Racial and ethnic disparities in cervical cancer incidence rates in the United States, 1992-2003

Survival disparities in non-Hispanic Black and White cervical cancer patients vary by histology and are largely explained by modifiable factors

PURPOSE

We investigated racial disparities in survival by histology in cervical cancer and examined the factors contributing to these disparities.

METHODS

Non-Hispanic Black and non-Hispanic White (hereafter known as Black and White) patients with stage I-IV cervical carcinoma diagnosed between 2004 and 2017 in the National Cancer Database were studied. Survival differences were compared using Cox modeling to estimate hazard ratio (HR) or adjusted HR (AHR) and 95% confidence interval (CI). The contribution of demographic, socioeconomic and clinical factors to the Black vs White differences in survival was estimated after applying propensity score weighting in patients with squamous cell carcinoma (SCC) or adenocarcinoma (AC).

RESULTS

This study included 10,111 Black and 43,252 White patients with cervical cancer. Black patients had worse survival than White cervical cancer patients (HR = 1.40, 95% CI = 1.35-1.45). Survival disparities between Black and White patients varied significantly by histology (HR = 1.20, 95% CI = 1.15-1.24 for SCC; HR = 2.32, 95% CI = 2.12-2.54 for AC, interaction p < 0.0001). After balancing the selected demographic, socioeconomic and clinical factors, survival in Black vs. White patients was no longer different in those with SCC (AHR = 1.01, 95% CI 0.97-1.06) or AC (AHR = 1.09, 95% CI = 0.96-1.24). In SCC, the largest contributors to survival disparities were neighborhood income and insurance. In AC, age was the most significant contributor followed by neighborhood income, insurance, and stage. Diagnosis of AC (but not SCC) at ≥65 years old was more common in Black vs. White patients (26% vs. 13%, respectively).

CONCLUSIONS

Histology matters in survival disparities and diagnosis at ≥65 years old between Black and White cervical cancer patients. These disparities were largely explained by modifiable factors.

Assessing Spanish Health Literacy and Cervical Cancer Knowledge, Attitudes, and Behaviors in a Student-Run Free Clinic

While the incidence of cervical cancer continues to decrease, there is a significant discrepancy in incidence rates and screening behaviors among Hispanic and non-Hispanic white patients in the USA. This project examines the relationship between Spanish health literacy and cervical cancer screening knowledge, attitudes, and practices among native Spanish-speaking patients at risk for cervical cancer at the USF BRIDGE Healthcare Clinic, a student-run free clinic in Tampa, FL. Spanish-speaking patients ≥21 years (n = 34) participated in a quality improvement project that included an assessment of Spanish health literacy and a written survey on cervical cancer knowledge. Chi-squared tests were performed to assess potential relationships between health literacy and cervical cancer knowledge, attitudes, health behaviors, and demographics. Seven participants (20.6%) scored between 0 and 14 on the SAHL-S, indicating inadequate health literacy. A significant difference in cervical cancer health knowledge was found between patients with adequate health literacy compared to patients with inadequate health literacy (p = 0.002). There is a potential association between low Spanish health literacy and subsequent poorer understanding of cervical cancer in BRIDGE patients. This implies that patients of low health literacy may have poorer comprehension of other aspects of their care beyond cervical cancer screening. Strategies are discussed to improve communication with BRIDGE patients of low Spanish health literacy that may be applicable to other patient populations.

Racial and Ethnic Disparities in Cervical Cancer Incidence, Survival, and Mortality by Histologic Subtype

PURPOSE

We conducted an integrated population-based analysis of histologic subtype-specific cervical cancer incidence, survival, and incidence-based mortality by race and ethnicity, with correction for hysterectomy prevalence.

METHODS

Using the SEER 21 and 18 registries, we selected primary cases of malignant cervical cancer diagnosed among women ≥ 15 years. We evaluated age-adjusted incidence rates among cases diagnosed between 2000 and 2018 (SEER21) and incidence-based mortality rates among deaths from 2005 to 2018 (SEER18), per 100,000 person-years. Rates were stratified by histologic subtype and race/ethnicity (incidence and mortality), and stage, age at diagnosis, and county-level measures of social determinants of health (incidence only). Incidence and mortality rates were corrected for hysterectomy using data from the Behavioral Risk Factor Surveillance System. We estimated 5-year relative survival by histologic subtype and stratified by stage at diagnosis.

RESULTS

Incidence rates of cervical squamous cell carcinoma were highest in Black and Hispanic women, while incidence rates of cervical adenocarcinoma (ADC) were highest among Hispanic and White women, particularly for localized ADC. County-level income and education variables were inversely associated with squamous cell carcinoma incidence rates in all racial and ethnic groups but had less influence on ADC incidence rates. Black women had the highest overall mortality rates and lowest 5-year relative survival, irrespective of subtype and stage. Disparities in survival were particularly pronounced for Black women with regional and distant ADC, compared with other racial/ethnic groups.

CONCLUSION

Although Black women are less likely to be diagnosed with ADC compared with all other racial/ethnic groups, they experience the highest mortality rates for this subtype, likely attributed to the poor survival observed for Black women with regional and distant ADC.

Assessing Intersectional Disparities in Cervical Cancer Screening by Disability Status, Race, and Ethnicity

Introduction

Separate bodies of research have studied disparities by disability status and by race or ethnicity in receipt of cervical cancer screening. Much less is known about how these disparities intersect. The purpose of this study was to evaluate disparities in compliance with the U.S. Preventive Services Task Force guidelines for Pap testing in age-eligible women at the intersection of disability and race or ethnicity.

Methods

We conducted cross-sectional analyses of the Medical Expenditure Panel Survey Household Component deidentified public data files pooled for years 2007-2016, using a modified Poisson regression analysis to compute prevalence ratios for being up to date with Pap testing by disability status and race or ethnicity. We also calculated predicted marginal proportions adjusting for demographic and socioeconomic covariates.

Results

The analytic sample included 68,507 women with nonmissing covariates; 15.6% had a disability. Overall, the proportion current with Pap testing was significantly lower among women with disabilities than among those without disabilities (82.1% vs 88.6%, p<0.0001). Furthermore, within each racial and ethnic group, women with disabilities were less likely than those without disabilities to be current with Pap testing. In adjusted analyses, prevalence ratios for White women with disabilities (adjusted prevalence ratio=0.94; 95% CI=0.92, 0.96) and other race women with and without disabilities (adjusted prevalence ratio=0.91; 95% CI=0.86, 0.95 and adjusted prevalence ratio=0.91; 95% CI=0.89, 0.95, respectively) were significantly below those for the reference group of White women without disabilities. Hispanic women with disabilities did not differ significantly from White women without disabilities, and Black women with disabilities had significantly higher adjusted prevalence ratios than White women without disabilities (adjusted prevalence ratio=1.07; 95% CI=1.05, 1.09). When taking covariates into account, the proportion of Black women with disabilities current with screening was only slightly lower than the estimated proportion for Black women without disabilities (92% vs 93%). The gap in screening between White women with and without disabilities narrowed somewhat (from 9 percentage points to 4 percentage points) but remained significant.

Conclusions

Our results extend previous research focused separately on disability or race and ethnicity. Women with disabilities in all racial and ethnic groups fell short of Healthy People 2020 goals for cervical cancer screening.

COVID-19 and health inequality: the nexus of race, income and mortality in New York City

Purpose

The purpose of this paper is to evaluate socioeconomic factors related to COVID-19 mortality rates in New York City (NYC) to understand the connections between socioeconomic variables, including race and income and the disease.

Design/methodology/approach

Using multivariable negative binomial regression, the association between health and mortality disparities related to COVID-19 and socioeconomic conditions is evaluated. The authors obtained ZIP code-level data from the NYC Department of Health and Mental Hygiene and the US Census Bureau.

Findings

This study concludes that the mortality rate rises in areas with a higher proportion of Hispanic and Black residents, whereas areas with higher income rates had lower mortality associated with COVID-19, among over 18,000 confirmed deaths in NYC.

Originality/value

The paper highlights the impacts of social, racial and wealth disparities in mortality rates. It brings to focus the importance of targeted policies regarding these disparities to alleviate health inequality among marginalized communities and to reduce disease mortality.

