Human papillomavirus vaccination and subsequent cervical cancer screening in a large integrated healthcare system

Social factors and age play a significant role in cervical cancer and advanced-stage disease among Danish women

BACKGROUND

For cervical cancer (CC), the implementation of preventive strategies has the potential to make cervical cancer occurrence and death largely avoidable. To better understand the factors possibly responsible for cervical cancer, we aimed to examine possible differences in age and social parameters as well as screening status between women with low- or high-stage cervical cancer and matched controls.

METHODS

Through the Danish Cancer Registry (DCR), women diagnosed with cervical cancer in Denmark between 1987 and 2016 were included. These were age- and residence-matched in a 1:5 ratio with controls from the general female population. The study population was sub grouped into a low-stage subpopulation with women with early-stage cervical cancer and matched controls and a high-stage subpopulation with women with late-stage cervical cancer and matched controls. Age and social parameters were compared within the subpopulations as well as between low- and high-stage cases. For part of the study population, screening attendance was examined to compare differences in adherence.

RESULTS

Overall, we found that the risk of cervical cancer is significantly increased in socially disadvantaged women and not least non-attenders in screening. Interestingly, the high-stage subpopulation was significantly older than the low-stage subpopulation (p < 0.001), and when examining the impact of age further, we found that for cervical cancer cases, the risk of having low-stage disease decreases significantly with increasing age, whereas the risk of having high-stage disease increases significantly with increasing age. In the screening cohort, significantly less cases than controls were attenders in screening with the most pronounced differences seen in the old subpopulation (women aged 50-64 years) and in the high-stage subpopulation (p-values all < 0.001). Interestingly, when examining the risk of CC for attenders and non-attenders, we demonstrated that many social parameters continue to influence the risk of cervical cancer, even in women attending screening.

CONCLUSIONS

Older women, socially disadvantaged women, and non-attenders in screening are particularly vulnerable in terms of developing cervical cancer, especially high-stage disease. Therefore, improvements in the participating rate in screening as well as a revision of the current screening guidelines are needed.

Association of human papillomavirus vaccination with cervical cancer screening: A systematic review and meta-analysis

INTRODUCTION

Prophylactic vaccination and routine screening are effective at preventing most cases of cervical cancer. Globally, cervical cancer is the fourth most frequently diagnosed cancer among women. The aim of this study was to investigate the association between human papillomavirus virus (HPV) vaccination (1, 2, or 3 doses) and cervical cancer screening.

METHODS

PubMed (MEDLINE), Scopus, Web of Science, and Cochrane Library electronic databases were systematically searched from July 1, 2006, up to September 30, 2021. We pooled estimates using random-effects models. Heterogeneity between studies was quantified using Cochran Q test and I2 statistics. In total, 12 studies involving 2.4 million individuals were included in the meta-analysis.

RESULTS

In the adjusted estimates, uptake of HPV vaccination was associated with increased cervical cancer screening (pooled relative risk [RR]: 1.35; 95% confidence interval [CI]: 1.21, 1.50; n = 12). Between-study heterogeneity was large (I2 = 99%). Compared to unvaccinated, those who received 3 doses of HPV vaccine had the highest uptake of cervical cancer screening (RR: 1.85; 95% CI: 1.58, 2.17), followed by those who received 2 doses (RR: 1.34; 95% CI: 1.21, 1.47). No statistically significant association with screening was found for those who received a single dose of the HPV vaccine.

CONCLUSION

In this meta-analysis, uptake of HPV vaccination was associated with higher cervical cancer screening. It is plausible that vaccinated individuals are more likely to engage in preventive health behaviors. Healthcare providers should remind patients to continue with routine screening for cervical cancer regardless of their HPV vaccine status since vaccination does not protect against all HPV types.

Test Performance of Cervical Cytology Among Adults With vs Without Human Papillomavirus Vaccination

Importance

Current US cervical cancer screening guidelines do not differ by human papillomavirus (HPV) vaccination status. However, as the positive predictive value (PPV) of a screening test decreases, the risk of a false-positive result increases.

