 10, 12), HPV2: 16 per 1000 screens (95% CI: 15-17), BCS: 11 per 1000 screens (95% CI: 10, 11)). Adjusted models demonstrated reductions in referral rates in HPV1 (HR = 0.6, 95% CI: 0.5, 0.7) and HPV2 (HR = 0.7, 95% CI: 0.6, 0.8) relative to BCS by 54 and 72 months post-final HPV screen respectively.

Interpretation

Reduced colposcopy referral rates were observed after initial rounds of HPV-based screening. After initial HPV screening, referral rates to colposcopy after cytology triage were below the current rates seen in a centralized cytology program after approximately four years. Any expected increase in referrals at initiation of HPV-based screening could be countered by staged program implementation.

Funding

This work was supported by the National Institutes of Health (R01 CA221918), Michael Smith Health Research BC (RT-2021-1595), and the Canadian Institutes of Health Research (MCT82072).

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.

Lack of Awareness of Human Papillomavirus Testing Among U.S. Women

INTRODUCTION

National surveys provide important information for public health planning. Lack of preventive screenings awareness may result in unreliable survey estimates. This study examines women's awareness of receiving human papillomavirus testing using three national surveys.

METHODS

In 2022, self-reported data analyses on human papillomavirus testing status among women without hysterectomy were conducted from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) (n=80,648, aged 30-64 years), the 2019 National Health Interview Survey (NHIS) (n=7,062, aged 30-65 years), and the 2017-2019 National Survey of Family Growth (n=2,973, aged 30-49 years). Associations between human papillomavirus awareness status (yes, no, don't know) and demographic characteristics were examined with generalized multinomial logistic model to generate adjusted prevalence ratios. Adjusted risk differences were assessed with the t-test for the Don't know answer.

RESULTS

A total of 21.8% or >12 million in the study population of women in the BRFSS, 19.5%, (>10.5 million women) in the NHIS, and 9.4% in the National Survey of Family Growth responded don't know to human papillomavirus testing awareness status question. Women aged 40-64 years in BRFSS and 50-65 years in NHIS were more likely to answer don't know than those aged 30-34 (p<0.05 and p<0.01, respectively). Non-Hispanic White women were more likely to answer don't know than non-Hispanic Native Hawaiian/Pacific Islander, non-Hispanic Black, non-Hispanic Asian, and Hispanic women in BRFSS and non-Hispanic Black women in NHIS (adjusted prevalence ratio range=0.60-0.78; p<0.001 and adjusted prevalence ratio=0.72; p<0.001, respectively).

CONCLUSIONS

One in five women was unaware of her human papillomavirus testing status, and awareness was lower among older and non-Hispanic White women. The awareness gap may affect the reliability of estimated human papillomavirus testing population uptake using survey data.