HPV Vaccination in Young Males: A Glimpse of Coverage, Parental Attitude and Need of Additional Information from Lombardy Region, Italy

Background: In the Lombardy Region, Italy, HPV vaccination is recommended and offered free of charge to 12-years-old males since 2017. The expected vaccination thresholds are still far to be reached. Methods: A cross-sectional survey to investigate parents’ attitudes towards the HPV vaccine and knowledge about HPV was administered to parents of boys aged 6 to 18 years attending a large pediatric hospital for outpatient specialistic evaluations. Two parallel multiple logistic regression analyses were conducted to estimate the odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) for attitude towards HPV vaccination and perceived need for more information about HPV vaccination. Results: A positive attitude towards HPV vaccination was found in 74% of interviewed parents. Knowledge of HPV, having a generally positive attitude toward vaccination, and mothers filling in the survey were positively associated with a positive attitude to the HPV vaccine. Parents’ perceived need for more information about HPV vaccination was positively associated with the child’s age, general positive attitude toward vaccination, Christian religion, and positive attitude toward HPV vaccination; knowing that HPV vaccination is free of charge significantly reduced the risk of asking for more information on HPV vaccination. Conclusions: The majority of parents of male children and adolescents in our study have a positive attitude toward HPV vaccination. Attitude toward HPV vaccination and perceived need for more information on HPV vaccination were directly related to a positive attitude toward vaccines in general. In addition, knowledge of HPV and related pathologies favors a positive attitude toward HPV vaccination. Future health programs should target an even wider diffusion of evidence-based information on vaccines in general and on the HPV vaccine in young males, to support a positive attitude toward vaccines in the general population.

The Development of Human Papillomavirus (HPV) Vaccines and Current Barriers to Implementation

The identification of the human papillomavirus (HPV) as the causative agent of multiple cancers allowed for the development of vaccines and immunization strategies to prevent cancers caused by HPV infection. The public health ramifications of reduction of HPV disease burden are momentous in scope. Vaccine hesitancy has impacted widespread vaccination, but strategies have been identified to combat vaccine safety and efficacy misinformation and promote immunization.

Monitoring HPV vaccine impact on cervical disease: Status and future directions for the era of cervical cancer elimination

Post-licensure monitoring of the impact of HPV vaccines is critical to track the progress being made toward cervical cancer elimination and to identify areas where further progress can accelerate the achievement of this important public health goal. Over the past decade, a large body of evidence has revealed convincing benefits of HPV vaccination in preventing cervical infections and precancers at the individual-level (i.e., direct effectiveness) as well as in reducing the population-level burden of disease (i.e., overall effectiveness). At this time, effectiveness of the vaccines on preventing cervical cancer is just beginning to emerge given that there is a prolonged latency period for invasive disease. As we enter the era of cervical cancer elimination, these early and promising results may be expected in other countries in the near future. Thus, monitoring the direct and overall effectiveness for cervical cancer is an urgent research priority. In this article, we summarize what is known about the effectiveness of HPV vaccines on precancerous outcomes, and we highlight considerations for continuing these important public health activities going forward to monitor progress toward cervical cancer elimination.

The impact of socioeconomic status on HPV infection among young Brazilians in a nationwide multicenter study

The aim of this study is to evaluate genital human papillomavirus (HPV) infection according to socioeconomic categories in Brazil. This cross-sectional, nationwide study included 7,694 sexually active women and men aged 16-25 years. Individuals of all socioeconomic groups in all 26 Brazilian capitals and the Federal District were enrolled through public primary care units between September 2016 and November 2017. All participants answered a standardized interview administered by trained primary care health professionals. Socioeconomic class was analyzed using a pricing classification system for the Brazilian public that divides the market exclusively in terms of economic class based on the ownership of assets and the education level. Cervical samples were obtained using a Digene® HC2 DNA Collection, and penile/scrotum samples were obtained using a wet Dacron swab. HPV typing (overall and high-risk) was performed in a central lab. Of the 7,694 participants (47.85% women), 17.92% belonged to class A-B, 56.08% to class C, and 26.00% to class D-E. The prevalence of overall HPV was similar among the social classes: 51.16% for classes A-B, 53.39% for class C, and 55.47% for classes D-E (P = 0.479). Similar results were found for high-risk HPV. After adjustments, the presence of HPV in individuals with a brown skin color belonging to classes A-B was 57.00% higher [prevalence ratio 1.57 (95%: 1.23, 2.01)] than that in whites and had no impact on the other social classes. In conclusion, HPV infection affects all socioeconomic classes in Brazil, evidencing the importance of offering the HPV vaccine to the entire population.

Gynecologic cancer incidence and mortality among American Indian/Alaska Native women in the Pacific Northwest, 1996-2016

OBJECTIVES

Compare the incidence and mortality of gynecologic cancers among American Indian/Alaska Native (AI/AN) women to the Non-Hispanic White (NHW) population in the Pacific Northwest.

METHODS

Age-adjusted cancer incidence (1996-2016) and mortality (2006-2016) rates were calculated from population-based state cancer registry and death certificate data obtained from Washington, Oregon, and Idaho, and corrected for AI/AN misclassification. Incidence and mortality rate ratios (RR) were calculated to compare AI/AN and NHW women with gynecologic cancers.

RESULTS

Across all gynecologic cancer sites, AI/AN women were diagnosed at a younger age compared to NHW women. AI/AN women had a higher incidence of cervical cancer compared to NHW women with a RR of 1.53 (95% CI: 1.34, 1.75). For all age groups, AI/AN women had a higher incidence of cervical cancer and the disparity was greatest in the 50-64 age group with a RR of 1.76 (95% CI: 1.36, 2.30). Cervical cancer mortality was greater among AI/AN women, with an all-ages RR of 1.79 (95% CI: 1.30, 2.46); the disparity was greatest in the 50-64 age group (RR: 2.88, 95% CI: 1.89, 4.38). For uterine cancer, AI/AN women had similar incidence rates as NHW women but higher mortality rates (RR: 1.35, 95% CI: 1.03-1.75). Incidence and mortality for ovarian cancer were similar between groups.

CONCLUSION

Our analysis of gynecologic cancers among AI/AN in the PNW found significant disparities relative to NHW women in cervical cancer incidence and mortality. These disparities persist despite advances in prevention strategies.

Inequality in the Incidence of Cervical Cancer: Costa Rica 1980-2010

Introduction: Cervical cancer is the third most incident and the fourth most lethal cancer among Costa Rican women. The purpose of this study was to quantify incidence inequality along three decades and to explore its determinants. Materials and Methods: This is a population-based study. Main data sources were the National Tumor Registry (1980-2010), CRELES (Costa Rican Longevity and Healthy Aging Study) longitudinal survey (2013), and published indices of economic condition (2007) and access to healthcare (2000). Cartography was made with QGIS software. Inequality was quantified using the Theil-T index. With the purpose of detecting differences by tumor's behavior, inequality was estimated for "in situ" and invasive incidence. In Situ/Invasive Ratios were estimated as an additional marker of inequality. Poisson and spatial regression analyses were conducted with Stata and ArcMap software, respectively, to assess the association between incidence and social determinants such as economic condition, access to healthcare and sub-utilization of Papanicolaou screening. Results: As measured by Theil-T index, incidence inequality has reached high (83 to 87%) levels during the last three decades. For invasive cervical cancer, inequality has been rising especially in women aged 50-59; increasing from 58% in the 1980's to 66% in 2000's. Poisson regression models showed that sub-utilization of Papanicolaou smear was associated with a significant decrease in the probability of early diagnosis. Costa Rican guidelines establish a Pap smear every 2 years; having a Pap smear every 3 years or longer was associated with a 36% decrease in the probability of early "in situ" diagnosis (IRR = 0.64, p = 0.003) in the last decade. Spatial regression models allowed for the detection of specific areas where incidence of invasive cervical cancer was higher than expected. Conclusion: Results from this study provide evidence of inequality in the incidence of cervical cancer, which has been high over three decades, and may be explained by sub-utilization of Papanicolaou smear screening in certain regions. The reasons why women do not adequately use screening must be addressed in future research. Interventions should be developed to stimulate the utilization of screening especially among women aged 50 to 59 where inequality has been rising.

