Estimated Number of Cases of High-Grade Cervical Lesions Diagnosed Among Women - United States, 2008 and 2016

Self-Collection for HPV Testing: Potential Issues Related to Performance Measures and Quality Improvement Among Federally Qualified Health Centers

CONTEXT

Most incident cases of cervical cancer in the United States are attributable to inadequate screening. Federally qualified health centers (FQHCs) serve a large proportion of women who are low-income, have no insurance, and are underserved-risk factors for insufficient cervical cancer screening. FQHCs must maintain quality measures to preserve their accreditation, address financial reimbursements, and provide quality care. Implementation of human papillomavirus (HPV) self-collection can improve cervical cancer screening coverage within FQHCs.

OBJECTIVES

To understand perspectives from clinical personnel on current cervical cancer screening rates at FQHCs in North Carolina and the impact of implementing HPV self-collection among underscreened patients on screening rates and performance measures.

DESIGN

The study used focus groups and key informant interviews. Coding-based thematic analysis was applied to both focus group and interview transcripts. Emergent themes regarding perspectives on self-collection implementation were mapped onto Consolidated Framework for Implementation Research (CFIR) constructs to identify future barriers and facilitators to implementation.

SETTING

Two FQHCs in North Carolina and a cloud-based videoconferencing platform.

PARTICIPANTS

Six FQHCs in North Carolina; 45 clinical and administrative staff from the 6 FQHCs; 1 chief executive officer (n = 6), 1 senior-level administrator (n = 6), 1 chief medical officer (n = 6), and 1 clinical data manager (n = 6) from each FQHC.

MAIN OUTCOME MEASURE

Achievement of clinical perspectives.

RESULTS

Societal-, practice-, and patient-level factors currently contribute to subpar cervical cancer screening rates. HPV self-collection was expected to improve screening uptake among underscreened women at FQHCs, and thus quality and performance measures, by offering an alternative screening approach for in-clinic or at-home use. Implementation barriers include financial uncertainties and HPV self-collection not yet a Food and Drug Administration-approved test.

CONCLUSION

HPV self-collection has potential to improve cervical cancer screening quality and performance measures of FQHCs. For a successful implementation, multilevel factors that are currently affecting low screening uptake need to be addressed. Furthermore, the financial implications of implementation and approval of HPV self-collection as a test for cervical cancer screening quality measures need to be resolved.

The impact of herbal treatments on cervicovaginal human papillomavirus infection: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the effects of herbal treatments on cervicovaginal human papillomavirus infection.

METHODS

A comprehensive literature search was conducted in PubMed, Scopus, Science Direct, and the Cochrane Library until December 2023, following Cochrane guidelines. Data were analyzed using the Review Manager computer program (Version 5.4.1).

RESULTS

Five randomized controlled trials involving a total sample size of 662 women were included in the study. The pooled odds ratio for individuals testing negative for human papillomavirus after herbal intervention among human papillomavirus-positive patients was 1.86 (95% confidence interval (CI) 0.64-5.43), according to the fixed-effects model. Three out of the five studies indicated a significant relationship. The relationship between positive human papillomavirus infection and herbal treatments, measured by the fixed-effects model, resulted in a pooled odds ratio of 0.41 (95%CI 0.17-1.01), reporting a significant association (p=0.05). Subgroup analysis revealed a significant reduction in the relationship between herbal treatment and atypical squamous cells of undetermined significance (OR 0.16, 95%CI 0.03-0.88, p=0.04) but no significant impact on the relationship between herbal treatment and low-grade squamous intraepithelial lesion (OR 0.33, 95%CI 0.01-8.77, p=0.51).

CONCLUSION

The meta-analysis suggests that herbal treatments reduce human papillomavirus infections. While herbal treatments show a significant reduction in atypical squamous cells of undetermined significance, they do not significantly impact the regression of low-grade squamous intraepithelial lesions.

Effect of an HPV Vaccination Multi-Level, Multi-Component Program on HPV Vaccination Initiation and Completion in a Pediatric Clinic Network

Despite clear evidence of the public health benefits of the human papillomavirus (HPV) vaccine in preventing HPV-related cancers and genital warts, underutilization of HPV vaccination in the United States persists. Interventions targeting multi-level determinants of vaccination behavior are crucial for improving HPV vaccination rates. The study's purpose was to implement and evaluate the adapted Adolescent Vaccination Program (AVP), a clinic-based, multi-level, multi-component intervention aimed at increasing HPV vaccine initiation and completion rates in a five-clinic pediatric network in Bexar County, Texas. The adaptation process was guided by established frameworks and involved formative work with clinic stakeholders. The study utilized a quasi-experimental single group pre- and post- study design, with an external comparison data using the National Immunization Survey-Teen (NIS-Teen) datasets for the same time period to examine the AVP's effect on HPV vaccination initiation and completion. A series of interrupted time series analyses (ITSA) compared the clinic system patient outcomes (HPV vaccination initiation and completion rates) in the post-intervention to the general adolescent population (NIS-Teen). Of the 6438 patients (11-17 years) with clinic visits during the 3-year study period, HPV vaccination initiation rates increased from 64.7% to 80.2% (p < 0.05) and completion rates increased from 43.2% to 60.2% (p < 0.05). The AVP was effective across various demographic and economic subgroups, demonstrating its generalizability. ITSA findings indicated the AVP improved HPV vaccination initiation and completion rates in clinic settings and that AVP strategies facilitated resilience during the pandemic. The minimal adaptation required for implementation in a new clinic system underscores its feasibility and potential for widespread adoption.

Cervical precancer and cancer incidence among insured women with and without HIV in South Africa

HIV infection increases the risk of developing cervical cancer; however, longitudinal studies in sub-Saharan Africa comparing cervical cancer rates between women living with HIV (WLWH) and women without HIV are scarce. To address this gap, we compared cervical precancer and cancer incidence rates between WLWH and women without HIV in South Africa using reimbursement claims data from a medical insurance scheme from January 2011 to June 2020. We used Royston-Parmar flexible parametric survival models to estimate cervical precancer and cancer incidence rates as a continuous function of age, stratified by HIV status. Our study population consisted of 518 048 women, with exclusions based on the endpoint of interest. To analyse cervical cancer incidence, we included 517 312 women, of whom 564 developed cervical cancer. WLWH had an ~3-fold higher risk of developing cervical precancer and cancer than women without HIV (adjusted hazard ratio for cervical cancer: 2.99; 95% confidence interval [CI]: 2.40-3.73). For all endpoints of interest, the estimated incidence rates were higher in WLWH than women without HIV. Cervical cancer rates among WLWH increased at early ages and peaked at 49 years (122/100 000 person-years; 95% CI: 100-147), whereas, in women without HIV, incidence rates peaked at 56 years (40/100 000 person-years; 95% CI: 36-45). Cervical precancer rates peaked in women in their 30s. Analyses of age-specific cervical cancer rates by HIV status are essential to inform the design of targeted cervical cancer prevention policies in Southern Africa and other regions with a double burden of HIV and cervical cancer.

Adolescent cancer prevention in rural, pediatric primary care settings in the United States: A scoping review

Adolescence is a critical period for establishing habits and engaging in health behaviors to prevent future cancers. Rural areas tend to have higher rates of cancer-related morbidity and mortality as well as higher rates of cancer-risk factors among adolescents. Rural primary care clinicians are well-positioned to address these risk factors. Our goal was to identify existing literature on adolescent cancer prevention in rural primary care and to classify key barriers and facilitators to implementing interventions in such settings. We searched the following databases: Ovid MEDLINE®; Ovid APA PsycInfo; Cochrane Library; CINAHL; and Scopus. Studies were included if they reported on provider and/or clinic-level interventions in rural primary care clinics addressing one of these four behaviors (obesity, tobacco, sun exposure, HPV vaccination) among adolescent populations. We identified 3,403 unique studies and 24 met inclusion criteria for this review. 16 addressed obesity, 6 addressed HPV vaccination, 1 addressed skin cancer, and 1 addressed multiple behaviors including obesity and tobacco use. 10 studies were either non-randomized experimental designs (n = 8) or randomized controlled trials (n = 2). The remaining were observational or descriptive research. We found a dearth of studies addressing implementation of adolescent cancer prevention interventions in rural primary care settings. Priorities to address this should include further research and increased funding to support EBI adaptation and implementation in rural clinics to reduce urban-rural cancer inequities.

Attitudes towards HPV Vaccination Policy Strategies to Improve Adolescent Vaccination Coverage among Pediatric Providers in New York State

Pediatric providers' stances on HPV vaccination-related policies are largely unknown. To gain insight into pediatric providers' perspectives and potential recommendations for directed policy, we conducted a cross-sectional survey of the American Academy of Pediatrics members in New York. Almost all providers expressed confidence in discussing the HPV vaccine with patients (98.6%, n = 72). Among common barriers to vaccination, providers listed parental safety concerns (n = 60, 82.2%), vaccination not being required for school entry (n = 59, 80.8%), and moral opposition to vaccination (n = 48, 65.8%). Among all respondents, 29 (39.7%), 13 (17.8%), and 2 (2.7%) agreed the vaccine should be required for middle, high, and tertiary school entry, respectively. Support for pharmacist-provision of the vaccine varied, with 31 (42.5%) providers expressing support. Most providers supported adolescent self-consent to vaccination, (n = 67, 91.8%). Providers continued to encounter barriers to HPV vaccination and indicated support of HPV vaccination mandates for school entry, pharmacist provision of the vaccine, and adolescent self-consent to vaccination.