Objective

To evaluate whether HPV vaccination is associated with decreased PPV for abnormal cervical cytology.

Design, Setting, and Participants

This retrospective cohort study conducted via electronic medical record review included eligible patients aged 21 to 35 years who had at least 1 cervical cytology result within a single health system between January 2015 and December 2018. The health system comprises a partnership between an academic health center and a private not-for-profit health center. Patients with abnormal screening cytology and no diagnostic test results were omitted from analysis. Data were analyzed from December 2019 to November 2021.

Exposures

HPV vaccination, defined as receiving at least 1 dose of HPV vaccine. Subgroup analyses were performed for those completing all vaccination doses per Advisory Committee on Immunization Practices guidelines and by age at vaccination initiation, dichotomized as younger than 21 years vs 21 years or older.

Main Outcomes and Measures

PPV of abnormal cervical cytology for risk of cervical intraepithelial neoplasia (CIN) 2 or more severe diagnosis.

Results

A total of 46 988 patients (mean [SD] age, 28.7 [4.5] years; 3058 [6.5%] Asian; 4159 [8.9%] Black or African American; 35 446 [75.4%] White) were included; 15 494 (33.0%) were at least partially vaccinated, and 4289 (9.1%) had abnormal cytology results during the study period. Among the individuals with abnormal cytology, the PPV for CIN 2 or more severe diagnosis was lower among vaccinated individuals (17.4%; 95% CI, 16.4%-18.4%) than unvaccinated individuals (21.3%; 95% CI, 20.4%-22.3%). Among vaccinated individuals, PPV was significantly lower among those completing vaccination (15.9%; 95% CI, 14.9%-17.0%) than those with incomplete vaccination (22.4%; 95% CI, 20.0%-25.0%), especially among those initiating vaccination when younger than 21 years (11.9%; 95% CI, 10.9%-12.9%) vs those initiating at age 21 years or older (30.7%; 95% CI, 27.3%-34.4%).

Conclusions and Relevance

Among a population with relatively low HPV vaccine coverage, the PPV of cervical cytology for CIN 2 or more severe diagnosis was significantly lower among vaccinated individuals. PPV will likely further decrease in the future as a population with higher HPV vaccination coverage ages into screening. Confirmation of these results will call for changes in screening strategies, particularly for completely vaccinated individuals who initiated vaccination when younger than 21 years.

Impact of a human papillomavirus vaccination programme within organized cervical cancer screening: cohort study

BACKGROUND

We assessed the effectiveness of an HPV vaccination programme in lowering cervical abnormality risk, and conferring herd protection.

METHODS

Retrospective cohort study using linked screening and vaccination administrative health data of the general population of Ancona Province, Italy. We included all female residents born in 1990-1993, eligible for catch-up HPV vaccination up to age 25y, and adhering to organised screening in 2015-2020 (n=4665). Cervical abnormalities rates were compared between: vaccinated and unvaccinated women, and cohorts with high and low vaccination uptake. Analyses were adjusted for age, country of birth, screening tests number, laboratory, and municipality average income. Main outcomes were ASC-US+ or LSIL+ Pap smears, and CIN1+ or CIN2+ histology.

RESULTS

Mean screening age was 26.6{plus minus}1.5 years, and 1,118 screened women (24.0%) were vaccinated (mean vaccination age 19.2{plus minus}1.5 years). The diagnosed cervical abnormalities were: 107 LSIL+ (2.3%), 70 CIN1+ (1.5%), and 35 CIN2+ (0.8%). The adjusted odds ratios of LSIL+, CIN1+ and CIN2+ among vaccinated vs unvaccinated women were, respectively: 0.55 (95% confidence interval 0.33-0.91), 0.43 (0.22-0.86), and 0.31 (0.11-0.91). Among the unvaccinated, those in the highest-uptake (45.3%) 1993 cohort, versus the last pre-vaccination 1990 cohort, showed AORs of LSIL+ and CIN1+ of 0.23 (0.10-0.50), and 0.22 (0.07-0.69), respectively.