Preference for Human Papillomavirus Self-Collection and Papanicolaou: Survey of Underscreened Women in North Carolina

OBJECTIVES

Self-collection of samples for human papillomavirus (HPV) testing (self-collection) has the potential to increase cervical cancer screening among underscreened women. We assessed attitudes toward at-home HPV self-collection compared with clinic-based Pap testing in this higher-risk population.

MATERIALS AND METHODS

Participants were low-income women in North Carolina overdue for cervical cancer screening. Women self-collected samples at home, returned samples by mail for HPV testing, and completed phone questionnaires about at-home HPV self-collection. Participants were referred to clinic-based Pap testing and invited to complete a second questionnaire about Pap testing. A cross-sectional questionnaire compared attitudes, experiences, and preferences for self-collection versus Pap testing and assessed predictors of preference for HPV self-collection.

RESULTS

Half (51%) of 221 women reported a preference for HPV self-collection, 19% preferred Pap testing, and 27% reported no preference. More women reported difficulty finding time to do the Pap test (31%) than the self-test (13%, p = .003) and being afraid of the self-test results (50%) than the Pap test results (36%, p = .02). There were relatively fewer reports of physical discomfort and pain from self-collection than Pap testing (discomfort: 18% self; 48% Pap; pain: 8% self; 30% Pap, p = .001). No differences were found in positive versus negative thoughts about the tests, trust in the tests' safety and accuracy, or willingness to do tests again.

CONCLUSIONS

Overall positive attitudes toward HPV self-collection compared with Pap testing among underscreened women suggest that self-collection is a promising option to increase cervical cancer screening in this high-risk population.

A contemporary framework of health equity applied to gynecologic cancer care: A Society of Gynecologic Oncology evidenced-based review

Health disparities are defined as the preventable difference in the burden of disease, injury, and violence, or opportunity to achieve optimal health that socially disadvantaged populations experience compared to the population as a whole. Disparities in incidence and cancer outcomes for women with gynecologic malignancies have been well described particularly for American women of Black race. The etiology of these disparities has been tied to socio-economics, cultural, educational and genetic factors. While access to high quality treatment has been primarily linked to survival from cervical and ovarian cancer, innate biologic distinctions have been principally cited as reasons for differences in incidence and mortality in cancers of the uterine corpus. This article will update the framework of disparities to incorporate a broader understanding of the social determinants of health and how they affect health equity by addressing the root causes of disparities within the health care system. Special populations are identified who are at risk for health inequities which include but are not limited to Black race, underserved racial and ethnic minorities (e.g. indigenous peoples, low English fluency), trans/gender nonconforming people and rural populations. Each of these populations at risk have unique structural barriers within the healthcare system impacting gynecologic cancer outcomes. The authors provide practical recommendations for practitioners aimed at eliminating cancer related outcome disparities.

Definitive radiation therapy for cervical cancer: Non-white race and public insurance are risk factors for delayed completion, a pilot study

This is a pilot study to assess whether racial disparities exist in time to initiation and completion of external beam pelvic radiation therapy and brachytherapy in cervical cancers treated with definitive chemoradiation.

A retrospective analysis was conducted on all cervical cancer patients treated with definitive radiotherapy between 2006 and 2016 at a single institution. Patient demographics including age, race, insurance status and stage at diagnosis were obtained. Analyses were performed according to the following definitions of wait times: interval from pathologic diagnosis of cervical cancer to (Siegel et al., 2016) initiation of radiation therapy, (Yoo et al., 2017) completion of external beam radiation therapy and (DeSantis et al., 2016) completion of external beam radiation therapy plus brachytherapy if indicated.

Of 50 women, 21 self-identified as white, 25 as black and 4 as Hispanic. Due to small numbers, Hispanic women were included with black women as a non-white group. The average age was 52 years for women in this cohort. Mean days to initiation of radiation therapy were 41.8 days: 33.7 days among white patients versus 47.8 days for non-white patients (p-value 0.101). Mean days from diagnosis to completion of external beam pelvic radiation therapy were 81.3 days: 70.9 days among white patients versus 88.9 days among non-white patients (p-value 0.006). Non-white patients were more likely to have public insurance, which was also associated with a longer time to completion of radiation treatment.

We conclude that non-white patients experienced delays to completing external beam radiation therapy, which was no longer present after adjusting for insurance status.

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Non-white patients experience delayed completion of external beam radiation therapy for cervical cancer.

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Public insurance is associated with delayed completion of therapy.

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Receipt of standard of care does not vary by race.

Impact of Widespread Cervical Cancer Screening: Number of Cancers Prevented and Changes in Race-specific Incidence

OBJECTIVES

With recent approval of standalone HPV testing and increasing uptake of HPV vaccination, some have postulated that we are moving toward a "post-Pap" era of cervical cancer prevention. However, the total number cases that have been prevented by Pap smear screening as well as its impact on racial disparities are unknown.

METHODS

We estimated national cervical cancer incidence from 1976 to 2009 using the Surveillance, Epidemiology, and End Result database. Screening data were obtained from the literature and National Cancer Institute Progress Reports. We examined early, late, and race-specific trends in cancer incidence, and calculated the estimated number of cancers prevented over the past 3 decades.

RESULTS

From 1976 to 2009, there was a significant decrease in the incidence of early-stage cervical cancer, from 9.8 to 4.9 cases per 100,000 women (P<0.001). Late-stage disease incidence also decreased, from 5.3 to 3.7 cases per 100,000 women (P<0.001). The incidence among black women decreased from 26.9 to 9.7 cases per 100,000 women (P<0.001), a greater decline compared with that of white women and women of other races. After adjusting for "prescreening era" rates of cervical cancer, we estimate that Pap smears were associated with a reduction of between 105,000 and 492,000 cases of cervical cancer over the past 3 decades in the United States.

CONCLUSIONS

A large number of early-stage and late-stage cervical cancers were prevented and racial disparity in cancer rates were reduced during an era of widespread Pap smear screening.

Role of Race/Ethnicity, Language, and Insurance in Use of Cervical Cancer Prevention Services Among Low-Income Hispanic Women, 2009-2013

Introduction

Hispanic women in the United States have an elevated risk of cervical cancer, but the existing literature does not reveal why this disparity persists.

Methods

We performed a retrospective cohort analysis of 17,828 low-income women aged 21 to 64 years seeking care at Oregon community health centers served by a hosted, linked electronic health record during 2009 through 2013. We assessed the odds of having had Papanicolaou (Pap) tests and receiving human papillomavirus (HPV) vaccine, by race/ethnicity, insurance status, and language.

Results

Hispanic women, regardless of pregnancy status or insurance, had greater odds of having had Pap tests than non-Hispanic white women during the study period. English-preferring Hispanic women had higher odds of having had Pap tests than Spanish-preferring Hispanic women (OR, 2.08; 95% confidence interval [CI], 1.63–2.66) but lower odds of having received HPV vaccination (OR, 0.21; 95% CI, 0.12–0.38). Uninsured patients, regardless of race/ethnicity, had lower odds of HPV vaccine initiation than insured patients did. Once a single dose was received, there were no significant racial/ethnic differences in vaccine series completion.

Conclusion

In this sample of low-income women seeking care at Oregon community health centers, we found minimal racial/ethnic disparities in the receipt of cervical cancer prevention services. Inequities by insurance status, especially in the receipt of HPV vaccine, persist. Community health center–based care may be a useful model to address racial/ethnic disparities in prevention, but this model would need further population-wide study.

Differential expression of microRNAs in the normal skin of the Han and Uyghur populations in Xinjiang Province

In this study, we investigated the expression of microRNAs (miRNAs) in the skin samples from the Han and Uyghur populations in Xinjiang, China. The miRNA levels of the normal skin samples from 10 individuals of Uyghur or Han were tested by microarray and the expression differentiations were compared. Among the 3100 probes for microarray, a total of 247 miRNAs were differentially expressed in the Han versus Uyghur population, including 76 upregulated miRNAs and 171 downregulated miRNAs. The most significantly upregulated miRNAs were miR-141-3p, miR-1915-5p, kshv-miR-K12-2-5p, and miR-222-3p. And the most significantly downregulated miRNAs included miR-1207-3p and miR-625-3p. We have confirmed the upregulation of miR-141-3p and miR-1915-5p by qRT-PCR. There were no statistical correlations in the expression of miR-141-3p or miR-1915-5p with the age or gender within each group. Interestingly, the differentially expressed miRNAs were enriched in some cancer-related pathways, such as p53, mitogen-activated protein kinase, and WNT signal pathways. Collectively, these dysregulated expressions of the miRNAs may provide a better understanding of the differences in the incidence and mortality of skin-related carcinoma between the Uyghur and Han populations in Xinjiang.

