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Clarke MA, Wentzensen N, Perkins RB, Garcia F, Arrindell D, Chelmow D, Cheung LC, Darragh TM, Egemen D, Guido R, Huh W, Locke A, Lorey TS, Nayar R, Risley C, Saslow D, Smith RA, Unger ER, Massad LS. Recommendations for Use of p16/Ki67 Dual Stain for Management of Individuals Testing Positive for Human Papillomavirus. J Low Genit Tract Dis 2024; 28:124-130. [PMID: 38446575 DOI: 10.1097/lgt.0000000000000802] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
OBJECTIVES The Enduring Consensus Cervical Cancer Screening and Management Guidelines Committee developed recommendations for dual stain (DS) testing with CINtec PLUS Cytology for use of DS to triage high-risk human papillomavirus (HPV)-positive results. METHODS Risks of cervical intraepithelial neoplasia grade 3 or worse were calculated according to DS results among individuals testing HPV-positive using data from the Kaiser Permanente Northern California cohort and the STudying Risk to Improve DisparitiES study in Mississippi. Management recommendations were based on clinical action thresholds developed for the 2019 American Society for Colposcopy and Cervical Pathology Risk-Based Management Consensus Guidelines. Resource usage metrics were calculated to support decision-making. Risk estimates in relation to clinical action thresholds were reviewed and used as the basis for draft recommendations. After an open comment period, recommendations were finalized and ratified through a vote by the Consensus Stakeholder Group. RESULTS For triage of positive HPV results from screening with primary HPV testing (with or without genotyping) or with cytology cotesting, colposcopy is recommended for individuals testing DS-positive. One-year follow-up with HPV-based testing is recommended for individuals testing DS-negative, except for HPV16- and HPV18-positive results, or high-grade cytology in cotesting, where immediate colposcopy referral is recommended. Risk estimates were similar between the Kaiser Permanente Northern California and STudying Risk to Improve DisparitiES populations. In general, resource usage metrics suggest that compared with cytology, DS requires fewer colposcopies and detects cervical intraepithelial neoplasia grade 3 or worse earlier. CONCLUSIONS Dual stain testing with CINtec PLUS Cytology is acceptable for triage of HPV-positive test results. Risk estimates are portable across different populations.
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Affiliation(s)
- Megan A Clarke
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, MD
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, MD
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA
| | | | | | - David Chelmow
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Li C Cheung
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, MD
| | - Teresa M Darragh
- The Department of Pathology, University of California, San Francisco, CA
| | - Didem Egemen
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, MD
| | - Richard Guido
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, PA
| | - Warner Huh
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Alexander Locke
- Department of Obstetrics and Gynecology (Retired), The Permanente Medical Group, Oakland, CA
| | - Thomas S Lorey
- Regional Laboratory, Kaiser Permanente Northern California, Oakland, CA
| | - Ritu Nayar
- Department of Pathology, Northwestern University Feinberg School of Medicine and Northwestern Medical Group, Chicago, IL
| | | | - Debbie Saslow
- Prevention and Early Detection Department, American Cancer Society, Atlanta, GA
| | - Robert A Smith
- Early Cancer Detection Science, American Cancer Society, Atlanta, GA
| | - Elizabeth R Unger
- Chronic Viral Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - L Stewart Massad
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, MO
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Wentzensen N, Garcia F, Clarke MA, Massad LS, Cheung LC, Egemen D, Guido R, Huh W, Saslow D, Smith RA, Unger ER, Perkins RB. Enduring Consensus Guidelines for Cervical Cancer Screening and Management: Introduction to the Scope and Process. J Low Genit Tract Dis 2024; 28:117-123. [PMID: 38446573 DOI: 10.1097/lgt.0000000000000804] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
OBJECTIVES The Enduring Consensus Cervical Cancer Screening and Management Guidelines (Enduring Guidelines) effort is a standing committee to continuously evaluate new technologies and approaches to cervical cancer screening, management, and surveillance. METHODS AND RESULTS The Enduring Guidelines process will selectively incorporate new technologies and approaches with adequate supportive data to more effectively improve cancer prevention for high-risk individuals and decrease unnecessary procedures in low-risk individuals. This manuscript describes the structure, process, and methods of the Enduring Guidelines effort. Using systematic literature reviews and primary data sources, risk of precancer will be estimated and recommendations will be made based on risk estimates in the context of established risk-based clinical action thresholds. The Enduring Guidelines process will consider health equity and health disparities by assuring inclusion of diverse populations in the evidence review and risk assessment and by developing recommendations that provide a choice of well-validated strategies that can be adapted to different settings. CONCLUSIONS The Enduring Guidelines process will allow updating existing cervical cancer screening and management guidelines rapidly when new technologies are approved or new scientific evidence becomes available.
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Affiliation(s)
- Nicolas Wentzensen
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, MD
| | - Francisco Garcia
- Health and Community Services Administration, Pima County, Tucson, AZ
| | - Megan A Clarke
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, MD
| | - L Stewart Massad
- Department of Obstetrics and Gynecology, Washington University, St. Louis, MO
| | - Li C Cheung
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, MD
| | - Didem Egemen
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, MD
| | - Richard Guido
- University of Pittsburgh School of Medicine, Magee-Womens Hospital, Pittsburgh, PA
| | - Warner Huh
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Elizabeth R Unger
- Chronic Viral Diseases Program, Centers for Disease Control and Prevention, Atlanta, GA
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine/Boston Medical Center, Boston, MA
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Michel AD, Fontenot HB, Fuzzell L, Brownstein NC, Lake P, Vadaparampil ST, Perkins RB. Attitudes toward the American Cancer Society's 2020 cervical cancer screening guidelines: A qualitative study of a national sample of US clinicians. Cancer 2024. [PMID: 38436396 DOI: 10.1002/cncr.35269] [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: 12/21/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND The 2020 American Cancer Society (ACS) guidelines are the most recent national guidelines for cervical cancer screening. These guidelines propose two major changes from current practice: initiating screening at age 25 years and using primary human papillomavirus (HPV) testing. Adoption of guidelines often occurs slowly, and therefore understanding clinician attitudes is important to facilitate practice change. METHODS Interviews with a national sample of clinicians who perform cervical cancer screening in a variety of settings explored attitudes toward the two major changes from the 2020 ACS cervical cancer screening guidelines. Clinicians participated in 30- to 60-min interviews exploring their attitudes toward various aspects of cervical cancer screening. Qualitative analysis was performed. RESULTS Seventy clinicians participated from across the United States. Few respondents were initiating screening at age 25 years, and none were using primary HPV testing. However, over half would be willing to adopt these practices if supported by scientific evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional societies, lack of laboratory availability and insurance coverage, limited autonomy within large health care systems, and concerns related to missed disease. CONCLUSIONS Few clinicians have adopted screening initiation or primary HPV testing, as recommended by the 2020 ACS guidelines, but over half were open to adopting these changes. Implementation may be facilitated via professional organization endorsement, clinician education, and laboratory, health care system, and insurance support. PLAIN LANGUAGE SUMMARY In 2020, the American Cancer Society (ACS) released updated guidelines for cervical cancer screening. The main changes to current practices were to initiate screening at age 25 years instead of age 21 years and to screen using primary human papillomavirus (HPV) testing rather than cytology alone or in combination with HPV testing. We performed in-depth interviews with 70 obstetrics and gynecology, family medicine, and internal medicine physicians and advanced practice providers about their attitudes toward these guidelines. Few clinicians are following the 2020 ACS guidelines, but over half were open to changing practice if the changes were supported by evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional medical organizations, logistical issues, and concerns about missed disease.
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Affiliation(s)
- Alexandra D Michel
- College of Nursing, Rosalind Franklin University, North Chicago, Illinois, USA
| | - Holly B Fontenot
- School of Nursing, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Lindsay Fuzzell
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Naomi C Brownstein
- Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Paige Lake
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Susan T Vadaparampil
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Rebecca B Perkins
- Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts, USA
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Perkins RB, Fuzzell L, Lake P, Brownstein NC, Fontenot HB, Michel A, Whitmer A, Vadaparampil ST. Factors Associated With Guideline-concordant and Excessive Cervical Cancer Screening: A Mixed Methods Study. Womens Health Issues 2024:S1049-3867(24)00001-X. [PMID: 38383228 DOI: 10.1016/j.whi.2024.01.001] [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: 10/11/2023] [Revised: 12/21/2023] [Accepted: 01/09/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION National guidelines recommend cervical cancer screening with Papanicolaou (Pap) testing at 3-year intervals or with human papillomavirus (HPV) testing alone or HPV/Pap cotesting at 5-year intervals for average-risk individuals aged 30-65 years. METHODS We explored factors associated with clinician-reported guideline-concordant screening, as well as facilitators and barriers to appropriate cervical cancer screening. RESULTS A national sample of clinicians (N = 1,251) completed surveys; a subset (n = 55) completed interviews. Most (94%) screened average-risk patients aged 30-65 years with cotesting. Nearly all clinicians who were categorized as nonadherent to national guidelines were overscreening (98%). Guideline concordant screening was reported by 47% and 82% of those using cotesting and HPV testing, respectively (5-year intervals), and by 62% of those using Pap testing only (3-year intervals). Concordant screening was reported more often by clinicians who were aged <40 years, non-Hispanic, and practicing in the West or Midwest, and less often by obstetrician-gynecologists and private practice physicians. Concordant screening was facilitated by beliefs that updated guidelines were evidence-based and reduced harms, health care system dissemination of guidelines, and electronic medical record prompts. Barriers to concordant screening included using outdated guidelines, relying on personal judgment, concern about missing cancers, inappropriate patient risk assessment, and lack of support for guideline adoption through health care systems or electronic medical records. CONCLUSIONS Most clinicians screened with Pap/HPV cotesting and approximately one-half endorsed a 5-year screening interval. Clinician knowledge gaps include understanding the evidence underlying 5-year intervals and appropriate risk assessment to determine which patients should be screened more frequently. Education and tracking systems can promote guideline-concordant screening.
