Prioritizing US Cervical Cancer Prevention With Results From a Geospatial Model

Using Geospatial Analysis to Identify Priority Communities for Cervical Cancer Prevention in Texas

Introduction

Despite being almost entirely preventable, cervical cancer is the fourth most frequently diagnosed cancer among women worldwide. Cervical cancer incidence suggests missed opportunities for prevention. Geospatial analysis could strategically guide public health interventions. This study aimed to identify geographic clusters of cervical cancer incidence in Texas, a state with higher than national rates of cervical cancer incidence and mortality.

Methods

In this population-based cross-sectional study, the authors analyzed incident cervical cancer data among Texas women aged 30-64 years, from 2014 to 2018. The authors conducted a purely spatial Poisson-based analysis function in SaTScan to examine geographic clusters of higher-than-expected proportions of cervical cancer incidence (i.e., hot spots) and adjusted for age.

Results

A total of 5,060 women aged 30-64 years with incident cervical cancer diagnosis (mean age: 45.7 years, SD=9.6), including 1,840 (36.4%) Hispanic, 591 (11.7%) non-Hispanic Black, 2,397 (47.4%) non-Hispanic White, and 232 (4.6%) other races, were analyzed. Spatial scan analysis detected 7 significant hot spots of cervical cancer incidence. Hot spots were identified in the South Texas Plains (near Mexico border), Gulf Coast (Houston), Prairies and Lakes (North Texas), Panhandle Plains (Northwest Texas), and Piney Woods (Southeast Texas) regions of Texas. Hot spots, compared with the rest of Texas, had higher proportions of Hispanic population and individuals with socioeconomic disadvantages.

Conclusions

This study found spatial variation in cervical cancer incidence in Texas. The hot spot areas can benefit from targeted, novel, scalable, and cost-effective interventions to increase human papillomavirus vaccination and screening and early detection and treatment of precancerous cervical lesions.

Missed Opportunities for Human Papillomavirus Vaccination by Parental Nativity, Minnesota, 2015-2018

OBJECTIVES

Human papillomavirus (HPV) vaccination coverage in the United States is far below coverage for other routine adolescent vaccines. We examined whether missed opportunities for HPV vaccination among adolescents differ by parental nativity (country of origin) in Minnesota.

METHODS

We retrospectively analyzed birth record and immunization information data for adolescents in Minnesota born during 2004-2007 using data from January 1, 2015, through December 31, 2018. Using logistic regression, we assessed the association between parental nativity and missed opportunities for HPV vaccine initiation, or receipt of other vaccines without receipt of the HPV vaccine. We adjusted for parent/child demographic and vaccination characteristics. We defined nativity as the number of non-US-born parents and maternal region of birth.

RESULTS

Adolescents with mothers born in Eastern Europe (adjusted odds ratio [aOR] = 2.33; 95% CI, 2.01-2.73) and Africa (aOR = 1.36; 95% CI, 1.28-1.43) had greater adjusted odds of missed opportunities for HPV vaccination than adolescents with US-born mothers. However, adolescents with mothers from Latin America and the Caribbean had lower odds of missed opportunities than adolescents with US-born mothers (aOR = 0.61; 95% CI, 0.58-0.65). Adolescents with 1 or 2 non-US-born parents had lower odds of missed opportunities for HPV vaccination than adolescents with 2 US-born parents (1 parent: aOR = 0.92; 95% CI, 0.88-0.96; 2 parents: aOR = 0.90; 95% CI, 0.87-0.94).

CONCLUSIONS

Future studies should evaluate outreach to groups with HPV vaccination disparities and identify other drivers of missed opportunities among adolescents with US-born parents, such as multiparity.

