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Hollington M. Cox proportional hazard-model application: time to cervical cancer screening among women living with HIV in South Africa. Infect Agent Cancer 2024; 19:6. [PMID: 38431636 PMCID: PMC10909268 DOI: 10.1186/s13027-023-00527-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 09/06/2023] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND There is an increased risk of cervical cancer among women living with HIV. While studies have long examined the association between cervical cancer among women with HIV, no study has examined the time taken for women with HIV to undergo cervical cancer screening as well as the hazard thereof in South Africa. METHODS The study used cross-sectional data from the 2016 South Africa Demographic and Health Survey. To allow for longitudinal analysis and to address the issue of right-censoring, the data were reformatted to a person-data file. The selection criteria were limited to women living with HIV (WLHIV) who had also responded to the question on cervical cancer screening. Descriptive statistics were employed to show the levels of HIV among women aged 15 and older in South Africa. Additionally, Kaplan‒Meier curves were employed to investigate the time to CCS by WLHIV in South Africa. Thereafter, an unadjusted Cox hazards regression model was employed to examine the hazard of undergoing CCS among WLHIV. Finally, it employed an adjusted model to examine the hazard of CCS among WLHIV while adjusting for other factors. RESULTS Nineteen percent (n = 1,159) of the women who participated in the study tested positive for HIV. Herein, it was found that the risk of CCS among WLHIV began at the age of approximately 19 years. Thereafter, the hazard of undergoing CCS among WLHIV began to decrease at 58 years. There was a significant association between CCS and WLHIV. Additionally, several covariates were found to be significantly associated with HIV. These were race, province, area of residence, marriage, educational attainment, employment, alcohol consumption, perceived health perception, and health insurance. CONCLUSION The hazard of CCS was lower among WLHIV compared to WLHIV who did not undergo CCS in South Africa. This puts HIV-positive women at risk of increased morbidity and mortality from potential cervical cancer and HIV comorbidity due to CCS deficits within this group. This is because they are susceptible to HPV and subsequent cervical cancer due to a compromised immune system. HIV-positive women need to routinely undergo CCS every 12 months from baseline for 3 years. Thereafter, they should undergo CCS once every 3 years to reduce their risk of developing the disease.
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Affiliation(s)
- Marcus Hollington
- Demography and Population Studies, University of the Witwatersrand, School of Public Health & School of Social Sciences, Johannesburg, South Africa.
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Engels EA, Shiels MS, Barnabas RV, Bohlius J, Brennan P, Castilho J, Chanock SJ, Clarke MA, Coghill AE, Combes JD, Dryden-Peterson S, D'Souza G, Gopal S, Jaquet A, Lurain K, Makinson A, Martin J, Muchengeti M, Newton R, Okuku F, Orem J, Palefsky JM, Ramaswami R, Robbins HA, Sigel K, Silver S, Suneja G, Yarchoan R, Clifford GM. State of the science and future directions for research on HIV and cancer: Summary of a joint workshop sponsored by IARC and NCI. Int J Cancer 2024; 154:596-606. [PMID: 37715370 PMCID: PMC11133517 DOI: 10.1002/ijc.34727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 09/17/2023]
Abstract
An estimated 38 million people live with human immunodeficiency virus (HIV) worldwide and are at excess risk for multiple cancer types. Elevated cancer risks in people living with HIV (PLWH) are driven primarily by increased exposure to carcinogens, most notably oncogenic viruses acquired through shared transmission routes, plus acceleration of viral carcinogenesis by HIV-related immunosuppression. In the era of widespread antiretroviral therapy (ART), life expectancy of PLWH has increased, with cancer now a leading cause of co-morbidity and death. Furthermore, the types of cancers occurring among PLWH are shifting over time and vary in their relative burden in different parts of the world. In this context, the International Agency for Research on Cancer (IARC) and the US National Cancer Institute (NCI) convened a meeting in September 2022 of multinational and multidisciplinary experts to focus on cancer in PLWH. This report summarizes the proceedings, including a review of the state of the science of cancer descriptive epidemiology, etiology, molecular tumor characterization, primary and secondary prevention, treatment disparities and survival in PLWH around the world. A consensus of key research priorities and recommendations in these domains is also presented.