Cervical Cancer Screening: A Review

Importance

Each year in the US, approximately 100 000 people are treated for cervical precancer, 14 000 people are diagnosed with cervical cancer, and 4000 die of cervical cancer.

Observations

Essentially all cervical cancers worldwide are caused by persistent infections with one of 13 carcinogenic human papillomavirus (HPV) genotypes: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. HPV vaccination at ages 9 through 12 years will likely prevent more than 90% of cervical precancers and cancers. In people with a cervix aged 21 through 65 years, cervical cancer is prevented by screening for and treating cervical precancer, defined as high-grade squamous intraepithelial lesions of the cervix. High-grade lesions can progress to cervical cancer if not treated. Cervicovaginal HPV testing is 90% sensitive for detecting precancer. In the general population, the risk of precancer is less than 0.15% over 5 years following a negative HPV test result. Among people with a positive HPV test result, a combination of HPV genotyping and cervical cytology (Papanicolaou testing) can identify the risk of precancer. For people with current precancer risks of less than 4%, repeat HPV testing is recommended in 1, 3, or 5 years depending on 5-year precancer risk. For people with current precancer risks of 4% through 24%, such as those with low-grade cytology test results (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesion [LSIL]) and a positive HPV test of unknown duration, colposcopy is recommended. For patients with precancer risks of less than 25% (eg, cervical intraepithelial neoplasia grade 1 [CIN1] or histologic LSIL), treatment-related adverse effects, including possible association with preterm labor, can be reduced by repeating colposcopy to monitor for precancer and avoiding excisional treatment. For patients with current precancer risks of 25% through 59% (eg, high-grade cytology results of ASC cannot exclude high-grade lesion [ASC-H] or high-grade squamous intraepithelial lesion [HSIL] with positive HPV test results), management consists of colposcopy with biopsy or excisional treatment. For those with current precancer risks of 60% or more, such as patients with HPV-16-positive HSIL, proceeding directly to excisional treatment is preferred, but performing a colposcopy first to confirm the need for excisional treatment is acceptable. Clinical decision support tools can facilitate correct management.

Conclusions and Relevance

Approximately 100 000 people are treated for cervical precancer each year in the US to prevent cervical cancer. People with a cervix should be screened with HPV testing, and if HPV-positive, genotyping and cytology testing should be performed to assess the risk of cervical precancer and determine the need for colposcopy or treatment. HPV vaccination in adolescence will likely prevent more than 90% of cervical precancers and cancers.

Enhancing long-term smoking abstinence among individuals with a history of cervical intraepithelial neoplasia or cervical cancer (Project ACCESS): protocol for a randomized clinical trial

BACKGROUND

The prevalence of smoking among cervical cancer survivors is high and evidence-based smoking cessation interventions are critically needed. This paper describes the study design, methods, and data analysis plans for a randomized clinical trial (RCT) designed to evaluate the efficacy of a novel, personally tailored SMS-delivered text-based digital treatment adjuvant designed to enhance the long-term efficacy of a "Motivation And Problem-Solving" (MAPS) approach for smoking cessation among individuals with a history of cervical intraepithelial neoplasia (CIN) or cervical cancer. MAPS is a phone counseling approach designed to facilitate long-term abstinence that comprises 6 counseling calls over 12 months. The current trial is evaluating the efficacy of MAPS+, which comprises all MAPS components plus a 24-month digital treatment adjuvant. This trial represents a logical extension of our previous RCT, which compared the efficacy of MAPS to a quitline control condition and found that MAPS resulted in greater than a 2-fold increase in smoking abstinence at 12 months (i.e., 26.4% vs. 11.9%). This treatment effect was no longer significant at 18 months, suggesting that efficacy dissipated as time from the end of treatment increased. The primary aim of the current trial is to compare the efficacy of MAPS + and ST in facilitating long-term abstinence.

METHODS

Individuals who smoke and have a history of cervical cancer or CIN (N = 340) are recruited throughout Florida and randomly assigned to Standard Treatment [ST] or MAPS+. ST participants are electronically connected with the Florida Quitline. MAPS + consists of 6 proactive MAPS-based counseling calls over 12 months plus the novel, personally tailored, text message-based treatment adjuvant delivered over 24 months. All participants receive 12 weeks of combination nicotine replacement therapy (patch and lozenge) and are followed for 24 months. Participant recruitment commenced in December 2022 and is ongoing.

DISCUSSION

This study builds on promising results from our recent trial which found that MAPS was associated with substantially higher abstinence from smoking at the end of the 12-month treatment period. Finding that this low-burden, personally tailored digital treatment adjuvant improves the long-term efficacy of MAPS would have important clinical and public health implications.

TRIAL REGISTRATION

Clinical Trials Registry NCT05645146; https://clinicaltrials.gov/ct2/show/NCT05645146 ; Registered on December 9, 2022.

Recurrent High-Grade Squamous Intraepithelial Lesion After Loop Excision Procedure Versus Loop Procedure With Top Hat

OBJECTIVE

To evaluate single-pass loop electrosurgical excision procedure (LEEP-SP) versus LEEP with top hat (LEEP-TH) in terms of treatment failure defined as high-grade squamous intraepithelial lesion (HSIL) cytology within 2 years' follow-up.

METHODS

This single-institution cohort study used a prospectively collected cervical dysplasia database including all patients who underwent LEEP-SP or LEEP-TH for biopsy-proven cervical intraepithelial neoplasia between 2005 and 2019.

RESULTS

Of 340 patients included, 178 underwent LEEP-SP and 162 LEEP-TH. The LEEP-TH patients were more likely to be older (mean age, 40.4 vs 36.5 years; p < .001) and have a positive preprocedure endocervical sampling (68.5% vs 11.8%; p < .001). Positive margins were found in 23 LEEP-SP (12.9%) and in 25 LEEP-TH (15.4%; p = .507). There was no significant difference in depth of excision between LEEP-SP (13.21 ± 23.19 mm) and LEEP-TH (17.37 ± 28.26 mm; p = .138). At 2 years, there was no difference in the rates of HSIL cytology (5.2% vs 6.3%; p = .698), any positive human papillomavirus test, or HSIL cytology (25% vs 15%; p = .284). The 57 patients undergoing repeat excision were more likely to be older (mean age, 40.95 vs 37.52 years; p = .023), have had a LEEP-TH (26.3% vs 73.7%; p < .001), and have initial cytologic HSIL (64.9% vs 35.0%; p < .001).

CONCLUSIONS

In this single-institution study, there is no difference in the rate of recurrent HSIL in patients undergoing LEEP-SP versus LEEP-TH. A LEEP-TH may have limited additional benefit over a LEEP-SP in the treatment of cervical HSIL.

Sexually Transmitted Human Papillomavirus: Update in Epidemiology, Prevention, and Management

This review presents the epidemiology, pathophysiology, prevention, and management of sexually transmitted human papillomavirus (HPV) and its associated diseases. HPV is the most common sexually transmitted infection worldwide. Prevalence varies regionally. Low-risk strains cause anogenital warts, which can be managed with patient- or provider-applied therapies. High-risk strains cause lower anogenital cancers. Primary and secondary prevention strategies include vaccination and screening for precancerous lesions, respectively. Management of abnormal screening results vary by test result, anatomic site, and individual cancer risk. Approaches include close rescreening, high-resolution visualization with biopsy, and-when biopsy-proven precancer is identified-removal or destruction of the lesion.

The Burden of Cervical Conization in Privately Insured Young and Mid-Adult Women in the United States

In 2019, the United States (US) Advisory Committee on Immunization Practices (ACIP) recommended that healthcare providers engage in shared clinical decision making for adults aged 27-45 who may benefit from HPV vaccination. However, it is difficult to assess these benefits as there is a lack of data on HPV burden on young and mid-adult women. This analysis estimates the incidence of conization and the burden associated with treating pre-cancerous states related to HPV with a loop electrosurgical excision procedure (LEEP) or a cold knife conization (CKC) among commercially insured women aged 18-45. This retrospective cohort study used the IBM MarketScan commercial claims encounter database for women aged 18-45 treated with conization. We assessed the annual incidence of conization (2016-2019) and adjusted the two-year health care costs post-conization using a multivariable Generalized Linear Model (GLM)-accounting for follow-up time and other characteristics-stratified by the age groups, namely 18-26 and 27-45. The inclusion criteria were met by 6735 women, with a mean age of 33.9 years (SD = 6.2). Conization incidence was lowest for women aged 18-26 (41/100,000 to 62/100,000 women-years) and highest for women aged 31-35 (243/100,000 to 269/100,000). The GLM-adjusted, all-cause healthcare costs per patient per year were USD 7279 and USD 9249 in the 18-26 and 27-45 age groups, respectively. The adjusted costs for disease-specific care were USD 3609 and USD 4557 for women ages 18-26 and 27-45, respectively. The burden of conization and the associated costs were significant, indicating a potential healthcare benefit of HPV vaccination among young and middle-aged women.

