Differential uptake of recent Papanicolaou testing by HPV vaccination status among young women in the United States, 2008-2013

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.

HPV vaccination uptake among foreign-born Blacks in the US: insights from the National Health Interview Survey 2013-2017

INTRODUCTION

Human papillomavirus (HPV) vaccination uptake is lower among foreign-born than US-born individuals, but HPV-related (e.g., cervical) cancer risks are disproportionately higher among immigrant populations. Although timely vaccination can help reduce these risks, less is known about differences in the low HPV vaccination uptake among foreign-born groups, especially Black immigrants. The purpose of this study was to examine the differences in HPV vaccination initiation among US- and foreign-born Black men and women.

METHOD

Data from the 2013-2017 National Health Interview Survey on Black adults, aged 18-37 years, were analyzed in 2019. HPV vaccination initiation prevalence among US- and foreign-born blacks by region of birth were examined. Multivariate binary logistic regression analysis was used to examine the relationship between foreign-birth status and HPV vaccination initiation separately among men and women, after adjusting for sociodemographic and health-related factors.

RESULTS

There were significant differences (p < 0.001) in HPV vaccination initiation among Blacks from the US (22.5%), Africa (14.2%), and Americas/Caribbean Islands (11.4%). Adjusted odds of HPV vaccination initiation were lower among foreign- than US-born Blacks (AOR 0.71, CI 0.52, 0.98) but insignificant after controlling for health-related factors. Being ≤ 17 years versus 18-26 years at age of vaccine eligibility (AOR 3.44, CI 2.90, 4.07) was associated with HPV vaccination, and this relationship remained significant among men and women. Being single was associated with vaccination initiation among men, and some college experience, fair/poor health, obstetric/gynecological visit, and pap test were associated with HPV vaccination. Conclusion Cancer prevention strategies to promote HPV vaccination should consider making age-appropriate, gender-specific, and culturally relevant programs among foreign-born blacks in the US. Health insurance is also a key factor that might help with the lower rates of vaccinated black immigrants.

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.

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.

Cervical Cancer Screening of Adolescents and Young Women: Further Evidence Shows a Lack of Clinical Value

STUDY OBJECTIVE

To assess the prevalence of cytological abnormalities among young people from a large population in the city of São Paulo (Brazil).

DESIGN

Retrospective, observational analysis of data from the institution's data processing center.

SETTING

A private laboratory in São Paulo (Brazil).

PARTICIPANTS

Comparison of 3 different groups (ie, adolescent women [aged ≤19 years], young adult women [aged between 20 and 24 years], and adult women [aged 25 years and older]).

INTERVENTIONS

Assessment of results from all cervical-vaginal smears collected for cytology between January 2010 and December 2015.

MAIN OUTCOME MEASURES

Comparative analysis of cytological abnormalities in the 3 different groups.

RESULTS

A total of 1,026,671 satisfactory cytology tests were performed. The proportion of cytological abnormalities was found to decrease with age (P < .001) and was similar in the groups comprised of adolescents and young adults, with 3.405/ 20.921 (16.3%) and 13,635/ 78,277 (17.4%), respectively, and 74,320/ 927,473 (8.0%) in the group of adult patients (P < .001). Among the positive cytologies in the group of adolescents, 3,331/ 3,405 (97.8%) represented low-grade lesions and 74/ 3,405 (2.2%) high-grade lesions, whereas among adults older than 25 years old, these figures were 69,092/ 74.320 (93%) and 5,228/ 74.320 (6.9%), respectively. No cases of cancer were found in the group of adolescents.

CONCLUSION

Cytological screening of young people is not recommended because of the low prevalence of high-grade cytological abnormalities in this population, with cancer being a rare event. This inadvertent screening could lead to unnecessary complementary exams and overtreatment, which could compromise the reproductive future of these young women.