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Affiliation(s)
- Rebecca B Perkins
- Boston University, Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts.
| | - Lindsay Fuzzell
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and Behavior, Office of Community Outreach, Engagement, and Equity, Tampa, Florida
| | - Paige Lake
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and Behavior, Office of Community Outreach, Engagement, and Equity, Tampa, Florida
| | - Naomi C Brownstein
- Medical University of South Carolina, Public Health Sciences, Charleston, South Carolina
| | | | | | - Ashley Whitmer
- Boston University, Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Susan T Vadaparampil
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and Behavior, Office of Community Outreach, Engagement, and Equity, Tampa, Florida
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Zimmerman M, Zapata LP, Bachiller K, Devera JL, Hall TA, Casey SM, Perkins RB, Pierre-Joseph N. Attitudes Toward Routine Vaccines and COVID-19 Vaccines Among Parents of Infants and Toddlers in an Urban Safety-Net Setting. Clin Pediatr (Phila) 2024:99228231224168. [PMID: 38279858 DOI: 10.1177/00099228231224168] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
This study explores attitudes toward diphtheria-tetanus-acellular pertussis (DTaP), measles-mumps-rubella (MMR), influenza, and coronavirus disease 2019 (COVID-19) vaccines among English-speaking and Spanish-speaking parents of infants in a safety-net setting. Parents aged 18 years or older were recruited from outpatient clinics between December 2020 and December 2021. The interviews were then recorded, transcribed, translated, and qualitatively analyzed using the modified grounded theory. Thirty-two individuals participated (18 English-speaking and 14 Spanish-speaking). Almost all supported receiving routine childhood vaccines, DTaP, influenza, and MMR and believed that vaccines promote health. Vaccine concerns differed by each vaccine. Few participants expressed concerns about DTaP and MMR vaccines. Concerns around influenza vaccines often stemmed from personal experience and perceived increased risk of flu-like illnesses. Participants expressed the most concerns related to COVID-19 vaccinations, including age-based immunity of their infants. Based on these findings, future interventions to improve vaccine uptake may focus on benefits common to all vaccines, while addressing vaccine-specific concerns.
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Affiliation(s)
- Margaux Zimmerman
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Lesly P Zapata
- Barry M. Manuel Center for Continuing Education, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Karla Bachiller
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jean L Devera
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Taylor A Hall
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sharon M Casey
- Barry M. Manuel Center for Continuing Education, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Rebecca B Perkins
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Natalie Pierre-Joseph
- Department of Pediatrics, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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de Sanjosé S, Perkins RB, Campos N, Inturrisi F, Egemen D, Befano B, Rodriguez AC, Jerónimo J, Cheung LC, Desai K, Han P, Novetsky AP, Ukwuani A, Marcus J, Ahmed SR, Wentzensen N, Kalpathy-Cramer J, Schiffman M. Design of the HPV-automated visual evaluation (PAVE) study: Validating a novel cervical screening strategy. eLife 2024; 12:RP91469. [PMID: 38224340 PMCID: PMC10945624 DOI: 10.7554/elife.91469] [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] [Indexed: 01/16/2024] Open
Abstract
Background The HPV-automated visual evaluation (PAVE) Study is an extensive, multinational initiative designed to advance cervical cancer prevention in resource-constrained regions. Cervical cancer disproportionally affects regions with limited access to preventive measures. PAVE aims to assess a novel screening-triage-treatment strategy integrating self-sampled HPV testing, deep-learning-based automated visual evaluation (AVE), and targeted therapies. Methods Phase 1 efficacy involves screening up to 100,000 women aged 25-49 across nine countries, using self-collected vaginal samples for hierarchical HPV evaluation: HPV16, else HPV18/45, else HPV31/33/35/52/58, else HPV39/51/56/59/68 else negative. HPV-positive individuals undergo further evaluation, including pelvic exams, cervical imaging, and biopsies. AVE algorithms analyze images, assigning risk scores for precancer, validated against histologic high-grade precancer. Phase 1, however, does not integrate AVE results into patient management, contrasting them with local standard care.Phase 2 effectiveness focuses on deploying AVE software and HPV genotype data in real-time clinical decision-making, evaluating feasibility, acceptability, cost-effectiveness, and health communication of the PAVE strategy in practice. Results Currently, sites have commenced fieldwork, and conclusive results are pending. Conclusions The study aspires to validate a screen-triage-treat protocol utilizing innovative biomarkers to deliver an accurate, feasible, and cost-effective strategy for cervical cancer prevention in resource-limited areas. Should the study validate PAVE, its broader implementation could be recommended, potentially expanding cervical cancer prevention worldwide. Funding The consortial sites are responsible for their own study costs. Research equipment and supplies, and the NCI-affiliated staff are funded by the National Cancer Institute Intramural Research Program including supplemental funding from the Cancer Cures Moonshot Initiative. No commercial support was obtained. Brian Befano was supported by NCI/ NIH under Grant T32CA09168.
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Affiliation(s)
- Silvia de Sanjosé
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
- ISGlobalBarcelonaSpain
| | - Rebecca B Perkins
- University Chobanian and Avedisian School of Medicine/Boston Medical CenterBostonUnited States
| | - Nicole Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public HealthBostonUnited States
| | - Federica Inturrisi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Brian Befano
- Information Management Services IncCalvertonUnited States
- Department of Epidemiology, University of Washington School of Public HealthSeattleUnited States
| | - Ana Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Jose Jerónimo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Kanan Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Paul Han
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Akiva P Novetsky
- Westchester Medical Center/New York Medical CollegeValhallaUnited States
| | - Abigail Ukwuani
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Jenna Marcus
- Feinberg School of Medicine at Northwestern UniversityChicagoUnited States
| | - Syed Rakin Ahmed
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General HospitalBostonUnited States
- Harvard Graduate Program in Biophysics, Harvard Medical School, Harvard UniversityCambridgeUnited States
- Massachusetts Institute of TechnologyCambridgeUnited States
- Geisel School of Medicine at Dartmouth, Dartmouth CollegeHanoverUnited States
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General HospitalBostonUnited States
- University of Colorado Anschutz Medical CampusAuroraUnited States
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
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Inturrisi F, de Sanjosé S, Desai KT, Dagnall C, Egemen D, Befano B, Rodriguez AC, Jeronimo JA, Zuna RE, Hoffman A, Farhat Nozzari S, Walker JL, Perkins RB, Wentzensen N, Palefsky JM, Schiffman M. A rapid HPV typing assay to support global cervical cancer screening and risk-based management: A cross-sectional study. Int J Cancer 2024; 154:241-250. [PMID: 37772799 DOI: 10.1002/ijc.34698] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 05/17/2023] [Revised: 07/12/2023] [Accepted: 07/31/2023] [Indexed: 09/30/2023]
Abstract
The World Health Organization recommends human papillomavirus (HPV) testing for cervical screening. Extended genotyping can identify the highest-risk HPV-positive women. An inexpensive, rapid, mobile isothermal amplification assay (ScreenFire HPV RS test) was recently redesigned to yield four channels ordered by cancer risk (ie, hierarchical approach): HPV16, HPV18/45, HPV31/33/35/52/58 and HPV39/51/56/59/68. Stored specimens from 2076 women (mean age 30.9) enrolled in a colposcopy clinic, with high HPV prevalence, were tested with ScreenFire. We calculated hierarchical channel positivity and non-hierarchical channel and type positivity, according to histologic diagnosis (256 cancer, 350 cervical intraepithelial neoplasia [CIN]3, 409 CIN2, 1020 < CIN2) and known virologic reference results (Linear Array and TypeSeq). Additionally, we analyzed ScreenFire time-to-positive up to 60 min by channel and histology. Overall clinical sensitivity for CIN3+ was 94.7% (95% confidence interval 92.6-96.4), similar to Linear Array (92.3, 89.7-94.3) and TypeSeq (96.0, 93.9-97.6). Sensitivity was high for all types and channels. The hierarchical approach was well in line with HPV typing and histologic diagnosis, prioritizing higher risk women having HPV16 and precancer. For HPV16, time-to-positive was shorter in women with precancer. ScreenFire showed excellent agreement with research reference typing tests and detection of CIN2+. Risk-based type results could help guide clinical management of HPV-positive women. Time-to-positive combined with genotyping might be useful. ScreenFire is rapid, mobile, relatively inexpensive and designed for implementation of HPV-based screening and management, including in lower-resource settings. Further validation in screening by self-sampling and practical effectiveness merit evaluation.
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Affiliation(s)
- Federica Inturrisi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Silvia de Sanjosé
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
- ISGlobal, Barcelona, Spain
| | - Kanan T Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Casey Dagnall
- Cancer Genomics Research Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research Inc., Frederick, Maryland, USA
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Brian Befano
- Information Management Services Inc., Calverton, Maryland, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Ana Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Jose A Jeronimo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Rosemary E Zuna
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amanda Hoffman
- Cancer Genomics Research Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research Inc., Frederick, Maryland, USA
| | - Sepideh Farhat Nozzari
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Joan L Walker
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston Medical Center/Boston University School of Medicine, Boston, Maryland, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Joel M Palefsky
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
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8
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Egemen D, Perkins RB, Cheung LC, Befano B, Rodriguez AC, Desai K, Lemay A, Ahmed SR, Antani S, Jeronimo J, Wentzensen N, Kalpathy-Cramer J, De Sanjose S, Schiffman M. Artificial intelligence-based image analysis in clinical testing: lessons from cervical cancer screening. J Natl Cancer Inst 2024; 116:26-33. [PMID: 37758250 PMCID: PMC10777665 DOI: 10.1093/jnci/djad202] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 08/16/2023] [Revised: 09/11/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023] Open
Abstract
Novel screening and diagnostic tests based on artificial intelligence (AI) image recognition algorithms are proliferating. Some initial reports claim outstanding accuracy followed by disappointing lack of confirmation, including our own early work on cervical screening. This is a presentation of lessons learned, organized as a conceptual step-by-step approach to bridge the gap between the creation of an AI algorithm and clinical efficacy. The first fundamental principle is specifying rigorously what the algorithm is designed to identify and what the test is intended to measure (eg, screening, diagnostic, or prognostic). Second, designing the AI algorithm to minimize the most clinically important errors. For example, many equivocal cervical images cannot yet be labeled because the borderline between cases and controls is blurred. To avoid a misclassified case-control dichotomy, we have isolated the equivocal cases and formally included an intermediate, indeterminate class (severity order of classes: case>indeterminate>control). The third principle is evaluating AI algorithms like any other test, using clinical epidemiologic criteria. Repeatability of the algorithm at the borderline, for indeterminate images, has proven extremely informative. Distinguishing between internal and external validation is also essential. Linking the AI algorithm results to clinical risk estimation is the fourth principle. Absolute risk (not relative) is the critical metric for translating a test result into clinical use. Finally, generating risk-based guidelines for clinical use that match local resources and priorities is the last principle in our approach. We are particularly interested in applications to lower-resource settings to address health disparities. We note that similar principles apply to other domains of AI-based image analysis for medical diagnostic testing.