Towards a cervical cancer-free future: women's healthcare decision making and cervical cancer screening uptake in sub-Saharan Africa

OBJECTIVE

We investigated the association between women's healthcare decision making and cervical cancer screening uptake in sub-Saharan Africa.

DESIGN

Secondary data from the Demographic and Health Surveys of six countries in sub-Saharan Africa were used. We employed multilevel binary logistic regression modelling.

SETTING

Sub-Saharan Africa.

PARTICIPANTS

Women aged 15-49 years in Benin (n=5282), Côte d'Ivoire (n=1925), Cameroon (n=7558), Kenya (n=6696), Namibia (n=1990) and Zimbabwe (n=5006).

PRIMARY OUTCOME MEASURES

Cervical cancer screening uptake.

RESULTS

The overall prevalence of cervical cancer screening across the six sub-Saharan African countries was 13.4%. Compared with women whose healthcare decisions were made solely by husbands/partners/someone else, the likelihood of cervical cancer screening uptake was significantly higher among women who took healthcare decisions in consultation with their husbands/partners (aOR=1.38; 95% CI 1.19 to 1.59), but highest among those who made healthcare decisions alone (aOR=1.66; 95% CI 1.44 to 1.91). Women aged between 40 and 45 years (aOR=5.18; 95% CI 3.15 to 8.52), those with higher education (aOR=2.13; 95% CI 1.57 to 2.88), those who had ever heard of cervical cancer (aOR=32.74; 95% CI 20.02 to 53.55), read newspaper or magazine at least once a week (aOR=2.11; 95% CI 1.83 to 2.44), listened to the radio at least once a week (aOR=1.35; 95% CI1.18 to 1.52) and those in households with richest wealth index (aOR=1.55; 95% CI 1.20 to 2.00) had significantly higher odds of screening for cervical cancer compared to their counterparts.

CONCLUSION

Women who are able to make autonomous healthcare decisions and those who practice shared decision making are more likely to uptake cervical cancer screening. Therefore, policy interventions should focus on empowering women to be able to take autonomous healthcare decisions or shared decision making while targeting subpopulations (ie, multiparous and rural-dwelling women, as well as those in other religious affiliations aside from Christianity) that are less likely to uptake cervical cancer screening. Also, the radio and print media could be leveraged in raising awareness about cervical cancer screening to accelerate cervical cancer screening uptake in sub-Saharan Africa.

Effectiveness, immunogenicity, and safety of the quadrivalent HPV vaccine in women and men aged 27–45 years

Among women aged 27–45 years, the quadrivalent human papillomavirus (qHPV; HPV6/11/16/18) vaccine was generally well tolerated, efficacious, and immunogenic in the placebo-controlled FUTURE III study (NCT00090220; n = 3253). The qHPV vaccine was also generally well tolerated and highly immunogenic in men aged 27–45 years who participated in the single-cohort mid-adult male (MAM) study (NCT01432574; n = 150). Here, we report results of a long-term follow up (LTFU) extension of FUTURE III with up to 10 years follow-up. To understand the relevance of the mid-adult women LTFU study in the context of mid-adult men vaccination, we report results from post-hoc, cross-study immunogenicity analyses conducted to compare immunogenicity (geometric mean titers; GMTs) at 1-month post-qHPV vaccine dose 3 in women and men aged 27–45 years versus women and men aged 16–26 years from prior efficacy studies. The qHPV vaccine demonstrated durable protection against the combined endpoint of HPV6/11/16/18-related high-grade cervical dysplasia and genital warts up to 10 years (median 8.9) post-dose 3 and sustained HPV6/11/16/18 antibody responses through approximately 10 years in women aged 27–45 years. Efficacy of qHPV vaccine in men aged 27–45 years was inferred based on the cross-study analysis of qHPV vaccine immunogenicity demonstrating non-inferior HPV6/11/16/18 antibody responses in men aged 27–45 years versus 16–26 years. In conclusion, durable effectiveness of the qHPV vaccine was demonstrated in women 27–45 years of age, and vaccine efficacy was inferred in men 27–45 years of age based on the serological results.

Human Papillomavirus Vaccine Impact and Effectiveness Through 12 Years After Vaccine Introduction in the United States, 2003 to 2018

BACKGROUND

Human papillomavirus (HPV) vaccination was introduced in 2006 for females and in 2011 for males.

OBJECTIVE

To estimate vaccine impact and effectiveness against quadrivalent HPV vaccine (4vHPV)-type prevalent infection among sexually experienced U.S. females and vaccine effectiveness for sexually experienced U.S. males.

DESIGN

NHANES (National Health and Nutrition Examination Survey) conducted in 2003 to 2006 (prevaccine era) and in 2007 to 2010, 2011 to 2014, and 2015 to 2018 (vaccine eras).

SETTING

Nationally representative U.S. surveys.

PARTICIPANTS

Sexually experienced participants aged 14 to 24 years.

INTERVENTION

U.S. HPV vaccination program.

MEASUREMENTS

Participant-collected cervicovaginal and penile specimens were tested for HPV DNA. The prevalences of 4vHPV and non-4vHPV types were estimated in each era for females and in 2013 to 2016 for males. Prevalences among the female population overall, vaccinated females, and unvaccinated females were compared in vaccine eras versus the prevaccine era (vaccine impact). Within each vaccine era, prevalence among vaccinated females was compared with that among unvaccinated females (vaccine effectiveness). Vaccine impact and effectiveness were estimated as (1 - prevalence ratio) · 100.

RESULTS

Among sexually experienced females aged 14 to 24 years, the impact on 4vHPV-type prevalence in 2015 to 2018 was 85% overall, 90% among vaccinated females, and 74% among unvaccinated females. No significant declines were found in non-4vHPV-type prevalence. Vaccine effectiveness ranged from 60% to 84% during vaccine eras for females and was 51% during 2013 to 2016 for males.

LIMITATION

Self- or parent-reported vaccination history and small numbers in certain subgroups limited precision.

CONCLUSION

Nationally representative data show increasing impact of the vaccination program and herd protection. Vaccine effectiveness estimates will be increasingly affected by herd effects.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity

Cervical cancer is highly preventable when precancerous lesions are detected early and appropriately managed. However, the complexity of and frequent updates to existing evidence-based clinical guidelines make it challenging for clinicians to stay abreast of the latest recommendations. In addition, limited availability and accessibility to information technology (IT) decision supports make it difficult for groups who are medically underserved to receive screening or receive the appropriate follow-up care. The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC), is leading a multiyear initiative to develop computer-interpretable ("computable") version of already existing evidence-based guidelines to support clinician awareness and adoption of the most up-to-date cervical cancer screening and management guidelines. DCPC is collaborating with the MITRE Corporation, leading scientists from the National Cancer Institute, and other CDC subject matter experts to translate existing narrative guidelines into computable format and develop clinical decision support tools for integration into health IT systems such as electronic health records with the ultimate goal of improving patient outcomes and decreasing disparities in cervical cancer outcomes among populations that are medically underserved. This initiative meets the challenges and opportunities highlighted by the President's Cancer Panel and the President's Cancer Moonshot 2.0 to nearly eliminate cervical cancer.

Changes in Cervical Cytology Results and Human Papillomavirus Types Among Persons Screened for Cervical Cancer, 2007 and 2015-2017

OBJECTIVES

Since 2006, the US human papillomavirus (HPV) vaccination program has led to decreases in HPV infections caused by high-risk vaccine-targeted HPV types (HPV 16/18). We assessed differences in high-risk HPV prevalence by cervical cytology result among 20- to 24-year-old persons participating in routine cervical cancer screening in 2015-2017 compared with 2007.

MATERIALS AND METHODS

Residual routine cervical cancer screening specimens were collected from 20- to 24-year-old members of 2 integrated healthcare delivery systems as part of a cross-sectional study and were tested for 37 HPV types. Cytology results and vaccination status (≥1 dose) were extracted from medical records. Cytology categories were normal, atypical squamous cells of undefined significance, low-grade squamous intraepithelial lesions (SIL), or high-grade SIL/atypical squamous cells cannot exclude high-grade SIL. Prevalences of HPV categories (HPV 16/18, HPV 31/33/45/52/58, HPV 35/39/51/56/59/66/68) were estimated by cytology result for 2007 and 2015-2017.

RESULTS

Specimens from 2007 (n = 4046) were from unvaccinated participants; 4574 of 8442 specimens (54.2%) from 2015-2017 were from vaccinated participants. Overall, HPV 16/18 positivity was lower in 2015-2017 compared with 2007 in all groups: high-grade SIL/atypical squamous cells cannot exclude high-grade SIL, 16.0% vs 69.2%; low-grade SIL, 5.4% vs 40.1%; atypical squamous cells of undefined significance, 5.0% vs 25.6%; and normal, 1.3% vs 8.1%. Human papillomavirus 31/33/45/52/58 prevalence was stable for all cytology groups; HPV 35/39/51/56/59/66/68 prevalence increased among low-grade SIL specimens (53.9% to 65.2%) but remained stable in other groups.

CONCLUSIONS

Prevalence of vaccine-targeted high-risk HPV types 16/18 was dramatically lower in 2015-2017 than 2007 across all cytology result groups while prevalence of other high-risk HPV types was mainly stable, supporting vaccine impact with no evidence of type replacement.