Detection of transformation zone cells in liquid-based cytology and its comparison with conventional smears

BACKGROUND

To compare the differences between liquid-based cytology (LBC) and conventional cytology in respect of the detection of transformation zone cells (TZC) by age group and to assess test performance by correlating results with cytological abnormalities.

METHODS

A retrospective study assessing the results of cervical-vaginal cytology smears collected at a private laboratory in São Paulo (Brazil) between January 2010 and December 2015.

RESULTS

A total of 1 030 482 cytology tests were performed; of these, 3811 (0.36%) unsatisfactory samples were excluded. Cytology sampling in the patients studied was performed using the conventional technique in 394 879 (38.5%) cases and the liquid-based techniques in 631 792 (61.5%) cases. The proportion of samples with TZC for interpretation was 73.2% (288 956 samples) in conventional cytology and 52.7% (333 115 samples) in LBC (P < .001). The presence of TZC rate declined in both groups with age, but was consistently lower for LBC (P < .001). The presence of endocervical and metaplastic cells was associated with higher high-grade intraepithelial lesion detection rates.

CONCLUSION

Low representation of the transformation zone was found in the samples collected using the LBC technique, particularly in the over 50 age group. Conventional cytology was associated with a higher rate of detection of high-grade lesions.

Exacerbating disparities?: Cervical cancer screening and HPV vaccination

The human papillomavirus (HPV) vaccine is a powerful tool in cancer prevention. In combination with cervical cancer screening programs, this vaccine has the potential to nearly eliminate death from cervical cancer. However, this remarkable public health success can only be realized if vaccines reach those most at risk-unscreened women. Vaccinating only those already well-screened would have little impact on cervical cancer mortality, exacerbate disparities, and be a striking public health failure. We use data from the Behavioral Risk Factor Surveillance System optional Adult HPV Vaccination module between 2013 and 2016 to assess the association between HPV vaccine status and cervical cancer screening behavior. Only 27% of eligible women had received any HPV vaccination. Uninsured women were less likely to be vaccinated (aOR: 0.48, 95% CI:0.30-0.76) and less likely to be screened (aOR: 0.41, 95% CI:0.28-0.60) than insured women. Vaccinated women were more than twice as likely to be up to date on screening than unvaccinated women (aOR: 2.14, 95% CI:1.46-3.12). Younger women were 49% less likely to be up to date on screening (aOR: 0.51, 95% CI:0.37-0.71), but over 4 times more likely to be vaccinated (aOR: 4.44, 95% CI:3.20-6.17) than older women. Unvaccinated, unscreened women are at continued risk for cervical cancer. Uninsured women were most likely to be in this group. Concerted efforts should be focused on increasing vaccination and screening in this population. Cancer prevention innovations, like the HPV vaccine, must reach at-risk populations to avoid further protecting the protected and failing to reduce existing health disparities.

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.

When Pap Testing Fails to Prevent Cervix Cancer: A Qualitative Study of the Experience of Screened Women Under 50 with Advanced Cervix Cancer in Canada

INTRODUCTION

While Papanicolaou (Pap) smears have resulted in a significant decline in cervical cancer incidence and mortality, our clinical experience indicates some women still present with locally advanced cervical cancer (LACC) despite having received Pap smear screening. Recent guidelines have decreased the recommended frequency of Pap smears to every three years. Our study sought to investigate the experiences of young women compliant with cervical screening who presented with LACC.

METHODS

Women under 50 with LACC, FIGO (International Federation of Gynecology and Obstetrics) stage IB1 to IVA who underwent a Pap smear within two years of diagnosis and received curative intent chemoradiotherapy between September 2010 and December 2012 were included. Participants were treated at a tertiary academic cancer centre and invited for a semi-structured, in-person interview, which was analysed qualitatively using thematic analysis.

RESULTS

Thirteen out of 38 women had Pap screening two or less years before diagnosis. Ten consented to participate in an interview. Several key themes emerged: I) Belief that LACC does not occur in those who undergo screening; II) Lack of understanding about LACC symptoms/diagnosis of cervix cancer; III) Reluctance from health care providers to perform a detailed pelvic examination in the presence of symptoms; IV) Negative emotions including anger, shame, regret, mistrust; V) Changes in quality of life from treatment; VI) Advice for other women.