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Affiliation(s)
- Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Brian Befano
- Information Management Services Inc, Calverton, MD, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Ana Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Kanan Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Andreanne Lemay
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Syed Rakin Ahmed
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Graduate Program in Biophysics, Harvard Medical School, Harvard University, Cambridge, MA, USA
- Massachusetts Institute of Technology, Cambridge, MA, USA
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH, USA
| | - Sameer Antani
- National Library of Medicine, National Institutes of Health, Bethesda, MD, USA
| | - Jose Jeronimo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Silvia De Sanjose
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
- ISGlobal, Barcelona, Spain
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
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Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, Huh WK, Kim JJ, Moscicki AB, Nayar R, Saraiya M, Sawaya GF, Wentzensen N, Schiffman M. 2019 ASCCP Risk-Based Management Consensus Guidelines: Updates Through 2023. J Low Genit Tract Dis 2024; 28:3-6. [PMID: 38117563 PMCID: PMC10755815 DOI: 10.1097/lgt.0000000000000788] [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] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
ABSTRACT This Research Letter summarizes all updates to the 2019 Guidelines through September 2023, including: endorsement of the 2021 Opportunistic Infections guidelines for HIV+ or immunosuppressed patients; clarification of use of human papillomavirus testing alone for patients undergoing observation for cervical intraepithelial neoplasia 2; revision of unsatisfactory cytology management; clarification that 2012 guidelines should be followed for patients aged 25 years and older screened with cytology only; management of patients for whom colposcopy was recommended but not completed; clarification that after treatment for cervical intraepithelial neoplasia 2+, 3 negative human papillomavirus tests or cotests at 6, 18, and 30 months are recommended before the patient can return to a 3-year testing interval; and clarification of postcolposcopy management of minimally abnormal results.
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Affiliation(s)
| | | | - Philip E. Castle
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - David Chelmow
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mark H. Einstein
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Francisco Garcia
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Warner K. Huh
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Jane J. Kim
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Anna-Barbara Moscicki
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Ritu Nayar
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mona Saraiya
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - George F. Sawaya
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Nicolas Wentzensen
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mark Schiffman
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - 2019 ASCCP Risk-Based Management Consensus Guidelines Committee
- Boston University School of Medicine/ Boston Medical Center, Boston, MA; University of Pittsburgh/ Magee-Women’s Hospital, Pittsburgh, PA; Albert Einstein College of Medicine, New York, NY; Virginia Commonwealth University School of Medicine, Richmond, VA; Rutgers, New Jersey Medical School, Newark, NJ; Pima County Health & Community Services, Tucson, AZ; UAB School of Medicine, Birmingham, AL; Harvard T.H. Chan School of Public Health Boston, MA; University of California, Los Angeles, CA; Northwestern University, Feinberg School of Medicine-Northwestern Memorial Hospital, Chicago, IL; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; University of California, San Francisco; San Francisco, California; Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD; Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
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Wolf AMD, Oeffinger KC, Shih TYC, Walter LC, Church TR, Fontham ETH, Elkin EB, Etzioni RD, Guerra CE, Perkins RB, Kondo KK, Kratzer TB, Manassaram-Baptiste D, Dahut WL, Smith RA. Screening for lung cancer: 2023 guideline update from the American Cancer Society. CA Cancer J Clin 2024; 74:50-81. [PMID: 37909877 DOI: 10.3322/caac.21811] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 11/03/2023] Open
Abstract
Lung cancer is the leading cause of mortality and person-years of life lost from cancer among US men and women. Early detection has been shown to be associated with reduced lung cancer mortality. Our objective was to update the American Cancer Society (ACS) 2013 lung cancer screening (LCS) guideline for adults at high risk for lung cancer. The guideline is intended to provide guidance for screening to health care providers and their patients who are at high risk for lung cancer due to a history of smoking. The ACS Guideline Development Group (GDG) utilized a systematic review of the LCS literature commissioned for the US Preventive Services Task Force 2021 LCS recommendation update; a second systematic review of lung cancer risk associated with years since quitting smoking (YSQ); literature published since 2021; two Cancer Intervention and Surveillance Modeling Network-validated lung cancer models to assess the benefits and harms of screening; an epidemiologic and modeling analysis examining the effect of YSQ and aging on lung cancer risk; and an updated analysis of benefit-to-radiation-risk ratios from LCS and follow-up examinations. The GDG also examined disease burden data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms. The GDG judged that the overall evidence was moderate and sufficient to support a strong recommendation for screening individuals who meet the eligibility criteria. LCS in men and women aged 50-80 years is associated with a reduction in lung cancer deaths across a range of study designs, and inferential evidence supports LCS for men and women older than 80 years who are in good health. The ACS recommends annual LCS with low-dose computed tomography for asymptomatic individuals aged 50-80 years who currently smoke or formerly smoked and have a ≥20 pack-year smoking history (strong recommendation, moderate quality of evidence). Before the decision is made to initiate LCS, individuals should engage in a shared decision-making discussion with a qualified health professional. For individuals who formerly smoked, the number of YSQ is not an eligibility criterion to begin or to stop screening. Individuals who currently smoke should receive counseling to quit and be connected to cessation resources. Individuals with comorbid conditions that substantially limit life expectancy should not be screened. These recommendations should be considered by health care providers and adults at high risk for lung cancer in discussions about LCS. If fully implemented, these recommendations have a high likelihood of significantly reducing death and suffering from lung cancer in the United States.
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Affiliation(s)
- Andrew M D Wolf
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine and Duke Cancer Institute Center for Onco-Primary Care, Durham, North Carolina, USA
| | - Tina Ya-Chen Shih
- David Geffen School of Medicine and Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, California, USA
| | - Louise C Walter
- Department of Medicine, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Timothy R Church
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth T H Fontham
- Health Sciences Center, School of Public Health, Louisiana State University, New Orleans, Louisiana, USA
| | - Elena B Elkin
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Ruth D Etzioni
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - Carmen E Guerra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca B Perkins
- Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Karli K Kondo
- Early Cancer Detection Science, American Cancer Society, Atlanta, Georgia, USA
| | - Tyler B Kratzer
- Cancer Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia, USA
| | | | | | - Robert A Smith
- Early Cancer Detection Science, American Cancer Society, Atlanta, Georgia, USA
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11
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Kajtezovic S, Morgan JR, Fiascone S, Brandt HM, Perkins RB. Optimizing timing of adolescent vaccines: Impact of initiating HPV vaccination before Tdap or meningococcal vaccination on timely completion of the HPV vaccine series. Hum Vaccin Immunother 2023; 19:2175541. [PMID: 36798049 PMCID: PMC10026864 DOI: 10.1080/21645515.2023.2175541] [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] [Indexed: 02/18/2023] Open
Abstract
To explore the impact on timely series completion of initiating the HPV vaccine series prior to other vaccines in the adolescent platform (Tdap or meningococcal vacccines), we created a cohort of children aged 9 in 2015 who were continuously enrolled through the age of 13 (2019) from a national administrative database of employee-sponsored insurance in the United States (MarketScan). Logistic regressions were used to predict the odds of HPV vaccine series completion among those who started the series prior to, concurrent with, or after receiving Tdap or meningococcal vaccination. The cohort included 100,857 eligible children. Compared with adolescents who received their HPV and Tdap or HPV and meningococcal vaccinations concurrently, those who received HPV prior to other vaccines had higher completion (aOR = 1.38 for Tdap, aOR 1.62 for meningococcal), while those who received their HPV vaccination after other vaccines had lower odds of HPV vaccine series completion (aOR = 0.68 for Tdap, aOR = 0.62 for meningococcal). Other factors associated with series completion included female sex, residing in an urban (vs. rural) area, residing in the Northeast, and receiving primary care from a pediatrician (vs. family medicine physician). These data indicate that beginning the HPV vaccine series prior to the adolescent platform may improve on-time series completion.
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Affiliation(s)
- Sidika Kajtezovic
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
| | - Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Stephen Fiascone
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
| | - Heather M Brandt
- HPV Cancer Prevention Program, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
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12
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Lake P, Fuzzell L, Brownstein NC, Fontenot HB, Michel A, McIntyre M, Whitmer A, Rossi SL, Perkins RB, Vadaparampil ST. HPV vaccine recommendations by age: A survey of providers in federally qualified health centers. Hum Vaccin Immunother 2023; 19:2181610. [PMID: 36882951 PMCID: PMC10054304 DOI: 10.1080/21645515.2023.2181610] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Clinician recommendation remains a critical factor in improving HPV vaccine uptake. Clinicians practicing in federally qualified health centers were surveyed between October 2021 and July 2022. Clinicians were asked how they recommended HPV vaccination for patients aged 9-10, 11-12, 13-18, 19-26, and 27-45 y (strongly recommend, offer but do not recommend strongly, discuss only if the patient initiates the conversation, or recommend against). Descriptive statistics were assessed, and exact binomial logistic regression analyses were utilized to examine factors associated with HPV vaccination recommendation in 9-10-y-old patients. Respondents (n = 148) were primarily female (85%), between the ages of 30-39 (38%), white, non-Hispanic (62%), advanced practice providers (55%), family medicine specialty (70%), and practicing in the Northeast (63%). Strong recommendations for HPV vaccination varied by age: 65% strongly recommended for ages 9-10, 94% for ages 11-12, 96% for ages 13-18, 82% for age 19-26, and 26% for ages 27-45 y. Compared to Women's Health/OBGYN specialty, family medicine clinicians were less likely to recommend HPV vaccination at ages 9-10 (p = .03). Approximately two-thirds of clinicians practicing in federally qualified health centers or safety net settings strongly recommend HPV vaccine series initiation at ages 9-10. Additional research is needed to improve recommendations in younger age groups.
