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Gilman SD, Gravitt PE, Paz-Soldán VA. Implementation of new technologies designed to improve cervical cancer screening and completion of care in low-resource settings: a case study from the Proyecto Precancer. Implement Sci Commun 2024; 5:35. [PMID: 38581011 PMCID: PMC10998344 DOI: 10.1186/s43058-024-00566-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 03/09/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND This case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management (CCSM) program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes. METHODS Proyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú, through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of human papillomavirus (HPV) testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation, at the primary level. RESULTS This approach, blending participatory action research, implementation science, and systems-thinking, led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy. CONCLUSIONS Proyecto Precancer facilitated the adoption and sustainment of HPV testing with subsequent treatment of HPV-positive women (after visual inspection) using portable thermal ablation at the primary level. This was accompanied by the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study highlights how implementation science approaches were used to guide the sustained adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.
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Affiliation(s)
- Sarah D Gilman
- Department of Clinical Research and Leadership, The George Washington University, Washington, DC, USA
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Valerie A Paz-Soldán
- Department of Tropical Medicine and Infectious Disease, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA.
- Behavioral Sciences Research Unit, Asociación Benéfica Prisma, Lima, Peru.
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Damgaard RK, Jenkins D, Stoler MH, de Koning M, van de Sandt M, Lycke KD, Kahlert J, Gravitt PE, Quint WGV, Steiniche T, Petersen LK, Hammer A. Human papillomavirus genotypes and risk of persistence and progression in women undergoing active surveillance for cervical intraepithelial neoplasia grade 2. Am J Obstet Gynecol 2024:S0002-9378(24)00072-3. [PMID: 38336125 DOI: 10.1016/j.ajog.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND In recent years, active surveillance has been introduced as an alternative to excisional treatment in younger women with cervical intraepithelial neoplasia grade 2 because regression rates are high and excisional treatment is associated with increased risk of preterm birth. However, early identification of women at increased risk of persistence/progression is important to ensure timely treatment. Evidence is limited on biomarkers that may be used to identify women at increased risk of persistence/progression. OBJECTIVE This study aimed to describe human papillomavirus HPV type-specific persistence/progression in women undergoing active surveillance for cervical intraepithelial neoplasia grade 2. STUDY DESIGN We conducted a historical cohort study of women aged 23 to 40 years diagnosed with cervical intraepithelial neoplasia grade 2 at Aarhus University Hospital from 2000 to 2010. Women were identified through the Danish Pathology Data Bank (DPDB) and were considered as undergoing active surveillance if they had a first record of a cervical biopsy within 2 years after index diagnosis and no loop electrosurgical excision procedure before this. Human papillomavirus genotyping was performed on archived tissue samples using the HPV SPF10-DEIA-LiPA25 system (DNA ELISA [enzyme-linked immunosorbent assay] HPV SPF10 kit and RHA HPV SPF10-LiPA25 kit). Persistence/progression was defined as having a record of cervical intraepithelial neoplasia grade ≥2 in the DPDB determined on the last and worst diagnosis on a biopsy or loop electrosurgical excision procedure specimen during follow-up. We estimated the relative risk (95% confidence interval) of persistence/progression using a modified Poisson model. RESULTS A total of 455 women were included. Two-thirds were aged ≤30 years (73.8%) at index diagnosis, and nearly half had a high-grade index cytology (48.8%). Overall, 52.2% of all women had cervical intraepithelial neoplasia grade ≥2 during follow-up; 70.5% were human papillomavirus-16-positive and 29.5% were positive for other human papillomavirus types. Human papillomavirus-16 was associated with a significantly higher risk of persistence/progression (relative risk, 1.64; 95% confidence interval, 1.37-1.95) compared with non-human papillomavirus-16. The risk of persistence/progression was highest in human papillomavirus-16-positive women with a high-grade index cytology compared with human papillomavirus-16-positive women with a low-grade cytology (relative risk, 1.29; 95% confidence interval, 1.03-1.61), whereas no differences were observed across age groups. CONCLUSION The highest risk of persistence/progression was observed among human papillomavirus-16-positive women, particularly those with associated high-grade cytology. These findings suggest that early excisional treatment should be considered in this group of women.
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Affiliation(s)
- Rikke Kamp Damgaard
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark; NIDO, Center for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - David Jenkins
- Viroclinics-DDL, Cerba Research, Rijswijk, the Netherlands
| | - Mark H Stoler
- Department of Pathology, University of Virginia, Charlottesville, VA
| | | | | | - Kathrine Dyhr Lycke
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark; NIDO, Center for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Wim G V Quint
- Viroclinics-DDL, Cerba Research, Rijswijk, the Netherlands
| | - Torben Steiniche
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Kjeld Petersen
- Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Anne Hammer
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark; NIDO, Center for Research and Education, Gødstrup Hospital, Herning, Denmark.
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Morse RM, Brown J, Gage JC, Prieto BA, Jurczuk M, Matos A, Vásquez Vásquez J, Reátegui RR, Meza-Sanchez G, Córdova LAD, Gravitt PE, Tracy JK, Paz-Soldan VA. "Easy women get it": pre-existing stigma associated with HPV and cervical cancer in a low-resource setting prior to implementation of an HPV screen-and-treat program. BMC Public Health 2023; 23:2396. [PMID: 38042779 PMCID: PMC10693157 DOI: 10.1186/s12889-023-17324-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/24/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Cervical cancer is preventable with vaccination and early detection and treatment programs. However, for these programs to work as intended, stigma related to HPV and cervical cancer must be understood and addressed. We explored pre-existing stigma associated with HPV and cervical cancer in the public healthcare system and community of a low-resource setting prior to implementation of an HPV screen-and-treat program. METHODS This study conducted thematic analysis of data collected during implementation of a novel HPV screen-and-treat system for cervical cancer early detection and treatment in Iquitos, Peru. We included 35 semi-structured interviews (19 health professionals, 16 women with cervical precancer or cancer), eight focus groups (70 community women), one workshop (14 health professionals), 210 counseling observations (with 20 nurse-midwives), and a document review. We used the Socio-Ecological Model to organize the analysis. RESULTS We identified three main themes: 1. the implication that women are to blame for their HPV infection through characterizations of being easy or promiscuous, 2. the implication that men are to blame for women's HPV infections through being considered careless or unfaithful, 3. HPV is shameful, embarrassing, and something that should be hidden from others. Consequently, in some cases, women refrained from getting screened for HPV. These themes were seen at the individual level among women, relationship level among women, men, and family members, community level among healthcare staff, and societal level within components of cervical cancer guidelines and male chauvinism. CONCLUSIONS Cervical cancer early detection and treatment programs in limited resource settings must address stigma entrenched throughout the entire healthcare system and community in order to sustainably and successfully implement and scale-up new programs. Interventions to tackle this stigma can incorporate messages about HPV infections and latency to lessen the focus on the influence of sexual behavior on HPV acquisition, and instead, promote screening and treatment as paramount preventative measures.
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Affiliation(s)
- Rachel M Morse
- Department of Tropical Medicine and Infectious Disease, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | | | - Julia C Gage
- Center for Global Health, National Cancer Institute, Bethesda, MD, USA
| | - Bryn A Prieto
- Department of Tropical Medicine and Infectious Disease, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Magdalena Jurczuk
- Department of Tropical Medicine and Infectious Disease, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Andrea Matos
- Dirección de Prevención y Control de Cancer (DPCAN) of Peruvian Ministry of Health, Lima, Peru
| | | | | | | | | | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J Kathleen Tracy
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| | - Valerie A Paz-Soldan
- Department of Tropical Medicine and Infectious Disease, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
- Asociación Benéfica PRISMA, Lima, Peru.
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Lycke KD, Kahlert J, Damgaard RK, Eriksen DO, Bennetsen MH, Gravitt PE, Petersen LK, Hammer A. Clinical course of cervical intraepithelial neoplasia grade 2: a population-based cohort study. Am J Obstet Gynecol 2023; 229:656.e1-656.e15. [PMID: 37595822 DOI: 10.1016/j.ajog.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/01/2023] [Accepted: 08/09/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Cervical intraepithelial neoplasia grade 2 has historically been the threshold for surgical excision, but because of high regression rates, many countries are transitioning to active surveillance. However, estimates for regression rates are based on small studies with heterogeneous definitions of regression and progression. OBJECTIVE This study aimed to describe regression and progression rates of cervical intraepithelial neoplasia grade 2 using nationwide healthcare registry data. STUDY DESIGN This was a nationwide population-based cohort study on women aged 18 to 40 years who had undergone active surveillance for cervical intraepithelial neoplasia grade 2 in Denmark from 1998 to 2020. This study excluded women with a previous record of cervical intraepithelial neoplasia grade 2 or worse or surgical excision. Cumulative incidence functions were used to estimate the rates of regression and progression at 6, 12, 18, and 24 months after diagnosis. In addition, a modified Poisson regression was used to estimate the crude and adjusted relative risks of progression within 24 months stratified by index cytology and age. RESULTS During the study period, 11,056 women underwent active surveillance, 6767 of whom regressed and 3580 of whom progressed within 24 months. This corresponded to regression rates of 62.9% (95% confidence interval, 61.9-63.8) and progression rates of 33.3% (95% confidence interval, 32.4-34.2) at 24 months of follow-up. Most women regressed (90%) or progressed (90%) within the first 12 months. Women with high-grade index cytology had a higher risk of progression than women with normal index cytology (adjusted relative, 1.58; 95% confidence interval, 1.43-1.76), whereas there was no difference in the risk of progression between women aged 30 and 40 years and women aged 23 to 29 years (adjusted relative risk, 0.98; 95% confidence interval, 0.88-1.10). CONCLUSION The observed high regression rates of cervical intraepithelial neoplasia grade 2 supported the transition in clinical management from surgical excision to active surveillance, particularly among women with low-grade or normal index cytology.
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Affiliation(s)
- Kathrine D Lycke
- Department of Gynecology and Obstetrics, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rikke K Damgaard
- Department of Gynecology and Obstetrics, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Dina O Eriksen
- Department of Gynecology and Obstetrics, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mary H Bennetsen
- Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Patti E Gravitt
- Center for Global Health, National Cancer Institute, Rockville, MD
| | - Lone K Petersen
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anne Hammer
- Department of Gynecology and Obstetrics, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Lycke KD, Kahlert J, Petersen LK, Damgaard RK, Cheung LC, Gravitt PE, Hammer A. Untreated cervical intraepithelial neoplasia grade 2 and subsequent risk of cervical cancer: population based cohort study. BMJ 2023; 383:e075925. [PMID: 38030154 PMCID: PMC10685285 DOI: 10.1136/bmj-2023-075925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE To describe the long term risk of cervical cancer in women with untreated (that is, undergoing active surveillance) or immediately treated cervical intraepithelial neoplasia grade 2 (CIN2). DESIGN Nationwide population based historical cohort study. SETTING Danish healthcare registries. PARTICIPANTS Women with CIN2 diagnosed in 1998-2020 and aged 18-40 years at diagnosis, who had either active surveillance or immediate treatment with large loop excision of the transformation zone (LLETZ). Women with a previous record of CIN2 or worse or LLETZ were excluded. MAIN OUTCOME MEASURE A Weibull survival model for interval censored time-to-event data was used to estimate the cumulative risk of cervical cancer. Inverse probability treatment weighting was used to adjust estimates for age, index cytology, calendar year, and region of residence. RESULTS The cohort included 27 524 women with CIN2, of whom 12 483 (45%) had active surveillance and 15 041 (55%) had immediate LLETZ. During follow-up, 104 cases of cervical cancer were identified-56 (54%) in the active surveillance group and 48 (46%) in the LLETZ group. The cumulative risk of cervical cancer was comparable across the two groups during the active surveillance period of two years. Thereafter, the risk increased in the active surveillance group, reaching 2.65% (95% confidence interval 2.07% to 3.23%) after 20 years, whereas it remained stable in the LLETZ group at 0.76% (0.58% to 0.95%). CONCLUSIONS Undergoing active surveillance for CIN2, thereby leaving the lesion untreated, was associated with increased long term risk of cervical cancer compared with immediate LLETZ. These findings show the importance of continued follow-up of women having active surveillance.