Current Management of Locally Advanced and Metastatic Cervical Cancer in the United States

Despite decreases in incidence in the twentieth century, cervical cancer continues to be a highly morbid disease in the United States. For those diagnosed with locally advanced disease, single-agent cisplatin-based chemotherapy concurrent with radiation remains the mainstay of treatment. For patients with metastatic, progressive, and recurrent disease, treatment typically consists of combination chemotherapy and incorporation of bevacizumab, and recent data show benefits with the addition of upfront immunotherapy in women whose cancer expresses programmed death ligand-1. The physical sequelae of locally advanced cervical cancer treatments stem largely from irradiation of the pelvis, and treatment of these is aimed at identifying reversible or treatable causes of symptoms and palliating those with irreversible causes. From a psychologic standpoint, patients with cervical cancer face the stigma of having a preventable cancer caused by a sexually transmitted infection and the ramifications of sexual dysfunction. Clinicians must invite honest dialogue to be able to address specific survivorship issues.

Disparities in Cervical Cancer Screening with HPV Test among Females with Diabetes in the Deep South

Simple Summary

Diabetes is linked with poorer cervical cancer prognosis, and people residing in the Southern region of the U.S. are disproportionately diagnosed with diabetes and cancer. The HPV test was recently recognized as the preferred method of cervical cancer screening by the American Cancer Society. Through our observational study, we sought to investigate the HPV testing behaviors among females with and without diabetes across the U.S. Our nationally representative estimates reveal that less than half of females reported HPV testing, and females with diabetes in the Deep South have the lowest rates of HPV testing. Various risk factors were identified to significantly lower the odds of HPV testing, including a diabetes diagnosis, older age, living in the Southern region of the U.S., and absence of certain comorbidities. The lower rates of HPV testing among females with diabetes, especially those living in the Deep South, leave these populations vulnerable to cervical cancer.

Abstract

Background: Due to diabetes being linked with poorer cervical cancer prognosis, this study aimed to evaluate HPV testing behaviors among females with and without diabetes across the U.S. by geographic area in 2016, 2018, and 2020. Methods: This cross-sectional study used the Behavioral Risk Factor Surveillance System (BRFSS) from 2016, 2018, and 2020. The study population included females aged 25–69 years old, stratified by self-reported diabetes status. The primary outcome measure was cervical cancer screening behavior, which was evaluated by self-reported HPV test uptake/receipt (yes/no). Results: A total of 361,546 females from across the U.S. were sampled. Within the study population combined from all study years, the overall likelihood of receiving an HPV test was significantly lower among females with diabetes [37.95% (95% CI: 36.87–39.04)] compared to those without diabetes [46.21% (95% CI: 45.84–46.58)] (p < 0.001). Screening rates with HPV tests were lowest among females with diabetes in the South in 2016 (29.32% (95% CI: 26.82–31.83)), 2018 (39.63% (95% CI: 36.30–42.96)), and 2020 (41.02% (95% CI: 37.60–44.45)). Conclusions: Females with diabetes are screening with HPV tests less frequently than females without diabetes, and females living in the South, particularly states in the Deep South, report the lowest rates of HPV testing.

Cervical cancer sociodemographic and diagnostic disparities in Florida: a population-based study (1981-2013) by stage at presentation

Objective: Florida has one of the highest cervical cancer mortality rates and socioeconomically diverse populations in the United States. We used statewide population-based cancer registry data to assess disparities in cervical cancer stage at diagnosis. Design: Primary invasive adult female cervical cancer patients in the Florida Cancer Data Registry (1981-2013) were linked with 2000 United States Census data. Early (localized) and advanced (regional and distant) stage at diagnosis was assessed by age, race, ethnicity, neighborhood socioeconomic-, marital-, and smoking- status. Univariate and multivariable logistic regression models were fit to identify factors associated with the risk of advanced cervical cancer stage at diagnosis. Adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95%CI) were calculated. Results: Of 18,279 women (mean_age 51.3 years old), most were non-Hispanic (83.5%), white (79.1%), middle-low neighborhood socioeconomic status (NSES) (34.7%), married (46.0%), and never smoked (56.0%). Higher odds of advanced stage was observed for blacks (aOR: 1.42, 95%CI: 1.30-1.55, p < 0.001) compared to whites, Hispanics (1.15, 1.06-1.25, p = 0.001) compared to non-Hispanics, and middle-low (1.13, 1.02-1.25, p = 0.02) and low NSES (1.42, 1.28-1.57, p < 0.001) compared to high NSES. Previously (1.30, 1.21-1.39, p < 0.001) and never married (1.37, 1.27-1.48, p < 0.001) had higher odds of presenting with advanced stage versus married women. Never smokers had decreased odds of presenting with advanced stage compared to women with history of (1.41, 1.32-1.52, p < 0.001) or current (1.29, 1.18-1.42, p < 0.001)smoking status. Conclusions: There are cancer disparities in women of black race, Hispanic ethnicity and of middle-low and lowest NSES in Florida. Evidence-based interventions targeting these vulnerable groups are needed. Abbreviations: HPV: Human Papilloma Virus; CDC: Center for Disease Control and Prevention; SES: socioeconomic status; FCDS: Florida Cancer Data System; NSES: Neighborhood Socioeconomic Status; NPCR: National Program of Cancer Registries; IRB: Institutional Review Board; ACS: American Community Survey; SEER: Surveillance, Epidemiology and End Results; OR: Odds Ratio; CI: Confidence Interval.