CONCLUSIONS

One-third of women presenting with LACC had appropriate Pap screening prior to diagnosis. Patients believe delays in their diagnosis resulted in detrimental quality of life. There is a need to educate physicians and the public about the symptoms of cervix cancer and to consider this diagnosis even when Pap screening has occurred.

Screening for persistent high-risk HPV infections may be a valuable screening method for young women; A retrospective cohort study

Introduction

Screening of young women is often discouraged because of the high risk of unnecessary diagnostics or overtreatment. Multiple countries therefore use cytology instead of high risk human papillomavirus (hrHPV)-testing as screening method for young women because of the limited specificity of hrHPV-testing. The objective of this study was to investigate how hrHPV screening before the age of 30, can be used to reduce the future prevalence of high-grade cervical lesions in young women.

Methods

We retrospectively analyzed follow-up data from a cohort study on HPV prevalence in unscreened Dutch women aged 18–29 years. Women performed multiple self-collected cervico-vaginal samples for HPV detection and genotyping. At least one valid cervical pathology result was obtained from 1,018 women. Women were categorized as hrHPV negative, cleared- or persistent hrHPV infection. Anonymized follow-up data for each group was obtained. Composite outcome measures were defined as; normal, low-grade squamous intraepithelial lesion (LSIL) or high-grade squamous intraepithelial lesion (HSIL). The association between prior hrHPV status and cytology and histology outcome was analyzed.

Results

After exclusion, a pathology result was registered for 962 women. The prevalence of HSIL was 19.3% in women with a persistent HPV infection at a younger age. This is significantly higher (p<0,001) compared with the HSIL prevalence of 1.5% in HPV-negative women, and 3.1% (n = 8) in women who cleared the hrHPV infection in the past.

Conclusion

Women with a persistent hrHPV infection in their 20s, show an increased prevalence of HSIL lesions in their early 30s. Screening for persistent hrHPV infections, instead of cytology screening before the age of 30, can be used to reduce the future prevalence of cervical cancer in young women.

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.

HPV vaccination and the effects on rates of HPV-related cancers

Globally, human papillomavirus (HPV) infection is one of the most common sexually transmitted infection. HPV is linked to at least five malignancies including vulvar, vaginal, anal penile, oropharyngeal, and cervical cancer. Three HPV vaccines are currently available: bivalent (HPV 16,18), quadrivalent (HPV 6,11,16,18), and nonavalent (6,11,16,18,31,33,45,52,58) targeting between 2 and 7 oncogenic HPV serotypes. This review highlights the currently epidemiologic burden of HPV-related cancers, efficacy of current HPV vaccines, and speculates about the benefits of widespread HPV vaccination. At present, all three vaccines are effective in reducing cervical disease and anogenital dysplasia in industry sponsored clinical trials and in limited study of clinical effectiveness. Models predict elimination of HPV infection with global vaccination rates of 80% and benefits in reducing malignancy at 20% global coverage. Large population-based clinical efficacy studies of these vaccines will be necessary to assess the true impact of vaccination. HPV vaccines provide a promising primary approach to preventing malignancy and barriers to vaccine access must be addressed to meet vaccination goals.

Prevalence and age-wise distribution of Human Papillomavirus type 16/18 infections among hospital screened women of a peri-urban area in West Bengal: Impact of socio-demographic factors

BACKGROUND

We undertook the current study on cervical Human Papillomavirus (HPV) prevalence along with cytology in women visiting the Gynecology Out-patient Department of a hospital for common gynecological ailments, subsequent to our earlier population-based study on HPV prevalence from India.

METHODS

We analyzed data on cervical-cytology (Pap smears) and PCR-based molecular detection of HPV infection along with socio-demographic variables (N = 696).