Impact of prior underinsurance on cervical cancer screening among Davidson County, Tennessee, women diagnosed with invasive cervical cancer, 2008-2018

INTRODUCTION

We sought to investigate the association between insurance coverage history and cervical cancer screening among Davidson County, Tennessee, women diagnosed with incident cervical cancer.

METHODS

We reviewed medical records of women diagnosed with invasive cervical cancer from 2008 through 2018 identified via the state's cancer registry and by active surveillance of diagnostic pathology reports for the HPV-IMPACT project. Per 2012 United States Preventive Services Task Force recommended cervical cancer screening guidelines, women were characterized into three screening history categories: "no screening", "no follow-up" and "test/screening failure". Multivariable logistic regression measured the association of prior inadequate insurance (underinsurance) and screening history ("no screening/no follow-up" compared to "test/screening failure").

RESULTS

Of 212 women, most (77%) had not undergone recommended cervical cancer screening or follow-up prior to cancer diagnosis. Overall, 28% of women had history of underinsurance in 5 years prior to diagnosis. In adjusted analyses, underinsured women were more likely to have a "no screening/no follow-up" prior to cancer diagnosis (aOR 4.26; 95% CI 1.15-15.80) compared to "test/screening failure" history. Non-white race (aOR 2.73; 95% CI 0.98-7.61), older age (aOR 1.03 per year; 95% CI 1.00-1.07), and history of smoking (aOR 4.07; 95% CI 1.54-10.74) were also associated with increased likelihood of "no screening/no follow-up".

CONCLUSIONS

Previous underinsurance was independently associated with non-adherence to cervical cancer screening and follow-up guidelines among women with incident cervical cancer. Further study of factors contributing to inadequate cervical cancer screening and interventions to increase cervical cancer screening in high-risk populations is needed.

Human Papillomavirus Vaccine Impact on Cervical Precancers in a Low-Vaccination Population

INTRODUCTION

Demonstrating human papillomavirus vaccine impact is critical for informing guidelines to increase vaccination and decrease human papillomavirus‒related outcomes, particularly in states with suboptimal vaccination coverage, such as Tennessee. This study examines the trends in high-grade cervical lesion incidence among Tennessee Medicaid-enrolled women aged 18-39 years and the subset of women who were screened for cervical cancer.

METHODS

Using a validated claims-based model to identify incident cervical intraepithelial neoplasia Grades 2 or 3 or adenocarcinoma in situ events, annual age group‒specific incidence rates from Tennessee Medicaid billing data, 2008-2018, were calculated. Significant trends were determined by Joinpoint. Analyses were conducted in 2020.

RESULTS

From 2008 to 2018, high-grade cervical lesion incidence significantly declined in women aged 18-20 years (average annual percentage change= -31.9, 95% CI= -38.6, -24.6), 21-24 years (average annual percentage change= -12.9, 95% CI= -22.3, -2.4), and 25-29 years (average annual percentage change= -6.4, 95% CI= -8.1, -4.6). Among screened women, rates significantly declined for ages 18-20 years (average annual percentage change= -20.3, 95% CI= -25.3, -15.0), 21-24 years (average annual percentage change= -10.2, 95% CI= -12.6, -7.8), and 25-29 years (average annual percentage change= -2.6, 95% CI= -3.9, -1.2). Trends from 2008 to 2018 were stable for older age groups (30-34 and 35-39 years).

CONCLUSIONS

Results show reductions in high-grade cervical lesion incidence among ages most likely to have benefited from the human papillomavirus vaccine. Declines among young, screened women suggest causes other than reduction in screening. Evidence of vaccine impact in populations with low-vaccination coverage, such as Tennessee, is promising.

The Loop Electrosurgical Excision Procedure and Cone Conundrum: The Role of Cumulative Excised Depth in Predicting Preterm Birth

Objective  The objective was to determine factors associated with spontaneous preterm birth at less than 37 weeks in a cohort of patients who underwent a loop electrosurgical excision procedure (LEEP) or cone prior to pregnancy. Study Design  This was a nested case-control study within a cohort of patients who underwent at least one LEEP or cone and had care for the next singleton pregnancy at either of two institutions between 1994 and 2014. Cases had spontaneous preterm birth at less than 37 weeks. Exposures included potential risk factors for preterm birth such as cumulative depth of excised cervix and time since excision. Reverse stepwise selection was used to identify the covariates for multivariable logistic regression. Results  A total of 134 patients were included. Eighteen (13%) had a spontaneous preterm birth at less than 37 weeks. Median second-trimester cervical lengths were similar between those who delivered preterm and term (3.9-cm preterm and 3.6-cm term, p  = 0.69). Patients who delivered preterm had a significantly greater median total excised depth of cervix (1.2 vs. 0.8 cm, p  = 0.04). After adjustment for confounders, total excised depth remained significantly associated with preterm birth (adjusted odds ratio [aOR] = 2.2, 95% confidence interval [CI]: 1.3-3.8). Conclusion  Total excised depth should be considered in addition to cervical length screening when managing subsequent pregnancies. Key Points A history of a LEEP or cone excision has been associated with spontaneous preterm birth.A two-fold increase in spontaneous preterm birth was seen per cumulative centimeter excised.There was no difference in second-trimester cervical length between the term and preterm groups.

Real-world impact and effectiveness assessment of the quadrivalent HPV vaccine: a systematic review of study designs and data sources

INTRODUCTION

Vaccine effectiveness and impact studies are typically observational, generating evidence after vaccine launch in a real-world setting. For human papillomavirus (HPV) vaccination studies, the variety of data sources and methods used is pronounced. Careful selection of study design, data capture and analytical methods can mitigate potential bias in such studies.

AREAS COVERED

We systematically reviewed the different study designs, methods, and data sources in published evidence (1/2007-3/2020), which assessed the quadrivalent HPV vaccine effectiveness and impact on cervical/cervicovaginal, anal, and oral HPV infections, anogenital warts, lesions in anus, cervix, oropharynx, penis, vagina or vulva, and recurrent respiratory papillomatosis.

EXPERT OPINION

The rapid growth in access to real-world data allows global monitoring of effects of different public health interventions, including HPV vaccination programs. But the use of data which are not collected or organized to support research also underscore a need to develop robust methodology that provides insight of vaccine effects and consequences of different health policy decisions. To achieve the WHO elimination goal, we foresee a growing need to evaluate HPV vaccination programs globally. A critical appraisal summary of methodology used will provide timely guidance to researchers who want to initiate research activities in various settings.

Median Age at HPV Infection Among Women in the United States: A Model-Based Analysis Informed by Real-world Data

Background

The US Advisory Committee for Immunization Practices (ACIP) recommended shared clinical decision-making for human papillomavirus (HPV) vaccination of individuals aged 27 to 45 years (mid-adults) in June 2019. Determining the median age at causal HPV infection and CIN2+ diagnosis based on the natural history of HPV disease can help elucidate the incidence of HPV infections and the potential benefits of vaccination in mid-adults.

Methods

Real-world data on CIN2+ diagnosis from the prevaccine era were sourced from a statewide surveillance registry in Connecticut. Age distribution of CIN2+ diagnosis in 2008 and 2009 was estimated. A discrete event simulation model was developed to predict the age distribution of causal HPV infection. The optimal age distribution of causal HPV infection provided the best goodness-of-fit statistic to compare the predicted vs real-world age distribution of CIN2+ diagnosis.

Results

The median age at CIN2+ diagnosis from 2008 through 2009 in Connecticut was 28 years. The predicted median age at causal HPV infection was estimated to be 23.9 years. There was a difference of 5.2 years in the median age at acquisition of causal HPV infection and the median age at CIN2+ diagnosis.

Conclusions

Real-world data on CIN2+ diagnosis and model-based analysis indicate a substantial burden of infection and disease among women aged 27 years or older, which supports the ACIP recommendation to vaccinate some mid-adults. When natural history is known, this novel approach can also help determine the timing of causal infections for other commonly asymptomatic infectious diseases.

Video colposcopy versus headlight for large loop excision of the transformation zone (LLETZ): a randomised trial

Purpose

To compare resected cone mass and resection margin status when performing Large Loop Excision of the Transformation Zone (LLETZ) using video colposcopy (LLETZ-VC) versus a headlight (LLETZ-HL) in women with cervical dysplasia.

Methods

Prospective, randomised trial (monocentric) at a specialised cervical dysplasia unit in a University Hospital. Women with a biopsy-proven CIN2 + or persisting CIN1 or diagnostic LLETZ were recruited and randomised. LLETZ was performed either under video colposcopic vision or using a standard surgical headlight. The primary endpoint was resected cone mass. Secondary endpoints were the rate of involved margins, fragmentation of the specimen, procedure time, time to complete haemostasis (TCH), blood loss, pain, intra- and postoperative complications, and surgeon preference.

Results

LLETZ-VC and LLETZ-HL (109 women each) had comparable cone masses (1.57 [0.98–2.37] vs. 1.67 [1.15–2.46] grams; P = 0.454). TCH was significantly shorter in the LLETZ-VC arm (60 [41–95.2] vs. 90 [47.2–130.2] seconds; P = 0.008). There was no statistically significant difference in involved resection margins (6/87 [6.5%] vs. 16/101 [13.7%], P = 0.068) and postoperative complications (13/82 [13.7%] vs. 22/72 [23.4%], P = 0.085). Patient-reported outcomes favoured LLETZ-VC with a lower use of analgesics (6/80 [7.0%] vs. 17/87 [16.3%]; P = 0.049). However, LLETZ-VC was more difficult to perform with significantly lower ratings for handling (7 [5–9] vs. 9 [8–10]; P < 0.001) and general satisfaction (7.5 [5–9] vs. 10 [8–10]; P < 0.001).