CONCLUSIONS

In the first evaluation from Central Italy, catch-up HPV vaccination considerably reduced the risk of all cervical abnormalities diagnosed within organized screening, and conferred an elevated degree of herd protection among unvaccinated women.

IMPACT

The high protection conferred by HPV vaccination suggests the need to update cervical screening.

Cervical cancer screening varies by HPV vaccination status among a National Cohort of privately insured young women in the United States 2006-2016

Human papillomavirus (HPV) vaccination in young women is low. Women aged 21 to 65 years in the United States (U.S.) have not reached the Healthy People 2020 objective of 93% for cervical cancer screening. The main aim of this study was to investigate the association between HPV vaccination status and cervical cancer screening among privately insured women aged 21 to 26 years in the U.S.This was a retrospective cohort study using the IBM MarketScan database (2006-2016). The study population included 190,982 HPV-vaccinated women and 763,928 matched unvaccinated women. Adjusted incidence rate ratio (IRR) and the 95% confidence intervals (CIs) were obtained using the generalized estimating equations models with a Poisson distribution.Among a total of 954,910 women included in the analysis, age (mean [SD]) was 23.3 [1.6] years. During 967,317 person-years of follow-up, a total of 475,702 incidents of cervical cancer screening were identified. The incidence density rates of cervical cancer screening were 461 per 1000 person-years (PY) for unvaccinated women and 787 per 1000 PY for those who received 3 doses of the HPV vaccine. After adjusting for other covariates, the IRR of cervical cancer screening was 34% higher among HPV-vaccinated women with at least one vaccine dose than unvaccinated women (adjusted IRR = 1.34, 95% CI: 1.33-1.35; P < .0001). The IRR of cervical cancer screening varied by the dose of HPV vaccination. There was evidence of a linear dose-response relationship between the number of HPV vaccine doses and cervical cancer screening (P-trend < .0001). Compared with unvaccinated women, the IRR of cervical cancer screening were 14%, 39%, and 60% higher among those who received 1, 2, and 3 doses of the HPV vaccine, respectively.In this large retrospective cohort study of privately insured women, HPV-vaccinated women were more likely to be screened for cervical cancer compared with unvaccinated women.

Trends in the use of cervical cancer screening tests in a large medical claims database, United States, 2013-2019

OBJECTIVE

To examine trends in the use of cervical cancer screening tests during 2013-2019 among commercially insured women.

METHODS

The study population included women of all ages with continuous enrollment each year in the IBM MarketScan commercial or Medicare supplemental databases and without known history of cervical cancer or precancer (range = 6.9-9.8 million women per year). Annual cervical cancer screening test use was examined by three modalities: cytology alone, cytology plus HPV testing (cotesting), and HPV testing alone. Trends were assessed using 2-sided Poisson regression.

RESULTS

Use of cytology alone decreased from 34.2% in 2013 to 26.4% in 2019 among women aged 21-29 years (P < .0001). Among women aged 30-64 years, use of cytology alone decreased from 18.9% in 2013 to 8.6% in 2019 (P < .0001), whereas cotesting use increased from 14.9% in 2013 to 19.3% in 2019 (P < .0001). Annual test use for HPV testing alone was below 0.5% in all age groups throughout the study period. Annually, 8.7%-13.6% of women aged 18-20 years received cervical cancer screening. There were persistent differences in screening test use by metropolitan residence and census regions despite similar temporal trends.

CONCLUSIONS

Temporal changes in the use of cervical cancer screening tests among commercially insured women track changes in clinical guidelines. Screening test use among individuals younger than 21 years shows that many young women are inappropriately screened for cervical cancer.