RESULTS

We identified 36.84% HPV-positive women amongst whom, HPV16 and 18 together predominated (79.37%) over other HPV types (20.63%). Contrarily, only 6.4% women revealed abnormal cytological lesions, of which, 46.51% were HPV-positive and 95% of such women harbored HPV16/18, while 5% harbored other HPV types. Individuals with normal cytology portrayed 36.09% HPV infections, of which, 77.97% were HPV16/18-positive and 22.03% harbored other HPV types. Overall HPV prevalence decreased significantly (p_trend  = 0.047) with increase in age, but HPV16/18 infections were significantly over-represented compared to the other HPV types across all age-groups. Specifically, HPV16 prevalence increased (p _trend < 0.01) with increase in severity of cervical lesions. HPV16 prevalence did not differ between the Hindus and Muslims but HPV18 was significantly higher among the cytologically normal Muslim women (24.14%, p = 0.02), compared to the Hindus (11.91%), specifically among those ≥ 30 years of age. There was a significant (p < 0.05) overrepresentation of HPV16 prevalence among women who were users of oral contraceptive-pills, irrespective of cytology.

CONCLUSIONS

Our study highlights the need for HPV16/18-based screening of cervical cancers in India considering the immense socio-cultural and genetic diversity at the population level.

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.

Healthcare providers' beliefs and attitudes regarding risk compensation following HPV vaccination

Background

Provider recommendation is a significant predictor of HPV vaccine uptake. Prior research suggests that concerns regarding risk compensation could cause some providers to hesitate recommending the HPV vaccine.

Methods

During 15–30 min semi-structured interviews in early 2015, 22 U.S. pediatric providers were asked about their beliefs regarding sexual risk compensation and cervical cancer screening following HPV vaccination. Providers were asked if these beliefs result in reservations recommending the vaccine. Interviews were audio-recorded, transcribed, and analyzed using inductive content analysis.

Results

None of the providers believed the HPV vaccine would result in risky sexual behavior. Half indicated it was better to start vaccination early, before sexual activity was a worry. Others noted that patients’ risky behavior decisions happen independently of vaccination. When providers were asked if they were concerned about decreased cervical cancer screening, half said they did not know and some stated they had never thought about it before. The main themes addressed were the significant time lapse between vaccination and screening and that women tend to get over-screened as opposed to under-screened.

Conclusion

Providers were generally in favor of HPV vaccination and do not perceive risk compensation as a barrier to HPV recommendation.

Associations between sexual habits, menstrual hygiene practices, demographics and the vaginal microbiome as revealed by Bayesian network analysis

The vaginal microbiome plays an influential role in several disease states in reproductive age women, including bacterial vaginosis (BV). While demographic characteristics are associated with differences in vaginal microbiome community structure, little is known about the influence of sexual and hygiene habits. Furthermore, associations between the vaginal microbiome and risk symptoms of bacterial vaginosis have not been fully elucidated. Using Bayesian network (BN) analysis of 16S rRNA gene sequence results, demographic and extensive questionnaire data, we describe both novel and previously documented associations between habits of women and their vaginal microbiome. The BN analysis approach shows promise in uncovering complex associations between disparate data types. Our findings based on this approach support published associations between specific microbiome members (e.g., Eggerthella, Gardnerella, Dialister, Sneathia and Ruminococcaceae), the Nugent score (a BV diagnostic) and vaginal pH (a risk symptom of BV). Additionally, we found that several microbiome members were directly connected to other risk symptoms of BV (such as vaginal discharge, odor, itch, irritation, and yeast infection) including L. jensenii, Corynebacteria, and Proteobacteria. No direct connections were found between the Nugent Score and risk symptoms of BV other than pH, indicating that the Nugent Score may not be the most useful criteria for assessment of clinical BV. We also found that demographics (i.e., age, ethnicity, previous pregnancy) were associated with the presence/absence of specific vaginal microbes. The resulting BN revealed several as-yet undocumented associations between birth control usage, menstrual hygiene practices and specific microbiome members. Many of these complex relationships were not identified using common analytical methods, i.e., ordination and PERMANOVA. While these associations require confirmatory follow-up study, our findings strongly suggest that future studies of the vaginal microbiome and vaginal pathologies should include detailed surveys of participants' sanitary, sexual and birth control habits, as these can act as confounders in the relationship between the microbiome and disease. Although the BN approach is powerful in revealing complex associations within multidimensional datasets, the need in some cases to discretize the data for use in BN analysis can result in loss of information. Future research is required to alleviate such limitations in constructing BN networks. Large sample sizes are also required in order to allow for the incorporation of a large number of variables (nodes) into the BN, particularly when studying associations between metadata and the microbiome. We believe that this approach is of great value, complementing other methods, to further our understanding of complex associations characteristic of microbiome research.