Conclusion

Intraoperative video colposcopy for LLETZ has minimal benefits at the cost of surgeons’ satisfaction.

Clinical trial registration

NCT04326049 (ClinicalTrials.gov).

Management of Cervical Dysplasia Using Office Loop Electrosurgical Excision Procedure

Declining cervical cancer rates in the United States highlights the value of prevention and early detection of premalignant cervical disease afforded by the human papillomavirus vaccine and Pap smear. The availability of in-office loop electrosurgical excision procedure affords clinicians with a cost-effective and preferred tool for the excision of high-grade lesions of the cervix with minimal risk for severe adverse outcomes. The most recent American Society for Colposcopy and Cervical Pathology guidelines recommend a risk-based approach for the detection, treatment, and surveillance of cervical disease and specifically focus on the risk of developing cervical intraepithelial neoplasia 3 or worse histology.

Hispanic Ethnicity and Cervical Cancer Precursors Among Low-Income Women in Arizona

Purpose

In the United States, Hispanics are more likely to be diagnosed with cervical cancer compared to Non-Hispanic Whites. Annually, 250,000 to 1 million women are diagnosed with a precursor to CC. The aim of this study was to assess whether Hispanics have a higher prevalence of cervical dysplasia compared to Non-Hispanics Whites among a population of low-income women.

Patients and Methods

We analyzed the results of 10,911 cervical cytology tests administered between 2003 and 2016 that were funded through the Center for Disease Control and Prevention’s (CDC) program for low-income, uninsured women entitled the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). In the state of Arizona, the program is called the Well Women HealthCheck Program (WWHP). Logistic regression was used to identify increased risk of dysplasia, including low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL/ICC), and multinomial logistic regression was used to assess increased likelihood for LSIL and HSIL/ICC as separate categories.

Results

In the crude analysis, Hispanic ethnicity was modestly associated with higher prevalence of LSIL (odds ratio (OR)=1.39, 95% CI=1.01–1.91), but this association was not statistically significant after adjusting for confounders. However, in the final models, lower income was independently associated with LSIL (adjusted odds ratio [aOR]=1.55, 95% CI=1.30–1.44), while smoking (aOR=2.88, 95% CI=1.21–6.84) and no history of Pap test within five years (aOR=3.54, 95% CI=1.61–6.99) were independently associated with HSIL.

Conclusion

After adjusting for confounding in a sample of low-income women with comparable Pap screening rates, ethnicity was not associated with greater prevalence of abnormal pap smears. However, other variables were independently associated with LSIL and HSIL. The higher proportion of LSIL cases among lower income individuals compared to those with higher incomes, and the higher proportion of HSIL cases observed among those screened least regularly stresses the importance of programs like WWHP: programs that target low-income, uninsured women. These programs help save lives.

Knowledge of HPV, its vaccines, and attitudes toward HPV vaccines among obstetrician-gynecologists, pediatricians and immunization services providers in Western China

Background

In mainland China, HPV vaccines have been available to the public. However, only a few related studies among health care providers, as the key information providers, were reported although public concerns on HPV vaccines still exist. In this study, we aim to assess the knowledge of HPV, its vaccines, and attitudes toward HPV vaccines among the three most important groups of health care providers in Western China.

Method

This was a cross-sectional questionnaire-based study. Health care providers including obstetrician-gynecologists (OB-GYNs), pediatricians, and immunization service providers in Western China were investigated regarding their knowledge of HPV and its vaccines and their attitudes toward HPV vaccines.

Results

Of 1079 health care providers completing the survey, 1015 (94.1%) knew HPV infection is the primary cause of cervical cancer. However, lower knowledge levels of other HPV-related diseases were also found (43.2%). About three-quarters (74.1%) of practitioners interviewed would be willing to recommend HPV vaccination, which was found to be lower among the OB-GYNs (69.6%) and the pediatricians (73.2%). “Lack of relevant knowledge,” “concerns on safety and efficacy” and price were the three most important concerns surrounding HPV vaccination.

Conclusion

The interviewed practitioners did not have adequate knowledge of HPV and its vaccines in depth. Education interventions are highly recommended to the health care providers, especially for OB-GYNs and pediatricians, to increase the coverage of HPV vaccination among the population. For the currently high price of vaccines, a future co-sharing mechanism between the government, the providers, and the individuals might be a solution.

Cervical cancer incidence stratified by age in women with HIV compared with the general population in the United States, 2002-2016

OBJECTIVE

Recommendations for the age of initiating screening for cervical cancer in women with HIV (WWH) in the United States have not changed since 1995 when all women (regardless of immune status) were screened for cervical cancer from the age of onset of sexual activity, which often occurs in adolescence. By 2009, recognizing the lack of benefit as well as harms in screening young women, guidelines were revised to initiate cervical cancer screening for the general population at age 21 years. By comparing cervical cancer incidence in young WWH to that of the general population, we assessed the potential for increasing the recommended age of initiating cervical cancer screening in WWH.

DESIGN

We compared age-specific invasive cervical cancer (ICC) rates among WWH to the general population in the United States HIV/AIDS Cancer Match Study.

METHODS

We estimated standardized incidence ratios as the observed number of cervical cancer cases among WWH divided by the expected number, standardized to the general population by age, race/ethnicity, registry, and calendar year.

RESULTS

ICC rates among WWH were elevated across all age groups between ages 25 and 54 years (SIR = 3.80; 95% CI 3.48--4.15) but there were zero cases among ages less than 25 years.

CONCLUSION

The absence of ICC among WWH less than 25 years supports initiating cervical cancer screening at age 21 years, rather than adolescence, to prevent cancers in WWH at ages with higher risk of ICC.

Public health impact and cost-effectiveness of catch-up 9-valent HPV vaccination of individuals through age 45 years in the United States

The Advisory Committee on Immunization Practices (ACIP) recommended catch-up 9-valent Human Papillomavirus (HPV) vaccination through age 26 years, and shared clinical decision-making for adults aged 27-45 years, compared with catch-up through age 26 years and 21 years for females and males, respectively (status quo; pre-June-2019 recommendations). This study assessed the public health impact and cost-effectiveness of expanded catch-up vaccination through age 45 years (expanded catch-up) compared with status quo. We used an HPV dynamic transmission infection and disease model to assess disease outcomes and incremental cost-effectiveness ratio (ICER) of expanded catch-up compared with status quo. Costs (2018 USD), calculated from a healthcare sector perspective, and quality-adjusted life years (QALY) were discounted at 3% annually. Historical vaccination coverage was estimated using NIS-TEEN survey data (NHANES data for sensitivity analysis). Alternative scenario analyses included restricting upper age of expanded catch-up through 26 years (June-2019 ACIP recommendation), 29 years, and further 5-year increments. Our results show expanded catch-up vaccination would prevent additional 37,856 cancers, 314,468 cervical intraepithelial neoplasia-2/3s, 1,743,461 genital warts, and 10,698 deaths compared with status quo over 100 years at cost of $141,000/QALY. With NHANES coverage, the ICER was $96,000/QALY. The June-2019 ACIP recommendation also provided public health benefits with an ICER of $117,000/QALY, compared with status quo. The ICER for expanded vaccination through age 34 years was $107,000/QALY. Expanding catch-up vaccination program through age 45 years-old in the US is expected to provide public health benefits, and cost-effectiveness improves with expanding catch-up through age 34.

Increases in Human Papillomavirus Testing Preceding Diagnosis of Cervical Precancer in 5 US States, 2008-2016

OBJECTIVE

The aim of the study was to describe trends in human papillomavirus (HPV) testing preceding diagnosis of cervical precancer during a time of changing screening recommendations.

MATERIALS AND METHODS

We conducted a cross-sectional analysis of data from active, population-based, laboratory surveillance among 1.5 million residents of 5 areas in the United States. We included women aged 21-39 years diagnosed with cervical intraepithelial neoplasia grades 2, 2/3, or 3 or adenocarcinoma in situ (collectively, CIN2+) during 2008-2016, who had a cytology and/or HPV test before diagnosis (n = 16,359).

RESULTS

The proportion of women with an HPV test preceding CIN2+ increased from 42.9% in 2008 to 73.3% in 2016 (p < .01); testing increased in all age groups (21-24 y: 35.3% to 47.6%, 25-29 y: 40.9% to 64.1%, 30-39 y: 51.7% to 85.9%, all p < .01). The HPV testing varied by cytology result and was highest among women with atypical squamous cells of unknown significance (n = 4,310/4,629, 93.1%), negative for intraepithelial lesion or malignancy (n = 446/517, 86.3%), and atypical glandular cells (n = 145/257, 56.4%). By 2016, at least half of all cases in every surveillance area had an HPV test before diagnosis.