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Affiliation(s)
- Kathrine Dyhr Lycke
- Department of Obstetrics and Gynaecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynaecology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rikke Kamp Damgaard
- Department of Obstetrics and Gynaecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Patti E Gravitt
- Centre for Global Health, National Cancer Institute, Rockville, MD, USA
| | - Anne Hammer
- Department of Obstetrics and Gynaecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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6
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Morse RM, Brown J, Gage JC, Prieto BA, Jurczuk M, Matos A, Vásquez JV, Reátegui RR, Meza-Sanchez G, Córdova LAD, Gravitt PE, Tracy JK, Paz-Soldan VA. "Easy women get it": Pre-existing stigma associated with HPV and cervical cancer in a low-resource setting prior to implementation of an HPV screen-and-treat program. Res Sq 2023:rs.3.rs-3256535. [PMID: 37790338 PMCID: PMC10543436 DOI: 10.21203/rs.3.rs-3256535/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Background Cervical cancer is preventable with vaccination and early detection and treatment programs. However, in order for these programs to work as intended, stigma related to HPV and cervical cancer must be understood and addressed. We explored pre-existing stigma associated with HPV and cervical cancer in the public healthcare system of a low-resource setting prior to implementation of an HPV screen-and-treat program. Methods This study conducted thematic analysis of data collected during implementation of a novel HPV screen-and-treat system for cervical cancer early detection and treatment in Iquitos, Peru. We included 35 semi-structured interviews (19 health professionals, 16 women with cervical precancer or cancer), eight focus groups (70 community women), one workshop (14 health professionals), 210 counseling observations (with 20 nurse-midwives), and a document review. We used the Socio-Ecological Model to organize the analysis. Results We identified three main themes: 1. the implication that women are to blame for their HPV infection through characterizations of being easy or promiscuous, 2. the implication that men are to blame for women's HPV infections through being considered careless or unfaithful, 3. HPV is shameful, embarrassing, and something that should be hidden from others. Consequently, in some cases, women refrained from getting screened for HPV. These themes were seen at the individual level among women, relationship level among women, men, and family members, community level among healthcare staff, and societal level within components of cervical cancer guidelines and male chauvinism. Conclusions Cervical cancer early detection and treatment programs in limited resource settings must address stigma entrenched throughout the entire healthcare system in order to sustainably and successfully implement and scale-up new programs. Interventions to tackle this stigma can incorporate messages about HPV infections and latency to lessen the focus on the influence of sexual behavior on HPV acquisition, and instead, promote screening and treatment as paramount preventative measures.
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Affiliation(s)
- Rachel M Morse
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine
| | | | - Julia C Gage
- Center for Global Health, National Cancer Institute
| | - Bryn A Prieto
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine
| | - Magdalena Jurczuk
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine
| | - Andrea Matos
- Dirección de Prevención y Control de Cancer (DPCAN) of Peruvian Ministry of Health
| | | | | | | | | | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - J Kathleen Tracy
- Department of Medicine, University of Vermont College of Medicine
| | - Valerie A Paz-Soldan
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine
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Gravitt PE. How to turn evidence into policy in resource-limited settings. Nat Med 2023; 29:2166. [PMID: 37198456 DOI: 10.1038/s41591-023-02349-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Patti E Gravitt
- US National Cancer Institute, Center for Global Health, Rockville, MD, USA.
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8
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White JL, Grabowski MK, Rositch AF, Gravitt PE, Quinn TC, Tobian AAR, Patel EU. Trends in Adolescent Human Papillomavirus Vaccination and Parental Hesitancy in the United States. J Infect Dis 2023; 228:615-626. [PMID: 36869689 PMCID: PMC10469123 DOI: 10.1093/infdis/jiad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/25/2023] [Accepted: 02/28/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Human papillomavirus (HPV) vaccination coverage remains suboptimal in the United States, underscoring the importance of monitoring trends in vaccine hesitancy. METHODS Cross-sectional data from the 2011-2020 National Immunization Survey-Teen were used to assess trends in HPV vaccination initiation among 13-17-year-olds, parental intent to initiate vaccination, and primary reasons for parental hesitancy. RESULTS Among all sex and race and ethnicity groups, the prevalence of HPV vaccination initiation increased over time, but parental intent to vaccinate against HPV for unvaccinated teens remained consistently low (≤45%). Among hesitant parents, "safety concerns" increased in nearly all demographic groups, with the greatest increases observed for non-Hispanic white female and male teens and no change for non-Hispanic black female teens. In 2019-2020, parents of unvaccinated non-Hispanic white teens were least likely to intend on vaccinating their teens, and the most common reason for hesitancy varied by sex and race and ethnicity (eg, "safety concerns" for white teens and "not necessary" for black female teens). CONCLUSIONS Although HPV vaccination initiation increased over time, a substantial fraction of parents remain hesitant, and trends in their reason varied by sex and race and ethnicity. Health campaigns and clinicians should address vaccine safety and necessity.
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Affiliation(s)
- Jodie L White
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - M Kate Grabowski
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Patti E Gravitt
- Center for Global Health, National Cancer Institute, Rockville, Maryland, USA
| | - Thomas C Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Morse R, Brown J, Ríos López EJ, Prieto BA, Kohler-Smith A, Gonzales Díaz K, Figueredo Escudero M, Del Cuadro DL, Vásquez Del Aguila G, Daza Grandez H, Meza G, Tracy JK, Gravitt PE, Paz-Soldan VA. Challenges associated with follow-up care after implementation of an HPV screen-and-treat program with ablative therapy for cervical cancer prevention in Iquitos, Peru: a mixed methods study. Res Sq 2023:rs.3.rs-3210614. [PMID: 37674724 PMCID: PMC10479451 DOI: 10.21203/rs.3.rs-3210614/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Background Cervical cancer is a preventable cancer; however, decreasing its prevalence requires early detection and treatment strategies that reduce rates of loss to follow-up. This study explores factors associated with loss to follow-up among HPV-positive women after implementation of a screen-and-treat approach with visual triage and ablative therapy for cervical cancer prevention in Iquitos, Peru. Methods We conducted semi-structured interviews with nurse-midwives (n = 15) working in cervical cancer prevention and women (n = 24) who were recorded as lost to follow-up after positive HPV results. We used the Health Care Access Barriers Model to guide analysis. We utilize manifest content analysis to describe barriers to follow-up according to the nurse-midwives and thematic analysis to report themes from the women's perspectives. We also report the steps and time taken to contact women and report discrepancies and concordances between nurse-midwives and women regarding reasons for loss to follow-up. Results Women in this study expressed a desire to receive treatment. Barriers, including fragmented and incomplete registry systems, made receiving follow-up care more challenging. Nurse-midwives faced structural barriers in attempting to deliver positive results to women who were challenging to contact, and women did not have clear knowledge of how to receive their HPV results. Women faced cognitive barriers including a lack of understanding about HPV results and treatment procedures, fear or anxiety about HPV or treatment, and confusion about the follow-up process. Women also reported having important work matters as a barrier. Reported financial barriers were minimal. There was agreement between women's and nurse-midwives' reported barriers to follow-up in slightly over half of the cases. Conclusion This study highlights the barriers to follow-up after implementation of a primary-level HPV-based screen-and-treat approach. While some barriers that have previously been associated with loss to follow-up were not observed in this study (e.g., financial), we emphasize the need for screen-and-treat programs to focus on strategies that can address incomplete registry systems, structural challenges in results delivery, cognitive barriers in understanding results and treatment, and work-related barriers.
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Affiliation(s)
- Rachel Morse
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine
| | | | | | - Bryn A Prieto
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine
| | | | - Karina Gonzales Díaz
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto
| | | | | | | | | | - Graciela Meza
- Facultad de Medicina Humana, Universidad Nacional de la Amazonía Peruana
| | - J Kathleen Tracy
- Department of Medicine, University of Vermont College of Medicine
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Valerie A Paz-Soldan
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine
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10
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Gilman SD, Gravitt PE, Paz-Soldán VA. Implementation of new technologies designed to improve cervical cancer screening and completion of care in low-resource settings: A case study from the Proyecto Precancer. Res Sq 2023:rs.3.rs-3093534. [PMID: 37461540 PMCID: PMC10350167 DOI: 10.21203/rs.3.rs-3093534/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Background This case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) research methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes. Methods Proyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of molecular-based primary cervical cancer screening using HPV-testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation at the primary level. Results The participatory and system-thinking-oriented approach led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy. Conclusions Proyecto Precancer facilitated the adoption and sustainment of molecular-based primary cervical cancer screening using HPV-testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation at the primary level and the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study shows how PP used implementation science approaches to guide the adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.
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11
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Vedham V, Parascandola M, Gravitt PE. Redefining Expertise and Evidence in Global Implementation Research. Cancer Epidemiol Biomarkers Prev 2023; 32:e1-e3. [PMID: 37259552 DOI: 10.1158/1055-9965.epi-23-0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023] Open
Abstract
The theme for the 11th Annual Symposium on Global Cancer Research, co-convened with partners by the U.S. NCI Center for Global Health is "Closing the Research-to-Implementation Gap." Here, we reflect on the evolving role of implementation science from the lens of the needs of low- and middle-income countries. We highlight the importance for stronger and sustained engagement of implementation scientists and cancer control and prevention practitioners to enable more context-relevant co-design of implementation plans and strategies. We argue that deep learning from embedded implementation research through inductive analytic approaches is a critical first step to acceleration of evidence-to-practice translation and suggest an important role for systems approaches to facilitate this transition.
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Affiliation(s)
- Vidya Vedham
- U.S NCI, Center for Global Health, Rockville, Maryland
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12
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Morse RM, Jurczuk M, Brown J, Jara LEC, Meza G, López EJR, Tracy JK, Gravitt PE, Paz-Soldan VA. "Day or night, no matter what, I will go": Women's perspectives on challenges with follow-up care after cervical cancer screening in Iquitos, Peru: a qualitative study. BMC Womens Health 2023; 23:293. [PMID: 37259075 DOI: 10.1186/s12905-023-02414-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/05/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND The study's objective was to explore the factors associated with loss to follow-up among women with abnormal cervical cancer screening results in Iquitos, Peru from women's perspectives. METHODS In-depth interviews were conducted with 20 screen-positive women who were referred for follow-up care but for whom evidence of follow-up was not found. Interview transcripts were thematically analyzed inductively, and the codes were then categorized using the Health Care Access Barriers Model for presentation of results. RESULTS All interviewed women were highly motivated to complete the continuum of care but faced numerous barriers along the way, including cognitive barriers such as a lack of knowledge about cervical cancer and poor communication from health professionals regarding the process, structural barriers such as challenges with scheduling appointments and unavailability of providers, and financial barriers including out-of-pocket payments and costs related to travel or missing days of work. With no information system tracking the continuum of care, we found fragmentation between primary and hospital-level care, and often, registration of women's follow-up care was missing altogether, preventing women from being able to receive proper care and providers from ensuring that women receive care and treatment as needed. CONCLUSIONS The challenges elucidated demonstrate the complexity of implementing a successful cervical cancer prevention program and indicate a need for any such program to consider the perspectives of women to improve follow-up after a positive screening test.
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Affiliation(s)
- Rachel M Morse
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Magdalena Jurczuk
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | | | - Lita E Carrillo Jara
- Department of Cancer Control and Prevention, Dirección Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | - Graciela Meza
- Facultad de Medicina Humana, Universidad Nacional de La Amazonia Peruana, Iquitos, Peru
| | | | - J Kathleen Tracy
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Valerie A Paz-Soldan
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA.
- Asociación Benéfica PRISMA, Lima, Peru.
- Department of Tropical Medicine, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA.
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13
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Morse RM, Brown J, Noble HE, Ríos López EJ, Kohler-Smith A, Soto S, Del Cuadro DL, Gonzales Díaz K, Figueredo Escudero M, Vásquez Del Aguila G, Carrillo Jara LE, Silva Delgado HF, Palacios VA, Santos-Ortiz C, Gravitt PE, Paz-Soldan VA. Women's perspectives on the acceptability and feasibility of an HPV screen-and-treat approach to cervical cancer prevention in Iquitos, Peru: a qualitative study. BMC Womens Health 2022; 22:414. [PMID: 36217187 PMCID: PMC9552409 DOI: 10.1186/s12905-022-01943-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The objective of this study was to explore women's experiences of a screen-and-treat approach with ablative therapy (referred to by the Spanish acronym TVT-TA) as a method of treatment following a positive HPV test in Iquitos, Peru. METHODS A total of 111 in-depth interviews were conducted with 47 HPV positive women who attended the TVT-TA procedure at a primary-level healthcare facility. Interviews were conducted immediately before, immediately after, and six-weeks after TVT-TA. RESULTS Most interviewed women reported experiencing moderate pain during ablative therapy and minimal pain immediately after and six weeks after ablative therapy. Women also stated that the pain was less intense than they had expected. The most common physical after-effects of treatment were bleeding and vaginal odor. Women experienced oscillating emotions with fear upon receiving a positive HPV result, calming after hearing about ablative therapy treatment, worry about pain from the treatment itself, relaxation with counseling about the procedure, and relief following treatment. CONCLUSIONS Nearly all participants emphasized that they were pleased with the TVT-TA process even if they had experienced pain during TVT-TA, recommended that TVT-TA be expanded and available to more women, and stated that TVT-TA was faster and easier than expected. This study found that TVT-TA is a feasible and acceptable means of treating HPV according to the women receiving the treatment.
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Affiliation(s)
- Rachel M Morse
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | | | - Helen E Noble
- Global Health Fogarty International Program, University of Washington Northern Pacific, Seattle, WA, USA
| | | | | | | | - Daniel Lenin Del Cuadro
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | - Karina Gonzales Díaz
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | - Magaly Figueredo Escudero
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | | | - Lita E Carrillo Jara
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | | | - Victor A Palacios
- Dirección de Prevención y Control de Cáncer, Ministerio de Salud, Lima, Peru
| | - Carlos Santos-Ortiz
- Dirección de Prevención y Control de Cáncer, Ministerio de Salud, Lima, Peru
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Valerie A Paz-Soldan
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
- Asociación Benéfica PRISMA, Lima, Peru.