Correlates of Cervical Cancer Screening Among Adult Latino Women: A 5-Year Follow-Up

BACKGROUND

Latinas have the highest incidence rates of cervical cancer in the United States, and Latinas in the United States are less likely to utilize cervical cancer screening.

METHOD

We used secondary data analysis of a non-clinical convenience sample (n=316 women at baseline; n=285 at five-year follow-up) to examine correlates of cervical cancer screening among adult Latina women. Univariate and multiple logistic regression models using Generalized Estimated Equations (GEE) algorithm were utilized to assess the influence of the independent variables.

RESULTS

Women who reported their main healthcare source as community health clinics, women who were sexually active, and women who reported that a healthcare provider discussed HIV prevention with them were more likely to report having a cervical cancer screening (aOR=2.06; CI=1.20, 3.52).

CONCLUSION

The results suggest a need for continued efforts to ensure that medically underserved women (e.g., Latina women) receive counseling and education about the importance of preventive cancer screening.

Disparities in parental human papillomavirus (HPV) vaccine awareness and uptake among adolescents

Trends in HPV vaccine awareness among parents of adolescent girls and boys (ages 13-17) and HPV vaccine uptake (≥1 dose) among girls (ages 13-17) were evaluated in Los Angeles County, California. Between 2007 and 2011, parental HPV vaccine awareness increased from 72% to 77% overall, with significant increases among mothers, Latinos, and respondents with daughters and Medi-Cal insured children. In 2011, parents who were male, older, less educated, Asian/Pacific Islander, and had sons remained significantly less likely to be aware. HPV vaccine initiation among daughters nearly doubled from 25% in 2007 to 48% in 2011, and girls who were older, uninsured, and had access-related barriers showed the largest improvements. In 2011, daughters who were younger and who had older and African American parents were at risk for low uptake. Thus, initiatives targeting male and younger adolescents, culturally-relevant information, and access to vaccination may help to reduce identified disparities.

Medicaid Expansions and Cervical Cancer Screening for Low-Income Women

OBJECTIVE

Medicaid coverage for low-income women may play an important role in ensuring access to preventive care. This study examines how Medicaid eligibility expansions to nonelderly adults impact cervical cancer screening among low-income women.

DATA SOURCES

We use data from the Behavioral Risk Factor Surveillance System from 2000 to 2010. The primary outcome of interest is whether women in the relevant guideline consistent age range reported having a Pap test in the previous year.

STUDY DESIGN

We use a difference-in-differences approach with matched treatment and comparison states and a simulated eligibility approach based on a continuous measure of Medicaid generosity.

PRINCIPAL FINDINGS

Our results indicate that cervical cancer screening increased among low-income women in expansion states relative to comparison states. Increases in screening rates are largest among low-income Hispanic women.

CONCLUSIONS

Medicaid expansions during the period from 2000 to 2010 were associated with improved cervical cancer screening rates, which is critical for early cervical cancer detection and prevention of cancer morbidity and mortality in women. The results suggest that more widespread Medicaid expansions may have positive effects on preventive health care for women.

Mailed HPV self-sampling for cervical cancer screening among underserved minority women: study protocol for a randomized controlled trial

Background

Underserved ethnic minority women experience significant disparities in cervical cancer incidence and mortality, mainly due to lack of cervical cancer screening. Barriers to Pap smear screening include lack of knowledge, lack of health insurance and access, and cultural beliefs regarding disease prevention. In our previous SUCCESS trial, we demonstrated that HPV self-sampling delivered by a community health worker (CHW) is efficacious in circumventing these barriers. This approach increased screening uptake relative to navigation to Pap smear screening. SUCCESS trial participants, as well as our community partners, provided feedback that women may prefer the HPV self-sampler to be delivered through the mail, such that they would not need to schedule an appointment with the CHW. Thus, our current trial aims to elucidate the efficacy of the HPV self-sampling method when delivered via mail.

Design

We are conducting a randomized controlled trial among 600 Haitian, Hispanic, and African-American women from the South Florida communities of Little Haiti, Hialeah, and South Dade. Women between the ages of 30 and 65 years who have not had a Pap smear within the past 3 years are eligible for the study. Women are recruited by CHWs and complete a structured interview to assess multilevel determinants of cervical cancer risk. Women are then randomized to receive HPV self-sampling delivered by either the CHW (group 1) or via mail (group 2). The primary outcome is completion of HPV self-sampling within 6 months post enrollment.

Discussion

Our trial is among the first to examine the efficacy of the mailed HPV self-sampling approach. If found to be efficacious, this approach may represent a cost-effective strategy for cervical cancer screening within underserved and underscreened minority groups.

Trial registration

ClinicalTrials.gov, NCT02202109. Registered on 9 July 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1721-6) contains supplementary material, which is available to authorized users.

Novel Somatic Copy Number Alteration Identified for Cervical Cancer in the Mexican American Population

Cervical cancer affects millions of Americans, but the rate for cervical cancer in the Mexican American is approximately twice that for non-Mexican Americans. The etiologies of cervical cancer are still not fully understood. A number of somatic mutations, including several copy number alterations (CNAs), have been identified in the pathogenesis of cervical carcinomas in non-Mexican Americans. Thus, the purpose of this study was to investigate CNAs in association with cervical cancer in the Mexican American population. We conducted a pilot study of genome-wide CNA analysis using 2.5 million markers in four diagnostic groups: reference (n = 125), low grade dysplasia (cervical intraepithelial neoplasia (CIN)-I, n = 4), high grade dysplasia (CIN-II and -III, n = 5) and invasive carcinoma (squamous cell carcinoma (SCC), n = 5) followed by data analyses using Partek. We observed a statistically-significant difference of CNA burden between case and reference groups of different sizes (>100 kb, 10-100 kb and 1-10 kb) of CNAs that included deletions and amplifications, e.g., a statistically-significant difference of >100 kb deletions was observed between the reference (6.6%) and pre-cancer and cancer (91.3%) groups. Recurrent aberrations of 98 CNA regions were also identified in cases only. However, none of the CNAs have an impact on cancer progression. A total of 32 CNA regions identified contained tumor suppressor genes and oncogenes. Moreover, the pathway analysis revealed endometrial cancer and estrogen signaling pathways associated with this cancer (p < 0.05) using Kyoto Encyclopedia of Genes and Genomes (KEGG). This is the first report of CNAs identified for cervical cancer in the U.S. Latino population using high density markers. We are aware of the small sample size in the study. Thus, additional studies with a larger sample are needed to confirm the current findings.

Disparities in collaborative patient-provider communication about human papillomavirus (HPV) vaccination

BACKGROUND

Healthcare providers may vary their communications with different patients, which could give rise to differences in vaccination coverage. We examined demographic disparities in parental report of collaborative provider communication and implications for human papillomavirus (HPV) vaccination.

METHODS

Participants were 4,124 parents who completed the National Immunization Survey-Teen about daughters ages 13-17. We analyzed disparities in collaborative communication (mutual information exchange, deliberation, and decision) and whether they mediated the relationship between demographic characteristics and HPV vaccine initiation.

RESULTS

Half of parents (53%) in the survey reported collaborative communication. Poor, less educated, Spanish-speaking, Southern, and rural parents, and parents of non-privately insured and Hispanic adolescents, were least likely to report collaborative communication (all p<.05). These disparities in communication accounted for geographic variation in HPV vaccination, specifically, the higher rates of uptake in the Northeast versus the South (mediation z=2.31, p<.01) and in urban/suburban vs. rural areas (mediation z=2.87, p<.01). These disparities were also associated with vaccination among subgroups with relatively high coverage, minimizing what could have been even higher uptake among Hispanic compared to non-Hispanic white adolescents (mediation z=-3.04, p<.01) and non-privately versus privately insured adolescents (mediation z=-3.67, p<.001). Controlling for provider recommendation attenuated some of these associations (but all p<.10).