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Affiliation(s)
- Paige Lake
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Lindsay Fuzzell
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Naomi C Brownstein
- Office of Community Outreach, Engagement, and Equity, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Holly B Fontenot
- Nancy Atmospera-Walch School of Nursing, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Alexandra Michel
- Nancy Atmospera-Walch School of Nursing, University of Hawaii at Manoa, Honolulu, HI, USA
| | - McKenzie McIntyre
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ashley Whitmer
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Sarah L Rossi
- Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston University, Boston, MA, USA
| | - Rebecca B Perkins
- Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston University, Boston, MA, USA
| | - Susan T Vadaparampil
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Office of Community Outreach, Engagement, and Equity, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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Perkins RB, Humiston S, Oliver K. Evidence supporting the initiation of HPV vaccination starting at age 9: Collection overview. Hum Vaccin Immunother 2023; 19:2269026. [PMID: 37824444 PMCID: PMC10572037 DOI: 10.1080/21645515.2023.2269026] [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: 10/14/2023] Open
Affiliation(s)
- Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
| | | | - Kristin Oliver
- Departments of Environmental Medicine and Public Health, Pediatrics, Icahn School of Medicine, New York, NY, USA
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Perkins RB, Wentzensen N, Schiffman M. Primary HPV Screening vs Cotesting for Cervical Cancer-Reply. JAMA 2023; 330:2121-2122. [PMID: 38051330 DOI: 10.1001/jama.2023.20373] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Rebecca B Perkins
- Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
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de Sanjosé S, Perkins RB, Campos NG, Inturrisi F, Egemen D, Befano B, Rodriguez AC, Jerónimo J, Cheung LC, Desai K, Han P, Novetsky AP, Ukwuani A, Marcus J, Ahmed SR, Wentzensen N, Kalpathy-Cramer J, Schiffman M. Design of the HPV-Automated Visual Evaluation (PAVE) Study: Validating a Novel Cervical Screening Strategy. medRxiv 2023:2023.08.30.23294826. [PMID: 37693492 PMCID: PMC10491363 DOI: 10.1101/2023.08.30.23294826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Objective To describe the HPV-Automated Visual Evaluation (PAVE) Study, an international, multi-centric study designed to evaluate a novel cervical screen-triage-treat strategy for resource-limited settings as part of a global strategy to reduce cervical cancer burden. The PAVE strategy involves: 1) screening with self-sampled HPV testing; 2) triage of HPV-positive participants with a combination of extended genotyping and visual evaluation of the cervix assisted by deep-learning-based automated visual evaluation (AVE); and 3) treatment with thermal ablation or excision (Large Loop Excision of the Transformation Zone). The PAVE study has two phases: efficacy (2023-2024) and effectiveness (planned to begin in 2024-2025). The efficacy phase aims to refine and validate the screen-triage portion of the protocol. The effectiveness phase will examine acceptability and feasibility of the PAVE strategy into clinical practice, cost-effectiveness, and health communication within the PAVE sites. Study design Phase 1 Efficacy: Around 100,000 nonpregnant women, aged 25-49 years, without prior hysterectomy, and irrespective of HIV status, are being screened at nine study sites in resource-limited settings. Eligible and consenting participants perform self-collection of vaginal specimens for HPV testing using a FLOQSwab (Copan). Swabs are transported dry and undergo testing for HPV using a newly-redesigned isothermal DNA amplification HPV test (ScreenFire HPV RS), which has been designed to provide HPV genotyping by hierarchical risk groups: HPV16, else HPV18/45, else HPV31/33/35/52/58, else HPV39/51/56/59/68. HPV-negative individuals are considered negative for precancer/cancer and do not undergo further testing. HPV-positive individuals undergo pelvic examination with collection of cervical images and targeted biopsies of all acetowhite areas or endocervical sampling in the absence of visible lesions. Accuracy of histology diagnosis is evaluated across all sites. Cervical images are used to refine a deep learning AVE algorithm that classifies images as normal, indeterminate, or precancer+. AVE classifications are validated against the histologic endpoint of high-grade precancer determined by biopsy. The combination of HPV genotype and AVE classification is used to generate a risk score that corresponds to the risk of precancer (lower, medium, high, highest). During the efficacy phase, clinicians and patients within the PAVE sites will receive HPV testing results but not AVE results or risk scores. Treatment during the efficacy phase will be performed per local standard of care: positive Visual Inspection with Acetic Acid impression, high-grade colposcopic impression or CIN2+ on colposcopic biopsy, HPV positivity, or HPV 16,18/45 positivity. Follow up of triage negative patients and post treatment will follow standard of care protocols. The sensitivity of the PAVE strategy for detection of precancer will be compared to current SOC at a given level of specificity.Phase 2 Effectiveness: The AVE software will be downloaded to the new dedicated image analysis and thermal ablation devices (Liger Iris) into which the HPV genotype information can be entered to provide risk HPV-AVE risk scores for precancer to clinicians in real time. The effectiveness phase will examine clinician use of the PAVE strategy in practice, including feasibility and acceptability for clinicians and patients, cost-effectiveness, and health communication within the PAVE sites. Conclusion The goal of the PAVE study is to validate a screen-triage-treat protocol using novel biomarkers to provide an accurate, feasible, cost-effective strategy for cervical cancer prevention in resource-limited settings. If validated, implementation of PAVE at larger scale can be encouraged. Funding The consortial sites are responsible for their own study costs. Research equipment and supplies, and the NCI-affiliated staff are funded by the National Cancer Institute Intramural Research Program including supplemental funding from the Cancer Cures Moonshot Initiative. No commercial support was obtained. Brian Befano was supported by NCI/NIH under Grant T32CA09168. Date of protocol latest review: September 24 th 2023.
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Bloom JC, Kaufmann N, Koss S, Edwards HA, Perkins RB, Faden DL. Deciphering Knowledge and Opinions of Human Papillomavirus and Human Papillomavirus Vaccination for Facilitation of Point-of-Care Vaccination in Adults. JAMA Otolaryngol Head Neck Surg 2023; 149:870-877. [PMID: 37651109 PMCID: PMC10472267 DOI: 10.1001/jamaoto.2023.2073] [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: 03/25/2023] [Accepted: 06/11/2023] [Indexed: 09/01/2023]
Abstract
Importance Human papillomavirus (HPV) vaccination rates remain significantly below rates for other common childhood vaccines, which has implications for future rates of HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Objective To assess whether individuals who were aware of the association between HPV and OPSCC would be more likely to have been previously vaccinated. Design, Setting, and Participants This survey study included patients aged 18 to 45 years who sought routine outpatient care at the otolaryngology clinic at Boston Medical Center from September 1, 2020, to May 19, 2021. A survey (HPV-Associated Head and Neck Cancer Epidemiology, Awareness and Demographics) [HEAD]) composed of validated questions to assess patient knowledge of HPV and HPV vaccination and barriers to vaccination was delivered to participants. The survey was paired with a novel point-of-care vaccination program housed within an otolaryngology department. Main Outcomes and Measures The main outcome was prevalence of knowledge of the relationship between HPV infection and OPSCC based on survey responses. The association of knowledge of HPV-associated OPSCC with likelihood of having been vaccinated was assessed in the overall cohort and by demographic characteristics using multivariate logistic regression. Results Of 405 patients given the survey, 288 (71.1%) responded. Of these patients, 271 (94.1%) had surveys included; 158 (58.3%) were female, and median age was 29 years (IQR, 24-35 years). The baseline vaccination rate in the surveyed population was low (26.6%; n = 72) overall (10.6% among men [12 of 113]; 37.9% among women [60 of 158]). Few participants understood the relationship between HPV infection and OPSCC (63 of 271 [23.3%]) or that HPV-associated OPSCC is the most common HPV-associated cancer type (9 of 121 [7.4%]). Compared with men, women were more likely to have been previously vaccinated (odds ratio [OR], 6.5; 95% CI, 3.0-13.9), more aware that HPV causes cancer (OR, 3.7; 95% CI, 1.9-7.1), and more likely to have heard about HPV and HPV vaccination from their health care practitioner (OR, 2.6; 95% CI, 1.2-5.7). Knowledge of the relationship between HPV infection and cancer and between HPV and OPSCC was associated with increased likelihood of having been vaccinated (HPV and cancer: OR, 4.1 [95% CI, 1.8-9.5]; HPV and OPSCC: OR, 3.7 [95% CI, 1.8-7.6]). Among 156 unvaccinated participants, 12 of 98 men (12.2%) and 7 of 131 women (5.3%) received point-of-care vaccination. Conclusions Most participants in this survey study were unaware that HPV causes OPSCC. Understanding that HPV causes OPSCC was associated with increased likelihood of having been vaccinated. However, most patients surveyed were not informed of this relationship by their health care practitioners. Targeted education aimed at unvaccinated adults establishing the relationship between HPV infection and OPSCC, paired with point-of-care vaccination, may be an innovative strategy for increasing HPV vaccination rates in adults.
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Affiliation(s)
- Jacob C. Bloom
- Department of Otolaryngology–Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts
| | - Nicole Kaufmann
- Department of Epidemiology, Harvard University School of Public Health, Boston, Massachusetts
| | - Shirley Koss
- Department of Otolaryngology–Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts
| | - Heather A. Edwards
- Department of Otolaryngology–Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts
| | - Rebecca B. Perkins
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts
| | - Daniel L. Faden
- Department of Otolaryngology–Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Mass Eye and Ear, Boston, Massachusetts
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Vadaparampil ST, Fuzzell LN, Brownstein NC, Fontenot HB, Lake P, Michel A, McIntyre M, Whitmer A, Perkins RB. A cross-sectional survey examining clinician characteristics, practices, and attitudes associated with adoption of the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines. Cancer 2023; 129:2671-2684. [PMID: 37221653 DOI: 10.1002/cncr.34838] [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: 03/03/2023] [Revised: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND The 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) risk-based management consensus guidelines are the most recent national guidelines for the management of abnormal cervical cancer screening tests. These guidelines benefit patients by concentrating testing and treatment in those at highest cervical cancer risk. Adoption of guidelines often occurs slowly, with few studies examining the factors associated with guideline-adherent management of abnormal results. METHODS To elucidate the factors associated with the use of the 2019 ASCCP guidelines among clinicians who perform cervical cancer screening, physicians and advanced practice professionals who perform cervical cancer screening were cross-sectionally surveyed. Clinicians responded to screening vignettes with differing recommendations for management between the 2019 and prior management guidelines. Screening vignette 1 involved reduction of invasive testing on a low-risk patient; screening vignette 2 involved increased surveillance testing on a high-risk patient. Binomial logistic regression models determined the factors associated with the use of the 2019 guidelines. RESULTS A total of 1251 clinicians participated from across the United States. For screening vignettes 1 and 2, guideline-adherent responses were given by 28% and 36% of participants, respectively. Management recommendations differed by specialty and were incorrect in different situations: there was inappropriate invasive testing by obstetrics and gynecology physicians (vignette 1) and inappropriate discontinuation of screening by family and internal medicine physicians (vignette 2). Regardless of their chosen response, over half erroneously believed they were guideline adherent. CONCLUSIONS Many clinicians who believe they are following appropriate guidelines may not realize their management strategy is inconsistent with the 2019 guidelines. Education initiatives tailored to clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms. PLAIN LANGUAGE SUMMARY The 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines are the most recent national guidelines for abnormal cervical cancer screening test management. We surveyed over 1200 obstetrics and gynecology (OB/GYN), family medicine, and internal medicine physicians and advanced practice providers about their screening and abnormal results follow-up practices in relation to guidelines. Few clinicians are following the 2019 guidelines. Management recommendations differed by clinician specialty and were incorrect in different situations: there was inappropriate invasive testing by OB/GYN physicians and inappropriate screening discontinuation by family and internal medicine physicians. Education tailored by clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.