Catch-up HPV Vaccination and Subsequent Uptake of Papanicolaou Testing in A State-mandated Health System

The objective of this study was to evaluate the association between human papillomavirus (HPV) vaccination and uptake of initial Papanicolaou (Pap) testing in Israel among women not previously vaccinated through the national immunization program. In this retrospective cohort we used health provider records of vaccinations and cancer screening attendance among female members of a state-mandated health provider in Israel (Maccabi Healthcare Services, MHS). All eligible female members (N = 20,904) immunized with at least one dose of HPV vaccine from the date of its introduction in Israel (June 2007) until December 31, 2018 were individually matched with nonvaccinated MHS members on one to one ratio by year of birth, residential area socioeconomic level, and district of residence. Data on the uptake of Pap smears until December 2018 were extracted from MHS central datasets, and the number of Pap smears for each woman during the study period was counted. During the observed follow-up period (mean, 6.6 years; interquartile range, 3.9-8.7 year), the cumulative uptake rate of Pap testing in vaccinated women (26.8%) was significantly (P < 0.001) greater than among unvaccinated (22.4%) women. In a multivariable model, HPV vaccination was associated with an HR of 1.34 [95% confidence interval (CI), 1.29-1.41] to perform Pap testing. Our findings suggest that uptake of catch-up HPV vaccine was positively correlated to increased uptake of Pap testing. PREVENTION RELEVANCE: We found that catch-up HPV vaccination was associated with increased attention to long-term cervical screening attendance. Whereas, those who are not vaccinated and unprotected from HPV, are more likely to abstain from secondary prevention screening tests too and further increase their cervical cancer risk.

Human papillomavirus vaccine effectiveness within a cervical cancer screening programme: cohort study

OBJECTIVE

To assess the effectiveness of an HPV vaccination programme in reducing the risk of cervical abnormalities identified at subsequent screening.

DESIGN

Retrospective cohort study using administrative health data.

SETTING

General population of Ferrara Province, Italy.

POPULATION

Female residents born in 1986-1993 and participating in the organized cervical screening programme in 2011-2018, who were eligible for HPV vaccination in catch-up cohorts.

METHODS

Logistic regression to evaluate the potential association between abnormal cervical cytology and one, two, three or at least one dose of HPV vaccine.

MAIN OUTCOME MEASURES

Cervical abnormalities, as predicted by low-grade or high-grade cytology, by number of vaccine doses, stratified by age.

RESULTS

The sample consisted of 7785 women (mean age 27.5 years, SD 2.3). Overall, 391 (5.0%) were vaccinated with ≥1 dose and 893 (11.5%) had abnormal cytology. Women receiving at least one vaccine dose were significantly less likely to have an abnormal cytology (adjusted odds ratio 0.52; 95% confidence interval 0.34-0.79). Similar results were observed for women receiving a single dose, for both bivalent and quadrivalent vaccines, and applying buffer periods (excluding cytological outcomes within 1 month, 6 months and 1 year of the first dose).

CONCLUSIONS

In the context of an organised cervical screening programme in Italy, catch-up HPV vaccination almost halved the risk of cytological abnormalities.

TWEETABLE ABSTRACT

Among Ferrara women, vaccination against human papillomavirus halved the risk of screening cervical abnormalities.

Effectiveness and Cost-Effectiveness of Human Papillomavirus Vaccination Through Age 45 Years in the United States

BACKGROUND

In the United States, the routine age for human papillomavirus (HPV) vaccination is 11 to 12 years, with catch-up vaccination through age 26 years for women and 21 years for men. U.S. vaccination policy on use of the 9-valent HPV vaccine in adult women and men is being reviewed.

OBJECTIVE

To evaluate the added population-level effectiveness and cost-effectiveness of extending the current U.S. HPV vaccination program to women aged 27 to 45 years and men aged 22 to 45 years.

DESIGN

The analysis used HPV-ADVISE (Agent-based Dynamic model for VaccInation and Screening Evaluation), an individual-based transmission dynamic model of HPV infection and associated diseases, calibrated to age-specific U.S. data.

DATA SOURCES

Published data.

TARGET POPULATION

Women aged 27 to 45 years and men aged 22 to 45 years in the United States.

TIME HORIZON

100 years.

PERSPECTIVE

Health care sector.

INTERVENTION

9-valent HPV vaccination.

OUTCOME MEASURES

HPV-associated outcomes prevented and cost-effectiveness ratios.