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14
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Damgaard RK, Jenkins D, de Koning MN, Quint WG, Stoler MH, Doorbar J, Kahlert J, Gravitt PE, Steiniche T, Petersen LK, Hammer A. Performance of HPV E4 and p16 INK4a biomarkers in predicting regression of cervical intraepithelial neoplasia grade 2 (CIN2): protocol for a historical cohort study. BMJ Open 2022; 12:e059593. [PMID: 35793925 PMCID: PMC9260811 DOI: 10.1136/bmjopen-2021-059593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Cervical intraepithelial neoplasia grade 2 (CIN2) represents a spectrum of lesions with variable progression and regression. Pathological diagnosis of CIN2 is subjective and poorly reproducible. Accurate diagnosis and identification of different patterns of CIN2 related to outcome are essential to reduce the risks of overtreatment or undertreatment. It is important to explore novel methods for risk stratification of CIN2 to enable targeted treatment of women at high risk of progression or persistent disease and follow-up of women at low risk. The combination of the novel biomarker human papillomavirus (HPV) E4 with p16INK4a targets steps in the transition from a productive oncogenic HPV infection (CIN1) to a transformed lesion (CIN3) within CIN2. Previous cross-sectional studies suggest that HPV E4 combined with p16INK4a may be valuable for risk assessment of CIN2. However, data on HPV E4/p16INK4a as a predictor for CIN2 regression is lacking. METHODS AND ANALYSIS We will conduct a historical cohort study including 500 women aged 23-40 years with a first CIN2 diagnosis in Aarhus, Denmark during 2000-2010. Women will be eligible if they have undergone active surveillance and have no previous record of hysterectomy, cone biopsy, and CIN2 or worse. Women will be randomly selected through the Danish Pathology Databank. Tissue samples from women included will be sectioned for p16INK4a and HPV E4 immunohistochemical staining in addition to conventional hematoxylin and eosin (H&E) staining. A positive result will be defined as HPV E4 positive. Through the Danish Pathology Databank, we will collect results on all subsequent cervical biopsies. Regression will be used as the primary outcome. ETHICS AND DISSEMINATION The study has been approved by the Ethical Committee in Central Denmark Region (1-10-72-60-20) and registered at the Faculty of Health, Aarhus University. Results will be published in a peer-reviewed journal and presented at scientific meetings. TRIAL REGISTRATION NUMBER NCT05049252.
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Affiliation(s)
- Rikke Kamp Damgaard
- Dep. Clinical Medicine, Aarhus University, Aarhus, Denmark
- Dep. Gynecology and Obstetrics, Center for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - David Jenkins
- Viroclinics-DDL, DDL Diagnostic Laboratory, Rijswijk, The Netherlands
| | | | - Wim Gv Quint
- Viroclinics-DDL, DDL Diagnostic Laboratory, Rijswijk, The Netherlands
| | - Mark H Stoler
- Dep. Pathology, University of Virginia, Charlottesville, Virginia, USA
| | - John Doorbar
- Dep. Pathology, Division of Virology, University of Cambridge, Cambridge, UK
| | - Johnny Kahlert
- Dep. Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Patti E Gravitt
- National Cancer Institute, University of Virginia Cancer Center, Charlottesville, Virginia, USA
| | - Torben Steiniche
- Dep. Clinical Medicine, Aarhus University, Aarhus, Denmark
- Dep. Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Kjeld Petersen
- Dep. Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
- OPEN, University of Southern Denmark, Odense, Denmark
| | - Anne Hammer
- Dep. Clinical Medicine, Aarhus University, Aarhus, Denmark
- Dep. Gynecology and Obstetrics, Center for Research and Education, Gødstrup Hospital, Herning, Denmark
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15
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Hammer A, Blaakaer J, de Koning MNC, Steiniche T, Mejlgaard E, Svanholm H, Roensbo MT, Fuglsang K, Doorbar J, Andersen RH, Quint WGV, Gravitt PE. Evidence of latent HPV infection in older Danish women with a previous history of cervical dysplasia. Acta Obstet Gynecol Scand 2022; 101:608-615. [PMID: 35481603 DOI: 10.1111/aogs.14362] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Understanding whether human papillomavirus (HPV) may establish latency in the uterine cervix is important. A better understanding of HPV natural history is useful for clinical counseling of women attending screening and to accurately inform health prevention strategies such as screening and HPV vaccination. We evaluated the extent of latent HPV infections in older women with a history of abnormal cytology. MATERIAL AND METHODS We conducted a cross-sectional study in Aarhus, Denmark, from March 2013 through April 2015. Women were enrolled if they underwent cervical amputation or total hysterectomy because of benign disease. Prior to surgery, women completed a questionnaire and a cervical smear was collected for HPV testing and morphological assessment. For evaluation of latency (i.e., no evidence of active HPV infection, but HPV detected in the tissue), we selected women with a history of abnormal cervical cytology or histology, as these women were considered at increased risk of harboring a latent infection. Cervical tissue underwent extensive HPV testing using the SPF10-DEIA-LipA25 assay. RESULTS Of 103 women enrolled, 26 were included in this analysis. Median age was 55 years (interquartile range [IQR] 52-65), and most women were postmenopausal and parous. The median number of sexual partners over the lifetime was six (IQR 3-10), and 85% reported no recent new sexual partner. Five women (19.2%) had evidence of active infection at the time of surgery, and 19 underwent latency evaluation. Of these, a latent infection was detected in 11 (57.9%), with HPV16 being the most prevalent type (50%). Nearly 80% (n = 14) of the 18 women with a history of previous low-grade or high-grade cytology with no treatment had an active or latent HPV infection, with latent infections predominating. HPV was detected in two of the six women with a history of high-grade cytology and subsequent excisional treatment, both as latent infections. CONCLUSIONS HPV can be detected in cervical tissue specimens without any evidence of an active HPV infection, indicative of a latent, immunologically controlled infection. Modeling studies should consider including a latent state in their model when estimating the appropriate age to stop screening and when evaluating the impact of HPV vaccination.
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Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Gødstrup Hospital, Gødstrup, Denmark
| | - Jan Blaakaer
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Torben Steiniche
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Else Mejlgaard
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Svanholm
- Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Mette T Roensbo
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Katrine Fuglsang
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - John Doorbar
- Department of Pathology, University of Cambridge, Cambridge, UK
| | - Rikke H Andersen
- Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Wim G V Quint
- DDL Diagnostic Laboratory, Viroclinics-DDL, Rijswijk, the Netherlands
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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16
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Correa-Mendez M, Paz-Soldan V, Blechter B, Gravitt PE, Rositch AF, Meza G. Exploring Barriers and Facilitators for Cervical Cancer Screening in Iquitos, Peru: Application of the COM-B Behavior Model to Inform Program Implementation. JCO Glob Oncol 2022. [DOI: 10.1200/go.22.25000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cervical cancer is the second cause of death among Peruvian women. In Iquitos, Proyecto Precancer engages key stakeholders to develop interventions that address women's needs and prevent cervical cancer. Successful prevention programs rely on behavior change interventions that must be supported by a theoretical understanding of the behavior. The Capability, Opportunity, Motivation, Behavior (COM-B) model informs what must be modified for a behavior change intervention to be effective. METHODS A cervical cancer prevention focused Knowledge-Attitudes-Practices (KAP) survey was administered in 2017 to women ages 18-65 years living in Iquitos, Peru using census-based random sampling. To identify context-specific barriers and facilitators for cervical cancer screening in Iquitos, we mapped KAP survey data onto key themes in the COM-B model. RESULTS Out of 619 women, 67.9% had been screened for cervical cancer at least once. Facilitators to screening-seeking behaviors were having the knowledge about cervical cancer (80.5% of women), partner support (74.8%), attending a health post (79.5%) and receiving information from a health post (63.6%). Among women not previously screened, fear was the primary barrier (41.7%). Perceived risk of cervical cancer was high (79.1%) but experiencing symptoms as a reason to seek screening remains a common misconception (36%). CONCLUSION Behavior change interventions must address the sources of fear and raise awareness about seeking cervical cancer screening prior to symptom development. Focusing on health posts and partners as key facilitators could help improve the outcomes of programs implemented by Proyecto Precancer in Iquitos.
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Affiliation(s)
| | - Valerie Paz-Soldan
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | | | | | - Anne F. Rositch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Graciela Meza
- Facultad de Medicina Humana, Universidad Nacional de la Amazonía Peruana, Iquitos, Peru
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17
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Hammer A, Gravitt PE, Adcock R, Patterson N, Cuzick J, Wheeler CM. Burden of Mycoplasma genitalium and Bacterial Coinfections in a Population-Based Sample in New Mexico. Sex Transm Dis 2021; 48:e186-e189. [PMID: 33993157 PMCID: PMC8590705 DOI: 10.1097/olq.0000000000001472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/03/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT In this population-based US study, the overall prevalence of Mycoplasma genitalium was 1.95% (95% confidence interval [CI], 1.62%-2.34%), declining from 6.12% (95% CI, 4.72%-7.92%) in women aged 21 to 24 years to 0.48% (95% CI, 0.25%-0.94%) in women aged 40 to 64 years. The prevalence of coinfections with Chlamydia trachomatis and Trichomonas vaginalis was low.
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Affiliation(s)
- Anne Hammer
- From the Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning
- Department of Clinical Medicine, Aarhus University, Aarhus N
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Patti E. Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Rachael Adcock
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, United Kingdom
| | | | - Jack Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, United Kingdom
| | - Cosette M. Wheeler
- Departments of Pathology
- Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC02-1670 House of Prevention Epidemiology, Albuquerque, NM
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18
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Clark EH, Gilman RH, Chiao EY, Gravitt PE. Gut Helminth Infection-Induced Immunotolerance and Consequences for Human Papillomavirus Persistence. Am J Trop Med Hyg 2021; 105:573-583. [PMID: 34280146 DOI: 10.4269/ajtmh.21-0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/10/2021] [Indexed: 11/07/2022] Open
Abstract
Cervical cancer, a malignancy caused by persistent human papillomavirus (HPV) infection, develops in more than 500,000 women annually. More than 90% of deaths from cervical cancer occur in low- and middle-income countries. A common epidemiological feature of countries with high cervical cancer incidence is a high burden of intestinal helminth infection. The ability of intestinal helminths to trigger immunoregulation, resulting in a "tolerogenic" systemic immune environment, provides fertile soil for the persistence of oncogenic viruses such as HPV. Animal models have shown that intestinal helminth infection permits the persistence of some viruses, however, HPV-specific and human studies are lacking. Large, well-organized trials evaluating the consequences of intestinal helminth infection on the human immune system and HPV persistence may lead to improved strategies for HPV prevention in helminth-endemic regions of the world. Additionally, such studies would offer insight into the specific ways that intestinal helminth infection contributes to immunomodulation, which could identify new therapeutic targets for a range of diseases, from inflammatory disorders to cancer. In this review, we discuss the evidence for helminth-induced systemic and local immune dysregulation, discuss possible mechanisms by which chronic intestinal helminth infection may facilitate HPV persistence, and suggest novel helminth-related interventions that could offer a high leverage (if somewhat unconventional) approach to HPV and cervical cancer control in resource-constrained regions.
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Affiliation(s)
- Eva H Clark
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas.,Department of Medicine, Section of Health Services Research, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas.,National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas
| | - Robert H Gilman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth Y Chiao
- Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of General Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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19
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Nowak RG, Liska TA, Bentzen SM, Kim E, Chipato T, Salata RA, Celentano DD, Morrison CS, Gravitt PE. Brief Report: Herpes Simplex Virus Type-2 Shedding and Genital Ulcers During Early HIV in Zimbabwean Women. J Acquir Immune Defic Syndr 2021; 87:789-793. [PMID: 33587502 PMCID: PMC8131209 DOI: 10.1097/qai.0000000000002641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Herpes simplex virus type-2 (HSV-2) seropositive persons have a 3- to 5-fold higher risk of acquiring HIV, possibly because of HSV-2-induced inflammation and recruitment of susceptible immune cells to exposure sites. We hypothesized that cervical HSV-2 activation (ie, viral DNA shedding and/or ulcers) preceded HIV acquisition in the hormonal contraception and HIV cohort. METHODS Zimbabwean women who acquired HIV were matched to HIV-negative women on visit, age, and bacterial sexually transmitted infections. Up to 5 cervical swabs bracketing first polymerase chain reaction detection of HIV DNA (the index visit) were selected (t-6months, t-3months, tindex, t+3months, t+6months). Women with HSV-2 immunoglobulin G+ before tindex were polymerase chain reaction tested for viral shedding. Self-reported and clinician-diagnosed ulcers were documented. Multivariable logistic regression, accounting for matching, estimated adjusted odds ratios (aOR) and 95% confidence intervals (CIs) at each visit. RESULTS Of 387 HSV-2 seropositive women, most had prevalent as compared with incident HSV-2 (91% vs. 9%, respectively). HSV-2 viral shedding was more common among HIV seroconverters than HIV-negative women (26% vs. 14%, P < 0.01). Shedding occurred around HIV acquisition (t-3months aOR, 2.7; 95% CI, 0.8 to 8.8; tindex aOR, 2.6; 95% CI, 1.1 to 6.5; t+3months aOR, 2.6; 95% CI, 1.0 to 6.6). Genital ulcers were reported more often among HIV seroconverters than HIV-negative women (13% vs. 7%; P = 0.06) and detection was after HIV acquisition (t+6months aOR, 14.5; 95% CI, 1.6 to 133.9). CONCLUSIONS HSV-2 shedding appeared synergistic with HIV acquisition followed by presentation of ulcers. Evaluating all sexually transmitted infections rather than HSV-2 alone may clarify the relationship between inflammation and HIV acquisition.