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Affiliation(s)
- Susan T Vadaparampil
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
- Office of Community Outreach, Engagement, and Equity, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Lindsay N Fuzzell
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Naomi C Brownstein
- Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Holly B Fontenot
- Nancy Atmospera-Walch School of Nursing, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Paige Lake
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Alexandra Michel
- Nancy Atmospera-Walch School of Nursing, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - McKenzie McIntyre
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Ashley Whitmer
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Rebecca B Perkins
- Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts, USA
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Fuzzell L, Brownstein NC, Fontenot HB, Lake PW, Michel A, Whitmer A, Rossi SL, McIntyre M, Vadaparampil ST, Perkins RB. Examining the association of clinician characteristics with perceived changes in cervical cancer screening and colposcopy practice during the COVID-19 pandemic: a mixed methods assessment. eLife 2023; 12:e85682. [PMID: 37656169 PMCID: PMC10473834 DOI: 10.7554/elife.85682] [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: 12/20/2022] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
Background The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed method study we explored perceived pandemic-related practice changes to cervical cancer screenings and colposcopies. Methods In 2021, a national sample of 1251 clinicians completed surveys, including 675 clinicians who performed colposcopy; a subset (n=55) of clinicians completed qualitative interviews. Results Nearly half of all clinicians reported they were currently performing fewer cervical cancer screenings (47%) and colposcopies (44% of those who perform the procedure) than before the pandemic. About one-fifth (18.6%) of colposcopists reported performing fewer LEEPs than prior to the pandemic. Binomial regression analyses indicated that older, as well as internal medicine and family medicine clinicians (compared to OB-GYNs), and those practicing in community health centers (compared to private practice) had higher odds of reporting reduced screening. Among colposcopists, internal medicine physicians and those practicing in community health centers had higher odds of reporting reduced colposcopies. Qualitative interviews highlighted pandemic-related care disruptions and lack of tracking systems to identify overdue screenings. Conclusions Reductions in cervical cancer screening and colposcopy among nearly half of clinicians more than 1 year into the pandemic raise concerns that inadequate screening and follow-up will lead to future increases in preventable cancers. Funding This study was funded by the American Cancer Society, who had no role in the study's design, conduct, or reporting.
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Affiliation(s)
- Lindsay Fuzzell
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
| | | | - Holly B Fontenot
- University of Hawaii at Manoa, Nancy Atmospera-Walch School of NursingHonoluluUnited States
| | - Paige W Lake
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
| | - Alexandra Michel
- University of Hawaii at Manoa, Nancy Atmospera-Walch School of NursingHonoluluUnited States
| | - Ashley Whitmer
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
| | - Sarah L Rossi
- Boston University, Chobanian & Avedisian School of MedicineBostonUnited States
| | - McKenzie McIntyre
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
| | - Susan T Vadaparampil
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and BehaviorTampaUnited States
- H. Lee Moffitt Cancer Center & Research Institute, Office of Community Outreach, Engagement, and EquityTampaUnited States
| | - Rebecca B Perkins
- Boston University, Chobanian & Avedisian School of MedicineBostonUnited States
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Guido R, Perkins RB. Management of Abnormal Cervical Cancer Screening Test: A Risk-based Approach. Clin Obstet Gynecol 2023; 66:478-499. [PMID: 37650663 DOI: 10.1097/grf.0000000000000794] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Cervical cancer screening plays a major role in preventing cervical cancer. The field is based on understanding the natural history of human papillomavirus and its role in cervical cancer. Screening has evolved to assessing the risk for cervical intraepithelial neoplasia grade 3, a true cancer precursor, and performing diagnostic tests based on those risks. This article summarizes the present state of management of abnormal cervical cancer screening tests in the United States, based on the most recent 2019 American Society of Colposcopy and Cervical Pathology guidelines.
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Affiliation(s)
- Richard Guido
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of the UPMC System, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rebecca B Perkins
- Boston University School of Medicine Chobanian & Avedisian School of Medicine, Boston Medical Center, Massachusetts
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Burrowes SAB, Casey SM, Pierre-Joseph N, Talbot SG, Hall T, Christian-Brathwaite N, Del-Carmen M, Garofalo C, Lundberg B, Mehta PK, Mottl-Santiago J, Schechter-Perkins EM, Weber A, Yarrington CD, Perkins RB. COVID-19 pandemic impacts on mental health, burnout, and longevity in the workplace among healthcare workers: A mixed methods study. J Interprof Educ Pract 2023; 32:100661. [PMID: 37305404 PMCID: PMC10248469 DOI: 10.1016/j.xjep.2023.100661] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Abstract
To explore the mental health impacts of the COVID-19 pandemic on healthcare workers in Massachusetts and identify potential strategies to maintain the healthcare workforce we conducted a sequential exploratory mixed methods study. Fifty-two individuals completed interviews from April 22nd - September 7th, 2021; 209 individuals completed an online survey from February 17th - March 23rd, 2022. Interviews and surveys asked about the mental health impacts of working in healthcare during the COVID-19 pandemic, burnout, longevity in the workplace, and strategies for reducing attrition. Interview and survey participants were predominantly White (56%; 73%, respectively), female (79%; 81%) and worked as physicians (37%; 34%). Interviewees indicated high stress and anxiety levels due to frequent exposure to patient deaths from COVID-19. Among survey respondents, 55% reported worse mental health than before the pandemic, 29% reported a new/worsening mental health condition for themselves or their family, 59% reported feeling burned out at least weekly, and 37% intended to leave healthcare in less than 5 years. To decrease attrition, respondents suggested higher salaries (91%), flexible schedules (90%), and increased support to care for patients (89%). Healthcare workers' experiences with death, feeling unvalued, and overworked resulted in unprecedented rates of burnout and intention to leave healthcare.
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Affiliation(s)
- Shana A B Burrowes
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sharon M Casey
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Natalie Pierre-Joseph
- Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Simon G Talbot
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Taylor Hall
- Graduate Medical Sciences, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | | | - Marcela Del-Carmen
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Garofalo
- Department of Family Medicine and Department of Obstetrics and Gynecology at Sturdy Memorial Hospital, Attleboro, MA, USA
- Family Medicine Associates of South Attleboro, South Attleboro, Massachusetts, USA
| | | | - Pooja K Mehta
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
- Cityblock Health, Brooklyn, NY, USA
| | - Julie Mottl-Santiago
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Elissa M Schechter-Perkins
- Department of Emergency Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Ariana Weber
- Department of Emergency Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Christina D Yarrington
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
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Ghosh S, Fantes J, Leschly K, Mazul J, Perkins RB. Electronic data review, client reminders, and expanded clinic hours for improving cervical cancer screening rates after the COVID-19 pandemic shutdowns: A multicomponent quality improvement program. eLife 2023; 12:e85724. [PMID: 37606365 PMCID: PMC10471159 DOI: 10.7554/elife.85724] [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: 12/21/2022] [Accepted: 08/13/2023] [Indexed: 08/23/2023] Open
Abstract
Background To improve cervical cancer screening (CCS) rates, the East Boston Neighborhood Health Center implemented a quality improvement initiative from March to August 2021. Methods Staff training was provided. A 21-provider team validated overdue CCS indicated by electronic medical record data. To improve screening, CCS-only sessions were created during regular clinic hours (n = 5) and weekends/evenings (n = 8). Patients were surveyed on their experience. Results A total of 6126 charts were reviewed. Of the list of overdue patients, outreach was performed on 1375 patients to schedule the 13 sessions. A total of 459 (33%) patients completed screening, 622 (45%) could not be reached, and 203 (15%) canceled or missed appointments. The proportion of total active patients who were up to date with CCS increased from 68% in March to 73% in August 2021. Survey results indicated high patient satisfaction, and only 42% of patients would have scheduled CCS without outreach. Conclusions The creation of a validated patient chart list and extra clinical sessions devoted entirely to CCS improved up-to-date CCS rates. However, high rates of unsuccessful outreach and cancelations limited sustainability. This information can be used by other community health centers to optimize clinical workflows for CCS. Funding All funding was internal from the EBNHC Adult Medicine, Family Medicine, and Women's Health Departments.