Use of patient navigators to increase HPV vaccination rates in a pediatric clinical population

A patient navigator (PN) program was implemented in pediatric clinics to increase uptake of the human papillomavirus (HPV) vaccine. The purpose of this study is to examine the impact of this program. All visits between April 1, 2013 and December 31, 2017 for 9-17 year old patients at 3 program and 5 non-program clinics were examined using electronic medical records. These dates included patient visits before and after program initiation (February 1, 2015). Visits including 1 dose of the HPV vaccine were assessed as a proportion of total visits for each month. Multivariable binary logistic regression was used to examine the odds of HPV vaccination across time, between program and non-program clinics, and age group. A total of 128,051 visits by 21,395 patients were examined. HPV vaccines were administered during 12,742 visits (10.0%). Odds of HPV vaccination during visits by 13-17 year olds was greater than during visits by 9-12 year olds in the pre-intervention period (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.04-1.19). However, this association changed during the intervention period, with odds of HPV vaccination among visits by 13-17 year olds lower compared to visits by 9-12 year olds (OR: 0.78, 95% CI: 0.75-0.82). The odds of HPV vaccination were elevated among 9-12 year olds in program clinics as compared to 2014, the year before the program was implemented. Having on-site PNs can increase the frequency of HPV vaccination in pediatric clinics, particularly among patients 9-12 years of age.

Geographical disparities in human papillomavirus herd protection

BACKGROUND

Human papillomavirus (HPV) vaccination has occurred unequally across the United States, potentially contributing to uneven vaccine-type HPV prevalence between regions. We examined whether emerging vaccine-related herd protection exhibits regional differences among unvaccinated girls and women.

METHODS

We evaluated the prevalence of vaginal HPV among women 14-59 years of age from 2003 to 2014 using repeated cross-sectional data from the National Health and Nutrition Examination Survey (NHANES). Women who provided an adequate vaginal swab sample were included. Vaginal prevalence of vaccine-type HPV (types 6, 11, 16, 18) were examined in four regions of the United States between 2003 and 2014. We examined vaccine-type HPV prevalence in 2007-2014 in each US census region among younger participants (14-34 years old) stratified by vaccination status to determine whether one or both groups contributed to uneven HPV prevalence.

RESULTS

A total of 12 175 participants 14-59 years of age met inclusion criteria. Vaccine-type HPV prevalence decreased in all regions. Vaccine-type HPV varied by region only among unvaccinated 14-34 year olds, with a higher prevalence in the Midwest (13.8%, 95% confidence interval (CI): 10.7-17.0) and South (12.5%, 95% CI: 10.2-14.8) compared to the Northeast (8.9%, 95% CI: 6.5-11.2). No regional variation in vaccine-type HPV prevalence was observed among vaccinated participants.

CONCLUSIONS

Higher prevalence of vaccine-type HPV among unvaccinated women in the South and Midwest may contribute to regional disparities in HPV-related cancer incidence, as emerging herd immunity may not be as strong in those regions.