CONCLUSIONS

Collaborative communication showed widespread disparities, being least common among underserved groups. Collaborative communication helped account for differences-and lack of differences-in HPV vaccination among some subgroups of adolescent girls. Leveraging patient-provider communication, especially for underserved demographic groups, could improve HPV vaccination coverage.

Factors Associated with HPV Vaccine Awareness in a Population-Based Sample of Hispanic Women in Puerto Rico

OBJECTIVES

The objective of this study was to investigate the factors associated with HPV awareness among women aged 16 to 64 years, among underserved minority Hispanic women living in Puerto Rico.

METHODS

A population-based, cross-sectional sample of 566 women, ages 16 to 64 years, living in the San Juan metropolitan area were surveyed regarding sexual behavior, HPV knowledge, and HPV vaccine uptake. Data was analyzed using descriptive statistics and multivariate logistic regression.

RESULTS

Overall, 64.8 % of the women in the sample had heard about the HPV vaccine. Among those in the recommended catch-up vaccination age range (16-26 years, n = 86), 4.7 % had received at least one dose of the HPV vaccine. Of those aware of the availability of the HPV vaccine, most had learned about it through the media, whereas, only 39.6 % had learned about it from a physician. Multivariate logistic regression analysis showed that HPV awareness (OR 8.6; 95 % CI 5.0-14.8) and having had an abnormal Pap smear (OR 2.0; 95 % CI 1.2-3.4) were associated with HPV vaccine awareness (p < 0.05).

CONCLUSION

HPV vaccine awareness among Hispanic women in the San Juan metropolitan area of Puerto Rico continues to be low. Strong recommendations from physicians and participation in HPV vaccine educational efforts are essential if the rate of HPV vaccination is to increase in the targeted population. Compared to the USA, and to their US Hispanic counterparts, a health disparity with regard to HPV vaccine awareness and coverage is evident in Puerto Rico; targeted action to deal with this disparity is urgently needed.

Multiple Sexual Partners as a Potential Independent Risk Factor for Cervical Cancer: a Meta-analysis of Epidemiological Studies

It's known that having multiple sexual partners is one of the risk factors of human papillomavirus (HPV) infection which is a major cause of cervical cancer. However, it is not clear whether the number of sexual partners is an independent risk factor for cervical cancer. We identified relevant studies by searching the databases of MEDLINE, PubMed and ScienceDirect published in English from January 1980 to January 2014. We analyzed those studies by combining the study-specific odds ratios (ORs) using random-effects models. Forty-one studies were included in this meta-analysis. We observed that the number of sexual partners was associated with the occurrence of non-malignant cervical disease (OR=1.82, 95%CI 1.63-2.00) and invasive cervical carcinoma (OR=1.77, 95%CI 1.50-2.05). Subgroup analyses revealed that the association remained significant after controlling for HPV infection (OR=1.52, 95%CI 1.21-1.83 for non-malignant disease; OR=1.53, 95%CI 1.30- 1.76 for invasive cervical carcinoma). We found that there was a non-linear relation of the number of sexual partners with both non-malignant cervical disease and invasive cervical carcinoma. The risk of both malignant and non-malignant disease is relatively stable in women with more than 4-7 sexual partners. Furthermore, the frequency-risk of disease remained significant after controlling for HPV infection.The study suggested that having multiple sexual partners, with or without HPV infection, is a potential risk factor of cervical cancer.

Trends in Cervical Cancer Among Delivery-Related Discharges and its Impact on Maternal-Infant Birth Outcomes (United States, 1998-2009)

OBJECTIVES

To estimate the national prevalence of cervical cancer (CCA) in women discharged from hospital after delivery, and to examine its associations with birth outcomes.

METHODS

We did a retrospective cross-sectional analysis of maternal hospital discharges in the United States (1998-2009). We used the Nationwide Inpatient Sample (NIS) database to identify hospital stays for women who gave birth. We determined length of hospital stay, in-hospital mortality, and used ICD-9-CM codes to identify CCA and all outcomes of interest. Multivariable logistic regression modeling was used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI) for the associations between CCA and feto-maternal outcome.

RESULTS

In the 12-year period from 1998 to 2009, there were 8,387 delivery hospitalizations with a CCA diagnosis, a prevalence rate of 1.8 per 100,000 (95% CI=1.6, 1.9). After adjusting for potential confounders, CCA was associated with increased odds of maternal morbidities including: anemia (AOR, 1.78, 95% CI, 1.54-2.06), anxiety (AOR, 1.95, 95% CI, 1.11-3.42), cesarean delivery (AOR, 1.67, 95% CI, 1.46-1.90), and prolonged hospital stay (AOR, 1.51, 95% CI, 1.30-1.76), and preterm birth (AOR, 1.69, 95% CI, 1.46-1.97).

CONCLUSION

There is a recent increase in the prevalence of CCA during pregnancy. CCA is associated with severe feto-maternal morbidities. Interventions that promote safer sexual practice and regular screening for CCA should be promoted widely among women of reproductive age to effectively reduce the prevalence of CCA during pregnancy and its impact on the health of mother and baby.

Perceived risk of cervical cancer among low-income women

BACKGROUND

Risk perception is an important predictor of cancer prevention behaviors. We examined the perceived risk of cervical cancer among an ethnically diverse population of women of lower socioeconomic status.

MATERIALS AND METHODS

Females attending a women's health clinic were recruited for a study addressing cervical cancer prevention. Survey questions evaluated lifetime perceived risk of cervical cancer (0%-100%), beliefs about the accuracy of the Pap test, and estimated incidence of abnormal Pap test results. Risk estimates for oneself were followed with an item seeking a brief, qualitative explanation of the risk estimate.

RESULTS

Surveys were completed by 338 women. The mean (SD) age of respondents was 29.9 (8.6) years. Women self-identified as Hispanic/Latina (32%, n=107), White (34%, n=116), and African American (34%, n=115). Estimated perceived lifetime risk of getting cervical cancer ranged from 0% to 100% (59.2 [29.5]). Risk estimates were associated with perceived prevalence of abnormal results (r=0.24, p<.001) and perceptions regarding the accuracy of the Pap test (r=0.13, p<.05). On average, women estimated that nearly half of all women have ever had an abnormal result (49.2 [26.9]; n=335; range, 0%-100%), with African American women estimating a higher percentage compared to Hispanic/Latina and White women. Women who themselves experienced an abnormal Pap test result reported higher proportions of other women experiencing an abnormal result (t333=-3.67, p<.01).

CONCLUSIONS

This study advances our understanding of misperception of risk and how women qualitatively view their risk of cervical cancer. The findings underscore areas for practitioners to enhance patient education efforts.

The development of a brief jail-based cervical health promotion intervention

The primary objective of this article was to describe the development and pilot implementation of a brief jail-based cervical health promotion intervention. The intervention was guided by a preliminary study of incarcerated women's cervical health knowledge, awareness, and health literacy, as well as a social and feminist approach to intervention development. We developed and conducted a pilot implementation of the Sexual Health Empowerment Project to increase cervical health knowledge, reduce barriers related to beliefs about cervical cancer, and improve self-efficacy and confidence in navigating health systems. This article offers a framework for how empirically and theory-based interventions are developed and tailored for a jail setting. Future work should include the evaluation of the long-term effects of such a disease-specific program on health behaviors and outcomes among high-risk and vulnerable groups of women as they leave jails and enter communities.

Correlates of human papillomavirus vaccination among female university students

Human papillomavirus (HPV) is the most frequently occurring sexually transmitted infection in the United States, but only one third of adolescent girls have received the HPV vaccine (Centers for Disease Control and Prevention [CDC], 2012; Committee on Infectious Diseases, 2012). Understanding correlates of vaccination behavior among young women has important implications for health care delivery and public service messages targeting HPV vaccination. Female college students (N = 313) completed web-based surveys during their sophomore (second) year of college, fall 2008. Surveys included questions about HPV vaccination, demographic factors (ethnicity/race, socioeconomic status [SES]), individual characteristics (romantic relationship status, grade point average, religiosity), and sexual behavior. Lifetime HPV vaccination was reported by 46.5% of participants. Being African American/Black was associated with a lower likelihood of vaccination. Having a mother with more education, adhering to religious teachings about sex-related principles, and having engaged in recent penetrative sex were associated with a higher likelihood of vaccination. Health care providers should consider young women to be an important group for HPV vaccine education and catch-up, particularly for African American/Black young women and young women from lower SES backgrounds. Providing vaccine education and access to young women before they become sexually active is critical.