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Affiliation(s)
- Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Ruanne V Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julia Bohlius
- University of Basel, Basel, Switzerland
- Department for Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Paul Brennan
- Genomic Epidemiology Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Jessica Castilho
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen J Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Megan A Clarke
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Anna E Coghill
- Department of Cancer Epidemiology and Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Jean-Damien Combes
- International Agency for Research on Cancer (IARC/WHO), Early Detection, Prevention and Infections Branch, Lyon, France
| | - Scott Dryden-Peterson
- Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard School of Public Health, Boston, Massachusetts, USA
| | - Gypsyamber D'Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Antoine Jaquet
- National Institute for Health and Medical Research (INSERM), UMR, 1219, Research Institute for Sustainable Development (IRD), EMR 271, Bordeaux Population, Health Centre, University of Bordeaux, Bordeaux, France
| | - Kathryn Lurain
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Alain Makinson
- Infectious Disease Department, CHU La Colombière, Montpellier & Inserm U1175, University of Montpellier, Montpellier, France
| | - Jeffrey Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Mazvita Muchengeti
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Robert Newton
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- University of York, York, UK
| | - Fred Okuku
- Uganda Cancer Institute, Kampala, Uganda
| | | | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, California, USA
| | - Ramya Ramaswami
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Hilary A Robbins
- Genomic Epidemiology Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Keith Sigel
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, USA
| | - Robert Yarchoan
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Gary M Clifford
- International Agency for Research on Cancer (IARC/WHO), Early Detection, Prevention and Infections Branch, Lyon, France
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Risk Analysis Stratification of CIN 2+ Development in a Cohort of Women Living with HIV with Negative Pap Smear and HR-HPV Test during a Long-Term Follow-Up. Vaccines (Basel) 2023; 11:vaccines11020265. [PMID: 36851143 PMCID: PMC9961029 DOI: 10.3390/vaccines11020265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/10/2023] [Accepted: 01/21/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Women living with Human Immunodeficiency Virus are at higher risk of cervical cancer and precancer compared to women without HIV infection. The aim of the study is to evaluate the risk factors for the development of CIN2+ in a cohort of WLWH with negative colposcopy and cytology during a long follow-up period. METHODS We enrolled, in a multicentric retrospective cohort study, WLWH who attended the colposcopic services from 1999 to 2019. Patients with a normal Pap smear, a negative HR-HPV test, and at least one year of follow-up were considered for the anlysis. RESULTS The five-year cumulative incidence of histologically confirmed HSIL was 8.3% (95% CI = 2.6-13.6) among subjects with a CD4+ cell count of <200 cells/µL at any visit and 2.1% (95% CI = 0.7-3.4, p = 0.001) in women with a CD4+ cell count of persistently >200 cells/µL. In women with persistent HR-HPV infection, the five-year cumulative incidence of CIN 2+ was 6% (95% CI = 1.6-10.2) versus 2% (95% CI = 0.4-3.6, p = 0.012) in women without HPV infection. An HIV viremia of >200 copies/mL, a CD4+ cell count of <200 cells/µL, persistent HR-HPV infection, and smoking ≥10 cigarettes/day were all independent and statistically significant risk factors associated with the development of CIN2+ during follow-up. CONCLUSIONS WLWH with good immune status and negative Pap smear and HR-HPV test have a low risk for CIN2+.