HPV Vaccination Among Foreign-Born Women: Examining the National Health Interview Survey 2013-2015

INTRODUCTION

Human papillomavirus vaccination is less prevalent among foreign-born than U.S.-born women and may lead to disparities in human papillomavirus-related cancers in the future. There is limited research on factors associated with vaccination uptake between these two groups. This study examined the association between place of birth and human papillomavirus vaccine uptake, and what determinants of vaccination attenuate this relationship.

METHODS

The 2013-2015 National Health Interview Survey data on women was analyzed in 2016, to determine differences in prevalence of human papillomavirus vaccination between foreign- and U.S.-born women. Multivariate binary logistic regression analysis was used to examine the association between foreign-born status and human papillomavirus vaccine initiation, after controlling for health insurance status, having a usual source of care, obstetrician/gynecologist visits, Pap tests, length of U.S. residency, and citizenship.

RESULTS

Human papillomavirus vaccination prevalence varied significantly among women born in different regions of the world. European and South-American women had the highest vaccination rates among all foreign-born women. Compared with U.S.-born women, foreign-born women were significantly less likely to report human papillomavirus vaccine initiation. This relationship was partially attenuated after adjusting for the covariates. Among foreign-born women, Asians were significantly less likely to report human papillomavirus vaccination uptake than white women. Additionally, living in the U.S. for >5 years was significantly associated with vaccine initiation, but attenuated by U.S. citizenship status.

CONCLUSIONS

Public health interventions to improve human papillomavirus vaccination need to be developed to address multicultural audiences with limited access to health insurance and health care.

Association between mothers' screening uptake and daughters' HPV vaccination: a quasi-experimental study on the effect of an active invitation campaign

OBJECTIVES

In Emilia-Romagna, the Human Papillomavirus (HPV) vaccination campaign started in 2008 offering free vaccines for 1996 and 1997 cohorts. Systematic active invitation was implemented for the 1997 cohort. Our study aimed at measuring the impact of the active invitation campaign on HPV vaccine coverage and on coverage inequalities in 11-year-old girls. Second, we evaluated the effect of the HPV vaccination campaign on participation in cervical cancer screening by mothers of target girls.

METHODS

We collected information on vaccination status for girls residing in Reggio Emilia in 2008 and mothers' screening history, before and after the 2008 vaccination campaign. Log-binomial regression models were performed to estimate Relative Risk (RR) and 95% confidence intervals (CIs) of being vaccinated as regarded citizenship, siblings, mothers' education, marital status and screening history, stratified by birth cohort. We also calculated RR of receiving a Pap test after the vaccination campaign as regarded education, daughter's cohort and mothers' decision to have their daughter vaccinated. Interaction between education and cohort in mothers overdue for Pap testing was calculated.