CONCLUSIONS

During 2008-2016, the proportion of women with an HPV test preceding CIN2+ increased significantly for all age groups, cytology results, and surveillance areas. By 2016, most (85.9%) women aged 30-39 years had an HPV test, consistent with recommendations. Increasing utilization of HPV tests, which have demonstrated improved sensitivity for detecting cervical disease, may in part explain increasing rates of cervical precancer among women 30 years and older.

The effect of the Affordable Care Act dependent coverage provision on HPV vaccine uptake in young adult women, National Health and Nutrition Examination Survey 2007-2016

The human papillomavirus (HPV) vaccine protects against cancers caused by HPV. The study objective was to examine the effect of the Affordable Care Act (ACA) dependent child coverage provision on HPV vaccination initiation, HPV vaccine completion, HPV infection, and health insurance coverage among young women. Using cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), 2172 female participants were included. The impact of the dependent coverage provision on the four outcomes was examined using difference-in-difference analyses with linear probability regressions, controlling for race/ethnicity, age, income, head of household education, and family employment. ACA exposure group was operationalized by age, with those targeted by the dependent coverage provision (ages 19-25) serving as the intervention group and those similar in age but not targeted (ages 18 and 26) serving as the control group. From 2007 to 2016, HPV vaccine initiation, HPV vaccine completion, and health insurance prevalence increased and HPV infection prevalence decreased. In the difference-in-difference adjusted models, ACA exposure was not associated with HPV vaccine initiation (0.045 percentage points [95% CI -0.087, 0.178]), completion (-0.044 percentage points [95% CI -0.152, 0.063]), HPV 16/18 infection (-0.051 percentage points [95% CI -0.123, 0.021]), or health insurance (0.065 percentage points [95% CI -0.032, 0.162]) among women aged 19 to 25. The dependent coverage provision may not have addressed relevant barriers to HPV vaccination. However, given that the effect of the dependent coverage provision on HPV vaccination and health insurance has been demonstrated previously, small sample size is a concern.

Estimated Prevalence and Incidence of Disease-Associated Human Papillomavirus Types Among 15- to 59-Year-Olds in the United States

INTRODUCTION

Human papillomavirus (HPV) can cause anogenital warts and several types of cancer, including cervical cancers and precancers. We estimated the prevalence, incidence, and number of persons with prevalent and incident HPV infections in the United States in 2018.

METHODS

Prevalence and incidence were estimated for infections with any HPV (any of 37 types detected using Linear Array) and disease-associated HPV, 2 types that cause anogenital warts plus 14 types detected by tests used for cervical cancer screening (HPV 6/11/16/18/31/33/35/39/45/51/52/56/58/59/66/68). We used the 2013-2016 National Health and Nutrition Examination Survey to estimate prevalence among 15- to 59-year-olds, overall and by sex. Incidences in 2018 were estimated per 10,000 persons using an individual-based transmission-dynamic type-specific model calibrated to US data. We estimated number of infected persons by applying prevalences and incidences to 2018 US population estimates.

RESULTS

Prevalence of infection with any HPV was 40.0% overall, 41.8% in men, and 38.4% in women; prevalence of infection with disease-associated HPV was 24.2% in men and 19.9% in women. An estimated 23.4 and 19.2 million men and women had a disease-associated HPV type infection in 2018. Incidences of any and disease-associated HPV infection were 1222 and 672 per 10,000 persons; incidence of disease-associated HPV infection was 708 per 10,000 men and 636 per 10,000 women. An estimated 6.9 and 6.1 million men and women had an incident infection with a disease-associated HPV type in 2018.

CONCLUSIONS

We document a high HPV burden of infection in the United States in 2018, with 42 million persons infected with disease-associated HPV and 13 million persons acquiring a new infection. Although most infections clear, some disease-associated HPV type infections progress to disease. The HPV burden highlights the need for continued monitoring of HPV-associated cancers, cervical cancer screening, and HPV vaccination to track and prevent disease.

Considerations for Child Cancer Survivors and Immunocompromised Children to Prevent Secondary HPV-associated Cancers

Survivors of childhood cancer and other immunocompromised children are at high risk for the development of secondary human papillomavirus (HPV)-associated cancers. In this overview, the authors examine the epidemiology of vaccine efficacy, the natural history of HPV infections, and accelerated HPV-associated cancer development in these populations. The authors highlight the opportunities for preventive care and future research directives.

Human Papillomavirus Distribution in Women with Abnormal Pap Smear and/or Cervical Intraepithelial Neoplasia in Vaccination Era. A Single-Center Study in the North Italian Population

Time trends prevalence of human papillomavirus (HPV) genotypes including negative and untypable infections were analyzed during a 15-year period (2005–2019) among 5807 subjects with abnormal pap-smears and/or cervical intraepithelial neoplasia (CIN). The rates of HPV16 dropped by 13% every 3 years (Prevalence Ratio, PR = 0.87, 95% CI = 0.82–0.93) in the CIN1 biopsy, while HPV16 status was unchanged over time in the CIN2+ biopsy. In CIN1 lesions, there was a corresponding increase of HR-HPV types unrelated to nonavalent vaccine. The rates of HPV 18, 31, and 52, decreased by 35% (PR = 0.65, 95% CI = 0.54–0.79), 19% (PR = 0.81, 95% CI = 0.73–0.91), and 21% (PR = 0.79, 95% CI = 0.73–0.86) every 3-year interval in CIN2+, respectively. Overall, the prevalence of negative/untypable HPV specimens in the entire database increased from 9.6% (129/1349) in the period 2011–2013 to 17.6% (161/913) and 28.4% (224/790) in the 2014–2016 period and in the 2017–2019 period, respectively (PR = 1.69, 95% CI = 1.52–1.88). HPV 16 prevalence decreased significantly among subjects with low-grade cervical squamous lesions. A significant increase of both HPV types unrelated to nonavalent vaccination and negative/untypable HPV infections was reported. The prevalence of HPV types among subjects with abnormal pap smears in Northern Italy is changing. Many variables including demographic factors and possibly vaccination could be responsible for this modification.

Immunogenicity and safety of a nine-valent human papillomavirus vaccine in women 27-45 years of age compared to women 16-26 years of age: An open-label phase 3 study

BACKGROUND

Efficacy of the nine-valent human papillomavirus (9vHPV; HPV types 6/11/16/18/31/33/45/52/58) vaccine was demonstrated in a phase 3 study in women 16-26 years of age. We present a phase 3 immunogenicity and safety study of the 9vHPV vaccine in women 27-45 versus 16-26 years of age.

METHODS

This international, open-label study (NCT03158220) was conducted in women 16-45 years of age. Participants (16-26 years, n = 570 and 27-45 years, n = 642) received a three-dose 9vHPV vaccination regimen (day 1, month 2, month 6). Month 7 geometric mean titers (GMTs) and seroconversion percentages to anti-HPV 6/11/16/18/31/33/45/52/58 were assessed. Participants were followed for safety throughout the study.

RESULTS

At month 7, anti-HPV 6/11/16/18/31/33/45/52/58 GMTs in women 27-45 years were compared to those in women 16-26 years of age. The primary hypothesis of non-inferiority of anti-HPV 16/18/31/33/45/52/58 GMTs in older versus younger women was met. The lower bound of the GMT ratio 95% confidence interval (27-45 years to 16-26 years) was 0.60-0.67 depending on HPV type, exceeding the non-inferiority margin of 0.5 for all HPV types. Month 7 seroconversion percentages in women 27-45 years of age were >99% for all HPV types. Injection-site and vaccine-related systemic adverse events (AEs) were observed in 87.5% and 25.1% of women 16-26 years, and 85.2% and 24.1% of women 27-45 years of age, respectively; no vaccine-related serious AEs were reported and no deaths occurred during the study.

CONCLUSIONS

The 9vHPV vaccine elicited non-inferior anti-HPV GMTs in women 27-45 years compared with women 16-26 years of age for HPV 16/18/31/33/45/52/58. The vaccine was generally well tolerated with a similar AE profile across the age groups. These data support bridging 9vHPV vaccine efficacy findings in women 16-26 years to women 27-45 years of age. Clinical trial registration NCT03158220.

The role and utility of population-based cancer registries in cervical cancer surveillance and control

Population-based cancer registries (PBCR) are vital to the assessment of the cancer burden and in monitoring and evaluating national progress in cervical cancer surveillance and control. Yet the level of their development in countries exhibiting the highest cervical cancer incidence rates is suboptimal, and requires considerable investment if they are to document the impact of WHO global initiative to eliminate cervical cancer as a public health problem. As a starting point we propose a comprehensive cancer surveillance framework, positioning PBCR in relation to other health information systems that are required across the cancer control continuum. The key concepts of PBCR are revisited and their role in providing a situation analysis of the scale and profile of the cancer-specific incidence and survival, and their evolution over time is illustrated with specific examples. Linking cervical cancer data to screening and immunization information systems enables the development of a comprehensive set of measures capable of assessing the short- and long-term achievements and impact of the initiative. Such data form the basis of national and global estimates of the cancer burden and permit comparisons across countries, facilitating decision-making or triggering cancer control action. The initiation and sustainable development of PBCR must be an early step in the scale-up of cervical cancer control activities as a means to ensure progress is successfully monitored and appraised.