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Fabbro M, Hahn K, Novaes O, Ó'Grálaigh M, O'Mahony JF. Cost-Effectiveness Analyses of Lung Cancer Screening Using Low-Dose Computed Tomography: A Systematic Review Assessing Strategy Comparison and Risk Stratification. PHARMACOECONOMICS - OPEN 2022; 6:773-786. [PMID: 36040557 PMCID: PMC9596656 DOI: 10.1007/s41669-022-00346-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Our first study objective was to assess the range of lung cancer screening intervals compared within cost-effectiveness analyses (CEAs) of low-dose computed tomography (LDCT) and to examine the implications for the strategies identified as optimally cost effective; the second objective was to examine if and how risk subgroup-specific policies were considered. METHODS PubMed, Embase and Web of Science were searched for model-based CEAs of LDCT lung screening. The retrieved studies were assessed to examine if the analyses considered sufficient strategy variation to permit incremental estimation of cost effectiveness. Regarding risk selection, we examined if analyses considered alternative risk strata in separate analyses or as alternative risk-based eligibility criteria for screening. RESULTS The search identified 33 eligible CEAs, 23 of which only considered one screening frequency. Of the 10 analyses considering multiple screening intervals, only 4 included intervals longer than 2 years. Within the 10 studies considering multiple intervals, the optimal policy choice would differ in 5 if biennial intervals or longer had not been considered. Nineteen studies conducted risk subgroup analyses, 12 of which assumed that subgroup-specific policies were possible and 7 of which assumed that a common screening policy applies to all those screened. CONCLUSIONS The comparison of multiple strategies is recognised as good practice in CEA when seeking optimal policies. Studies that do include multiple intervals indicate that screening intervals longer than 1 year can be relevant. The omission of intervals of 2 years or longer from CEAs of LDCT screening could lead to the adoption of sub-optimal policies. There also is scope for greater consideration of risk-stratified policies which tailor screening intensity to estimated disease risk. Policy makers should take care when interpreting current evidence before implementing lung screening.
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Affiliation(s)
- Matthew Fabbro
- School of Medicine, Trinity College Dublin, 2-4 Foster Place, Dublin, Ireland
| | - Kirah Hahn
- School of Medicine, Trinity College Dublin, 2-4 Foster Place, Dublin, Ireland
| | - Olivia Novaes
- School of Medicine, Trinity College Dublin, 2-4 Foster Place, Dublin, Ireland
| | - Mícheál Ó'Grálaigh
- School of Medicine, Trinity College Dublin, 2-4 Foster Place, Dublin, Ireland
| | - James F O'Mahony
- School of Medicine, Trinity College Dublin, 2-4 Foster Place, Dublin, Ireland.
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Klein KL, Goron AR, Taylor GH, Roque DM. Pap smear outcomes in elderly women living with HIV and HIV-negative matched controls. Int J STD AIDS 2022; 33:954-962. [PMID: 35980835 DOI: 10.1177/09564624221111280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe risk factors/incidence of abnormal cervical/vaginal cytology/histology and cancer among women living with human immunodeficiency virus (WLHIV) ≥65 years compared to HIV-negative matched controls. STUDY DESIGN Retrospective cohort of patients who underwent Pap screening at the University of Maryland 01/2003-04/2019. RESULTS WLHIV and HIV-negative controls (n = 70 each) underwent 140/151 Pap tests, respectively. Among WLHIV, 29% exhibited abnormal results and were less likely than HIV-negative women with normal Paps to have had serially negative Pap tests prior to age 65 (p = .03). In both groups, 1.4% developed cervical cancer. Abnormal Paps were more frequent in WLHIV than in HIV-negative women (31% vs 10%, p < .0001, RR:3.2, 95%CI1.9-5.4) as was HRHPV (high-risk human papillomavirus) status (43% vs 19%, p = .0233, RR:2.3, 95%CI1.2-4.6). The RR for an abnormal Pap was 2.6 (95% CI:1.1-4.2) for VL >1000 copies/mL and 0.4 (95% CI:0.2-0.7) for CD4 count of >200 cells/μL. No individual with an initially normal Pap experienced an abnormal result over a mean of 42.5 and 43.5 months in the HIV-positive and HIV-negative groups, respectively. CONCLUSIONS HIV status was associated with a higher rate of abnormal Pap/HRHPV; however, no significant difference in cervical/vaginal cancer. Elevated VL/low CD4 count were associated with greater risk for an abnormal Pap.