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Affiliation(s)
- Rebecca G Nowak
- Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD
| | - Tobias A Liska
- Nathan Schnaper Internship Program in Translational Cancer Research, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Søren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Esther Kim
- Beth Israel Lahey Health Beverly Hospital, Beverly MA
| | - Tsungai Chipato
- Department of Obstetrics and Gynecology, University of Zimbabwe, Harare, Zimbabwe
| | - Robert A Salata
- Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - David D Celentano
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and
| | | | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
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20
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Rositch AF, Patel EU, Petersen MR, Quinn TC, Gravitt PE, Tobian AAR. Importance of Lifetime Sexual History on the Prevalence of Genital Human Papillomavirus (HPV) Among Unvaccinated Adults in the National Health and Nutrition Examination Surveys: Implications for Adult HPV Vaccination. Clin Infect Dis 2021; 72:e272-e279. [PMID: 32710745 DOI: 10.1093/cid/ciaa1050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although the United States Food and Drug Administration recently approved the human papillomavirus (HPV) vaccine for individuals aged 27-45 years, the Centers for Disease Control and Prevention did not change its guidelines for routine HPV vaccination. Since recommendations for adult vaccination emphasize shared clinical decision-making based on risk of new infections, we examined the relationship between HPV prevalence and sexual behavior. METHODS This study was conducted among 5093 HPV-unvaccinated, sexually experienced adults aged 18-59 years in the National Health and Nutrition Examination Surveys (2013-2016). For each sex and age group, adjusted prevalences of 9-valent vaccine-specific, high-risk, and any HPV infection were estimated by number of lifetime sexual partners (LTSPs) using logistic regression. An analysis restricted to persons who did not have a new sexual partner in the past year (ie, removing those at highest risk of newly acquired HPV) was also conducted. RESULTS In each age group, genital HPV prevalence was higher among persons with >5 LTSPs compared with 1-5 LTSPs in both males and females. There were only slight reductions in HPV prevalence after removing participants who reported a new sexual partner in the past year. For example, among females aged 27-45 years with >5 LTSPs, the adjusted prevalence of 9-valent vaccine-type HPV infection was 13.4% (95% confidence interval [CI], 9.9%-17.0%) in the full population compared to 12.1% (95% CI, 8.8%-15.4%) among those with no new sexual partners. CONCLUSIONS Prevalent HPV infection was primarily reflective of cumulative exposures over time (higher LTSPs). New exposures had limited impact, emphasizing the need to consider sexual history in the decision-making process for adult HPV vaccination.
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Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Eshan U Patel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Molly R Petersen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland, USA
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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21
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Shardell M, Gravitt PE, Burke AE, Ravel J, Brotman RM. Association of Vaginal Microbiota with Signs and Symptoms of the Genitourinary Syndrome of Menopause across Reproductive Stages. J Gerontol A Biol Sci Med Sci 2021; 76:1542-1550. [PMID: 33903897 DOI: 10.1093/gerona/glab120] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Indexed: 02/07/2023] Open
Abstract
The genitourinary syndrome of menopause (GSM) describes signs and symptoms resulting from effects of estrogen deficiency on the female genitourinary tract, including the vagina, labia, urethra, and bladder. Signs/symptoms associated with GSM may occur during any reproductive stage from multiple etiologies but are most common during menopause due to low estrogen. Vaginal microbiota, particularly Lactobacillus spp., are beneficial to the female genital tract; however, their abundance declines during menopause. We aimed to longitudinally assess vaginal microbiota characterized by 16S rRNA gene amplicon sequencing and GSM-associated endpoints across reproductive stages. In a two-year cohort study of 750 women aged 35-60 years at enrollment and 2,111 semiannual person-visits, low-Lactobacillus vaginal microbiota communities were observed at 21.2% (169/798), 22.9% (137/597), and 49.7% (356/716) of person-visits among pre-, peri-, and postmenopausal women, respectively (p<.001). Compared to communities that have high Gardnerella vaginalis relative abundance and diverse anaerobes, the following communities were associated with a lower covariate-adjusted odds of vaginal atrophy: L. crispatus-dominated communities among postmenopausal women (odds ratio[OR]=0.25; 95% confidence interval[CI], 0.08, 0.81), L. gasseri/L. jensenii (OR=0.21; 95%CI, 0.05, 0.94) and L. iners (OR=0.21; 95%CI, 0.05, 0.85) among perimenopausal women, and L. iners-dominated communities (OR=0.18; 95%CI, 0.04, 0.76) among premenopausal women. Postmenopausal women with L. gasseri/L. jensenii-dominated communities had the lowest odds of vaginal dryness (OR=0.36; 95%CI, 0.12, 1.06) and low libido (OR=0.28; 95%CI, 0.10, 0.74). Findings for urinary incontinence were inconsistent. Associations of vaginal microbiota with GSM signs/symptoms are most evident after menopause, suggesting an avenue for treatment and prevention.
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Affiliation(s)
- Michelle Shardell
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Anne E Burke
- Department of Gynecology and Obstetrics, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rebecca M Brotman
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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22
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Miles TT, Riley-Powell AR, Lee GO, Gotlieb EE, Barth GC, Tran EQ, Ortiz K, Huaynate CA, Cabrera L, Gravitt PE, Oberhelman RA, Paz-Soldan VA. Knowledge, attitudes, and practices of cervical cancer prevention and pap smears in two low-income communities in Lima, Peru. BMC Womens Health 2021; 21:168. [PMID: 33882904 PMCID: PMC8059236 DOI: 10.1186/s12905-021-01291-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cervical cancer is a leading cause of death among Peruvian women. Barriers at multiple levels impact effective screening and treatment, including a lack of knowledge about cervical cancer and how regular screening can reduce morbidity and mortality through earlier detection. The aim of this study is to assess knowledge, attitudes, and practices regarding cervical cancer and its prevention in the peri-urban communities of Oasis and Pampas in southern Lima, Peru that can be used to inform future campaigns about cervical cancer prevention. METHODS A cross-sectional survey that included several open-ended questions was administered to women in Pampas and Oasis between 2015 and 2016 to evaluate the knowledge, attitudes, and practices regarding cervical cancer and Pap smears. RESULTS In total, 224 women were interviewed. Knowledge about cervical cancer and Pap smears was high, and attitudes were predominantly positive among most participants. Most participants knew how often they should get Pap smears (89.7%), when to begin seeking screening (74.6%), knew the price of a Pap smear (61.9%), and felt Pap smears were important for their health (70.1%). About one third (29.5%) of premenopausal women reported receiving a Pap smear in the last year. However, open ended questions revealed some knowledge gaps around Pap smears, as well as some stigma associated to Human Papilloma Virus (HPV) infection. CONCLUSION Although knowledge of cervical cancer prevention was generally high and perceptions were positive among women in peri-urban Peruvian communities, our findings revealed there is a need for education on HPV infection prevalence among sexually active individuals to reduce stigma. Future research should focus on exploring experiences with follow-up and treatment associated with abnormal Pap smears, as well as perspectives from health authorities and professionals about barriers in the early detection and treatment process for cervical cancer.
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Affiliation(s)
- Thomas T Miles
- Global Community Health and Behavioral Sciences Department, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St., Suite 2200, New Orleans, LA, 70112, USA
| | - Amy R Riley-Powell
- Global Community Health and Behavioral Sciences Department, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St., Suite 2200, New Orleans, LA, 70112, USA
| | - Gwenyth O Lee
- Global Community Health and Behavioral Sciences Department, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St., Suite 2200, New Orleans, LA, 70112, USA
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA
| | - Esther E Gotlieb
- Global Community Health and Behavioral Sciences Department, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St., Suite 2200, New Orleans, LA, 70112, USA
| | - Gabriela C Barth
- Tulane University, 6823 St Charles Ave, New Orleans, LA, 70118, USA
| | - Emma Q Tran
- Tulane University, 6823 St Charles Ave, New Orleans, LA, 70118, USA
| | - Katherine Ortiz
- Global Community Health and Behavioral Sciences Department, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St., Suite 2200, New Orleans, LA, 70112, USA
| | - Cynthia Anticona Huaynate
- Global Community Health and Behavioral Sciences Department, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St., Suite 2200, New Orleans, LA, 70112, USA
| | - Lilia Cabrera
- Asociación Benéfica PRISMA, Lima, Peru - Carlos Gonzales 251, San Miguel, 15088, USA
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Richard A Oberhelman
- Global Community Health and Behavioral Sciences Department, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St., Suite 2200, New Orleans, LA, 70112, USA
| | - Valerie A Paz-Soldan
- Global Community Health and Behavioral Sciences Department, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St., Suite 2200, New Orleans, LA, 70112, USA.
- Asociación Benéfica PRISMA, Lima, Peru - Carlos Gonzales 251, San Miguel, 15088, USA.
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23
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Imburgia TM, Shew ML, Gravitt PE, Katzenellenbogen RA. Considerations for Child Cancer Survivors and Immunocompromised Children to Prevent Secondary HPV-associated Cancers. Transplantation 2021; 105:736-742. [PMID: 32890137 DOI: 10.1097/tp.0000000000003444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Teresa M Imburgia
- Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN
- Epidemiology Department, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN
| | - Marcia L Shew
- Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
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24
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Gravitt PE, Silver MI, Hussey HM, Arrossi S, Huchko M, Jeronimo J, Kapambwe S, Kumar S, Meza G, Nervi L, Paz-Soldan VA, Woo YL. Achieving equity in cervical cancer screening in low- and middle-income countries (LMICs): Strengthening health systems using a systems thinking approach. Prev Med 2021; 144:106322. [PMID: 33678230 DOI: 10.1016/j.ypmed.2020.106322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 01/01/2023]
Abstract
The World Health Organization (WHO) is leading a call to action to eliminate cervical cancer by the end of the century through global implementation of two effective evidence-based preventive interventions: HPV vaccination and cervical screening and management (CSM). Models estimate that without intervention, over the next 50 years 12.2 million new cases of cervical cancer will occur, nearly 60% of which are preventable only through CSM. Given that more than 80% of the cervical cancer occurs in low- and middle-income countries (LMICs), scaling up sustainable CSM programs in these countries is a top priority for achieving the global elimination goals. Multiple technologies have been developed and validated to meet this need. Now it is critical to identify strategies to implement these technologies into complex, adaptive health care delivery systems. As part of the coordinated cervical cancer elimination effort, we applied a systems thinking lens to reflect on our experiences with implementation of HPV-based CSM programs using the WHO health systems framework. While many common health system barriers were identified, the effectiveness of implementation strategies to address them was context dependent; often reflecting differences in stakeholder's belief in the quality of the evidence supporting a CSM algorithm, the appropriateness of the evidence and algorithm to context, and the 'implementability' of the algorithm under realistic assessments of resource availability and constraints. A structured planning process, with early and broad stakeholder engagement, will ensure that shared-decisions in CSM implementation are appropriately aligned with the culture, values, and resource realities of the setting.
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Affiliation(s)
- Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | | | - Heather M Hussey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Megan Huchko
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | | | | | - Graciela Meza
- Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | - Laura Nervi
- College of Population Health, University of New Mexico, Albuquerque, NM, USA
| | - Valerie A Paz-Soldan
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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25
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Paul P, Hammer A, Rositch AF, Burke AE, Viscidi RP, Silver MI, Campos N, Youk AO, Gravitt PE. Rates of New Human Papillomavirus Detection and Loss of Detection in Middle-aged Women by Recent and Past Sexual Behavior. J Infect Dis 2020; 223:1423-1432. [PMID: 32870982 DOI: 10.1093/infdis/jiaa557] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/27/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Understanding the source of newly detected human papillomavirus (HPV) in middle-aged women is important to inform preventive strategies, such as screening and HPV vaccination. METHODS We conducted a prospective cohort study in Baltimore, Maryland. Women aged 35-60 years underwent HPV testing and completed health and sexual behavior questionnaires every 6 months over a 2-year period. New detection/loss of detection rates were calculated and adjusted hazard ratios were used to identify risk factors for new detection. RESULTS The new and loss of detection analyses included 731 women, and 104 positive for high-risk HPV. The rate of new high-risk HPV detection was 5.0 per 1000 woman-months. Reporting a new sex partner was associated with higher detection rates (adjusted hazard ratio, 8.1; 95% confidence interval, 3.5-18.6), but accounted only for 19.4% of all new detections. Among monogamous and sexually abstinent women, new detection was higher in women reporting ≥5 lifetime sexual partners than in those reporting <5 (adjusted hazard ratio, 2.2; 95% confidence interval, 1.2-4.2). CONCLUSION Although women remain at risk of HPV acquisition from new sex partners as they age, our results suggest that most new detections in middle-aged women reflect recurrence of previously acquired HPV.