Elimination of cervical cancer in U.S. Hispanic populations: Puerto Rico as a case study

Cervical cancer remains a major burden for women around the world. In 2018, the World Health Organization called for the elimination of cervical cancer worldwide (<4 cases per 100,000 women-years), within the 21st century. In the U.S., despite great progress toward this goal, existing disparities among racial/ethnic groups in cervical cancer raise concerns about whether elimination can be achieved for all women. We describe: 1) disparities in cervical cancer among Hispanics in the U.S. and factors that contribute to their increased risk, 2) prevention and control efforts to increase equity in the elimination of cervical cancer in this population, and 3) cervical cancer control efforts in Puerto Rico (PR), a U.S. territory, as a case study for cervical cancer elimination among a minority and underserved Hispanic population. Hispanics have the highest incidence rates of cervical cancer among all racial/ethnic groups in the U.S. Despite being more likely to complete HPV vaccination series, lower cervical cancer screening and access to treatment may lead to a higher cervical cancer mortality in Hispanics compared to non-Hispanic White women. These disparities are influenced by multiple individual-, sociocultural-, and system-level factors. To achieve the goal of cervical cancer elimination in the U.S., systematic elimination plans that consider the needs of Hispanic populations should be included within the Comprehensive Cancer Control Plans of each state. Because PR has implemented coordinated efforts for the prevention and control of cervical cancer, it represents a notable case study for examining strategies that can lead to cervical cancer elimination among Hispanics.

Economic Value of Lost Productivity Attributable to Human Papillomavirus Cancer Mortality in the United States

Objectives: To estimate years of potential life lost (YPLL) and present value of future lost productivity (PVFLP) associated with premature mortality due to HPV-attributable cancers, specifically those targeted by nonavalent HPV (9vHPV) vaccination, in the United States (US) before vaccine use. Methods: YPLL was estimated from the reported number of deaths in 2017 due to HPV-related cancers, the proportion attributable to 9vHPV-targeted types, and age- and sex-specific US life expectancy. PVFLP was estimated as the product of YPLL by age- and sex-specific probability of labor force participation, annual wage, value of non-market labor, and fringe benefits markup factor. Results: An estimated 7,085 HPV-attributable cancer deaths occurred in 2017 accounting for 154,954 YPLL, with 5,450 deaths (77%) and 121,226 YPLL (78%) attributable to 9vHPV-targeted types. The estimated PVFLP was $3.3 billion for cancer deaths attributable to 9vHPV-targeted types (86% from women). The highest productivity burden was associated with cervical cancer in women and anal and oropharyngeal cancers in men. Conclusions: HPV-attributable cancer deaths are associated with a substantial economic burden in the US, much of which could be vaccine preventable.

Improving Cervical Precancer Surveillance: Validity of Claims-Based Prediction Models in ICD-9 and ICD-10 Eras

Background

Human papillomavirus vaccine (HPV) impact on cervical precancer (cervical intraepithelial neoplasia grades 2+ [CIN2+]) is observable sooner than impact on cancer. Biopsy-confirmed CIN2+ is not included in most US cancer registries. Billing codes could provide surrogate metrics; however, the International Classification of Diseases, ninth (ICD-9) to tenth (ICD-10) transition disrupts trends. We built, validated, and compared claims-based models to identify CIN2+ events in both ICD eras.

Methods

A database of Davidson County (Nashville), Tennessee, pathology-confirmed CIN2+ from the HPV Vaccine Impact Monitoring Project (HPV-IMPACT) provided gold standard events. Using Tennessee Medicaid 2008-2017, cervical diagnostic procedures (N = 8549) among Davidson County women aged 18-39 years were randomly split into 60% training and 40% testing sets. Relevant diagnosis, procedure, and screening codes were used to build models from CIN2+ tissue diagnosis codes alone, least absolute shrinkage and selection operator (LASSO), and random forest. Model-classified index events were counted to estimate incident events.

Results

HPV-IMPACT identified 983 incident CIN2+ events. Models identified 1007 (LASSO), 1245 (CIN2+ tissue diagnosis codes alone), and 957 (random forest) incident events. LASSO performed well in ICD-9 and ICD-10 eras: 77.3% (95% confidence interval [CI] = 72.5% to 81.5%) vs 81.1% (95% CI = 71.5% to 88.6%) sensitivity, 93.0% (95% CI = 91.9% to 94.0%) vs 90.2% (95% CI = 87.2% to 92.7%) specificity, 61.3% (95% CI = 56.6% to 65.8%) vs 60.3% (95% CI = 51.0% to 69.1%) positive predictive value, 96.6% (95% CI = 95.8% to 97.3%) vs 96.3% (95% CI = 94.1% to 97.8%) negative predictive value, 91.0% (95% CI = 89.9% to 92.1%) vs 88.8% (95% CI = 85.9% to 91.2%) accuracy, and 85.1% (95% CI = 82.9% to 87.4%) vs 85.6% (95% CI = 81.4% to 89.9%) C-indices, respectively; performance did not statistically significantly differ between eras (95% confidence intervals all overlapped).

Conclusions

Results confirmed model utility with good performance across both ICD eras for CIN2+ surveillance. Validated claims-based models may be used in future CIN2+ trend analyses to estimate HPV vaccine impact where population-based biopsies are unavailable.

Potential Effects of Human Papillomavirus Type Substitution, Superinfection Exclusion and Latency on the Efficacy of the Current L1 Prophylactic Vaccines

There are >200 different types of human papilloma virus (HPV) of which >51 infect genital epithelium, with ~14 of these classed as high-risk being more commonly associated with cervical cancer. During development of the disease, high-risk types have an increased tendency to develop a truncated non-replicative life cycle, whereas low-risk, non-cancer-associated HPV types are either asymptomatic or cause benign lesions completing their full replicative life cycle. HPVs can also be present as non-replicative so-called “latent” infections and they can also show superinfection exclusion, where cells with pre-existing infections with one type cannot be infected with a different HPV type. Thus, the HPV repertoire and replication status present in an individual can form a complex dynamic meta-community which changes with respect to both time and exposure to different HPV types. In light of these considerations, it is not clear how current prophylactic HPV vaccines will affect this system and the potential for iatrogenic outcomes is discussed in light of recent outcome data.

TAF1A and ZBTB41 serve as novel key genes in cervical cancer identified by integrated approaches

Cervical cancer (CC) is the second most common cancer and the leading cause of cancer mortality in women. Numerous studies have found that the development of CC was associated with multiple genes. However, the mechanisms on gene level are enigmatic, hindering the understanding of its functional roles. This study sought to identify prognostic biomarkers of CC, and explore their biological functions. Here we conducted an integrated analysis to screen potential vital genes. Candidate genes were further tested by experiments in clinical specimens and cancer cell line. Then, molecular modeling was used to predict the three-dimensional structure of candidate genes’ proteins, and the interaction pattern was analyzed by docking simulation technique. Among the potential genes identified, we found that TAF1A and ZBTB41 were highly correlated. Furthermore, there was a definite interaction between the proteins of TAF1A and ZBTB41, which was affected by the activity of the p53 signaling pathway. In conclusion, our findings identified TAF1A and ZBTB41 could serve as biomarkers of CC. We confirmed their biological function and deciphered their interaction for the first time, which may be helpful for developing further researches.

Clearance of human papillomavirus infection in patients with cervical intraepithelial neoplasia: A systemic review and meta-analysis

BACKGROUND

There are currently no available standard drugs treating human papillomavirus (HPV) infection, especially for patients with low-grade cervical lesion. Several therapies are explored but the results are inconclusive. The objective of this study was to evaluate the efficacy of reported non-invasive treatments in patients with HPV infection and cervical lesions by meta-analysis.

METHODS

A comprehensive search of prospective and randomized studies published from April 2000 to April 2020 was conducted in electronic databases. The statistical analyses of the pooled risk ratios (RRs) and the corresponding 95% confidence intervals (95% CIs) were performed using the Revman 5.2 software.

RESULTS

Twelve articles including 12 randomized controlled studies and 1 prospective controlled randomized pilot study were enrolled. Therapeutic medications included biological and herbal regimen, interferon regimen and probiotics. The meta-analysis showed the experimental treatments had a statistically significant improvement in HPV clearance rate compared with the controls (RR = 0.71, 95% CI [0.63, 0.80], P < .00001); subgroup analyses stratified by regimen categories were consistent with results in the overall group. Treatment using biological and herbal regimen, interferon regimen or probiotics also resulted in a beneficial outcome in regression rate of cervical lesions compared with the controls (RR = 0.55, 95% CI [0.39, 0.79], P = .001). The trend was more favorable in the probiotics than that in the biological and herbal regimen (RR 0.48 vs 0.72).

CONCLUSION

Treatment of biological and herbal regimen, interferon regimen and probiotics benefit patients who have HPV infection and cervical lesions. Both the clearance of HPV and regression of cervical lesions are significant. More studies with less heterogeneity are needed to draw a concrete conclusion.

Screening for Cervical Cancer

The most effective strategy for cervical cancer prevention involves vaccination to prevent human papillomavirus (HPV) infections during adolescence followed by screening to detect HPV infections during adulthood. HPV vaccination before sexual debut can prevent HPV infections, precancers, and cancers. HPV vaccination of sexually active populations does not prevent cancer. Screening with HPV testing is the most effective method of detecting precancers and cancers between ages 25 and 65. Ensuring adequate screening around the age of menopause may be the key to preventing cervical cancer among elderly women. Most cervical cancers at all ages occur among unscreened or underscreened women.