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Affiliation(s)
- Kylie L Klein
- Department of Obstetrics, Gynecology, and Reproductive Sciences, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abby R Goron
- Department of Obstetrics, Gynecology, and Reproductive Sciences, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory H Taylor
- Department of Family and Community Medicine, Evelyn Jordan Center, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dana M Roque
- Division of Gynecologic Oncology, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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Demarco M, Egemen D, Hyun N, Chen X, Moscicki AB, Cheung L, Carter-Pokras O, Hammer A, Gage JC, Clarke MA, Castle PE, Befano B, Chen J, Dallal C, He X, Desai K, Lorey T, Poitras N, Raine-Bennett TR, Perkins RB, Wentzensen N, Schiffman M. Contribution of Etiologic Cofactors to CIN3+ Risk Among Women With Human Papillomavirus-Positive Screening Test Results. J Low Genit Tract Dis 2022; 26:127-134. [PMID: 35249974 PMCID: PMC8940696 DOI: 10.1097/lgt.0000000000000667] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The US screening and management guidelines for cervical cancer are based on the absolute risk of precancer estimated from large clinical cohorts and trials. Given the widespread transition toward screening with human papillomavirus (HPV) testing, it is important to assess which additional factors to include in clinical risk assessment to optimize management of HPV-infected women. MATERIALS AND METHODS We analyzed data from HPV-infected women, ages 30-65 years, in the National Cancer Institute-Kaiser Permanente Northern California Persistence and Progression study. We estimated the influence of HPV risk group, cytology result, and selected cofactors on immediate risk of cervical intraepithelial neoplasia grade 3 or higher (CIN 3+) among 16,094 HPV-positive women. Cofactors considered included, age, race/ethnicity, income, smoking, and hormonal contraceptive use. RESULTS Human papillomavirus risk group and cytology test result were strongly correlated with CIN 3+ risk. After considering cytology and HPV risk group, other cofactors (age, race/ethnicity, income, smoking, and hormonal contraceptive use) had minimal impact on CIN 3+ risk and did not change recommended management based on accepted risk thresholds. We had insufficient data to assess the impact of long-duration heavy smoking, parity, history of sexually transmitted infection, or immunosuppression. CONCLUSIONS In our study at the Kaiser Permanente Northern California, the risk of CIN 3+ was determined mainly by HPV risk group and cytology results, with other cofactors having limited impact in adjusted analyses. This supports the use of HPV and cytology results in risk-based management guidelines.
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Affiliation(s)
- Maria Demarco
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Noorie Hyun
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Xiaojian Chen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | | | - Li Cheung
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Olivia Carter-Pokras
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | | | - Julia C. Gage
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Megan A. Clarke
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Philip E. Castle
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Brian Befano
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Jie Chen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Cher Dallal
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Xin He
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Kanan Desai
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Thomas Lorey
- Kaiser Permanente Northern California, San Francisco, CA
| | - Nancy Poitras
- Kaiser Permanente Northern California, San Francisco, CA
| | | | | | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
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Nissim O, Dees A, Cooper SL, Patel K, Lazenby GB. Cervical Cancer Among Women With HIV in South Carolina During the Era of Effective Antiretroviral Therapy. J Low Genit Tract Dis 2022; 26:109-114. [PMID: 35125483 DOI: 10.1097/lgt.0000000000000656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We aimed to determine whether women with HIV (WWH) and cervical cancer were more likely to experience cancer-related death and to be diagnosed with cervical cancer at a younger age and in more advanced stages. MATERIALS AND METHODS This is a retrospective cohort study of all women diagnosed with cervical cancer in South Carolina from 1998 to 2018. Deidentified data were obtained from 2 statewide databases. A survival analysis was performed to evaluate differences in cancer survival between women with and without HIV. Wilcoxon rank sum test was used to determine differences in the median age at cancer diagnosis. χ2 test was used to assess differences in cancer stage according to HIV status. RESULTS Four thousand three hundred fourteen women were diagnosed with cervical cancer, and 53 (1.2%) had HIV infection. Survival time in months was similar between WWH and HIV-negative women (86 months [interquartile range {IQR} = 32-146] and 62 months [IQR = 18-153], p = .37; log-rank p = .26). Compared with HIV-negative women, WWH were less likely to experience cervical cancer-related death (36% vs. 19%, p = .005). Women with HIV were diagnosed with cervical cancer at a younger age (44 [IQR = 37-54] vs. 49 [IQR = 39-61], p = .02). Cervical cancer stage was similar at diagnosis between groups (tumor node metastasis stage, p = .97, and Surveillance, Epidemiology, and End Results summary stage, p = .41). CONCLUSIONS Women with HIV were younger at diagnosis than HIV-negative women, but they were no more likely to die from or have more advanced cervical cancer. Women with HIV were not more likely to develop cervical cancer before the age of 21 years and earlier screening is likely unnecessary.