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Affiliation(s)
- Proma Paul
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anne Hammer
- Department of Obstetrics and Gynecology, Regional Hospital West Jutland, Herning, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anne E Burke
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Raphael P Viscidi
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michelle I Silver
- Division of Public Health Sciences, Washington University School of Medicine, St Louis, Missouri, USA
| | - Nicole Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ada O Youk
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patti E Gravitt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine Baltimore, Maryland, USA
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26
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Castle PE, Pierz AJ, Adcock R, Aslam S, Basu PS, Belinson JL, Cuzick J, El-Zein M, Ferreccio C, Firnhaber C, Franco EL, Gravitt PE, Isidean SD, Lin J, Mahmud SM, Monsonego J, Muwonge R, Ratnam S, Safaeian M, Schiffman M, Smith JS, Swarts A, Wright TC, Van De Wyngard V, Xi LF. A Pooled Analysis to Compare the Clinical Characteristics of Human Papillomavirus-positive and -Negative Cervical Precancers. Cancer Prev Res (Phila) 2020; 13:829-840. [PMID: 32655005 DOI: 10.1158/1940-6207.capr-20-0182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/16/2020] [Accepted: 07/02/2020] [Indexed: 11/16/2022]
Abstract
Given that high-risk human papillomavirus (HPV) is the necessary cause of virtually all cervical cancer, the clinical meaning of HPV-negative cervical precancer is unknown. We, therefore, conducted a literature search in Ovid MEDLINE, PubMed Central, and Google Scholar to identify English-language studies in which (i) HPV-negative and -positive, histologically confirmed cervical intraepithelial neoplasia grade 2 or more severe diagnoses (CIN2+) were detected and (ii) summarized statistics or deidentified individual data were available to summarize proportions of biomarkers indicating risk of cancer. Nineteen studies including 3,089 (91.0%) HPV-positive and 307 (9.0%) HPV-negative CIN2+ were analyzed. HPV-positive CIN2+ (vs. HPV-negative CIN2+) was more likely to test positive for biomarkers linked to cancer risk: a study diagnosis of CIN3+ (vs. CIN2; 18 studies; 0.56 vs. 0.24; P < 0.001) preceding high-grade squamous intraepithelial lesion cytology (15 studies; 0.54 vs. 0.10; P < 0.001); and high-grade colposcopic impression (13 studies; 0.30 vs. 0.18; P = 0.03). HPV-negative CIN2+ was more likely to test positive for low-risk HPV genotypes than HPV-positive CIN2+ (P < 0.001). HPV-negative CIN2+ appears to have lower cancer risk than HPV-positive CIN2+. Clinical studies of human high-risk HPV testing for screening to prevent cervical cancer may refer samples of HPV test-negative women for disease ascertainment to correct verification bias in the estimates of clinical performance. However, verification bias adjustment of the clinical performance of HPV testing may overcorrect/underestimate its clinical performance to detect truly precancerous abnormalities.
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Affiliation(s)
- Philip E Castle
- Albert Einstein College of Medicine, Department of Epidemiology and Population Health, Bronx, New York.
| | - Amanda J Pierz
- Albert Einstein College of Medicine, Department of Epidemiology and Population Health, Bronx, New York
| | - Rachael Adcock
- Queen Mary University of London, Centre for Cancer Prevention, London, United Kingdom
| | | | - Partha S Basu
- International Agency for Research on Cancer, Screening Group, Lyon, France
| | - Jerome L Belinson
- Preventive Oncology International and the Cleveland Clinic, Cleveland, Ohio
| | - Jack Cuzick
- Queen Mary University of London, Centre for Cancer Prevention, London, United Kingdom
| | - Mariam El-Zein
- Division of Cancer Epidemiology, McGill University, Montréal, Quebec, Canada
| | - Catterina Ferreccio
- Advanced Center for Chronic Diseases, ACCDiS, Santiago, Chile
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, Montréal, Quebec, Canada
| | - Patti E Gravitt
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Sandra D Isidean
- Division of Cancer Epidemiology, McGill University, Montréal, Quebec, Canada
| | - John Lin
- HPV Research Group, University of Washington, Seattle, Washington
| | - Salaheddin M Mahmud
- Rady Faculty of Health Sciences, Department of Community Health, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Joseph Monsonego
- Institute of the Cervix, Federation Mutualiste Parisienne, Paris, France
| | - Richard Muwonge
- International Agency for Research on Cancer, Screening Group, Lyon, France
| | - Samuel Ratnam
- Division of Cancer Epidemiology, McGill University, Montréal, Quebec, Canada
| | | | - Mark Schiffman
- Division of Cancer Epidemiology & Genetics, NIH, NCI, Bethesda, Maryland
| | - Jennifer S Smith
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Avril Swarts
- Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas C Wright
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | - Vanessa Van De Wyngard
- Advanced Center for Chronic Diseases, ACCDiS, Santiago, Chile
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Long Fu Xi
- HPV Research Group, University of Washington, Seattle, Washington
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27
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Gravitt PE, Rositch AF, Jurczuk M, Meza G, Carillo L, Jeronimo J, Adsul P, Nervi L, Kosek M, Tracy JK, Paz-Soldan VA. Integrative Systems Praxis for Implementation Research (INSPIRE): An Implementation Methodology to Facilitate the Global Elimination of Cervical Cancer. Cancer Epidemiol Biomarkers Prev 2020; 29:1710-1719. [PMID: 32561563 DOI: 10.1158/1055-9965.epi-20-0501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) has called for a systems thinking approach to health systems strengthening to increase adoption of evidence-based interventions (EBI). The Integrative Systems Praxis for Implementation Research (INSPIRE) methodology operationalizes the WHO systems thinking framework to meet cervical cancer elimination-early detection and treatment (CC-EDT) goals. METHODS Using a systems thinking approach and grounded in the consolidated framework for implementation research, INSPIRE integrates multiple research methodologies and evaluation frameworks into a multilevel implementation strategy. RESULTS In phase I (creating a shared understanding), soft systems methodology and pathway analysis are used to create a shared visual understanding of the CC-EDT system, incorporating diverse stakeholder perspectives of the "what, how, and why" of system behavior. Phase II (finding leverage) facilitates active stakeholder engagement in knowledge transfer and decision-making using deliberative dialogues and multiple scenario analyses. Phase III (acting strategically) represents stakeholder-engaged implementation planning, using well-defined implementation strategies of education, training, and infrastructure development. In phase IV (learning and adapting), evaluation of key performance indicators via a reach, effectiveness, adoption, implementation, and maintenance framework is reviewed by stakeholder teams, who continuously adapt implementation plans to improve system effectiveness. CONCLUSIONS The INSPIRE methodology is a generalizable approach to context-adapted implementation of EBIs. IMPACT Replacing static dissemination of implementation "roadmaps" with learning health systems through the integration of systems thinking and participatory action research, INSPIRE facilitates the development of scalable and sustainable implementation strategies adapted to local contexts.
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Affiliation(s)
- Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Magdalena Jurczuk
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Graciela Meza
- Facultad de Medicina Humana, Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | | | - Jose Jeronimo
- Global Coalition Against Cervical Cancer, Arlington, Virginia
| | - Prajakta Adsul
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Laura Nervi
- College of Population Health, University of New Mexico, Albuquerque, New Mexico
| | - Margaret Kosek
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - J Kathleen Tracy
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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28
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Barrett BW, Paz-Soldan VA, Mendoza-Cervantes D, Sánchez GM, Córdova López JJ, Gravitt PE, Rositch AF. Understanding Geospatial Factors Associated With Cervical Cancer Screening Uptake in Amazonian Peruvian Women. JCO Glob Oncol 2020; 6:1237-1247. [PMID: 32755481 PMCID: PMC7456312 DOI: 10.1200/go.20.00096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Cervical cancer (CC) is the most common and second-most deadly cancer among Peruvian women. Access to services is strongly associated with CC screening uptake. This study investigated geospatial features contributing to utilization of screening. We used geolocated data and screening information from a Knowledge, Attitudes, and Practice (KAP) survey implemented in Iquitos, Peru in 2017. MATERIALS AND METHODS The KAP collected cross-sectional CC screening history from 619 female interviewees age 18-65 years within 5 communities of varying urbanization levels. We used spatial statistics to determine if screened households tended to cluster together or cluster around facilities offering screening in greater numbers than expected, given the underlying population density. RESULTS On the basis of K-functions, screened households displayed greater clustering among each other as compared with clustering among unscreened households. Neighborhood-level factors, such as outreach, communication, or socioeconomic condition, may be functioning to generate pockets of screened households. Cross K-functions showed that screened households are generally located closer to health facilities than unscreened households. The significance of facility access is apparent and demonstrates that travel and time barriers to seeking health services must be addressed. CONCLUSION This study highlights the importance of considering geospatial features when determining factors associated with CC screening uptake. Given the observed clustering of screened households, neighborhood-level dynamics should be further studied to understand how they may be influencing screening rates. In addition, results demonstrate that accessibility issues must be carefully considered when designing an effective cancer screening program that includes screening, follow-up, and treatment.
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Affiliation(s)
- Benjamin W Barrett
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Valerie A Paz-Soldan
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | | | - Graciela Meza Sánchez
- Facultad de Medicina Humana, Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | | | - Patti E Gravitt
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Paz-Soldan VA, Meza G, Carillo L, Jurczuk M, Rositch A, Soto S, Kosek M, Zevallos K, Jeronimo J, Ladron de Guevara G, Brown J, Kohler-Smith A, Vasquez J, Lopez R, Rios R, Gravitt PE. Facilitating Adoption of Evidence-Based Cervical Cancer Screening Strategies in the Peruvian Amazon Using a Novel Methodology: The Integrative Systems Praxis for Implementation Research (INSPIRE). JCO Glob Oncol 2020. [DOI: 10.1200/go.20.44000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The aim to this work was to develop an operational research methodology for context-appropriate selection, adaptation, and evaluation of the implementation of novel cervical cancer screening and treatment methods. METHODS We developed the Integrative Systems Practice for Implementation Research (INSPIRE) methodology, a multifaceted strategy that blends existing theoretical implementation research frameworks and defines specific research methods for use at each phase. INSPIRE is a participatory, iterative process involving 4 phases: system understanding, finding leverage, acting, and learning/adapting. Mixed methods were used to meet the objectives of each INSPIRE phase. Qualitative methods were grounded in soft systems methodology and CFIR, and quantitative methods in RE-AIM. Pathway and scenario analyses supplemented standard research methods. RESULTS We engaged more than 90 multilevel stakeholders in the design of a new and improved screen-and-treat system. Elaboration of system process maps through triangulation of the mixed-methods data served to create a shared reference of the current system in participatory discussions. Significant leverage opportunities were identified, including reducing fragmentation, inefficiency, and a lack of standardization to increase women’s acceptability of screening and adherence to the continuum of care. A variety of interventions were evaluated using a multiple scenario analysis tool and, ultimately, stakeholders recommended adoption of human papillomavirus testing/self-sampling to increase coverage and ablative treatment of all human papillomavirus–positive women to reduce loss to follow up. Implementation was launched in July 2019, and iterative application of INSPIRE to early implementation challenges is being used to ensure real-time adaptation to emerging system behaviors and the acceptability and sustainability of the program. CONCLUSION Continued success in the engagement of stakeholders in shared decision making suggests that using the INSPIRE methodology in designing implementation strategies increases a sense of ownership in the process, which may lead to more sustainable screening programs in low- and middle-income countries compared with top-down approaches.