RESULTS OF BASE-CASE ANALYSIS

The model predicts that the current U.S. HPV vaccination program will reduce the number of diagnoses of anogenital warts and cervical intraepithelial neoplasia of grade 2 or 3 and cases of cervical cancer and noncervical HPV-associated cancer by 82%, 80%, 59%, and 39%, respectively, over 100 years and is cost saving (vs. no vaccination). In contrast, extending vaccination to women and men aged 45 years is predicted to reduce these outcomes by an additional 0.4, 0.4, 0.2, and 0.2 percentage points, respectively. Vaccinating women and men up to age 30, 40, and 45 years is predicted to cost $830 000, $1 843 000, and $1 471 000, respectively, per quality-adjusted life-year gained (vs. current vaccination).

RESULTS OF SENSITIVITY ANALYSIS

Results were most sensitive to assumptions about natural immunity and progression rates after infection, historical vaccination coverage, and vaccine efficacy.

LIMITATION

Uncertainty about the proportion of HPV-associated disease due to infections after age 26 years and about the level of herd effects from the current HPV vaccination program.

CONCLUSION

The current HPV vaccination program is predicted to be cost saving. Extending vaccination to older ages is predicted to produce small additional health benefits and result in substantially higher incremental cost-effectiveness ratios than the current recommendation.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Non-Adherence To Childhood HPV Vaccination Is Associated With Non-Participation In Cervical Cancer Screening - A Nationwide Danish Register-Based Cohort Study

Background

The combination of organized cervical cancer screening and childhood HPV vaccination programs has the potential to eliminate cervical cancer in the future. However, only women participating in both programs gain the full protection, and combined non-attenders remain at high risk of developing cervical cancer. Our aim was to analyze the association between non-adherence to HPV vaccination and non-participation in cervical cancer screening for the total population and stratified by native background and parental education.

Participants

Women born in 1993 eligible for both childhood HPV vaccination and first cervical cancer screening.

Analysis

Logistic regression models were used to estimate the odds ratio (OR) of non-participation in cervical cancer screening with 95% confidence intervals (CI). Stratified and adjusted logistic regression models were used along with the Wald test in order to test for interaction.

Results

24,828 women were included in the study. Among vaccinated women, 61.4% participated in cervical cancer screening; only 39.0% of unvaccinated women participated in cervical cancer screening. Unvaccinated and unscreened women were often non-native and had the lowest socio-economic status, whereas vaccinated and screened women were often native and had the highest socio-economic status. The adjusted OR for non-participation in cervical cancer screening was 2.07 [95% CI: 1.88–2.28] for unvaccinated compared to vaccinated women. After stratifying by country of origin, unvaccinated natives had the highest adjusted OR of not participating in cervical cancer screening compared to non-native women from both western and non-western countries (adjusted ORs of 2.2 [95% CI: 2.0–2.4], 1.3 [95% CI: 0.6–2.8], and 1.5 [95% CI: 1.1–2.0], respectively) (Wald test p=0.019).

Conclusion

Among natives, non-adherence to HPV vaccination and non-participation in screening seem to be signs of generally poor health-preventive behavior, whereas among non-natives from non-western countries, non-attendance in HPV vaccination and cervical cancer screening seem to be influenced by unrelated factors. Therefore, a differentiated and culturally sensitive approach is needed to enhance overall cervical cancer preventive behavior across different nativities.

Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis

BACKGROUND

More than 10 years have elapsed since human papillomavirus (HPV) vaccination was implemented. We did a systematic review and meta-analysis of the population-level impact of vaccinating girls and women against human papillomavirus on HPV infections, anogenital wart diagnoses, and cervical intraepithelial neoplasia grade 2+ (CIN2+) to summarise the most recent evidence about the effectiveness of HPV vaccines in real-world settings and to quantify the impact of multiple age-cohort vaccination.

METHODS

In this updated systematic review and meta-analysis, we used the same search strategy as in our previous paper. We searched MEDLINE and Embase for studies published between Feb 1, 2014, and Oct 11, 2018. Studies were eligible if they compared the frequency (prevalence or incidence) of at least one HPV-related endpoint (genital HPV infections, anogenital wart diagnoses, or histologically confirmed CIN2+) between pre-vaccination and post-vaccination periods among the general population and if they used the same population sources and recruitment methods before and after vaccination. Our primary assessment was the relative risk (RR) comparing the frequency (prevalence or incidence) of HPV-related endpoints between the pre-vaccination and post-vaccination periods. We stratified all analyses by sex, age, and years since introduction of HPV vaccination. We used random-effects models to estimate pooled relative risks.