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Affiliation(s)
- Oriel Nissim
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC; and Department of Radiologic Oncology, Hollings Cancer Center, Charleston, SC
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Wells J, Chandler R, Flowers L, Paul S, Sharma A, Kalifa N, Holstad M. Perceptions of Anal Cancer Risk Among HIV-Positive and High-Risk HIV-Negative Women. J Low Genit Tract Dis 2022; 26:181-185. [PMID: 35019899 PMCID: PMC8940637 DOI: 10.1097/lgt.0000000000000652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Women living with HIV (WLWH) have a greater risk of anal cancer than women without HIV; however, there are limited studies that examine awareness of anal cancer risk among WLWH and "high-risk" HIV-negative women. This study examines risk factors for anal cancer, perceptions of risk for anal cancer, and perceptions of anal cancer screening among a cohort of WLWH and high-risk HIV-negative women. MATERIALS AND METHODS From the Atlanta, GA, and Bronx, NY, sites of the Women's Interagency HIV Study, 155 WLWH and HIV-negative women were enrolled and the Champion Health Belief Model Scale questionnaire measuring risk perceptions to anal cancer was administered to each participant. RESULTS The WLWH perceived anal cancer to be less serious and perceived facing fewer barriers to anal cancer screening than HIV-negative women (both p = .01). Older women (≥50 years) felt that they had less barriers to anal cancer screening (p = .047). Moreover, women who had less than a high school education felt more susceptible to anal cancer (p = .001), as did women who reported a history of anal intercourse (p = .017). CONCLUSIONS Despite being at an increased risk for anal cancer, perceptions of susceptibility to anal cancer and seriousness of anal cancer were low among WLWH. These findings highlight opportunities for provider and patient educational interventions to improve awareness of anal cancer risk among WLWH.
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Affiliation(s)
- Jessica Wells
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Rasheeta Chandler
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | | | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Anjali Sharma
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Nia Kalifa
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - Marcia Holstad
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
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D'Souza G, Bhondoekhan F, Benning L, Margolick JB, Adedimeji AA, Adimora AA, Alcaide ML, Cohen MH, Detels R, Friedman MR, Holman S, Konkle-Parker DJ, Merenstein D, Ofotokun I, Palella F, Altekruse S, Brown TT, Tien PC. Characteristics of the MACS/WIHS Combined Cohort Study: Opportunities for Research on Aging With HIV in the Longest US Observational Study of HIV. Am J Epidemiol 2021; 190:1457-1475. [PMID: 33675224 DOI: 10.1093/aje/kwab050] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 02/07/2021] [Accepted: 02/23/2021] [Indexed: 01/16/2023] Open
Abstract
In 2019, the National Institutes of Health combined the Multicenter AIDS Cohort Study (MACS) and the Women's Interagency HIV Study (WIHS) into the MACS/WIHS Combined Cohort Study (MWCCS). In this paper, participants who made a study visit during October 2018-September 2019 (targeted for MWCCS enrollment) are described by human immunodeficiency virus (HIV) serostatus and compared with people living with HIV (PLWH) in the United States. Participants include 2,115 women and 1,901 men with a median age of 56 years (interquartile range, 48-63); 62% are PLWH. Study sites encompass the South (18%), the Mid-Atlantic/Northeast (45%), the West Coast (22%), and the Midwest (15%). Participant race/ethnicity approximates that of PLWH throughout the United States. Longitudinal data and specimens collected for 35 years (men) and 25 years (women) were combined. Differences in data collection and coding were reviewed, and key risk factor and comorbidity data were harmonized. For example, recent use of alcohol (62%) and tobacco (28%) are common, as are dyslipidemia (64%), hypertension (56%), obesity (42%), mildly or severely impaired daily activities (31%), depressive symptoms (28%), and diabetes (22%). The MWCCS repository includes serum, plasma, peripheral blood mononuclear cells, cell pellets, urine, cervicovaginal lavage samples, oral samples, B-cell lines, stool, and semen specimens. Demographic differences between the MACS and WIHS can confound analyses by sex. The merged MWCCS is both an ongoing observational cohort study and a valuable resource for harmonized longitudinal data and specimens for HIV-related research.