Impact of socioeconomic status and ethnic enclave on cervical cancer incidence among Hispanics and Asians in California

OBJECTIVE

This study aimed to evaluate the incidence of cervical cancer by nativity [United States (US) versus non-US], neighborhood socioeconomic status and ethnic enclave among Hispanics and Asians in California.

METHODS

Using data from the California Cancer Registry, information on all primary invasive cervical cancer (Cca) patients diagnosed in California from January 1, 1990 through December 31, 2004 was obtained. We analyzed the influence of enclave, socioeconomic status and nativity on Cca incidence.

RESULTS

Among the 22,189 Cca cases diagnosed between 1990 and 2004, 50% were non-Hispanic white, 39% Hispanic and 11% Asian women, and 63% US-born. Seventy percent of the Cca cases were squamous cell carcinoma, 19% adenocarcinoma and 11% other histologies. Higher incidence of Cca was observed in high enclave (76%) and low socioeconomic status (70%) neighborhoods. By ethnic group, US-born women showed lower rates of squamous cell carcinoma compared to foreign-born women. Hispanics living in low socioeconomic and high enclave had 12.7 times higher rate of Cca than those living in high socioeconomic, low enclave neighborhoods. For Asian women incidence rates were 6 times higher in the low socioeconomic, high enclave neighborhoods compared to those living in high socioeconomic, low enclave neighborhoods.

CONCLUSION

More targeted outreach to increase Pap smear screening and human papilloma virus vaccination for women living in high enclave neighborhoods can help decrease the incidence of Cca in these groups of women.

Exploring the role of neighborhood socio-demographic factors on HPV vaccine initiation among low-income, ethnic minority girls

Little is known about whether neighborhood factors are associated with human papillomavirus (HPV) vaccine uptake, especially among disadvantaged groups that can benefit most from the vaccine. We used data collected from immigrant, low-income mothers of adolescent girls and data from the 2005-2009 American Community Survey to investigate the relationship between HPV vaccine initiation and neighborhood characteristics. We compared initiation rates across levels of neighborhood disadvantage and employed multilevel logistic regression models to examine contextual effects on uptake. Overall, 27 % of girls (n = 479) initiated the vaccine. Initiation rates were highest among girls from the most disadvantaged neighborhoods (30 %), however, neighborhood factors were not independently associated with vaccine initiation after adjusting for individual factors. Mother's awareness of HPV, age, and insurance status were strong predictors for initiation. Future interventions should focus on improving awareness among low-income mothers as well as targeting vulnerable families outside the catchment area of public programs.

Cost-effectiveness and equity impacts of three HPV vaccination programmes for school-aged girls in New Zealand

BACKGROUND

As with many high-income countries, vaccination coverage against human papilloma virus (HPV) infection is not high in New Zealand (NZ) at 47% in school-aged girls for three doses. We estimate the health gains, net-cost and cost-effectiveness of the currently implemented HPV national vaccination programme of vaccination dispersed across schools and primary care, and two alternatives: school-based only (assumed coverage as per Australia: 73%), and mandatory school-based vaccination but with opt-out permitted (coverage 93%). We also generate estimates by social group (sex, ethnic and deprivation group).

METHODS

A Markov macro-simulation model was developed for 12-year-old girls and boys in 2011, with future health states of: cervical cancer, pre-cancer (CIN I-III), genital warts, and three other HPV-related cancers (oropharyngeal, anal, vulvar cancer). In each state health sector costs, including additional health sector costs from extra life, and quality-adjusted life years (QALYs) were accumulated.

RESULTS

The current HPV vaccination programme has an estimated cost-effectiveness of NZ$18,800/QALY gained (about US$9700/QALY gained using the OECD's purchasing power parities; 95% UI: US$6900 to $33,700) compared to the status quo in NZ prior to 2008 (no vaccination, screening alone). The incremental cost-effectiveness ratio (ICER) of an intensive school-based only programme of girls, compared to the current situation, was US$33,000/QALY gained. Mandatory vaccination appeared least cost-effective (ICER compared to school-based of US$117,000/QALY gained, but with wide 95% uncertainty limits from $56,000 to $220,000). All interventions generated more QALYs per 12-year-old for Māori (indigenous population) and people living in deprived areas (range 5-25% greater QALYs gained).

INTERPRETATION

A more intensive school-only vaccination programme seems warranted. Reductions in vaccine price will greatly improve cost-effectiveness of all options, possibly making a law for mandatory vaccination optimal from a health sector perspective. All interventions could reduce ethnic and socioeconomic disparities in HPV-related disease.

Disparities in human papillomavirus vaccine awareness among U.S. parents of preadolescents and adolescents

BACKGROUND

Improved parental awareness of human papillomavirus (HPV) vaccines could increase uptake of vaccines early in the life course, thereby reducing adolescents' later risk for HPV infection and cancer. As such, we sought to determine factors related to parental awareness of HPV vaccines, using a nationally representative population-based sample.

METHODS

We examined data on 5735 parents of preadolescents and adolescents aged 8 to 17 years from the 2010 National Health Interview Survey. Parents were asked if they had ever heard of HPV vaccines or shots. Multivariable logistic regression analyses were used to examine the odds of parental awareness of HPV vaccines, controlling for relevant covariates.

RESULTS

Most US parents (62.6%) heard of HPV vaccines. Multivariable results revealed parents of children who were older, female, and insured were more likely to have heard of HPV vaccines; parents who were female, white (non-Hispanic), English speakers, born in the United States, married or living with a partner, more educated, and had higher income were also more likely to be aware of HPV vaccines. Notably, parents of children who had a well-child checkup in the last 12 months were significantly more likely to have heard of HPV vaccines (odds ratio, 1.23; 95% confidence interval, 1.04-1.46).

CONCLUSIONS

Given the significant disparities in parental awareness of HPV vaccines, improving access to preventive pediatric health care could offer an opportunity to increase parental awareness. In addition, public health efforts that provide culturally sensitive information in a variety of languages may be an effective way to reach vulnerable groups.

Optimizing technology for cervical cancer screening in high-resource settings

Although historically successful in reducing the burden of cervical cancer, Papanicolaou (Pap) testing faces numerous limitations. A growing body of evidence suggests that modern screening practice will benefit from primary screening for high-risk human papillomavirus (HPV) infection, the causative agent of cervical cancer. Molecular tests detecting the presence of HPV nucleic acids consistently demonstrate high sensitivity relative to Pap testing, and provide reliable, dichotomous results. Pap cytology is ideally suited to triage HPV-positive cases owing to its high test specificity, and the accuracy of cytological readings will be maximized in high-prevalence conditions. This algorithm of primary HPV testing with Pap triage has been shown to maintain the high sensitivity of HPV testing without compromising Pap cytology's strong ability to rule out falsely positive diagnoses. Given the anticipated decline of high-risk HPV-16 and -18 infections in the emergent post-HPV vaccination era, highly sensitive primary HPV testing is especially warranted. Novel screening technologies that identify HPV viral gene expression continue to emerge and seek to complement current HPV testing by identifying those women who may be at risk of progressive disease. How to best incorporate these new technologies into clinical practice presents our next great challenge. Implementation of novel algorithms for cervical screening is not a trivial task. Avoidance of exceedingly complex screening algorithms is an important priority.

Cervical cancer control for Hispanic women in Texas: strategies from research and practice

OBJECTIVE

Hispanic women in Texas have among the highest rates of cervical cancer incidence and mortality in the country. Increasing regular Papanicolaou test screening and HPV vaccination are crucial to reduce the burden of cervical cancer among Hispanics. This paper presents lessons learned from community-based cervical cancer control programs for Hispanics and highlights effective intervention programs, methods and strategies.

METHODS

We reviewed and summarized cervical cancer control efforts targeting Hispanic women, focusing on interventions developed by researchers at the University of Texas, School of Public Health. We identified commonalities across programs, highlighted effective methods, and summarized lessons learned to help guide future intervention efforts.