FINDINGS

We identified 1702 potentially eligible articles for this systematic review and meta-analysis, and included 65 articles in 14 high-income countries: 23 for HPV infection, 29 for anogenital warts, and 13 for CIN2+. After 5-8 years of vaccination, the prevalence of HPV 16 and 18 decreased significantly by 83% (RR 0·17, 95% CI 0·11-0·25) among girls aged 13-19 years, and decreased significantly by 66% (RR 0·34, 95% CI 0·23-0·49) among women aged 20-24 years. The prevalence of HPV 31, 33, and 45 decreased significantly by 54% (RR 0·46, 95% CI 0·33-0·66) among girls aged 13-19 years. Anogenital wart diagnoses decreased significantly by 67% (RR 0·33, 95% CI 0·24-0·46) among girls aged 15-19 years, decreased significantly by 54% (RR 0·46, 95% CI 0.36-0.60) among women aged 20-24 years, and decreased significantly by 31% (RR 0·69, 95% CI 0·53-0·89) among women aged 25-29 years. Among boys aged 15-19 years anogenital wart diagnoses decreased significantly by 48% (RR 0·52, 95% CI 0·37-0·75) and among men aged 20-24 years they decreased significantly by 32% (RR 0·68, 95% CI 0·47-0·98). After 5-9 years of vaccination, CIN2+ decreased significantly by 51% (RR 0·49, 95% CI 0·42-0·58) among screened girls aged 15-19 years and decreased significantly by 31% (RR 0·69, 95% CI 0·57-0·84) among women aged 20-24 years.

INTERPRETATION

This updated systematic review and meta-analysis includes data from 60 million individuals and up to 8 years of post-vaccination follow-up. Our results show compelling evidence of the substantial impact of HPV vaccination programmes on HPV infections and CIN2+ among girls and women, and on anogenital warts diagnoses among girls, women, boys, and men. Additionally, programmes with multi-cohort vaccination and high vaccination coverage had a greater direct impact and herd effects.

FUNDING

WHO, Canadian Institutes of Health Research, Fonds de recherche du Québec - Santé.

Prevalence and determinants of cervical cancer screening with a combination of cytology and human papillomavirus testing

PURPOSE

In the United States, recommended options for cervical cancer screening in women aged 30 years or older include cytology alone or a combination of cytology and human papillomavirus (HPV) testing (co-testing). Although there is a body of evidence suggesting that co-testing may be the preferred screening option in this group of women, little is known about the characteristics of women who screen for cervical cancer with co-testing.

METHODS

A multistage area probability design-based survey was administered to a representative sample of Texas residents. Of the 1348 female respondents, 572 women aged 30 years or older were included in this analysis. Population-weighted survey logistic regression was used to identify determinants of cervical screening with co-testing versus screening with cytology alone.

RESULTS

Women vaccinated against HPV (aOR: 4.48, 95% CI: 1.25-15.97) or hepatitis B virus [aOR: 2.48 (1.52-4.02)], those with a personal cancer history [aOR: 2.96 (1.29-6.77)], and hormonal contraception users [aOR: 2.03 (1.03-3.97)] were more likely to be screened with co-testing than with cytology alone. Moreover, the likelihood of being screened with co-testing decreased with increasing age and decreasing annual household income.

CONCLUSIONS

Benefits and indications of co-testing should be better explained to women and health care providers.