RESULTS

Vaccination coverage was 46.3% for the uninvited cohort (1046/2260) and 77.9% for the invited cohort (1798/2307). In the uninvited cohort, daughters' vaccination showed association with mothers' education (8 to 11 years of education vs. graduated mothers, RR 1.61 95% CI 1.14-2.28), citizenship (foreigners vs. Italians, RR 0.45 95% CI 0.37-0.56) and screening history (regular vs. non-participant; RR 1.72 95% CI 1.26-2.36). In the invited cohort, only a slight association with screening history persisted (regular vs. non-participant; RR 1.20 95% CI 1.04-1.40). Highly educated under-screened mothers of the invited cohort showed a higher probability of receiving a Pap test after the vaccination campaign period (RR 1.27 95% CI 1.04-1.56) compared with those not invited, CONCLUSION: Active invitation could increase overall HPV immunisation coverage and reduce socio-demographic inequalities and the association with mothers' screening participation.

Human Papillomavirus Vaccination and Pap Smear Uptake Among Young Women in the United States: Role of Provider and Patient

BACKGROUND

It has been reported that Pap smear use is higher among U.S. women who received the human papillomavirus (HPV) vaccine than unvaccinated women. This study assessed the role of provider and patient in the difference of Pap smear use by vaccination status.

METHODS

We conducted a cross-sectional study of 5416 young women (21-30 years of age) with detailed information on Pap smear use and HPV vaccination status from the National Health Interview Survey (NHIS) 2013-2015. Vaccinated women received at least one dose of HPV vaccine. Main outcomes included Pap smear in the past year, provider's recommendation for Pap smear, and patient-initiated Pap smear.

RESULTS

The prevalence of Pap smear in the past year was much higher among vaccinated women than unvaccinated women (67.5% vs. 52.8%, p < 0.001). Compared with unvaccinated women, vaccinated women were more likely to receive a provider's recommendation for Pap testing (60.8% vs. 50.8%, p < 0.001), to obtain Pap testing after receiving a provider's recommendation (75.1% vs. 67.9%, p = 0.004), and to initiate Pap testing themselves (57.7% vs. 38.2%, p < 0.001). However, among women who visited an obstetrician/gynecologist (OB/GYN) in the past year, the positive association between HPV vaccination and Pap smear recommendation and uptake vanished.

CONCLUSIONS

Unvaccinated women who have not visited an OB/GYN in the past year are less likely to receive a recommendation for Pap testing from their providers or to initiate Pap testing themselves without a provider's recommendation. They should be encouraged to visit an OB/GYN provider for cervical cancer screening.

Differences in cervical cancer screening knowledge, practices, and beliefs: An examination of survey responses

Among the identified barriers to HPV vaccination is the concern that women may compensate for their reduced susceptibility to cervical cancers by reducing cervical cancer screening. This exploratory study examined the relationship between cervical cancer screening rates and HPV vaccination. We conducted a cross-sectional survey using a convenience sample of women aged 21–35 attending a local minority health fair in July 2015. Data were analyzed in 2015–2016. Outcomes assessed were: receiving a Pap test within the last three years, awareness and comfort with current Pap test recommendations, and knowledge regarding the purpose of a Pap test. A total of 291 women were included in the analyses. Mean age was 28.5 years and 62% were non-Hispanic black. 84% had received a Pap test in the last three years and 33% had received at least one HPV vaccine. Logistic regression results showed that women who had been vaccinated did not have lower odds of having a Pap test in the past three years (OR = 1.32; 95% CI = 0.66–2.65). In an adjusted regression model controlling for age and race, vaccinated women were significantly more likely to have had a Pap test (AOR = 3.06; 95% CI = 1.37–6.83). Yet only 26% of women knew the purpose of a Pap test and the proportion who answered correctly was higher among non-Hispanic white women. Women who have been vaccinated for HPV are more likely to have been screened for cervical cancer. These results suggest areas for more robust studies examining pro-health attitudes, behaviors, and communication regarding vaccination and preventive screening.

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A comparison of cervical cancer screening practices among mostly minority women

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HPV vaccinated participants didn't have lower rates of cervical cancer screening.

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Knowledge about the purpose of a Pap test was low especially among minority women.

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Current recommendations and screening purpose are areas for future interventions.