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Affiliation(s)
| | - Graciela Meza
- Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | - Lita Carillo
- Dirección Regional De Salud Loreto, Iquitos, Peru
| | - Magdalena Jurczuk
- Tulane University School of Public Health and Tropical Medicine, Lima, Peru
| | - Anne Rositch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | | | - Jose Jeronimo
- Global Coalition Against Cervical Cancer, Arlington, VA
| | | | | | | | - Javier Vasquez
- Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | - Renso Lopez
- Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | - Reyles Rios
- Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
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30
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Castle PE, Adcock R, Cuzick J, Wentzensen N, Torrez-Martinez NE, Torres SM, Stoler MH, Ronnett BM, Joste NE, Darragh TM, Gravitt PE, Schiffman M, Hunt WC, Kinney WK, Wheeler CM. Relationships of p16 Immunohistochemistry and Other Biomarkers With Diagnoses of Cervical Abnormalities: Implications for LAST Terminology. Arch Pathol Lab Med 2020; 144:725-734. [PMID: 31718233 PMCID: PMC8575174 DOI: 10.5858/arpa.2019-0241-oa] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
CONTEXT.— Lower Anogenital Squamous Terminology (LAST) standardization recommended p16INK4a immunohistochemistry (p16 IHC) for biopsies diagnosed morphologically as cervical intraepithelial neoplasia (CIN) grade 2 (CIN2) to classify them as low-grade or high-grade squamous intraepithelial lesions (HSILs). OBJECTIVE.— To describe the relationships of p16 IHC and other biomarkers associated with cervical cancer risk with biopsy diagnoses. DESIGN.— A statewide, stratified sample of cervical biopsies diagnosed by community pathologists (CPs), including 1512 CIN2, underwent a consensus, expert pathologist panel (EP) review (without p16 IHC results), p16 IHC interpretation by a third pathology group, and human papillomavirus (HPV) genotyping, results of which were grouped hierarchically according to cancer risk. Antecedent cytologic interpretations were also available. RESULTS.— Biopsies were more likely to test p16 IHC positive with increasing severity of CP diagnoses, overall (Ptrend ≤ .001) and within each HPV risk group (Ptrend ≤ .001 except for low-risk HPV [Ptrend < .010]). All abnormal grades of CP-diagnosed biopsies were more likely to test p16 IHC positive with a higher HPV risk group (Ptrend < .001), and testing p16 IHC positive was associated with higher HPV risk group than testing p16 IHC negative for each grade of CP-diagnosed biopsies (P < .001). p16 IHC-positive, CP-diagnosed CIN2 biopsies were less likely than CP-diagnosed CIN3 biopsies to test HPV16 positive, have an antecedent HSIL+ cytology, or to be diagnosed as CIN3+ by the EP (P < .001 for all). p16 IHC-positive, CP-diagnosed CIN1 biopsies had lower HPV risk groups than p16 IHC-negative, CP-diagnosed CIN2 biopsies (P < .001). CONCLUSIONS.— p16 IHC-positive, CP-diagnosed CIN2 appears to be lower cancer risk than CP-diagnosed CIN3. LAST classification of "HSIL" diagnosis, which includes p16 IHC-positive CIN2, should annotate the morphologic diagnosis (CIN2 or CIN3) to inform all management decisions, which is especially important for young (<30 years) women diagnosed with CIN2 for whom surveillance rather than treatment is recommended.
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Affiliation(s)
- Philip E Castle
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Rachael Adcock
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Jack Cuzick
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Nicolas Wentzensen
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Norah E Torrez-Martinez
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Salina M Torres
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Mark H Stoler
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Brigitte M Ronnett
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Nancy E Joste
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Teresa M Darragh
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Patti E Gravitt
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Mark Schiffman
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - William C Hunt
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Walter K Kinney
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
| | - Cosette M Wheeler
- From Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Dr Castle); Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom (Ms Adcock and Dr Cuzick); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland (Drs Wentzensen and Schiffman); the Department of Pathology, University of New Mexico Cancer Center, Albuquerque (Ms Torrez-Martinez, Dr Torres, Dr Joste, Dr Gravitt, Mr Hunt, and Dr Wheeler); the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Stoler); the Department of Pathology, Johns Hopkins University, Baltimore, Maryland (Dr Ronnett); the Department of Pathology, University of California, San Francisco (Dr Darragh); and Sacramento, California (Dr Kinney)
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Hammer A, Demarco M, Campos N, Befano B, Gravitt PE, Cheung L, Lorey TS, Poitras N, Kinney W, Wentzensen N, Castle PE, Schiffman M. A study of the risks of CIN3+ detection after multiple rounds of HPV testing: Results of the 15-year cervical cancer screening experience at Kaiser Permanente Northern California. Int J Cancer 2020; 147:1612-1620. [PMID: 32141607 DOI: 10.1002/ijc.32950] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/22/2020] [Accepted: 02/10/2020] [Indexed: 11/10/2022]
Abstract
Many countries are transitioning to HPV testing for cervical cancer screening, despite a lack of long-term experience. To anticipate multi-round screening performance, we analyzed 15-year HPV testing results at Kaiser Permanente Northern California (KPNC). We evaluated HPV test result patterns among women aged 30-64 undergoing triennial HPV/cytology cotesting at KPNC during 2003-2018. We calculated incidence rates and proportion of CIN3+ diagnoses associated with the most frequent HPV testing patterns overall and stratified by age. From 2003 to 2018, a total of 1,361,581 women had a valid HPV test result, and 7,087 were diagnosed with CIN3+. Incidence rates of CIN3+ after HPV positivity were lowest when HPV detection was new and highest in women with prevalent infections (770 vs. 13,910/100,000 person-years). Repeat test negativity reduced subsequent incidence rates of CIN3+ to extremely low levels (18/100,000 person-years following four consecutive negative results). For mixed patterns of positivity/negativity, the recency and frequency of positive tests were associated with increased rates of CIN3+ diagnosis. Most CIN3+ cases (76%) were diagnosed in women who were positive at baseline (the first known positive HPV result); 16% were attributed to apparent newly detected infections and 3% to possible reappearing infections. These results corroborate previous findings that current HPV positivity, particularly when prevalent rather than new, is associated with the highest rates of CIN3+. In a screening program implementing HPV testing, most CIN3+ is detected at the first HPV positive test.
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Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology, Herning Hospital, Herning, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Demarco
- Division of Cancer Epidemiology and Genetics, Clinical Genetics Branch, National Cancer Institute, Bethesda, MD, USA
| | - Nicole Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Brian Befano
- Information Management Services Inc., Calverton, MD, USA
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Li Cheung
- Division of Cancer Epidemiology and Genetics, Clinical Genetics Branch, National Cancer Institute, Bethesda, MD, USA
| | - Thomas S Lorey
- Regional Laboratory, Kaiser Permanente Northern California, Berkeley, CA, USA
| | - Nancy Poitras
- Regional Laboratory, Kaiser Permanente Northern California, Berkeley, CA, USA
| | | | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, Clinical Genetics Branch, National Cancer Institute, Bethesda, MD, USA
| | | | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, Clinical Genetics Branch, National Cancer Institute, Bethesda, MD, USA
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32
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Baezconde-Garbanati L, Agurto I, Gravitt PE, Luciani S, Murphy S, Ochoa C, Gallegos K, Barahona R, Rodríguez Y. Barriers and innovative interventions for early detection of cervical cancer. Salud Publica Mex 2020; 61:456-460. [PMID: 31430087 DOI: 10.21149/10425] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/19/2019] [Indexed: 11/06/2022] Open
Abstract
Cervical cancer has decreased significantly over the past 30 years in some countries. However, it remains among the leading causes of cancer deaths in low-income, and racial/ethnic minority women. Cervical cancer prevention technologies are not always available. Laboratories are often not well equipped to use them. HPV information has not been widely disseminated. WHO guidelines, and US and Latin American data provide context for strategies on effective interventions to reduce cervical cancer disparities. Systemic, personal and cultural barriers, combined with decision-making guidelines, and impactful messaging can accelerate reductions in cervical cancer health inequities in the Americas.
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Affiliation(s)
- Lourdes Baezconde-Garbanati
- Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California. Los Angeles, California, USA.,Department of Preventive Medicine, Keck School of Medicine, University of Southern California. Los Angeles, California, USA.,Center for Health Equity in the Americas, Keck School of Medicine, University of Southern California. Los Angeles, California, USA
| | - Irene Agurto
- Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization. Chile
| | - Patti E Gravitt
- Department of Global Health, George Washington University Milken Institute School of Public Health. Washington DC, USA
| | - Silvana Luciani
- Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization. Chile
| | - Sheila Murphy
- Annenberg School for Communication and Journalism, University of Southern California. Los Angeles, California, USA
| | - Carol Ochoa
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California. Los Angeles, California, USA
| | - Katia Gallegos
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California. Los Angeles, California, USA.,Instituto Mexicano de Seguro Social. Mexico City, Mexico
| | - Rosa Barahona
- Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California. Los Angeles, California, USA.,Department of Preventive Medicine, Keck School of Medicine, University of Southern California. Los Angeles, California, USA.,Center for Health Equity in the Americas, Keck School of Medicine, University of Southern California. Los Angeles, California, USA
| | - Yaneth Rodríguez
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California. Los Angeles, California, USA.,Center for Health Equity in the Americas, Keck School of Medicine, University of Southern California. Los Angeles, California, USA
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Borgogna JC, Shardell MD, Santori EK, Nelson TM, Rath JM, Glover ED, Ravel J, Gravitt PE, Yeoman CJ, Brotman RM. The vaginal metabolome and microbiota of cervical HPV-positive and HPV-negative women: a cross-sectional analysis. BJOG 2019; 127:182-192. [PMID: 31749298 DOI: 10.1111/1471-0528.15981] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Characterise the vaginal metabolome of cervical HPV-infected and uninfected women. DESIGN Cross-sectional. SETTING The Center for Health Behavior Research at the University of Maryland School of Public Health. SAMPLE Thirty-nine participants, 13 categorised as HPV-negative and 26 as HPV-positive (any genotype; HPV+ ), 14 of whom were positive with at least one high-risk HPV strain (hrHPV). METHOD Self-collected mid-vaginal swabs were profiled for bacterial composition by 16S rRNA gene amplicon sequencing, metabolites by both gas and liquid chromatography mass spectrometry, and 37 types of HPV DNA. MAIN OUTCOME MEASURES Metabolite abundances. RESULTS Vaginal microbiota clustered into Community State Type (CST) I (Lactobacillus crispatus-dominated), CST III (Lactobacillus iners-dominated), and CST IV (low-Lactobacillus, 'molecular-BV'). HPV+ women had higher biogenic amine and phospholipid concentrations compared with HPV- women after adjustment for CST and cigarette smoking. Metabolomic profiles of HPV+ and HPV- women differed in strata of CST. In CST III, there were higher concentrations of biogenic amines and glycogen-related metabolites in HPV+ women than in HPV- women. In CST IV, there were lower concentrations of glutathione, glycogen, and phospholipid-related metabolites in HPV+ participants than in HPV- participants. Across all CSTs, women with hrHPV strains had lower concentrations of amino acids, lipids, and peptides compared with women who had only low-risk HPV (lrHPV). CONCLUSIONS The vaginal metabolome of HPV+ women differed from HPV- women in terms of several metabolites, including biogenic amines, glutathione, and lipid-related metabolites. If the temporal relation between increased levels of reduced glutathione and oxidised glutathione and HPV incidence/persistence is confirmed in future studies, anti-oxidant therapies may be considered as a non-surgical HPV control intervention. TWEETABLE ABSTRACT Metabolomics study: Vaginal microenvironment of HPV+ women may be informative for non-surgical interventions.
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Affiliation(s)
- J C Borgogna
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT, USA
| | - M D Shardell
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - E K Santori
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT, USA
| | - T M Nelson
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT, USA.,Department of Animal and Range Sciences, Montana State University, Bozeman, MT, USA
| | - J M Rath
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, College Park, MD, USA.,Truth Initiative, Washington, DC, USA
| | - E D Glover
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, College Park, MD, USA
| | - J Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - P E Gravitt
- Department of Global Health, George Washington University, Washington, DC, USA
| | - C J Yeoman
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT, USA.,Department of Animal and Range Sciences, Montana State University, Bozeman, MT, USA
| | - R M Brotman
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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34
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Brotman RM, Shardell MD, Gajer P, Fadrosh D, Chang K, Silver MI, Viscidi RP, Burke AE, Ravel J, Gravitt PE. Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy. Menopause 2019; 25:1321-1330. [PMID: 30358729 DOI: 10.1097/gme.0000000000001236] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The vaginal microbiota helps protect the female genital tract from disease. We sought to describe the composition of the vaginal microbiota in premenopausal, perimenopausal, and postmenopausal women and to explore the association between the microbiota and vulvovaginal atrophy (VVA). METHODS Eighty-seven women (aged 35-60 y) were classified as premenopausal (n = 30), perimenopausal (n = 29), or postmenopausal (n = 28) according to Stages of Reproductive Aging Workshop guidelines. Midvaginal bacterial community composition was characterized by 16S ribosomal RNA gene analysis. RESULTS Bacterial communities clustered into six community state types (CSTs), of which four were dominated by Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus iners, or Lactobacillus jensenii, and two (CST IV-A and CST IV-B) had low relative abundance of Lactobacillus. CST IV-A was characterized by Streptococcus and Prevotella, whereas CST IV-B was characterized by Atopobium. There were significant associations between menopause stage and CST (P = 0.004) and between VVA and CST (P = 0.002). Perimenopausal women were more likely to be classified as CST IV-A or L. gasseri CST, whereas postmenopausal women were often classified as CST IV-A. CSTs dominated by L. crispatus and L. iners were more prevalent in premenopausal women. Nineteen participants had signs of mild or moderate VVA. Compared with women with no VVA, the vaginal microbiota of women with mild or moderate atrophy had 25-fold greater odds of being classified as CST IV-A versus L. crispatus CST (adjusted odds ratio, 25.89; 95% credible interval, 2.98-406.79). CONCLUSIONS A distinct bacterial community state (CST IV-A) with a low relative abundance of Lactobacillus is associated with VVA. Future studies recruiting a larger number of women are needed to replicate the findings. This study provides an impetus for future longitudinal studies designed to manage, modulate, and restore vaginal microbiota homeostasis, which would provide stronger evidence for a causal relationship with VVA and ultimately improve the treatment and prevention of atrophic vaginitis in menopause.