Factors associated with human papillomavirus (HPV) test acceptability in primary screening for cervical cancer: A mixed methods research synthesis

Primary screening for cervical cancer is transitioning from the longstanding Pap smear towards implementation of an HPV-DNA test, which is more sensitive than Pap cytology in detecting high-risk lesions and offers greater protection against invasive cervical carcinomas. Based on these results, many countries are recommending and implementing HPV testing-based screening programs. Understanding what factors (e.g., knowledge, attitudes) will impact on HPV test acceptability by women is crucial for ensuring adequate public health practices to optimize cervical screening uptake. We used mixed methods research synthesis to provide a categorization of the relevant factors related to HPV primary screening for cervical cancer and describe their influence on women's acceptability of HPV testing. We searched Medline, Embase, PsycINFO, CINAHL, Global Health and Web of Science for journal articles between January 1, 1980 and October 31, 2017 and retained 22 empirical articles. Our results show that while most factors associated with HPV test acceptability are included in the Health Belief Model and/or Theory of Planned Behavior (e.g., attitudes, knowledge), other important factors are not encompassed by these theoretical frameworks (e.g., health behaviors, negative emotional reactions related to HPV testing). The direction of influence of psychosocial factors on HPV test acceptability was synthesized based on 14 quantitative studies as: facilitators (e.g., high perceived HPV test benefits), barriers (e.g., negative attitudes towards increased screening intervals), contradictory evidence (e.g., sexual history) and no impact (e.g., high perceived severity of HPV infection). Further population-based studies are needed to confirm the impact of these factors on HPV-based screening acceptability.

Opportunistic HPV vaccination at age 16-23 and cervical screening attendance in Sweden: a national register-based cohort study

OBJECTIVES

To investigate whether cervical screening attendance differs between human papillomavirus (HPV)-vaccinated and unvaccinated women and to investigate potential underlying socioeconomic factors.

DESIGN

Prospective cohort using registry linkage of vaccinations, screening invitations, screening attendance and socioeconomic covariates.

SETTING

Swedish national HPV vaccination and cervical screening programmes.

PARTICIPANTS

All Swedish women born between 1988 and 1991 and invited to screening (n=261 434).

OUTCOME MEASURES

All participants were followed for up to 3 years. Screening attendance was compared between HPV-vaccinated and unvaccinated women. HR and 95% CI were estimated using Cox regression.

RESULTS

Vaccination age averaged 18.1 years and the coverage for≥1 dose was 13.5%. In HPV-vaccinated women (n=35 460), screening attendance was higher than in unvaccinated women (n=225 974) (74%vs69%, p<0.001). The crude HR of attendance in HPV-vaccinated women was 1.32 (95% CI 1.30 to 1.34). A positive association remained after adjustment for education, income and migration history (HR=1.10, 95% CI 1.09 to 1.12).

CONCLUSION

HPV-vaccinated women were more likely to attend screening than unvaccinated women. Yet, the question needs to be reassessed in routinely vaccinated cohorts, since the vaccinated women included here represent a selected group and may be prone to more health-conscious habits.

Proposal for cervical cancer screening in the era of HPV vaccination

Eradication of cervical cancer involves the expansion of human papillomavirus (HPV) vaccine coverage and the development of efficient screening guidelines that take vaccination into account. In Korea, the HPV National Immunization Program was launched in 2016 and is expected to shift the prevalence of HPV genotypes in the country, among other effects. The experiences of another countries that implement national immunization programs should be applied to Korea. If HPV vaccines spread nationwide with broader coverage, after a few decades, cervical intraepithelial lesions or invasive cancer should become a rare disease, leading to a predictable decrease in the positive predictive value of cervical screening cytology. HPV testing is the primary screening tool for cervical cancer and has replaced traditional cytology-based guidelines. The current screening strategy in Korea does not differentiate women who have received complete vaccination from those who are unvaccinated. However, in the post-vaccination era, newly revised policies will be needed. We also discuss on how to increase the vaccination rate in adolescence.

Patterns and correlates of cervical cancer screening initiation in a large integrated health care system

BACKGROUND

The latest 2012 US Preventive Services Task Force cervical cancer screening guidelines recommended screening initiation at age 21 years. Little is known about the cervical cancer screening initiation practices in the community and whether there are critical gaps with respect to adherence to current clinical guidelines. Despite an overall decline in cervical cancer incidence across women of all ages, the incidence rate has not declined among 24-25 year olds between 2000 (2.79 per 100,000) and 2013 (2.93 per 100,000). Thus, it is important to understand cervical cancer screening initiation in young women and how woman- and provider-level factors affect the timing of screening initiation to identify areas for improving cervical cancer prevention.