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Affiliation(s)
- Sue Ghosh
- East Boston Neighborhood Health CenterEast BostonUnited States
| | - Jackie Fantes
- East Boston Neighborhood Health CenterEast BostonUnited States
| | - Karin Leschly
- East Boston Neighborhood Health CenterEast BostonUnited States
| | - Julio Mazul
- East Boston Neighborhood Health CenterEast BostonUnited States
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Abstract
Importance Each year in the US, approximately 100 000 people are treated for cervical precancer, 14 000 people are diagnosed with cervical cancer, and 4000 die of cervical cancer. Observations Essentially all cervical cancers worldwide are caused by persistent infections with one of 13 carcinogenic human papillomavirus (HPV) genotypes: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. HPV vaccination at ages 9 through 12 years will likely prevent more than 90% of cervical precancers and cancers. In people with a cervix aged 21 through 65 years, cervical cancer is prevented by screening for and treating cervical precancer, defined as high-grade squamous intraepithelial lesions of the cervix. High-grade lesions can progress to cervical cancer if not treated. Cervicovaginal HPV testing is 90% sensitive for detecting precancer. In the general population, the risk of precancer is less than 0.15% over 5 years following a negative HPV test result. Among people with a positive HPV test result, a combination of HPV genotyping and cervical cytology (Papanicolaou testing) can identify the risk of precancer. For people with current precancer risks of less than 4%, repeat HPV testing is recommended in 1, 3, or 5 years depending on 5-year precancer risk. For people with current precancer risks of 4% through 24%, such as those with low-grade cytology test results (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesion [LSIL]) and a positive HPV test of unknown duration, colposcopy is recommended. For patients with precancer risks of less than 25% (eg, cervical intraepithelial neoplasia grade 1 [CIN1] or histologic LSIL), treatment-related adverse effects, including possible association with preterm labor, can be reduced by repeating colposcopy to monitor for precancer and avoiding excisional treatment. For patients with current precancer risks of 25% through 59% (eg, high-grade cytology results of ASC cannot exclude high-grade lesion [ASC-H] or high-grade squamous intraepithelial lesion [HSIL] with positive HPV test results), management consists of colposcopy with biopsy or excisional treatment. For those with current precancer risks of 60% or more, such as patients with HPV-16-positive HSIL, proceeding directly to excisional treatment is preferred, but performing a colposcopy first to confirm the need for excisional treatment is acceptable. Clinical decision support tools can facilitate correct management. Conclusions and Relevance Approximately 100 000 people are treated for cervical precancer each year in the US to prevent cervical cancer. People with a cervix should be screened with HPV testing, and if HPV-positive, genotyping and cytology testing should be performed to assess the risk of cervical precancer and determine the need for colposcopy or treatment. HPV vaccination in adolescence will likely prevent more than 90% of cervical precancers and cancers.
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Affiliation(s)
- Rebecca B Perkins
- Boston University School of Medicine, Chobanian & Avedisian School of Medicine, Boston Medical Center, Massachusetts
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Richard S Guido
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Magee-Women's Hospital, Pittsburgh, Pennsylvania
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
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Zimmerman M, Zapata LP, Bachiller K, Devera JL, Hall TA, Casey SM, Pierre-Joseph N, Perkins RB. Comparison of attitudes toward routine maternal vaccines and COVID-19 vaccines among pregnant patients in an urban safety-net setting. J Natl Med Assoc 2023; 115:362-376. [PMID: 37210252 PMCID: PMC10194813 DOI: 10.1016/j.jnma.2023.04.003] [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: 12/26/2022] [Accepted: 04/18/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE To explore attitudes toward tetanus-diphtheria-acellular pertussis (Tdap), influenza, and COVID vaccines among English- and Spanish- speaking pregnant individuals in a safety net setting. METHODS Pregnant people aged 18 years or older were recruited from outpatient clinics between August 2020 and June 2021. Interviews were conducted via phone in English or Spanish, recorded, transcribed, and translated verbatim. Data were qualitatively analyzed using modified grounded theory and content analysis. RESULTS 42 patients participated (22 English-speaking, 20 Spanish-speaking). Most participants expressed positive attitudes towards both routine prenatal vaccinations and COVID-19 vaccines, endorsing the belief that vaccines promote health and considering vaccines a social norm. Positive attitudes were similar for the three vaccines, and among Spanish- and English-speaking individuals. Participants trusted their healthcare provider's recommendations and felt comfortable receiving booster doses of vaccines they had received successfully in the past. Vaccine concerns differed by each vaccine. Despite limited knowledge, few participants expressed concerns about Tdap vaccines. Concerns around influenza vaccines often stemmed from personal experience and centered around ineffectiveness and increased risk of flu-like illnesses. Participants expressed the most concerns related to COVID vaccinations, including misinformation about serious side effects and distrust around accelerated approval of the vaccines. Many participants wished to know more about the side effects and safety of vaccinating during pregnancy, especially regarding the fetus's health. CONCLUSIONS Most participants supported routine prenatal vaccinations, including COVID vaccines. Clinicians are trusted information sources and can help reinforce positive attitudes and social norms of receiving vaccinations in pregnancy while addressing vaccine-specific concerns. FUNDING This work was supported by Suzanne Cutler Vaccination Education & Research Fund at the Boston University Chobanian and Avedisian School of Medicine for funding and support.
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Affiliation(s)
- Margaux Zimmerman
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Lesly P Zapata
- Boston University School of Public Health, Boston, MA, United States
| | - Karla Bachiller
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Jean L Devera
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Taylor A Hall
- Graduate of Medical Sciences, Boston University School of Medicine, Boston, MA, United States
| | - Sharon M Casey
- Boston University School of Public Health, Boston, MA, United States
| | - Natalie Pierre-Joseph
- Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, United States
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, 775 Albany St, Dowling Buidling, Boston, MA 02118, United States.
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Wesselink AK, Lovett SM, Weinberg J, Geller RJ, Wang TR, Regan AK, Willis MD, Perkins RB, Yland JJ, Koenig MR, Rothman KJ, Hatch EE, Wise LA. COVID-19 vaccination and menstrual cycle characteristics: A prospective cohort study. Vaccine 2023; 41:4327-4334. [PMID: 37301706 PMCID: PMC10239900 DOI: 10.1016/j.vaccine.2023.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/19/2023] [Revised: 05/22/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023]
Abstract
We prospectively examined the association between COVID-19 vaccination and menstrual cycle characteristics in an internet-based prospective cohort study. We included a sample of 1,137 participants who enrolled in Pregnancy Study Online (PRESTO), a preconception cohort study of couples trying to conceive, during January 2021-August 2022. Eligible participants were aged 21-45 years, United States or Canadian residents, and trying to conceive without fertility treatment. At baseline and every 8 weeks for up to 12 months, participants completed questionnaires on which they provided information on COVID-19 vaccination and menstrual cycle characteristics, including cycle regularity, cycle length, bleed length, heaviness of bleed, and menstrual pain. We fit generalized estimating equation (GEE) models with a log link function and Poisson distribution to estimate the adjusted risk ratio (RR) for irregular cycles associated with COVID-19 vaccination. We used linear regression with GEE to estimate adjusted mean differences in menstrual cycle length associated with COVID-19 vaccination. We adjusted for sociodemographic, lifestyle, medical and reproductive factors. Participants had 1.1 day longer menstrual cycles after receiving the first dose of COVID-19 vaccine (95 % CI: 0.4, 1.9) and 1.3 day longer cycles after receiving the second dose (95 % CI: 0.2, 2.5). Associations were attenuated at the second cycle post-vaccination. We did not observe strong associations between COVID-19 vaccination and cycle regularity, bleed length, heaviness of bleed, or menstrual pain. In conclusion, COVID-19 vaccination was associated with a ∼1 day temporary increase in menstrual cycle length, but was not appreciably associated with other menstrual cycle characteristics.
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Affiliation(s)
- Amelia K Wesselink
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States.
| | - Sharonda M Lovett
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Janice Weinberg
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Ruth J Geller
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Tanran R Wang
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | | | - Mary D Willis
- Department of Obstetrics & Gynecology, Boston University Chobanian and Avedesian School of Medicine, Boston, MA, United States
| | - Rebecca B Perkins
- Department of Obstetrics & Gynecology, Boston University Chobanian and Avedesian School of Medicine, Boston, MA, United States
| | - Jennifer J Yland
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Martha R Koenig
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Kenneth J Rothman
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Elizabeth E Hatch
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
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Schiffman M, Mirabello L, Egemen D, Befano B, Xiao Y, Wentzensen N, Raine-Bennett T, Nayar R, Cheung LC, Rositch A, Beaty T, Perkins RB, de Sanjose S, Lorey T, Castle PE, Burk RD. The combined finding of HPV 16, 18, or 45 and cytologic Atypical Glandular Cells (AGC) indicates a greatly elevated risk of in situ and invasive cervical adenocarcinoma. Gynecol Oncol 2023; 174:253-261. [PMID: 37243996 DOI: 10.1016/j.ygyno.2023.05.011] [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: 03/24/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Cervical screening has not effectively controlled cervical adenocarcinoma (AC). Human papillomavirus (HPV) testing is recommended for cervical screening but the optimal management of HPV-positive individuals to prevent AC remains a question. Cytology and HPV typing are two triage options to predict the risk of AC. We combined two potential biomarkers (atypical glandular cell, AGC, cytology and HPV-types 16, 18, or 45) to assess their joint effect on detecting AC. METHODS Kaiser Permanente Northern California (KPNC) used triennial co-testing with cytology and HPV testing (positive/negative) for routine cervical screening between 2003 and 2020. HPV typing of a sample of residual HPV test specimens was performed on a separate cohort selected from KPNC (Persistence and Progression, PaP, cohort). We compared risk of prevalent and incident histologic AC/AIS (adenocarcinoma in situ) associated with preceding combinations of cytologic results and HPV typing. Risk of squamous cell cancer (SCC)/cervical intraepithelial neoplasia grade 3 (CIN3) (SCC/CIN3) was also included for comparison. RESULTS Among HPV-positive individuals in PaP cohort, 99% of prevalent AC and 96% of AIS were linked to HPV-types 16, 18, or 45 (denoted HPV 16/18/45). Although rare (0.09% of screening population), the concurrent detection of HPV 16/18/45 with AGC cytology predicted a highly elevated relative risk of underlying histologic AC/AIS; the absolute risk of diagnosing AC/AIS was 12% and odds ratio (OR) was 1341 (95%CI:495-3630) compared to patients with other high-risk HPV types and normal cytology. Cumulatively (allowing non-concurrent results), approximately one-third of the AC/AIS cases ever had HPV 16/18/45 and AGC cytology (OR = 1785; 95%CI:872-3656). AGC was not as strongly associated with SCC/CIN3. CONCLUSION Detection of HPV 16/18/45 positivity elevates risk of adenocarcinoma, particularly if AGC cytology is also found.