Effect of arsenic trioxide on cervical cancer and its mechanisms

Cervical cancer is one of the most common types of gynecological tumor, and thus identifying complementary or substitute treatment methods to treat cervical cancer is important. The present study aimed to evaluate the effect of arsenic trioxide (ATO), a traditional Chinese medicine, on cervical cancer cells and its underlying mechanism. MTT, colony formation and Transwell assays were performed to investigate the effects of different concentrations of ATO on cell proliferation and invasion, respectively. Western blotting and reverse transcription-quantitative PCR were applied to measure hypoxia-inducible factor-1α expression (HIF-1α) expression following ATO treatment. Finally, the effects of HIF-1α knockdown on cervical cancer cell proliferation, apoptosis and invasion were evaluated. The results demonstrated that ATO could inhibit cell proliferation and invasion. Moreover, ATO could induce reactive oxygen species production in a time- and dose-dependent manner. ATO could also promote the apoptosis of cervical cancer cells via HIF-1α. Therefore, the present study may provide a theoretical basis for identifying effective molecular targets for the prevention and treatment of cervical cancer.

Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society

The American Cancer Society (ACS) recommends that individuals with a cervix initiate cervical cancer screening at age 25 years and undergo primary human papillomavirus (HPV) testing every 5 years through age 65 years (preferred); if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable) (strong recommendation). The ACS recommends that individuals aged >65 years who have no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years, and who have documented adequate negative prior screening in the prior 10 years, discontinue all cervical cancer screening (qualified recommendation). These new screening recommendations differ in 4 important respects compared with the 2012 recommendations: 1) The preferred screening strategy is primary HPV testing every 5 years, with cotesting and cytology alone acceptable where access to US Food and Drug Administration-approved primary HPV testing is not yet available; 2) the recommended age to start screening is 25 years rather than 21 years; 3) primary HPV testing, as well as cotesting or cytology alone when primary testing is not available, is recommended starting at age 25 years rather than age 30 years; and 4) the guideline is transitional, ie, options for screening with cotesting or cytology alone are provided but should be phased out once full access to primary HPV testing for cervical cancer screening is available without barriers. Evidence related to other relevant issues was reviewed, and no changes were made to recommendations for screening intervals, age or criteria for screening cessation, screening based on vaccination status, or screening after hysterectomy. Follow-up for individuals who screen positive for HPV and/or cytology should be in accordance with the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors.

Impact of a High Coverage Vaccination Rate on Human Papillomavirus Infection Prevalence in Young Women: A Cross-sectional Study

OBJECTIVE

The aim of the study was to compare the rate of high-risk human papillomavirus (HR-HPV) genotypes in vaccinated (Gardasil [quadrivalent]) and unvaccinated cohorts of young women.

MATERIALS AND METHODS

This is a retrospective, cross-sectional study, consisting of the comparison of the prevalence of HPV 16, 18, and other HR genotypes in 2183 women younger than 25 years, according to their birth year (born >1994 [mostly vaccinated <13 years]; born 1992-1994 [vaccinated at 17 years]; born <1992 [not vaccinated/vaccinated >17 years]), in a private laboratory.

RESULTS

The rates of HPV 16, 18, 16/18, and others in the cohort born before 1992 (n = 331) were 6.3%, 1.5%, 7.9%, and 31.7%. In those born 1992-1994 (n = 901), the rates were 3.3%, 0.4%, 3.6%, and 32.5%; in the ones born after 1994 (n = 951), the rates were 0.7%, 0.2%, 0.9%, and 33.2%, respectively.There were no changes in the relative risk (RR) of HR-HPV infection by genotypes other than HPV 16/18 in any cohort.The RR was significantly reduced in the cohort born after 1994 for HPV 16 (0.12 [0.050-0.270], p < .0001), HPV 18 (0.14 [0.027-0.714], p = .02), and HPV 16/18 (0.12 [0.057-0.254], p < .0001).In those born 1992-1994, there was a nearly significant reduction in the RR of HPV 18 infection (0.29 [0.079-1.09], p = .07); the reduction was significant for HPV 16 (0.52 [0.305-0.904], p = .02) and HPV 16/18 (0.45 [0.274-0.747], p = .0018).

CONCLUSIONS

Young women vaccinated before 13 years had a nearly 90% risk reduction of HPV 16/18, whereas if vaccinated at 17 years, the decrease was of 50%. There was no impact in the nonvaccine genotypes.Our data highlight the importance of vaccinating at young age and of introducing vaccines covering more HR genotypes.

Human papillomavirus vaccination 2020 guideline update: American Cancer Society guideline adaptation

The American Cancer Society (ACS) presents an adaptation of the current Advisory Committee on Immunization Practices recommendations for human papillomavirus (HPV) vaccination. The ACS recommends routine HPV vaccination between ages 9 and 12 years to achieve higher on-time vaccination rates, which will lead to increased numbers of cancers prevented. Health care providers are encouraged to start offering the HPV vaccine series at age 9 or 10 years. Catch-up HPV vaccination is recommended for all persons through age 26 years who are not adequately vaccinated. Providers should inform individuals aged 22 to 26 years who have not been previously vaccinated or who have not completed the series that vaccination at older ages is less effective in lowering cancer risk. Catch-up HPV vaccination is not recommended for adults aged older than 26 years. The ACS does not endorse the 2019 Advisory Committee on Immunization Practices recommendation for shared clinical decision making for some adults aged 27 through 45 years who are not adequately vaccinated because of the low effectiveness and low cancer prevention potential of vaccination in this age group, the burden of decision making on patients and clinicians, and the lack of sufficient guidance on the selection of individuals who might benefit.

Prevalence, incidence, and natural history of HPV infection in adult women ages 24 to 45 participating in a vaccine trial

Objectives

The natural history of human papillomavirus (HPV) infection has been studied extensively in young women; this study investigated HPV infection in adult women.

Methods

Data from 3817 women aged 24–45 years in a global trial of the 4-valent HPV (6/11/16/18) vaccine were used to calculate prevalence of anogenital infections containing 9-valent (9v) HPV vaccine types (6/11/16/18/31/33/45/52/58) and five non-vaccine types (35/39/51/56/59). Incidence of infections and persistent infections was estimated for 989 placebo recipients naive to all 14 HPV types at baseline. Age-adjusted hazard ratios were calculated for various sociodemographic factors.

Results

Prevalence of anogenital infection was highest in France at 29.2% (9vHPV types) and 21.7% (non-vaccine types) and lowest in the Philippines at 7.6% (9vHPV types) and 5.1% (non-vaccine types). Overall, HPV incidence (per 100 person-years) was 5.2 (9vHPV types) and 4.7 (non-vaccine types), and incidence of persistent infection was 2.7 (9vHPV types) and 2.1 (non-vaccine types). Factors associated with new HPV infections included younger age, younger age at first intercourse, being single, current use of tobacco, and higher number of past and recent sex partners.

Conclusions

Because mid-adult women acquire new HPV infections, administration of the 9vHPV vaccine could reduce HPV-related morbidity and mortality in this population.

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Prevalence of HPV infection in mid-adult women varies by country for age.

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Mid-adult women still acquire new HPV infections, including persistent infections.

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Risk factors for acquiring new HPV infections are similar in mid-adult and young women.

Association between Dietary Vitamin A and HPV Infection in American Women: Data from NHANES 2003-2016

Objective

Evidence regarding the relationship between vitamin A and HPV infection was limited. Therefore, this study is designed to investigate whether vitamin A was independently related to HPV infection in 13412 American women from NHANES for seven cycles.

Methods

The present study is a cross-sectional study. A total of 13412 eligible participants who had available HPV tests and vitamin A intake data were registered in the NHANE database from 2003 to 2016. The targeted independent variable and the dependent variable were vitamin A measured at baseline and HPV infection, respectively. We analyzed the association between dietary vitamin A intake and the prevalence of HPV infection. Besides, GAM and smooth curve fittings were used to address the nonlinear relationship between vitamin A and HPV infection to determine the effect of HPV infection.

Results

The result of fully adjusted binary logistic regression showed vitamin A was not associated with the risk of HPV infection after adjusting confounders (odds ratio = 0.97, 95% confidence interval: 0.97-1.02). A nonlinear relationship was detected between vitamin A and HPV infection, whose inflection point was 10.5 of log2 vitamin A (by the recursive algorithm). One unit increase of log2 vitamin A is associated with the 10% reduced risk of HPV infection when dietary vitamin A is < 1448.155mcg. Conversely, when the dietary vitamin A intake is ≧1448.155 mcg, for each additional log2 of vitamin A, the risk of HPV infection increased by 70%.

Conclusions

We found that dietary vitamin A was quite different from the trend of HPV infection in different confidence intervals. The results suggested that an appropriate amount (95% CI: 0.9-1.0, <10.5 of log2 transformer, i.e., 1448.155 mcg) of dietary vitamin A may be beneficial to prevent HPV infection. However, excessive intake of dietary vitamin A (95% CI: 1.1-2.8, ≧10.5 of log2 transformer, i.e., 1448.155 mcg) may increase the risk of HPV infection.