RESULTS

Community-academic partnerships were fundamental in all steps of program development and implementation. Programs reviewed addressed psychosocial, cultural, and access barriers to cervical cancer control among low-income Hispanic women. Intervention approaches included lay health worker (LHW) and navigation models and used print media, interactive tailored media, photonovellas, client reminders, one-on-one and group education sessions.

CONCLUSIONS

Small media materials combined with LHW and navigation approaches were effective in delivering Pap test screening and HPV vaccination messages and in linking women to services. Common theoretical methods included in these approaches were modeling, verbal persuasion, and facilitating access. Adaptation of programs to an urban environment revealed that intensive navigation was needed to link women with multiple access barriers to health services. Collectively, this review reveals 1) the importance of using a systematic approach for planning and adapting cervical cancer control programs; 2) advantages of collaborative academic-community partnerships to develop feasible interventions with broad reach; 3) the use of small media and LHW approaches and the need for tailored phone navigation in urban settings; and 4) coordination and technical assistance of community-based efforts as a way to maximize resources.

Should cervical cancer screening begin at age 21 for everyone? A quantitative analysis in a high-risk, low-income, African American/Hispanic young-adult population

The American College of Obstetricians and Gynecologists has recommended modifying the baseline cervical cancer screening age from earlier of three years after first sexual intercourse or age 21 to age 21. In this study, we tracked abnormal cytologic diagnoses, with an emphasis on high-grade cervical lesions, in a high-risk, low-income, African American/Hispanic young-adult population. The intention was to assess if delaying cancer screening to 21 years of age would be effective in this subpopulation. A search of the cytopathology database between January 1, 2001 and December 31, 2009 was performed to identify all women with their first abnormal cytologic diagnosis prior to turning 21 years of age. All of the available follow-up cytologic and/or histologic diagnoses, made both prior to and after turning 21 years of age, were recorded and the results analyzed. Amongst the 8,011 total number of women under 21 years of age screened for cervical cancer at our institution from January 1, 2001 to December 31, 2009 the overall abnormal cytology rate was 25%, with a rate of 1% for HSIL, 3% for ASC-H/LG-H, and 22% for LSIL/ASC-US. The youngest subject diagnosed with HSIL was 14 years of age. Not a single study subject developed invasive cervical cancer prior to turning 21 years of age. In spite of the limitations of the study, we found that for patients served by our institution, delaying cervical cancer screening until 21 years of age is effective for the detection of early precancerous lesions.

Effects of socioeconomic status and health care access on low levels of human papillomavirus vaccination among Spanish-speaking Hispanics in California

Little is known about the effect of language preference, socioeconomic status, and health care access on human papillomavirus (HPV) vaccination. We examined these factors in Hispanic parents of daughters aged 11 to 17 years in California (n = 1090). Spanish-speaking parents were less likely to have their daughters vaccinated than were English speakers (odds ratio [OR] = 0.55; 95% confidence interval [CI] = 0.31, 0.98). Adding income and access to multivariate analyses made language nonsignificant (OR = 0.68; 95% CI = 0.35, 1.29). This confirms that health care use is associated with language via income and access. Low-income Hispanics, who lack access, need information about free HPV vaccination programs.

Age-specific trends in black-white disparities in cervical cancer incidence in the United States: 1975-2009

BACKGROUND

Although overall cervical cancer incidence rates have decreased in both black and white women in the U.S. since the mid 1950s due to widespread screening, rates continue to be higher among blacks than among whites. However, whether this pattern differs by age is unknown.

METHODS

Cervical cancer cases (1975-2009, N=36,503) were obtained from nine Surveillance, Epidemiology, and End Results (SEER) Program registries. Age-standardized incidence rates for white and black women were calculated from 1975-1979 through 2005-2009 by age group (<50, 50-64, and ≥65 years). Rate ratios (RRs) and 95% confidence intervals (CIs) evaluated differences in rates for blacks vs. whites by age group and stage at diagnosis during 1975-1979 and 2005-2009.

RESULTS

Among women aged <50 years, the black-to-white disparity RR decreased from nearly two-fold (RR, 1.9; 95% CI, 1.7-2.1) during 1975-1979 to unity during 2005-2009 (RR, 0.9; 95% CI, 0.8-1.0). In contrast, rates remained significantly elevated for blacks vs. whites aged 50-64 years (RR, 2.4; 95% CI, 2.1-2.7 and 1.7; 95% CI, 1.5-2.0), and for those aged ≥65 years (RR, 3.3; 95% CI, 2.9-3.8 and 2.2; 95% CI, 1.9-2.7) during both time periods, although the disparities decreased over time. Similar disparities persisted for older black women with cervical cancer of all stages.

CONCLUSION

Disparities in cervical cancer incidence rates were eliminated for younger blacks vs. whites but persisted for blacks aged 50 years and older. Additional strategies are needed to increase follow-up and treatment of precancerous lesions among middle-aged and older black women.

Human papillomavirus vaccine uptake among 18- to 26-year-old women in the United States: National Health Interview Survey, 2010

BACKGROUND

Human papillomavirus (HPV) vaccine uptake among young adult women has been reported to be very low. The authors conducted this study to provide an update on HPV vaccine uptake among 18- to 26-year-old women.

METHODS

The authors used the National Health Interview Survey 2010 data to estimate HPV vaccine coverage and their correlates.

RESULTS

Overall, 22.7% of women initiated (≥1 dose) and 12.7% completed the vaccine (≥3 doses). Thus, about 56% of women who initiated the vaccine completed it. Multivariate logistic regression analyses showed that younger age, unmarried status, Papanicolaou test, influenza vaccine, lifetime vaccines, and HPV vaccine awareness were positively associated with receiving ≥1 and ≥3 doses. In addition, uninsured women were less likely to receive ≥1 dose (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28-0.84), and blacks (OR, 0.48; 95% CI, 0.23-0.99) and women with a family income <100% of the federal poverty level (OR, 0.40; 95% CI, 0.21-0.73) were less likely to receive ≥3 doses. Furthermore, based on vaccine initiators, blacks were less likely than whites to complete the vaccine (OR, 0.29; 95% CI, 0.16-0.55). Two thirds of unvaccinated women were not interested in future vaccination. Among those who were interested, >76.4% preferred to receive it free or at a lower cost, whereas 20% would pay the full cost of the vaccine.

CONCLUSIONS

One in 8 women completed the 3-dose HPV vaccine. Educational and vaccine financing programs are needed to improve the uptake among low-income minority women who are at increased risk for cervical cancer.

Cervical cancer screening interventions for U.S. Latinas: a systematic review

The high cervical cancer mortality rate among Latinas compared with other ethnic groups in the United States is of major concern. Latina women are almost twice as likely to die from cervical cancer as non-Hispanic white women. To improve Latina cervical cancer screening rates, interventions have been developed and tested. This systematic review was undertaken to determine the effectiveness of such studies. Studies involving both experimental and quasi-experimental designs were located (N = 6), and odds ratios were calculated for screening behavior. The pooled effect of these programs was negligible, and implications are derived from this finding.

Impact of organised cervical screening on cervical cancer incidence and mortality in migrant women in Australia

Background

Organised cervical screening, introduced in 1991, appears to have reduced rates of cervical cancer incidence and mortality in women in Australia. This study aimed to assess whether cervical cancer rates in migrant women in the state of New South Wales (NSW) showed a similar pattern of change to that in Australian-born women after 1991.

Methods

Data from the NSW Central Cancer Registry were obtained for females 15+ years diagnosed with invasive cervical cancer from 1973 to 2008 (N=11,485). We used joinpoint regression to assess annual percent changes (APC) in cervical cancer incidence and mortality before and after the introduction of organised cervical screening in 1991.

Results

APC in incidence fell more rapidly after than before 1991 (p<0.001) amongst women from seven groups defined by country of birth (including Australia). There was only weak evidence that the magnitude of this incidence change varied by country-of-birth (p=0.088). The change in APC in mortality after 1991, however, was heterogeneous by country of birth (p=0.004). For Australian and UK or Ireland-born women the mortality APC fell more rapidly after 1991 than before (p=0.002 and p=0.001 respectively), as it did for New Zealand, Middle East, North Africa and Asian-born (p≥0.05), but in other European-born and women from the ’Rest of the World’ it appeared to rise (p=0.40 and p=0.013 respectively).