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Affiliation(s)
- Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA.
| | - Lisa Mirabello
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Brian Befano
- Information Management Services Inc, Calverton, MD, USA
| | - Yanzi Xiao
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Tina Raine-Bennett
- Women's Health Research Institute, Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Ritu Nayar
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Anne Rositch
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Terri Beaty
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rebecca B Perkins
- Boston University Chobanian and Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Silvia de Sanjose
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA; ISGlobal, Barcelona, Spain
| | - Thomas Lorey
- Regional Laboratory, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Philip E Castle
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA; Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Robert D Burk
- Departments of Pediatrics, Microbiology & Immunology, Epidemiology & Population Health, and Obstetrics, Gynecology & Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Bednarczyk RA, Brewer NT, Gilkey MB, Zorn S, Perkins RB, Oliver K, Saslow D. Human papillomavirus vaccination at the first opportunity: An overview. Hum Vaccin Immunother 2023:2213603. [PMID: 37218520 PMCID: PMC10294726 DOI: 10.1080/21645515.2023.2213603] [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] [Indexed: 05/24/2023] Open
Abstract
The Advisory Committee on Immunization Practices (ACIP) has recommended human papillomavirus (HPV) vaccination for adolescents in the United States since 2006. Though recommended at a similar time to the routine recommendations for adolescent tetanus, diphtheria, and acellular pertussis vaccination (Tdap) and quadrivalent meningococcal vaccination (MCV4), HPV vaccine uptake has consistently lagged behind these other adolescent vaccines. The ACIP recommends HPV vaccination at 11-12 y, with vaccination starting at 9 y of age included as an option that is routinely encouraged by the American Academy of Pediatrics and American Cancer Society. To support efforts to increase HPV vaccination at the first opportunity, this commentary summarizes the current HPV vaccination recommendations and available evidence regarding HPV vaccination starting at 9 y - including recent studies and trials documenting the effectiveness of HPV vaccination at 9 in supporting vaccine series completion, while providing future directions for research and implementation to improve HPV vaccination.
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Affiliation(s)
- Robert A Bednarczyk
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
- Cancer Prevention and Control Program, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Melissa B Gilkey
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sherri Zorn
- Washington State HPV Free Taskforce, Seattle, WA, USA
| | - Rebecca B Perkins
- Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Kristin Oliver
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Debbie Saslow
- Prevention and Early Detection, American Cancer Society, Atlanta, GA, USA
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Perkins RB, Smith DL, Jeronimo J, Campos NG, Gage JC, Hansen N, Rodriguez AC, Cheung LC, Egemen D, Befano B, Novetsky AP, Martins S, Kalpathy-Cramer J, Inturrisi F, Ahmed SR, Marcus J, Wentzensen N, de Sanjose S, Schiffman M. Use of risk-based cervical screening programs in resource-limited settings. Cancer Epidemiol 2023; 84:102369. [PMID: 37105017 DOI: 10.1016/j.canep.2023.102369] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 02/06/2023] [Revised: 03/29/2023] [Accepted: 04/16/2023] [Indexed: 04/29/2023]
Abstract
Cervical cancer screening and management in the U.S. has adopted a risk-based approach. However, the majority of cervical cancer cases and deaths occur in resource-limited settings, where screening and management are not widely available. We describe a conceptual model that optimizes cervical cancer screening and management in resource-limited settings by utilizing a risk-based approach. The principles of risk-based screening and management in resource limited settings include (1) ensure that the screening method effectively separates low-risk from high-risk patients; (2) directing resources to populations at the highest cancer risk; (3) screen using HPV testing via self-sampling; (4) utilize HPV genotyping to improve risk stratification and better determine who will benefit from treatment, and (5) automated visual evaluation with artificial intelligence may further improve risk stratification. Risk-based screening and management in resource limited settings can optimize prevention by focusing triage and treatment resources on the highest risk patients while minimizing interventions in lower risk patients.
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Affiliation(s)
- Rebecca B Perkins
- Boston University Chobanian and Avedisian School of Medicine/Boston Medical Center, Boston, MA, USA.
| | | | | | - Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | | | - Li C Cheung
- National Cancer Institute, Bethesda, MD, USA
| | | | - Brian Befano
- Information Management Services Inc, 3901 Calverton Blvd Suite 200, Calverton, MD, USA
| | - Akiva P Novetsky
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | | | | | | | - Syed Rakin Ahmed
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02129, USA; Harvard Graduate Program in Biophysics, Harvard Medical School, Harvard University, Cambridge, MA 02115, USA; Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 02139,USA
| | - Jenna Marcus
- Feinberg School of Medicine at Northwestern University, Chicago, IL, USA
| | | | - Silvia de Sanjose
- National Cancer Institute, Bethesda, MD, USA; ISGlobal, Barcelona, Spain
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Tamlyn AL, Tjilos M, Bosch NA, Barnett KG, Perkins RB, Walkey A, Assoumou SA, Linas BP, Drainoni ML. At the intersection of trust and mistrust: A qualitative analysis of motivators and barriers to research participation at a safety-net hospital. Health Expect 2023; 26:1118-1126. [PMID: 36896842 PMCID: PMC10154811 DOI: 10.1111/hex.13726] [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: 11/14/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 03/11/2023] Open
Abstract
INTRODUCTION The underrepresentation of Black, Indigenous, and People of Color (BIPOC) individuals in healthcare research limits generalizability and contributes to healthcare inequities. Existing barriers and attitudes toward research participation must be addressed to increase the representation of safety net and other underserved populations. METHODS We conducted semi-structured qualitative interviews with patients at an urban safety net hospital, focusing on facilitators, barriers, motivators, and preferences for research participation. We conducted direct content analysis guided by an implementation framework and used rapid analysis methods to generate final themes. RESULTS We completed 38 interviews and identified six major themes related to preferences for engagement in research participation: (1) wide variation in research recruitment preferences; (2) logistical complexity negatively impacts willingness to participate; (3) risk contributes to hesitation toward research participation; (4) personal/community benefit, interest in study topic, and compensation serve as motivators for research participation; (5) continued participation despite reported shortcomings of informed consent process; and (6) mistrust could be overcome by relationship or credibility of information sources. CONCLUSION Despite barriers to participation in research studies among safety-net populations, there are also facilitators that can be implemented to increase knowledge and comprehension, ease of participation, and willingness to join research studies. Study teams should vary recruitment and participation methods to ensure equal access to research opportunities. PATIENT/PUBLIC CONTRIBUTION Our analysis methods and study progress were presented to individuals within the Boston Medical Center healthcare system. Through this process community engagement specialists, clinical experts, research directors, and others with significant experience working with safety-net populations supported data interpretation and provided recommendations for action following the dissemination of data.
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Affiliation(s)
- Autumn L Tamlyn
- Boston Medical Center, Section of Infectious Disease, Boston, MA, USA
| | - Maria Tjilos
- Boston Medical Center, Section of Infectious Disease, Boston, MA, USA
| | - Nicholas A Bosch
- Boston Medical Center, The Pulmonary Center, Department of Medicine, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Pulmonary, Allergy, Sleep, & Critical Care, Department of Medicine, Boston, MA, USA
| | - Katherine Gergen Barnett
- Boston Medical Center, Department of Family Medicine, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Department of Family Medicine, Boston, MA, USA.,Harvard Center for Primary Care, Center for Primary Care, Boston, MA, USA.,Aspen Health Innovation, Washington, DC, USA
| | - Rebecca B Perkins
- Boston Medical Center, Department of Obstetrics and Gynecology, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Department of Obstetrics and Gynecology, Boston, MA, USA
| | - Allan Walkey
- Boston Medical Center, The Pulmonary Center, Department of Medicine, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Pulmonary, Allergy, Sleep, & Critical Care, Department of Medicine, Boston, MA, USA.,Boston University School of Public Health, Department of Health Law Policy & Management, Boston, MA, USA
| | - Sabrina A Assoumou
- Boston Medical Center, Section of Infectious Disease, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Infectious Disease Department of Medicine, Boston, MA, USA
| | - Benjamin P Linas
- Boston Medical Center, Section of Infectious Disease, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Infectious Disease Department of Medicine, Boston, MA, USA.,Boston University School of Public Health, Department of Epidemiology, Boston, MA, USA
| | - Mari-Lynn Drainoni
- Boston University School of Public Health, Department of Health Law Policy & Management, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Infectious Disease Department of Medicine, Boston, MA, USA
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Tjilos M, Tamlyn AL, Ragan EJ, Assoumou SA, Barnett KG, Martin P, Perkins RB, Linas BP, Drainoni ML. "Community members have more impact on their neighbors than celebrities": leveraging community partnerships to build COVID-19 vaccine confidence. BMC Public Health 2023; 23:350. [PMID: 36797724 PMCID: PMC9933023 DOI: 10.1186/s12889-023-15198-6] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 02/02/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Vaccines are a strong public health tool to protect against severe disease, hospitalization, and death from COVID-19. Still, inequities in COVID-19 vaccination rates and health outcomes continue to exist among Black and Latino populations. Boston Medical Center (BMC) has played a significant role in vaccinating medically underserved populations, and organized a series of community-engaged conversations to better understand community concerns regarding the COVID-19 vaccine. This paper describes the themes which resulted from these community-engaged conversations and proposes next steps for healthcare leaders. METHODS We accessed nine publicly available recordings of the community-engaged conversations which were held between March 2021 and September 2021 and ranged from 8 to 122 attendees. Six conversations prioritized specific groups: the Haitian-Creole community, the Cape Verdean community, the Latino community, the Black Christian Faith community, guardians who care for children living with disabilities, and individuals affected by systemic lupus erythematosus. Remaining conversations targeted the general public of the Greater Boston Area. We employed a Consolidated Framework for Implementation Research-driven codebook to code our data. Our analysis utilized a modified version of qualitative rapid analysis methods. RESULTS Five main themes emerged from these community-engaged conversations: (1) Structural factors are important barriers to COVID-19 vaccination; (2) Mistrust exists due to the negative impact of systemic oppression and perceived motivation of the government; (3) There is a desire to learn more about biological and clinical characteristics of the COVID-19 vaccine as well as the practical implications of being vaccinated; (4) Community leaders emphasize community engagement for delivering COVID-19 information and education and; (5) Community leaders believe that the COVID-19 vaccine is a solution to address the pandemic. CONCLUSION This study illustrates a need for community-engaged COVID-19 vaccine messaging which reflects the nuances of the COVID-19 vaccine and pandemic without oversimplifying information. In highlighting common concerns of the Greater Boston Area which contribute to a lack of confidence in the COVID-19 vaccine, we underscore important considerations for public health and healthcare leadership in the development of initiatives which work to advance health equity.