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Would Women With Solid Organ Transplant Qualify for Triennial Cervical Cancer Screening as Recommended by the American College of Obstetricians and Gynecologists in 2016 and American Society for Colposcopy and Cervical Pathology in 2019? J Low Genit Tract Dis 2021; 25:92-97. [PMID: 33631778 DOI: 10.1097/lgt.0000000000000588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to assess the applicability and safety of cervical cancer screening guidelines recommended by the American College of Obstetricians and Gynecologists (2016) and American Society for Colposcopy and Cervical Pathology (2019) for women with solid organ transplants (SOTs). MATERIALS AND METHODS We analyzed data previously abstracted through December 2015 for 971 women (18-60 y) who received their first SOT at Mayo Clinic (Rochester, MN) from January 17, 1995, through December 31, 2011. Inclusion criteria were initial benign findings on cervical cytology after SOT and at least 1 subsequent cytologic screening. RESULTS Of 415 women whose initial cytologic findings were benign, 310 met inclusion criteria. The cumulative incidence of abnormal cervical cytology among these 310 women was 4.3% (95% CI = 1.9%-6.7%) by 30 months and 11.2% (95% CI = 7.1%-15.4%) by 60 months after their initial benign results. Considering all women with SOT, 68.4% (284/415) had no documented abnormal cytologic findings within 60 months (26 had abnormality; 284 no abnormality; and 105 not assessed). In women with negative tests for human papillomavirus, high-grade squamous intraepithelial lesions were not documented on cytology with variable duration of follow-up. No cervical squamous cell carcinoma was identified. CONCLUSIONS Of women with initial benign cervical cytology after SOT, more than two thirds would have been eligible for extended-interval screening. Further study is needed, particularly regarding the role of high-risk human papillomavirus testing.
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Moodley J, Constant D, Mwaka AD, Scott SE, Walter FM. Mapping awareness of breast and cervical cancer risk factors, symptoms and lay beliefs in Uganda and South Africa. PLoS One 2020; 15:e0240788. [PMID: 33091035 PMCID: PMC7580973 DOI: 10.1371/journal.pone.0240788] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 10/03/2020] [Indexed: 12/30/2022] Open
Abstract
Background Breast and cervical cancer are leading causes of cancer burden in Sub-Saharan Africa (SSA). We measured breast and cervical cancer symptom and risk factor awareness and lay beliefs in Uganda and South Africa (SA). Methods Between August and December 2018 we conducted a cross-sectional survey of women ≥18 years in one urban and one rural site per country. Households were selected using systematic random sampling, then one woman per household randomly selected to participate. Data were collected by interviewers using electronic tablets customised with the locally validated African Women Awareness of Cancer (AWACAN) tool. This has unprompted questions (testing recall) followed by prompted questions (testing recognition) on risk factor, symptom awareness and lay beliefs for breast and cervical cancer. Mann Whitney and Kruskal Wallis tests were used to compare the association between socio-demographic variables and outcomes. Poisson regression with robust variance was conducted to identify independent socio-demographic predictors. Results Of the 1758 women interviewed, 90.8% had heard of breast and 89.4% of cervical cancer. 8.7% recalled at least one breast risk factor and 38.1% recalled at least one cervical cancer risk factor. 78.0% and 57.7% recalled at least one breast/cervical cancer symptom respectively. Recognition of risk factors and symptoms was higher than recall. Many women were unaware that HPV, HIV, and not being screened were cervical cancer risk factors (23.7%, 46.8%, 26.5% respectively). In SA, urban compared to rural women had significantly higher symptom and risk factor awareness for both cancers. In Uganda married women/living with a partner had higher awareness of breast cancer risk factors and cervical cancer symptoms compared to women not living with a partner. Women mentioned several lay beliefs (e.g. putting money in their bra as a breast cancer risk factor). Conclusion We identified gaps in breast and cervical cancer symptom and risk factor awareness. Our results provide direction for locally targeted cancer awareness intervention programs and serve as a baseline measure against which to evaluate interventions in SSA.