Elimination of cervical cancer: challenges for developing countries

Cervical cancer is one of the most preventable cancers today, yet over 500,000 new cases are diagnosed globally each year and every 2 minutes a woman dies from cervical cancer. The burden of this disease and the highest mortality from cervical cancer occur in developing countries. High-income countries are poised to eliminate cervical cancer in the 21st century, but despite a global call to eliminate this disease, low- and middle-income countries face many challenges as they strive to answer that call.

Acceptability and Feasibility of Community-Based, Lay Navigator-Facilitated At-Home Self-Collection for Human Papillomavirus Testing in Underscreened Women

Objective: Women without regular health care providers or a medical home routinely fail to complete recommended cervical cancer screening. At-home self-collection of samples to test for high-risk strains of human papillomavirus (hrHPV) can improve screening rates. This study documents acceptability and feasibility of community lay navigator (LN)-facilitated at-home self-collection for underscreened women in Appalachian Virginia. Materials and Methods: This study used mixed methods in three phases. Phase I involved focus groups of LNs to ensure cultural acceptability of self-collection, and to enhance recruitment of medically underserved women. An environmental scan of community resources and climate was created in Phase II. During Phase III, underscreened women in Appalachian Virginia (the far southwest corner of Virginia) were recruited to complete hrHPV testing using LN-provided self-collection kits. Results: LN-facilitated at-home self-collection for HPV testing was deemed culturally acceptable and feasible to participants in this community-based pilot study. Self-kit training included 64 LNs, of which 35 engaged in the study and were provided 77 kits and instructions. A total of 59 self-kits were returned, of which 42 were correctly completed with valid HPV results, yielding a 16.6% hrHPV rate. Conclusions: Over a quarter of the women LNs recruited had no medical home, indicating this delivery model may have potential to reach women at increased risk of being underscreened for cervical cancer. Research is needed to identify optimal approaches to increase LN participation in outreach self-collection interventions.

A community health worker-led multimedia intervention to increase cervical cancer screening uptake among South Asian women: study protocol for a cluster randomized wait-list controlled trial

Background

Marked ethnic disparities on cervical cancer screening have been observed among South Asian women. Multiple barriers, such as language difficulties, poor access to screening services, values, and beliefs, were identified. Multimedia interventions led by community health workers (CHWs) would likely reduce screening disparities and increase cervical screening uptake among South Asian women. This study aims to assess the effects of a CHW-led multimedia intervention on the uptake of cervical cancer screening among South Asian women.

Methods

This study is a cluster randomized wait-list controlled trial. A total of 408 South Asian women from Pakistan, India or Nepal will be recruited from six ethnic minority associations. Each association will be randomized to one of the two arms: an intervention arm (n = 3) that will undergo immediate treatment (CHW-led multimedia intervention) or a wait-list control arm (n = 3) that will receive delayed treatment. Each recruited CHW will be allocated to either arm according to the association she is affiliated with. The intervention arm will receive a CHW-led intervention comprising two components: multimedia education, and monthly telephone follow-up and navigation assistance. Participants in the control arm (n = 3) will be offered the CHW-led intervention after those in the intervention arm have completed the intervention. The primary outcome measure is the uptake of cervical cancer screening. Secondary outcomes include readiness to undergo screening and beliefs regarding cervical cancer screening. Outcomes assessments will be performed at baseline, immediately after, and 3 months after completion of the intervention.

Discussion

The results of this study will potentially provide significant practical implications for addressing the needs and increasing the uptake of cervical cancer screening among South Asian women.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1800017227. Registered on 18 July 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3378-4) contains supplementary material, which is available to authorized users.

Disparities in women's cancer-related quality of life by Southern Appalachian residence

PURPOSE

The purpose was to determine whether Appalachian residence alone or in combination with violence was linked to poorer quality of life (QOL).

METHODS

Women recently diagnosed and included in either the Kentucky or North Carolina Cancer Registries were interviewed by phone between 2009 and 2015 (n = 3320; mean age = 56.74). Response rates were similar by state (40.1 in Kentucky and 40.9% in North Carolina). Appalachian (N = 990) versus non-Appalachian residents (N = 2330) were hypothesized to have poorer QOL defined as (a) lower Functional Assessment of Cancer Therapy-General (FACT-G) scores and (b) more symptoms of depression, stress, or comorbid physical conditions. Lifetime intimate partner or sexual violence was first investigated as a moderator then mediator of regional differences. Multiple analyses of covariance (MANCOVA) models were used.