Conclusions

Like Australian-born women, most, but not all, groups of migrant women experienced an increased rate of fall in incidence of cervical cancer following introduction of organised cervical screening in 1991. An apparent rise in mortality in women in a ‘Rest of the World’ category might be explained by a recent rise in migration from countries with high cervical cancer incidence and mortality rates.

Are there socioeconomic disparities in women having discussions on human papillomavirus vaccine with health care providers?

Background

Human papillomavirus (HPV) vaccine recommendation by a health care provider (HCP) is an important predictor of vaccine receipt. We examined whether being of a minority race/ethnicity, having lower income and education, and the lack of health insurance and a regular HCP are each associated with a lower likelihood of a discussion on HPV vaccine occurring between a woman and her HCP.

Methods

A sample of 1,631 women aged 18 years and older was drawn from the 2007 Health Information National Trends Survey. Given that only a subgroup of women who were aware of the HPV vaccine were asked if they had a discussion with their HCPs, we estimated a probit model correcting for sample selection.

Results

Among those aware of the HPV vaccine, 17.3% of respondents reported having discussions on the vaccine with their HCPs. Compared with Whites, African Americans were less likely to be aware of the HPV vaccine but more likely to have discussions with their HCPs concerning the vaccine. A statistically significant association between lower income and education levels and a lower likelihood of HPV vaccine awareness was observed, but low levels of income and education did not appear to affect the probability of having HPV vaccine discussions with HCPs.

Conclusions

Socioeconomically disadvantaged women did not show a lower propensity to have vaccine discussions with their HCPs, suggesting that HCPs can be a major catalyst in increasing vaccine receipt among the higher risk group. The results of the study suggest a two-pronged approach that seeks to raise vaccine awareness among socioeconomically disadvantaged women at the population level and encourages HCPs to intensify discussions about the HPV vaccine with patients.

Provider factors associated with disparities in human papillomavirus vaccination among low-income 9- to 17-year-old girls

BACKGROUND

Many women who develop cervical cancer are eligible for or are participants of Medicaid. Providing human papillomavirus (HPV) vaccination to girls enrolled in Medicaid may reduce cervical cancer disparities in low-income and minority women. This study evaluated provider characteristics associated with HPV vaccination among 9- to 17-year-old female Medicaid enrollees.

METHODS

A random sample of 800 providers from the Florida Medicaid Master Provider File was mailed a survey in October 2009 that evaluated demographic and practice characteristics, HPV information and knowledge, barriers to HPV vaccination, vaccine practices, and vaccine recommendation practices. To measure HPV vaccination, Medicaid claims data were used to calculate the proportion of eligible patients who received at least 1 dose of the vaccine from participating providers within the study period. Provider factors associated with vaccination at the bivariate level were evaluated in a multiple linear regression model.

RESULTS

The response rate was 68.3% (N = 485). After excluding ineligible respondents, the current analysis included 433 providers. HPV vaccination prevalence ranged from 0% to 61.9% (M = 20.4, standard deviation = 14.5). HPV vaccination rates were higher among providers who were pediatricians, had a private practice, practiced in a single specialty setting, were providers under the Vaccines for Children program, saw primarily non-Hispanic white patients, used 2 or more strategies for vaccine series completion, and did not refer out for HPV vaccination.

CONCLUSIONS

Despite financial coverage for Medicaid-eligible girls, HPV vaccination rates are low. Study findings can be used to target health services interventions to providers least likely to administer HPV vaccine to female Medicaid enrollees.

An update on human papillomavirus vaccine uptake among 11-17 year old girls in the United States: National Health Interview Survey, 2010

PURPOSE

A 3-dose human papillomavirus (HPV) vaccine is recommended for adolescents to protect against HPV-related cervical and other cancers. The purpose of this study was to provide an update on HPV vaccine uptake among 11-17 year old girls residing in the US.

METHODS

Data from the 2010 National Health Interview Survey (NHIS) were obtained to assess HPV vaccination status and its correlates. Multivariate logistic regression analyses were performed to examine HPV vaccine uptake of ≥ 1 dose and ≥ 3 doses among all girls, and completion of the 3-dose series among those who initiated (received ≥ 1 dose) the vaccine.

RESULTS

Overall, 28.9% and 14.2% received ≥ 1 dose and ≥ 3 doses of vaccine: 14.5% and 3.0% among 11-12 year old girls, and 34.8% and 18.7% among 13-17 year olds, respectively. Hispanics had higher uptake of ≥ 1 dose (odds ratio (OR) 1.63, 95% confidence interval (CI) 1.22-2.17) than whites. Having received an influenza shot in the past year and parents' awareness of the vaccine were significantly associated with receiving ≥ 1 dose (OR 1.88, 95% CI 1.51-2.33 and OR 16.57, 95% CI 10.95-25.06) and ≥ 3 doses (OR 1.48, 95% CI 1.13-1.92 and OR 10.60, 95% CI 5.95-18.88). A separate multivariate model based on girls who initiated the vaccine did not identify any significant correlates of 3-dose series completion. Among parents of unvaccinated girls, 60% were not interested in vaccinating their daughters and mentioned three main reasons: "does not need vaccine" (25.5%), "worried about safety" (19.3%) and "does not know enough about vaccine" (16.6%). Of those who were interested, 53.7% would pay $360-$500 for the vaccination, while 41.7% preferred to receive it at a much lower cost or free.

CONCLUSIONS

Only 1 out of 3 girls (11-17 years) have received ≥ 1 dose of HPV vaccine and much less have completed all 3 doses. Strategies should be taken to improve this vaccine uptake among girls, especially those 11-12 year olds, and to educate parents about the importance of vaccination.

Follow-up analysis of adolescents partially vaccinated against human papillomavirus

PURPOSE

To evaluate factors associated with human papillomavirus vaccination among a cohort of female adolescents previously identified as receiving only one or two doses of vaccine.

METHODS

This was a 15-month follow-up analysis of a previously identified cohort of 9-18-year-old female adolescents seen in primary clinics within a university-based health system. Vaccine receipt and associated factors were identified by review of administrative records.

RESULTS

Among the 1,714 partially vaccinated female adolescents, 53% eventually completed the vaccination series. There was a wide range of dosing intervals ranging from 31 to 840 days between first and second doses and from 85 to 666 days between second and third doses. Race and insurance type were associated with lower rates of series completion, but not with receiving second doses.

CONCLUSIONS

Approximately half of the partially vaccinated girls in our cohort eventually completed the series, albeit often over a longer than recommended interval. There were important disparities in human papillomavirus vaccination.

Factors associated with parental intentions for male human papillomavirus vaccination: results of a national survey

BACKGROUND

In October 2009, a quadrivalent vaccine for human papillomavirus (HPV) was licensed in the United States for males aged 9 to 26 years. The attitudes and beliefs of parents play a critical role in uptake of this vaccine because parental consent is typically required for adolescent HPV vaccination. This study aimed to determine attitudes about, and intention for, male HPV vaccination among a national sample of parents and to evaluate the effect of different types of messages regarding benefits of male HPV vaccination on these outcomes.

METHODS

A nationally representative sample of parents completed a cross-sectional survey shortly before licensure of the HPV vaccine for men. Parents of boys (n = 1178) were asked questions about future intent to vaccinate their sons against HPV after randomly receiving one of 2 different messages about the potential benefits of male HPV vaccination.

RESULTS

Survey completion rate was 62%. Most parents (90%) believed that male HPV vaccination was generally important. However, only 51% of parents of boys intended to have their own sons vaccinated against HPV. The strongest predictors of vaccination intent included high perceived benefits of being vaccinated and low perceived barriers to vaccination. Black race and having less than a high school education were also associated with higher vaccination intent, but only among parents of adolescents (9-17 years), not among parents of younger boys (0-8 years). There were no differences in parental intentions or beliefs between the different message groups.

CONCLUSIONS

There is a significant discrepancy between parents' general support of male HPV vaccination and their intentions to have their own sons vaccinated. Our results highlight the beliefs and attitudes associated with increased parental intention for male HPV vaccination.