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Affiliation(s)
- J. Moodley
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
- South African Medical Research Council Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
- * E-mail:
| | - D. Constant
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
| | - A. D. Mwaka
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - S. E. Scott
- Centre for Oral, Clinical and Translational Sciences, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, London, United Kingdom
| | - F. M. Walter
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, United Kingdom
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Stewart KA, Allen SM, Chesnokova AE, Syed F, Levison JE. Incidence of abnormal cervical and vaginal cytology among women over age 65 years living with human immunodeficiency virus. Am J Obstet Gynecol 2020; 222:486.e1-486.e10. [PMID: 31678094 DOI: 10.1016/j.ajog.2019.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Women with human immunodeficiency virus have higher rates of abnormal cervical and vaginal cytology and, subsequently, of cervical and vaginal cancers. Although professional bodies currently advocate for indefinite cytology screening for women living with human immunodeficiency virus, these recommendations are based on expert opinion, not evidence-based. In the general population, women who have never had an abnormal cytology result can cease screening at age 65 years. This is due to the relatively low incidence of dysplasia in this group and the risk of false-positive results as women age, invasive follow-up testing, and destructive treatments of lesions that are unlikely to progress to cancer. What is unclear, however, is how human immunodeficiency virus-infected women over age 65 years who have no history of abnormal cytology should be screened to maximize benefit while reducing harms of overscreening. This is a crucial question, as women over age 65 years who are living with human immunodeficiency virus comprise a rapidly growing population. OBJECTIVE To describe the incidence of abnormal cervical and vaginal cytology results in women over the age of 65 years living with human immunodeficiency virus, with the goal of providing evidence for screening recommendations. MATERIALS AND METHODS A retrospective chart review was performed, identifying 69 women who received gynecologic follow-up in a county hospital system in Houston, Texas, between 2000 and 2018 and who met study criteria. Incidence of abnormal cytology after age 65 was determined by analyzing all available cytology results after age 65. Demographic and clinical risk factors, including human immunodeficiency virus-specific clinical risk factors, were analyzed. Matched cervical and vaginal pathology results, if conducted, were also evaluated. Statistical analyses were conducted using Stata 15, including χ2 tests and Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Estimates of the cumulative probability of developing an abnormal cytology result was calculated using the Kaplan-Meier method. RESULTS Among 69 women with no history of abnormal cervical cytology, 12 (17%) went on to develop abnormal cytology results, including 3 (4%) showing high-grade squamous intraepithelial lesions. The incidence rate was 3.5 cases per 100 woman-years (95% confidence interval, 1.58, 7.81). No demographic or gynecologic characteristics were associated with abnormal cytology. A CD4 count of <200 at the time of human immunodeficiency virus diagnosis or at the time of cytology was associated with an abnormal Papanicolaou test result (P < .0001, P = .031). Of women with pathology results in the county hospital system (n = 8), 4 (50%) had cervical intraepithelial neoplasia 2+ or vaginal intraepithelial neoplasia 2+. No women developed invasive cancer. However, 50% of women who had an abnormal Papanicolaou test result in the study period were lost to follow-up; outcomes for these patients are unknown. CONCLUSION Given the relatively high proportion (4%) of women with high-grade squamous intraepithelial lesions/cervical intraepithelial neoplasia 2+/vaginal intraepithelial neoplasia 2+ during the study period, we agree with current screening recommendations for continued routine Papanicolaou testing after the age of 65 years in women with human immunodeficiency virus. More evidence from larger studies is needed to solidify evidence-based screening recommendations in this unique and growing population.