OBJECTIVE

We examined patterns and correlates of cervical cancer screening initiation among women turning age 21 years in a large community-based practice.

STUDY DESIGN

Female members of Kaiser Permanente Southern California who turned age 21 years (baseline) during 2013-2015 and had not previously received a Papanicolaou test were included. Cervical cancer screening initiation through October 2016 was captured using electronic health records. Incidence rate and cumulative incidence of screening initiation was calculated. Associations between patient and provider characteristics and screening initiation were evaluated using multivariable Cox models.

RESULTS

A total of 38,257 women were included and the Papanicolaou screening initiation rate was 44 per 100 person-years during the study period. Approximately 40% initiated screening within 1 year after turning age 21 years. In multivariable analyses, Asian/Pacific Islanders (hazard ratio, 0.91; confidence interval, 0.86-0.96 compared with non-Hispanic whites); Medicaid enrollees (hazard ratio, 0.90; confidence interval, 0.83, 0.97); those whose primary language is not English (hazard ratio, 0.71; confidence interval, 0.67, 0.75); those who have a historical inpatient visit, primary care physician in pediatrics, internal medicine, or another specialty compared with family practice; and have a male rather than female primary care physician (hazard ratio, 0.46; confidence interval, 0.36, 0.57) less often initiated screening. On the other hand, those who used other preventive services such as getting a human papilloma virus and influenza vaccination and those with a history of pregnancy, contraception use, and sexually transmitted infections more often had timely screening initiation.

CONCLUSION

Less than half of the women insured for preventative services initiated screening at age 21 years. Strategies to improve adherence to screening initiation guidelines should consider a tailored approach for at-risk subgroups and addressing initiation challenges associated with male physicians.

National assessment of HPV and Pap tests: Changes in cervical cancer screening, National Health Interview Survey

BACKGROUND

Major organizations recommend cytology screening (Pap test) every 3years for women aged 21-65; women aged 30 to 65 have the option of adding the HPV test (co-test) every 5years. We examined national percentages of cervical cancer screening, and we examined use of co-testing as an option for screening.

METHODS

We used 2015 U.S. National Health Interview Survey (NHIS) data to examine recent cervical cancer screening (Pap test within 3years among women aged 21-65 without a hysterectomy; N=10,596) and co-testing (N=9,125). We also conducted a multivariable analysis to determine odds of having had a Pap test or co-test by demographic variables. To evaluate changes in screening over time, we examined Pap testing during the years 2000, 2005, 2008, 2010, 2013 and 2015. Analysis completed in Atlanta, GA during 2016.

RESULTS

Overall, 81.1% of eligible women reported having a Pap test within 3years; percentages declined over time among all age groups. An estimated 14 million women aged 21-65 had not been screened within the past 3years. Recent immigrants to the United States, women without insurance, and women without a usual source of healthcare had lower odds of being up to date with screening. About 1/3 of women up to date on Pap testing reported having a co-test with their most recent Pap test.

CONCLUSIONS

Declines in screening among women aged 21-65 are cause for concern. More research is needed on co-testing practices. Provider and patient education efforts may be needed to clarify recommended use of HPV tests.

Cervical cancer screening in the era of HPV vaccination: A review of shifting paradigms in cytopathology

Significant changes in cervical cancer screening practice, guidelines, and prevention of cervical cancer have taken place in recent years including the raising of initial cervical cancer screening age, changes in frequency of cytology screening, and the adoption of high risk HPV and cytology co-testing for some patients; the introduction of the bivalent, quadrivalent, and 9-valent HPV vaccines; and the recent approval of high risk HPV testing as primary screening with the use of cytology as triage in positive cases. This review discusses the significance of primary HPV screening, the impact of HPV vaccination in the prevalence of cervical cancer and its precursors, the interplay between high risk HPV testing and vaccination, and the implications for clinical and cytological management. Future strategies for cervical screening in the post-vaccination era are also discussed.