RESULTS

Violence modified the effect of Appalachian residence on poorer QOL outcomes; FACT-G total scores (p = .02) were lowest for women living in Appalachia who had additionally experienced violence. Socioeconomic indicators appeared to mediate or explain differences in QOL outcomes by Appalachian residence such that when adjusting for income, education and insurance, Appalachian residence remained associated only with poorer physical QOL outcomes (p < .05).

CONCLUSIONS

While violence rates did not differ by residence, the combined effect of living in Appalachia and experiencing violence resulted in significantly greater impact on poorer QOL among women recently diagnosed with cancer. Clinical consideration of patients' residence, socioeconomic status and violence experienced may help identify and mitigate the longer-term impact of these identifiable factors associated with poorer QOL.

Multimodal Counseling Interventions: Effect on Human Papilloma Virus Vaccination Acceptance

Human papilloma virus (HPV) vaccine was developed to reduce HPV-attributable cancers, external genital warts (EGW), and recurrent respiratory papillomatosis. Adolescent HPV vaccination series completion rates are less than 40% in the United States of America, but up to 80% in Australia and the United Kingdom. Population-based herd immunity requires 80% or greater vaccination series completion rates. Pro-vaccination counseling facilitates increased vaccination rates. Multimodal counseling interventions may increase HPV vaccination series non-completers’ HPV-attributable disease knowledge and HPV-attributable disease prophylaxis (vaccination) acceptance over a brief 14-sentence counseling intervention. An online, 4-group, randomized controlled trial, with 260 or more participants per group, found that parents were more likely to accept HPV vaccination offers for their children than were childless young adults for themselves (68.2% and 52.9%). A combined audiovisual and patient health education handout (PHEH) intervention raised knowledge of HPV vaccination purpose, p = 0.02, and HPV vaccination acceptance for seven items, p < 0.001 to p = 0.023. The audiovisual intervention increased HPV vaccination acceptance for five items, p < 0.001 to p = 0.006. That HPV causes EGW, and that HPV vaccination prevents HPV-attributable diseases were better conveyed by the combined audiovisual and PHEH than the control 14-sentence counseling intervention alone.

Urban/Rural Differences in Breast and Cervical Cancer Incidence: The Mediating Roles of Socioeconomic Status and Provider Density

BACKGROUND

Breast and cervical cancer incidence vary by urbanicity, and several ecological factors could contribute to these patterns. In particular, cancer screening or other sociodemographic and health care system variables could explain geographic disparities in cancer incidence.

METHODS

Governmental and research sources provided data on 612 counties in the Surveillance, Epidemiology, and End Results program for rural-urban continuum code, socioeconomic status (SES) quintile, percent non-Hispanic White residents, density of primary care physicians, cancer screening, and breast and cervical cancer incidence rates (2009-2013). Ecological mediation analyses used weighted least squares regression to examine whether candidate mediators explained the relationship between urbanicity and cancer incidence.

RESULTS

As urbanicity increased, so did breast cancer incidence (βˆ = 0.23; p < .001). SES quintile and density of primary care physicians mediated this relationship, whereas percent non-Hispanic White suppressed it (all p < .05); county-level mammography levels did not contribute to the relationship. After controlling for these variables, urbanicity and breast cancer incidence were no longer associated (βˆ = 0.11; p > .05). In contrast, as urbanicity increased, cervical cancer incidence decreased (βˆ = -0.33; p < .001). SES quintile and density of primary care physicians mediated this relationship (both p < .05); percent non-Hispanic White and Pap screening levels did not contribute to the relationship. After controlling for these variables, the relationship between urbanicity and cervical cancer incidence remained significant (βˆ = -0.13; p < .05).

CONCLUSIONS

County-level SES and density of primary care physicians explained the relationships between urbanicity and breast and cervical cancer incidence. Improving these factors in more rural counties could ameliorate geographic disparities in breast and cervical cancer incidence.