Effect of number of human papillomavirus vaccine doses on guideline adherent cervical cytology screening among 19-26year old females

PURPOSE

Little is known about how the number of HPV vaccine doses affect adherence to screening guidelines. This study compared adherence to cervical cancer screening by the number of HPV vaccine doses received by young women and assessed whether the specialty of vaccinating providers affected behavior.

METHODS

This retrospective cohort study using administrative insurance claims records included 24,964 19-26year old women who received at least 1 injection of the HPV vaccine between January 2006 and November 2009. Vaccinated young women continuously enrolled in a nationally-representative private insurance plan for 6months prior to and 37months after HPV vaccine administration were included. Logistic regression was used to compare the odds of Papanicolaou (Pap) testing 3years after vaccine initiation by number of vaccine doses and provider type.

RESULTS

In this sample, 79.3% had a Pap test 3years following vaccine initiation. Receiving 1 (aOR: 0.60, 95% CI 0.55-0.65) or 2 (aOR: 0.80, 95% CI 0.74-0.87) doses was associated with decreased odds of Pap testing compared to 3 doses. Many young women in our sample (16.5%) were diagnosed with cervical dysplasia prior to HPV vaccination. Patients vaccinated by non-obstetrician/gynecologists were less likely to get a Pap test following vaccination.

CONCLUSIONS

Women who received 1 or 2 doses of the HPV vaccine were less likely than those who received 3 doses to be screened for cervical cancer 3years following vaccine initiation. Pediatricians and primary care physicians should convey the importance of initiating and continuing screening to HPV vaccinated patients.

Epidemiological Investigation and Risk Factors for Cervical Lesions: Cervical Cancer Screening Among Women in Rural Areas of Henan Province China

BACKGROUND This cross-sectional study aimed to investigate the prevalence of cervical lesions and evaluate risk factors for cervical intraepithelial neoplasia (CIN) among women taking part in cervical cancer screening in rural areas of Henan province, China. MATERIAL AND METHODS Cervical cancer screening using the ThinPrep cytologic test (TCT) and gynecologic exam was conducted on 1315 women age 20-68 years in rural areas of Henan province, China. Colposcopy and biopsies were carried out for histopathologic diagnosis when indicated. Univariate and multivariate logistic regressions were performed to evaluate risk factors associated with cervical lesions. RESULTS Among 1315 women screened, CIN prevalence detected by histopathology was 1.22% (0.38% of CIN 1, 0.76% of CIN 2, and 0.08% of CIN 3). Cervical cancer prevalence was 2.66%. Multivariate analysis confirmed risk factors for cervical lesions included older age (the 21-40 age group vs. the 41-66 age group, OR=0.13, 95% CI: 0.03~0.57), postmenopause (OR=0.11, 95% CI: 0.03~0.45), cervical inflammation (OR=0.06, 95% CI: 0.01~0.31), and smoking (OR=6.78, 95% CI: 1.20~38.23). CONCLUSIONS Older age (41-66 years), presence of HPV infection, postmenopause, cervical inflammation, and smoking are strong risk factors for cervical lesions among women in rural areas of Henan province, China. Particular efforts should be made to provide cervical cancer screening for these women.

HPV immunisation and increased uptake of cervical screening in Scottish women; observational study of routinely collected national data

BACKGROUND

To measure the uptake of first invitation to cervical screening by vaccine status in a population-based cohort offered HPV immunisation in a national catch-up campaign.

METHODS

A retrospective observational study of routinely collected data from the Scottish Cervical Screening Programme. Data were extracted and linked from the Scottish Cervical Call Recall System, the Scottish Population Register and the Scottish Index of Multiple Deprivation. Records from 201 023 women born between 1 January 1988 and 30 September 1993 were assessed. Women born in or after 1990 were eligible for the national catch-up programme of HPV immunisation. Attendance for screening was within 12 months of the first invitation at age 20 years.