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Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, Huh WK, Kim JJ, Moscicki AB, Nayar R, Saraiya M, Sawaya GF, Wentzensen N, Schiffman M. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis 2020; 24:102-131. [PMID: 32243307 PMCID: PMC7147428 DOI: 10.1097/lgt.0000000000000525] [Citation(s) in RCA: 566] [Impact Index Per Article: 141.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Rebecca B Perkins
- From the Boston University School of Medicine/Boston Medical Center, Boston, MA
| | - Richard S Guido
- University of Pittsburgh/Magee-Women's Hospital, Pittsburgh, PA
| | | | - David Chelmow
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | | | | | | | - Jane J Kim
- Harvard T.H. Chan School of Public Health Boston, MA
| | | | - Ritu Nayar
- Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL
| | - Mona Saraiya
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
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14
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Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection. J Low Genit Tract Dis 2019; 23:87-101. [DOI: 10.1097/lgt.0000000000000468] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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15
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Abstract
Human papillomavirus (HPV) is the first identified necessary cause of human cancers and is associated with nearly 100% of all cervical cancers. Compared to the general female populations, HIV+ women have higher prevalence and incidence of cervical HPV infections, higher risks of persistent HPV infections and subsequent cervical intraepithelial lesions, and a higher incidence of cervical cancer. Although the wide use of combined antiretroviral therapy (cART) has improved the immune function and the longevity of HIV+ women, the incidence of cervical cancer in HIV+ women has not declined. For HIV+ women who follow routine cervical cancer screenings, their incidence of cervical cancer is comparable to that in HIV-negative women. Thus, adherence to the recommended cervical cancer screening is still critical for HIV+ women to prevent cervical cancer. Prophylactic HPV vaccines may also benefit HIV+ women, but prospective studies are needed to determine the effectiveness of HPV vaccination on reducing cervical cancer incidence in HIV+ women.
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Affiliation(s)
- Ping Du
- Department of Medicine, Department of Public Health Sciences, Penn State Hershey College of Medicine, 90 Hope Drive, Suite 2200, A210, Hershey, PA, USA.
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16
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Franceschi S. Second primary cancer in people with HIV. Lancet HIV 2018; 5:e610-e611. [PMID: 30245002 DOI: 10.1016/s2352-3018(18)30216-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Silvia Franceschi
- Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
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17
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Burchell AN, Kendall CE, Cheng SY, Lofters A, Cotterchio M, Bayoumi AM, Glazier RH, Antoniou T, Raboud J, Yudin MH, Loutfy M. Cervical cancer screening uptake among HIV-positive women in Ontario, Canada: A population-based retrospective cohort study. Prev Med 2018; 107:14-20. [PMID: 29197533 DOI: 10.1016/j.ypmed.2017.11.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 11/16/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
Abstract
Cervical cancer caused by oncogenic types of the human papillomavirus (HPV) is of concern among HIV-positive women due to impairment of immune responses required to control HPV infection. Our objectives were to describe patterns of cervical cancer screening using Pap cytology testing among HIV-positive women in Ontario, Canada from 2008 to 2013 and to identify factors associated with adequate screening. We conducted a retrospective, population-based cohort study among screen-eligible HIV-positive women using provincial administrative health data. We estimated annual proportions tested and reported these with 95% confidence intervals (CI). Next, using person-years as the unit of analysis, we identified factors associated with annual Pap testing using log-binomial regression. A total of 2271 women were followed over 10,697 person-years. In 2008, 34.0% (95%CI 31.1-37.0%) had a Pap test. By 2013, the proportion of HIV-positive women tested was 25.9% (95%CI 23.6-28.2%). Women who were most likely to undergo testing were younger, were immigrants from countries with generalized HIV epidemics, lived in the highest income neighbourhoods, had a female primary care physician, had two or more encounters per year with an infectious disease or internal medicine specialist, and had greater comorbidity. Nearly three in four HIV-positive women were under-screened despite all having universal insurance for medically-necessary services. Annual Pap testing decreased following the 2011-2013 release of new guidelines for a lengthened screen interval for average risk women and a billing disincentive. Clinic-based intervention such as physician alerts or reminders may be needed to improve screening coverage among HIV-positive women.
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Affiliation(s)
- Ann N Burchell
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
| | - Claire E Kendall
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada; C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Stephanie Y Cheng
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Aisha Lofters
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Michelle Cotterchio
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Ahmed M Bayoumi
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Richard H Glazier
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Tony Antoniou
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Janet Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Mark H Yudin
- Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mona Loutfy
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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18
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Franceschi S, Clifford GM. Cervical screening: toward an equal risk/equal management approach, irrespective of HIV status. AIDS 2017; 31:1045-1046. [PMID: 28350579 DOI: 10.1097/qad.0000000000001453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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