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Affiliation(s)
- Rebecca M Brotman
- Institute for Genome Sciences.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Michelle D Shardell
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Kathryn Chang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michelle I Silver
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Anne E Burke
- Obstetrics and Gynecology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jacques Ravel
- Institute for Genome Sciences.,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD
| | - Patti E Gravitt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Patel EU, Grabowski MK, Eisenberg AL, Packman ZR, Gravitt PE, Tobian AAR. Increases in Human Papillomavirus Vaccination Among Adolescent and Young Adult Males in the United States, 2011-2016. J Infect Dis 2019; 218:109-113. [PMID: 29584878 DOI: 10.1093/infdis/jiy165] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/22/2018] [Indexed: 12/31/2022] Open
Abstract
In the United States, human papillomavirus (HPV) vaccination has been recommended for females since 2006 and males since 2011. We assessed temporal trends in HPV vaccine coverage (defined as receipt of ≥1 dose) among 9-26-year-old participants in the 2011-2016 National Health and Nutrition Examination Surveys. While coverage increased overall, from 37.7% to 45.7%, among females (adjusted prevalence difference [aPD], 7.1%; 95% confidence interval [CI], .1%-13.7%), there was no change among female adolescents aged 9-17 years. For males, coverage increased overall, from 7.8% to 27.4% (aPD, 18.8%; 95% CI, 14.1%-23.5%), and among every stratum of age, race/ethnicity, health insurance status, poverty level, and immigration status (P ≤ .05). The increase in HPV vaccine coverage observed among males is encouraging, but coverage remains below national targets for both males and females.
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Affiliation(s)
- Eshan U Patel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore
| | - M Kate Grabowski
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore
| | - Anna L Eisenberg
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Zoe R Packman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore
| | - Patti E Gravitt
- Department of Global Health, George Washington University, Washington, D.C
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore
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36
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DeLong K, Bensouda S, Zulfiqar F, Zierden HC, Hoang TM, Abraham AG, Coleman JS, Cone RA, Gravitt PE, Hendrix CW, Fuchs EJ, Gaydos CA, Weld ED, Ensign LM. Conceptual Design of a Universal Donor Screening Approach for Vaginal Microbiota Transplant. Front Cell Infect Microbiol 2019; 9:306. [PMID: 31555606 PMCID: PMC6722226 DOI: 10.3389/fcimb.2019.00306] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/09/2019] [Indexed: 01/08/2023] Open
Abstract
The success of fecal microbiota transplant (FMT) in treating recurrent Clostridioides difficile infection has led to growing excitement about the potential of using transplanted human material as a therapy for a wide range of diseases and conditions related to microbial dysbiosis. We anticipate that the next frontier of microbiota transplantation will be vaginal microbiota transplant (VMT). The composition of the vaginal microbiota has broad impact on sexual and reproductive health. The vaginal microbiota in the "optimal" state are one of the simplest communities, dominated by one of only a few species of Lactobacillus. Diversity in the microbiota and the concomitant depletion of lactobacilli, a condition referred to as bacterial vaginosis (BV), is associated with a wide range of deleterious effects, including increased risk of acquiring sexually transmitted infections and increased likelihood of having a preterm birth. However, we have very few treatment options available, and none of them curative or restorative, for "resetting" the vaginal microbiota to a more protective state. In order to test the hypothesis that VMT may be a more effective treatment option, we must first determine how to screen donors to find those with minimal risk of pathogen transmission and "optimal" vaginal microbiota for transplant. Here, we describe a universal donor screening approach that was implemented in a small pilot study of 20 women. We further characterized key physicochemical properties of donor cervicovaginal secretions (CVS) and the corresponding composition of the vaginal microbiota to delineate criteria for inclusion/exclusion. We anticipate that the framework described here will help accelerate clinical studies of VMT.
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Affiliation(s)
- Kevin DeLong
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sabrine Bensouda
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Fareeha Zulfiqar
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Hannah C. Zierden
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Thuy M. Hoang
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alison G. Abraham
- Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Jenell S. Coleman
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Richard A. Cone
- Department of Biophysics, Johns Hopkins University, Baltimore, MD, United States
| | - Patti E. Gravitt
- Department of Epidemiology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
- Department of Global Health, George Washington University, Washington, DC, United States
| | - Craig W. Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Edward J. Fuchs
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Charlotte A. Gaydos
- Department of Epidemiology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ethel D. Weld
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Laura M. Ensign
- The Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, United States
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Hammer A, Kahlert J, Gravitt PE, Rositch AF. Authors' response: Higher cervical cancer mortality among older women in Denmark could be due to insufficient screening coverage. Acta Obstet Gynecol Scand 2019; 98:1491. [PMID: 31433080 DOI: 10.1111/aogs.13710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/15/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Patti E Gravitt
- Department of Global Health, Milken Institute School of Public Health, the George Washington University, Washington, DC, USA
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Hammer A, Kahlert J, Gravitt PE, Rositch AF. Hysterectomy‐corrected cervical cancer mortality rates in Denmark during 2002‐2015: A registry‐based cohort study. Acta Obstet Gynecol Scand 2019; 98:1063-1069. [DOI: 10.1111/aogs.13608] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/08/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
| | - Patti E. Gravitt
- Department of Global Health Milken Institute School of Public Healththe George Washington University Washington District of Columbia, USA
| | - Anne F. Rositch
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland, USA
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Hammer A, de Koning MN, Blaakaer J, Steiniche T, Doorbar J, Griffin H, Mejlgaard E, Svanholm H, Quint WG, Gravitt PE. Whole tissue cervical mapping of HPV infection: Molecular evidence for focal latent HPV infection in humans. Papillomavirus Res 2019; 7:82-87. [PMID: 30772498 PMCID: PMC6389775 DOI: 10.1016/j.pvr.2019.02.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/01/2019] [Accepted: 02/13/2019] [Indexed: 12/27/2022]
Abstract
In this study, we aimed to provide molecular evidence of HPV latency in humans and discuss potential challenges of conducting studies on latency. We analyzed the entire cervix of two women who underwent hysterectomy unrelated to cervical abnormality. The cervices were sectioned into 242 and 186 sets respectively, and each set was tested separately for HPV using the SPF10-PCR-DEIA-LiPA25 system. To identify whether there was any evidence of transforming or productive infection, we used the biomarkers E4 and P16INK4a to stain slides immediately adjacent to HPV-positive sections. HPV was detected in both cervices. In patient 1, 1/242 sets was positive for HPV31. In patient 2, 13/186 sets were positive for HPV18 and 1/186 was positive for HPV53. The infection was very focal in both patients, and there was no sign of a transforming or productive infection, as evaluated by the markers E4 and P16INK4a. Had we only analyzed one set from each block, the probability of detecting the infection would have been 32.3% and 2%, respectively.Our findings support the idea that HPV may be able to establish latency in the human cervix; however, the risk associated with a latent HPV infection remains unclear.
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Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | | | - Jan Blaakaer
- Department of Obstetrics and Gynecology, Odense University Hospital, Denmark
| | - Torben Steiniche
- Department of Clinical Medicine, Aarhus University, Denmark; Department of Pathology, Aarhus University Hospital, Denmark
| | - John Doorbar
- Department of Pathology, University of Cambridge, United Kingdom
| | - Heather Griffin
- Department of Pathology, University of Cambridge, United Kingdom
| | - Else Mejlgaard
- Department of Pathology, Aarhus University Hospital, Denmark
| | | | - Wim Gv Quint
- DDL Diagnostic Laboratory, Rijswijk, the Netherlands
| | - Patti E Gravitt
- Department of Global Health, Milken Institute School of Public Health, the George Washington University, USA
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40
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Gravitt PE, Landy R, Schiffman M. How confident can we be in the current guidelines for exiting cervical screening? Prev Med 2018; 114:188-192. [PMID: 29981791 DOI: 10.1016/j.ypmed.2018.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 06/15/2018] [Accepted: 07/04/2018] [Indexed: 01/08/2023]
Abstract
Current US guidelines recommend against cervical screening beyond age 65 in women who have had adequate negative screening. In anticipation of the next round of evidence review and guideline updates, we provide a critical review of the evidence supporting the exiting recommendation in the US, highlighting both practice changes and new insights into the epidemiology and natural history of HPV and cervical cancer. Current recommendations are based, by necessity, on cytology alone, and will be limited in generalizability to evolving screening strategies with co-testing and primary HPV testing. The lack of empirical data to define what constitutes 'adequate recent screening with negative results' is compounded by difficulties in predicting future risk without consideration of concepts of HPV latency and cohort effects of changing sexual behaviour in US women over time. We urge caution in extrapolating past risk experience in post-menopausal women to today's population, and suggest study designs to strengthen the evidence base in well-screened older women. We further recommend building the qualitative evidence base to better define the harms and benefits of screening among older women. Extending the lifetime of screening is a matter of finding the appropriate balance of benefits of cancer reduction and limitation of harms and costs of 'overscreening'. This will require moving beyond current emphasis on number of colposcopies as the metric of harm. Our commentary is meant to stimulate intellectual debate regarding the certainty of our existing knowledge base and set clear research priorities for the future.
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Affiliation(s)
- Patti E Gravitt
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA.
| | - Rebecca Landy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, DHHS, Bethesda, MD, USA
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Chen Z, Schiffman M, Herrero R, DeSalle R, Anastos K, Segondy M, Sahasrabuddhe VV, Gravitt PE, Hsing AW, Chan PKS, Burk RD. Classification and evolution of human papillomavirus genome variants: Alpha-5 (HPV26, 51, 69, 82), Alpha-6 (HPV30, 53, 56, 66), Alpha-11 (HPV34, 73), Alpha-13 (HPV54) and Alpha-3 (HPV61). Virology 2018; 516:86-101. [PMID: 29331867 PMCID: PMC6093212 DOI: 10.1016/j.virol.2018.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 12/25/2017] [Accepted: 01/02/2018] [Indexed: 11/17/2022]
Abstract
HPV variants from the same type can be classified into lineages and sublineages based on the complete genome differences and the phylogenetic topologies. We examined nucleotide variations of twelve HPV types within the species Alpha-5 (HPV26, 51, 69, 82), Alpha-6 (HPV30, 53, 56, 66), Alpha-11 (HPV34, 73), Alpha-13 (HPV54) and Alpha-3 (HPV61) by analyzing 1432 partial sequences and 181 complete genomes from multiple geographic populations. The inter-lineage and inter-sublineage mean differences of HPV variants ranged between 0.9-7.3% and 0.3-0.9%, respectively. The heterogeneity and phylogenies of HPV isolates indicate an independent evolutionary history for each type. The noncoding regions were the most variable regions whereas the capsid proteins were relatively conserved. Certain variant lineages and/or sublineages were geographically-associated. These data provide the basis to further classify HPV variants and should foster future studies on the evolution of HPV genomes and the associations of HPV variants with cancer risk.
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Affiliation(s)
- Zigui Chen
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, United States
| | - Rolando Herrero
- Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, San José, Costa Rica; Prevention and Implementation Group, International Agency for Research on Cancer, World Health Organization, France
| | - Rob DeSalle
- Sackler Institute of Comparative Genomics, American Museum of Natural History, NY, United States
| | - Kathryn Anastos
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States; Departments of Epidemiology & Population Health and Obstetrics, Gynecology & Woman's Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Michel Segondy
- Department of Biology and Pathology, Montpellier University Hospital, Montpellier, France
| | | | - Patti E Gravitt
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Ann W Hsing
- Stanford Cancer Institute and Stanford Prevention Research Center, Stanford School of Medicine, Stanford University, CA, United States
| | - Paul K S Chan
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Robert D Burk
- Departments of Epidemiology & Population Health and Obstetrics, Gynecology & Woman's Health, Albert Einstein College of Medicine, Bronx, NY, United States; Departments of Pediatrics, and Microbiology & Immunology, Albert Einstein College of Medicine, Bronx, NY, United States.
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43
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Silver MI, Rositch AF, Phelan-Emrick DF, Gravitt PE. Uptake of HPV testing and extended cervical cancer screening intervals following cytology alone and Pap/HPV cotesting in women aged 30-65 years. Cancer Causes Control 2017; 29:43-50. [PMID: 29124542 DOI: 10.1007/s10552-017-0976-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 10/28/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the adoption of HPV testing and recommended extended cervical cancer screening intervals in clinical practice, we described yearly uptake of Pap/HPV cotesting and estimated length of time between normal screens by patient characteristics. METHODS We examined 55,575 Pap/HPV records from 27,035 women aged 30-65 years from the Johns Hopkins Hospital Pathology Data System between 2006 and 2013. Cotest uptake and median times to next screening test for cotests and cytology only were calculated. Adjusted hazard ratios were estimated using Cox proportional hazards models, with random effects adjustment for clustering within clinic. RESULTS Cotest usage increased from < 10% in 2006 to 78% in 2013. The median time to next screening test following normal cytology alone remained constant around 1.5 years. Screening intervals following a dual-negative cotest increased from 1.5 years in 2006/2007 to 2.5 years in 2010, coincident with increases in the proportion of women cotested. Intervals following a dual negative cotest were longer among Medicare patients (3 years) compared with privately insured women (2.5 years), and shorter among black (2 years) compared with white women (2.8 years). CONCLUSION By mid-2013 we observed broad adoption of Pap/HPV cotesting in routine screening in a large academic medical center. Increased screening intervals were observed only among cotested women, while those screened by cytology alone continued to be screened almost annually. The influence of different combinations of race and insurance on screening intervals should be further evaluated to ensure balance of screening risks and benefits in the U.S. POPULATION
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Affiliation(s)
- Michelle I Silver
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, 6E584, Rockville, MD, 20850, USA.