RESULTS

There was a significant decline in overall attendance from the 1988 cohort to the 1993 cohort with the adjusted attendance ratio of the 1988 cohort being 1.49 times (95% CI 1.46-1.52) that of the 1993 cohort. Immunisation compensated for this decrease in uptake with unvaccinated individuals having a reduced ratio of attendance compared with those fully vaccinated (RR=0.65, 95% CI 0.64-0.65). Not taking up the opportunity for HPV immunisation was associated with an attendance for screening below the trend line for all women before the availability of HPV immunisation.

CONCLUSIONS

HPV immunisation is not associated with the reduced attendance for screening that had been feared. Immunised women in the catch-up cohorts appear to be more motivated to attend than unimmunised women, but this may be a result of a greater awareness of health issues. These results, while reassuring, may not be reproduced in routinely immunised women. Continued monitoring of attendance for the first smear and subsequent routine smears is needed.

Adherence to cervical cancer screening varies by human papillomavirus vaccination status in a high-risk population

Cervical cancer screening has reduced the incidence of cervical cancer over the past 75 years. The primary aim of this study was to determine if women receiving Gardasil™ (HPV4 vaccine) participated in future cervical cancer screening at the same rate as that observed for unvaccinated women matched on birth year and health care campus. This is a retrospective cohort study of subjects selected from 27,786 females born from 1980 to 1992 who received health care in the Truman Medical Center safety net health system in Kansas City Missouri, USA. 1154 women 14-26 years old who received at least one dose of HPV4 vaccine between 2006 and 2009 were chosen at random from the vaccine records. 1154 randomly chosen unvaccinated women were age and health campus matched to the vaccinated women and all were followed until July 1, 2013. Women who were screened after 21 years and received three vaccine doses before 21 years, had the lowest screening rate of 24%. Their only predictive factor for screening, compared to the unvaccinated, was being closer to 21 years than 14 years at vaccination (aOR = 1.71 95% CI: 1.45, 2.00). Women vaccinated with three doses and screened at or after 21 years had the highest screening rate of 84% predicting a six-fold increase in screening participation over no vaccine received (aOR = 5.94 95% CI: 3.77, 9.35). Our results suggest that women who receive HPV4 vaccination closer to 21 years, not 14, are more likely to participate in cervical cancer screening in an underserved US population.

The Participation of HPV-Vaccinated Women in a National Cervical Screening Program: Population-Based Cohort Study

Background

Concerns have been raised that HPV-vaccination might affect women’s cervical screening behavior. We therefore investigated the association between opportunistic HPV-vaccination and attendance after invitation to cervical screening.

Methods

A cohort of all women resident in Sweden, born 1977-1987 (N=629,703), and invited to cervical screening, was followed October 2006 - December 2012. Invitations to screening were identified via the National Quality Register for Cervical Cancer Prevention, as was the primary outcome of a registered smear. Vaccination status was obtained from two nationwide health data registers. Hazard ratios (HR) were estimated using Cox regression adjusted for age, education level and income (HR_adj). Women were individually followed for up to 6 years, of which the first and second screening rounds were analyzed separately.

Results

Screening attendance after three years of follow-up was 86% in vaccinated women (N=4,897) and 75% in unvaccinated women (N=625,804). The crude HR of screening attendance in vaccinated vs. unvaccinated women was 1.31 (95% CI 1.27-1.35) in the first screening round. Adjustment for education and income reduced but did not erase this difference (HR_adj=1.09, 95% CI 1.05-1.13). In the second screening round, attendance was likewise higher in HPV-vaccinated women (crude HR=1.26, 95% CI 1.21-1.32; HR_adj=1.15, 95% CI 1.10-1.20).

Conclusions

HPV-vaccination is so far associated with equal or higher attendance to cervical screening in Sweden in a cohort of opportunistically vaccinated young women. Most but not all of the difference in attendance was explained by socioeconomic differences between vaccinated and unvaccinated women. HPV vaccine effectiveness studies should consider screening attendance of HPV-vaccinated women when assessing incidence of screen-detected cervical lesions.