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Darcy F Phelan-Emrick
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Patti E Gravitt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department Global Health, George Washington University, Washington, DC, USA
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Eldridge RC, Pawlita M, Wilson L, Castle PE, Waterboer T, Gravitt PE, Schiffman M, Wentzensen N. Smoking and subsequent human papillomavirus infection: a mediation analysis. Ann Epidemiol 2017; 27:724-730.e1. [PMID: 29107447 DOI: 10.1016/j.annepidem.2017.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/24/2017] [Accepted: 10/02/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Smoking is an established risk factor for a human papillomavirus (HPV) infection advancing to cervical precancer and cancer, but its role earlier in the natural history is less clear. Smoking is inversely associated with possessing HPV antibodies from a past infection suggesting that smoking may influence acquiring subsequent infections. METHODS In a cohort of 1976 U.S. women, we evaluate whether reduced antibodies to HPV-16 is a mechanism for smoking's role on acquiring a subsequent HPV-16 infection, through the analytic technique of causal mediation analysis. We posit a causal model and estimate two counterfactually defined effects: a smoking impaired antibody-mediated indirect effect and a nonmediated direct effect representing all other potential mechanisms of smoking. RESULTS Compared to never smokers, current smokers had increased odds of HPV-16 infection by the antibody-mediated indirect effect (odds ratio [OR] = 1.29; 95% confidence interval [CI]: 1.11, 1.73); the estimated direct effect was very imprecise (OR = 0.57; 95% CI, 0.26-1.13). We observed a stronger estimated indirect effect among women who smoked at least half a pack of cigarettes daily (OR = 1.61, 95% CI, 1.27-2.15) than among women who smoked less than that threshold (OR = 1.09; 95% CI, 0.94-1.44). CONCLUSIONS This is the first study to directly test the mechanism underlying smoking as an HPV cofactor. The results support current smoking as a risk factor earlier in the natural history of HPV and are consistent with the hypothesis that smoking increases the risk of a subsequent infection by reducing immunity.
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Affiliation(s)
- Ronald C Eldridge
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD.
| | | | - Lauren Wilson
- National Institute of Environmental Health Sciences, Research Triangle Park, NC
| | | | | | | | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
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Ryser MD, Rositch A, Gravitt PE. Modeling of US Human Papillomavirus (HPV) Seroprevalence by Age and Sexual Behavior Indicates an Increasing Trend of HPV Infection Following the Sexual Revolution. J Infect Dis 2017; 216:604-611. [PMID: 28931221 DOI: 10.1093/infdis/jix333] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/14/2017] [Indexed: 12/22/2022] Open
Abstract
Background The United States has experienced an increase in the incidence of human papillomavirus (HPV)-related cancers that are not screen-detectable. It has been hypothesized, but not directly demonstrated, that this is due to increasing HPV prevalence in the unvaccinated population. Methods Female self-reported numbers of lifetime sex partners and HPV serology from the National Health and Nutrition Examination Survey (NHANES) were used to develop mathematical models of sexual partner acquisition and antibody dynamics. Modeled trends in sexual behaviors were compared to incidence data for cervical adenocarcinoma, oropharyngeal cancer, and anal cancer. Results The age-specific HPV seroprevalence data were best explained by a partner acquisition model that explicitly accounted for cohort-dependent changes in sexual behavior. Estimates of the mean time to loss of natural antibodies varied by model, ranging from 49 to 145 years. Inferred trends in sexual behavior over the past decades paralleled the increasing incidence of HPV-related cancers in the United States. Conclusions The findings suggest that lower HPV seroprevalence in older US women primarily reflects cohort-specific differences in sexual behaviors, and is only marginally attributable to immune waning with age. Our results emphasize the importance of continuing surveillance of sexual behaviors, alongside vaccine status, to predict future disease burden.
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Affiliation(s)
- Marc D Ryser
- Department of Surgery, Division of Advanced Oncologic and GI Surgery, Duke University Medical Center.,Department of Mathematics, Duke University, Durham, North Carolina
| | - Anne Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Patti E Gravitt
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
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Patel EU, Rositch AF, Gravitt PE, Tobian AAR. Concordance of Penile and Oral Human Papillomavirus Infections Among Men in the United States. J Infect Dis 2017; 215:1207-1211. [PMID: 28329127 DOI: 10.1093/infdis/jix116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/02/2017] [Indexed: 01/28/2023] Open
Abstract
This study examined the concordance of penile and oral human papillomavirus (HPV) infections in the United States. A total of 1683 men aged 18-59 years who participated in the 2013-2014 National Health and Nutrition Examination Survey and had results of oral and penile HPV DNA testing were examined. The prevalence of any HPV genotype was 45.3% on the penis, 11.2% in the oral cavity, and 8.8% at both sites. The prevalence of HPV in the oral cavity was higher among those with than among those without penile HPV infection (19.3% vs 4.4%; prevalence ratio, 4.37 [95% confidence interval, 2.66-7.16]). The prevalence of ≥1 genotype-concordant HPV infection was 3.2% and was associated with sexual behavior, independent of demographic characteristics and smoking status. Sexual behavior may partly explain the observed association between penile and oral HPV infections.
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Affiliation(s)
- Eshan U Patel
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Patti E Gravitt
- Department of Global Health, George Washington University, Washington, District of Columbia
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
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Shi G, Fischer AC, Zenilman JM, Gravitt PE, Fischer M, Sander IB, Cuda JD, Taube JM, Lilo M, Lee WPA, Tufaro AP. Abstract 674: HPV16 was the preponderant type of HPV infection in cutaneous squamous cell carcinoma. Cancer Res 2017. [DOI: 10.1158/1538-7445.am2017-674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose: Human papillomavirus (HPV) has been well established as a causative factor in mucosal oropharyngeal cancer and anogenital surface malignancies. However, its etiological role in cutaneous squamous cell carcinoma (cSCC) is still debated. The aim of this study is to identify the presence of HPV types in cSCC and identify their associations with cSCC.
Methods: 77 cSCC blocks from 54 patients underwent DNA isolation and a broad spectrum of HPV PCR tests to detect the presence of HPV genotypes by the use of a universal primer pair GP5+/GP6+. The resultant PCR products were cloned to T Vectors and subsequently underwent DNA sequencing and Nucleotide BLAST search to identify the HPV types in cSCC. To ensure the accuracy of the HPV PCR test, 16 blocks from 10 head and neck SCC (oropharyngeal) patients were also included in the HPV presence and type analyses. Cutaneous SCC patients’ demographics, pathology and clinical parameters were compared and analyzed statistically in conjunction with the HPV test results.
Results: HPV DNA was found in 37 of 77 (48.1%) blocks representing 32 of 54 (59.3%) cSCC patients. HPV16 was the preponderant type of HPV Infection, accounting for 28 of 32 (87.5%) and 30 of 37 (81.08%) HPV positive patients and blocks. Other HPV genotypes found included HPV18, 57, 10, 2, accounting for 4 of 32 (12.5%), 2 of 32 (6.25%), 2 of 32 (6.25%), 2 of 32 (6.25%) of the HPV positive patients and 4 of 37 (10.81%), 2 of 37 (5.41%), 2 of 37 (5.41%), 2 of 37 (5.41%) of the HPV positive blocks, respectively. HPV infection was significantly associated with the cSCC tumor size in this cohort of patients. Tumors with a size of ≤20mm were more frequently associated with HPV. Moreover, the average tumor size of the HPV positive group was also significantly smaller than that of the HPV negative group.
Conclusions: HPV infection is very commonly found in cSCC patients and HPV16 is the major type of HPV involved in cSCC oncogenesis, accounting for >80% of HPV infections. HPV is a contributing factor, which appears to be contributing to a smaller size of cSCC, which may improve the prognostic classification of patients to provide a new insight into tumorigenesis.
Citation Format: Gang Shi, Anne C. Fischer, Jonathan M. Zenilman, Patti E. Gravitt, Max Fischer, Inbal B. Sander, Jonathan D. Cuda, Janis M. Taube, Mohammed Lilo, W P Andrew Lee, Anthony P. Tufaro. HPV16 was the preponderant type of HPV infection in cutaneous squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 674. doi:10.1158/1538-7445.AM2017-674
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Affiliation(s)
- Gang Shi
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - Max Fischer
- 4University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Janis M. Taube
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mohammed Lilo
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | - W P Andrew Lee
- 1Johns Hopkins University School of Medicine, Baltimore, MD
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Grabowski MK, Gravitt PE, Gray RH, Serwadda D, Redd AD, Kigozi G, Kong X, Nalugoda F, Wawer MJ, Quinn TC, Tobian AAR. Trends and Determinants of Human Papillomavirus Concordance Among Human Immunodeficiency Virus-Positive and -Negative Heterosexual Couples in Rakai, Uganda. J Infect Dis 2017; 215:772-780. [PMID: 28011913 DOI: 10.1093/infdis/jiw631] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 12/20/2016] [Indexed: 12/13/2022] Open
Abstract
Background Limited data are available on human papillomavirus (HPV) infection among human immunodeficiency virus (HIV)-negative or HIV-positive couples followed longitudinally. Methods Genital HPV was assessed in 725 concordant HIV-negative couples and 209 HIV-positive couples enrolled in a male circumcision trial in Rakai, Uganda, using the Roche Linear Array assay, which detects 37 HPV genotypes. Human papillomavirus prevalence and determinants of genotype-specific concordance were assessed at annual visits. Cumulative detection of HPV genotypes over 2 years was also assessed. Results At enrollment, HPV infection was detected in 54% of HIV-negative women, 56% of HIV-negative men, and 93% of HIV-positive men and women. For HIV-negative couples, genotypic concordance was 30% at baseline (n = 219/725) and declined significantly with age (adjusted prevelance risk ratio [adjPRR] = 0.53; 95% confidence interval [CI] = 0.28-0.93 comparing women aged >40 years to those aged 15-19 years) and male circumcision (adjPRR = 0.60; 95% CI = 0.47-0.77) and increased among couples with recent intercourse (adjPRR = 1.26; 95% CI = 1.04-1.53). These associations were not seen in HIV-positive couples. Among couples with HPV results at all visits, ≥1 of the same genotypes were detected in both partners in 60% of HIV-negative couples and 96% of HIV-positive couples over 2 years. Conclusion Human papillomavirus genotype-specific concordance is more common in HIV-positive couples, and irrespective of HIV status, the majority of couples exhibit HPV concordance over 2 years.
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Affiliation(s)
- Mary K Grabowski
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Patti E Gravitt
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington D.C. USA
| | - Ronald H Gray
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, MD, USA.,Rakai Health Sciences Program, Entebbe, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda.,School of Public Health, Makerere University, Kampala, Uganda
| | - Andrew D Redd
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Xiangrong Kong
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Maria J Wawer
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, MD, USA.,Rakai Health Sciences Program, Entebbe, Uganda
| | - Thomas C Quinn
- Rakai Health Sciences Program, Entebbe, Uganda.,Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA.,Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Epidemiology, Bloomberg School of Public Health, Baltimore, MD, USA.,Rakai Health Sciences Program, Entebbe, Uganda.,Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
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Affiliation(s)
- Patti E Gravitt
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, D. C
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Ryser MD, Gravitt PE, Myers ER. Mechanistic mathematical models: An underused platform for HPV research. Papillomavirus Res 2017; 3:46-49. [PMID: 28720456 PMCID: PMC5518640 DOI: 10.1016/j.pvr.2017.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/20/2017] [Accepted: 01/31/2017] [Indexed: 01/19/2023]
Abstract
Health economic modeling has become an invaluable methodology for the design and evaluation of clinical and public health interventions against the human papillomavirus (HPV) and associated diseases. At the same time, relatively little attention has been paid to a different yet complementary class of models, namely that of mechanistic mathematical models. The primary focus of mechanistic mathematical models is to better understand the intricate biologic mechanisms and dynamics of disease. Inspired by a long and successful history of mechanistic modeling in other biomedical fields, we highlight several areas of HPV research where mechanistic models have the potential to advance the field. We argue that by building quantitative bridges between biologic mechanism and population level data, mechanistic mathematical models provide a unique platform to enable collaborations between experimentalists who collect data at different physical scales of the HPV infection process. Through such collaborations, mechanistic mathematical models can accelerate and enhance the investigation of HPV and related diseases.
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Affiliation(s)
- Marc D Ryser
- Department of Surgery, Division of Advanced Oncologic and GI Surgery, Duke University School of Medicine, Durham, NC, USA; Department of Mathematics, Duke University, Durham, NC, USA.
| | - Patti E Gravitt
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Evan R Myers
- Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC, USA
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