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Affiliation(s)
- Maria Tjilos
- Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Ave. Crosstown Center, 2nd Floor, 02118, Boston, MA, US.
| | - Autumn L. Tamlyn
- grid.239424.a0000 0001 2183 6745Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Ave. Crosstown Center, 2nd Floor, 02118 Boston, MA US
| | - Elizabeth J. Ragan
- grid.239424.a0000 0001 2183 6745Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Ave. Crosstown Center, 2nd Floor, 02118 Boston, MA US
| | - Sabrina A. Assoumou
- grid.239424.a0000 0001 2183 6745Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Ave. Crosstown Center, 2nd Floor, 02118 Boston, MA US ,grid.239424.a0000 0001 2183 6745 Section of Infectious Diseases, Boston University Chobanian & Edward Avedisian School of Medicine, Boston Medical Center, 72 E Concord St, 02118 Boston, MA US
| | - Katherine Gergen Barnett
- grid.239424.a0000 0001 2183 6745Department of Family Medicine, Boston Medical Center, 1 Boston Medical Center Place, 02118 Boston, MA US ,grid.189504.10000 0004 1936 7558 Department of Family Medicine, Boston University Chobanian & Edward Avedisian School of Medicine, 72 E Concord St, MA 02118 Boston, United States ,grid.38142.3c000000041936754X Harvard Center for Primary Care, Harvard Medical School, 25 Shattuck St, MA 02115 Boston, US
| | - Petrina Martin
- grid.239424.a0000 0001 2183 6745Boston Medical Center, Boston Medical Center Health System, 85 East Concord Street, 02118 Boston, MA US
| | - Rebecca B. Perkins
- grid.189504.10000 0004 1936 7558Department of Obstetrics and Gynecology, Boston University Chobanian & Edward Avedisian School of Medicine, 72 E Concord St, 02118 Boston, MA US ,grid.239424.a0000 0001 2183 6745 Department of Obstetrics and Gynecology, Boston Medical Center, 775 Albany St, MA 02118 Boston, US
| | - Benjamin P. Linas
- grid.239424.a0000 0001 2183 6745Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Ave. Crosstown Center, 2nd Floor, 02118 Boston, MA US ,grid.239424.a0000 0001 2183 6745 Section of Infectious Diseases, Boston University Chobanian & Edward Avedisian School of Medicine, Boston Medical Center, 72 E Concord St, 02118 Boston, MA US ,grid.189504.10000 0004 1936 7558 Department of Epidemiology, Boston University School of Public Health, 715 Albany St, 02118 Boston, MA US
| | - Mari-Lynn Drainoni
- grid.239424.a0000 0001 2183 6745 Section of Infectious Diseases, Boston University Chobanian & Edward Avedisian School of Medicine, Boston Medical Center, 72 E Concord St, 02118 Boston, MA US ,grid.189504.10000 0004 1936 7558 Department of Health Law, Policy & Management, Boston University School of Public Health, 715 Albany St, MA 02118 Boston, US
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Casey SM, Paiva T, Perkins RB, Villa A, Murray EJ. Could oral health care professionals help increase human papillomavirus vaccination rates by engaging patients in discussions? J Am Dent Assoc 2023; 154:10-23.e17. [PMID: 36503668 DOI: 10.1016/j.adaj.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/29/2022] [Accepted: 09/21/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Oral health care professionals are well positioned to contribute to the prevention of human papillomavirus (HPV)-related oropharyngeal and other HPV-related cancers through engaging patients in conversations about HPV vaccination. This scoping review evaluates evidence regarding oral health care provider knowledge of, and discussion related to, HPV prevention, transmission, and associated risks, including oropharyngeal cancer. This review outlines relevant barriers to, and facilitators of, this knowledge and discussion. In addition, to determine the potential population that could be reached by an oral health care provider for a conversation about HPV vaccination, this review evaluates the prevalence of HPV vaccination as well as dental visits in a US population. TYPES OF STUDIES REVIEWED Four databases were systematically searched (MEDLINE [PubMed], EMBASE, APA PsycInfo, Cumulative Index to Nursing and Allied Health Literature). Studies written in English and conducted in the United States were eligible. Eligibility criteria were not restricted to publication year or oral health care provider type. Behavioral Risk Factor Surveillance System 2018 data were analyzed to evaluate the prevalence of HPV vaccination and dental visits among patients aged 18 through 49 years. RESULTS After duplicate record removal and second-stage screening, 32 full-text articles were retrieved, and data were independently extracted by 2 reviewers. Twenty-four studies were included in this review. Knowledge regarding HPV prevalence, transmission, disease processes, and risks varied. In general, discussions related to HPV in dental settings were infrequent. Facilitators to improve knowledge and discussion included guidance from professional dental organizations, education, and communication skills. Behavioral Risk Factor Surveillance System data showed that most people who are not vaccinated have visited their oral health care providers in the past year, highlighting the potential role of oral health care providers regarding discussion of HPV and promoting awareness and acceptance of vaccination. CONCLUSIONS AND PRACTICAL IMPLICATIONS This review indicates that discussions related to HPV were infrequent in the oral health care setting, which may be related to lack of knowledge and communication skills among oral health care professionals; however, evidence exists supporting the interest of oral health care professionals in improving vaccine uptake to prevent oropharyngeal cancer.
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Burrowes SAB, Casey SM, Dobbins S, Hall T, Ma M, Bano R, Drainoni ML, Schechter-Perkins EM, Garofalo C, Perkins RB, Pierre-Joseph N. Healthcare workers' perspectives on the COVID-19 vaccine and boosters for themselves, their patients, and their communities: a mixed methods study. Z Gesundh Wiss 2022; 32:1-14. [PMID: 36588660 PMCID: PMC9790765 DOI: 10.1007/s10389-022-01793-1] [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] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/05/2022] [Indexed: 12/27/2022]
Abstract
Aim To examine experiences and attitudes of a diverse sample of clinical and non-clinical healthcare workers regarding COVID-19 vaccines and boosters for themselves, their patients, and their communities. Subject and methods We conducted a sequential exploratory mixed methods study; 52 healthcare workers participated in qualitative interviews between April 22 and September 7, 2021, and 209 healthcare workers completed surveys between February 17 and March 23, 2022. Interviews and survey questions asked about personal attitudes toward COVID-19 vaccination and boosters and experiences discussing vaccination with patients. Results Participants were predominantly White (56% and 73%, respectively) and female (79% and 81%, respectively). Factors motivating healthcare workers to take the vaccine were the belief that vaccination would protect themselves, their families, patients, and communities. Healthcare workers were accepting of and had high receipt of the booster, though some had diminished belief in its effectiveness after becoming infected with SARS-CoV-2 after initial vaccination. Race related mistrust, misinformation related to vaccine safety, and concerns about vaccine effects during pregnancy were the most common barriers that providers encountered among their patients and communities. Conclusions Healthcare workers' primary motivation to receive COVID-19 vaccines was the desire to protect themselves and others. Healthcare workers' perception was that concerns about safety and misinformation were more important barriers for their patients than themselves. Race-related medical mistrust amplified concerns about vaccine safety and hindered communication efforts.
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Affiliation(s)
- Shana A. B. Burrowes
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA USA
| | - Sharon M. Casey
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA 02118 USA
| | - Sidney Dobbins
- Boston University School of Public Health, Boston, MA USA
| | - Taylor Hall
- Graduate of Medical Sciences, Boston University Chobanian and Avedisian School of Medicine, Boston, MA USA
| | - Mengyu Ma
- Boston University School of Public Health, Boston, MA USA
| | - Ruqiyya Bano
- Boston University School of Public Health, Boston, MA USA
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA USA
- Department of Health Law Policy & Management, Boston University School of Public Health, Boston, MA USA
| | - Elissa M. Schechter-Perkins
- Department of Emergency Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA USA
| | - Christopher Garofalo
- Department of Family Medicine and Department of Obstetrics and Gynecology, Sturdy Memorial Hospital, Attleboro, MA USA
- Family Medicine Associates of South Attleboro, South Attleboro, MA USA
| | - Rebecca B. Perkins
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA 02118 USA
| | - Natalie Pierre-Joseph
- Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine, Boston, MA USA
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Casey SM, Legler A, Hanchate AD, Perkins RB. Likelihood of COVID-19 reinfection in an urban community cohort in Massachusetts. Dialogues Health 2022; 1:100057. [PMID: 36785636 PMCID: PMC9547391 DOI: 10.1016/j.dialog.2022.100057] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 11/22/2022]
Abstract
Background Understanding the association of prior SARS-CoV-2 infection with subsequent reinfection has public health relevance. Objective To explore COVID-19 severity and SARS-CoV-2 infection and reinfection rates. Design Retrospective cohort study. Setting Boston, Massachusetts, during the first COVID-19 surge (01/01/2020-05/31/2020; Period-1) and after the first surge (06/01/2020-02/28/2021; Period-2); Period-2 included the second surge (11/01/2020-02/28/2021). Participants Patients in an academic medical center and six community health centers who received a clinical diagnosis of COVID-19 between 01/01/2020 and 05/31/2020 or SARS-CoV-2 testing between 01/01/2020 and 02/28/2021. Measurements COVID-19 severity was compared between Period-1 and Period-2. Poisson regression models adjusted for demographic variables, medical comorbidities, and census tract were used to assess reinfection risk among patients with COVID-19 diagnoses or SARS-CoV-2 testing during Period-1 and additional SARS-CoV-2 testing during Period-2. Results Among 142,047 individuals receiving SARS-CoV-2 testing or clinical diagnoses during the study period, 15.8% were infected. Among COVID-19 patients, 22.5% visited the emergency department, 13% were hospitalized, and 4% received critical care. Healthcare utilization was higher during Period-1 than Period-2 (22.9% vs. 18.9% emergency department use, 14.7% vs. 9.9% hospitalization, 5.5% vs. 2.5% critical care; p < 0.001). Reinfection was assessed among 8961 patients with a SARS-CoV-2 test or COVID-19 diagnosis in Period-1 who underwent additional testing in Period-2. A total of 2.7% (n = 65/2431) with SARS-CoV-2 in Period-1 tested positive in Period-2, compared with 12.6% (n = 821/6530) of those who initially tested negative (IRR of reinfection = 0.19, 95% CI: 0.15-0.25). Conclusions Prior SARS-CoV-2 infection among this observational cohort was associated with an 81% lower reinfection rate.
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Affiliation(s)
- Sharon M. Casey
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, MA, United States of America
| | - Aaron Legler
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, MA, United States of America
| | - Amresh D. Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Rebecca B. Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, MA, United States of America,Corresponding author at: 85 E. Concord St., Boston, MA 02118, United States of America
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Casey SM, Burrowes SAB, Hall T, Dobbins S, Ma M, Bano R, Yarrington C, Schechter-Perkins EM, Garofalo C, Drainoni ML, Perkins RB, Pierre-Joseph N. Healthcare workers' attitudes on mandates, incentives, and strategies to improve COVID-19 vaccine uptake: A mixed methods study. Hum Vaccin Immunother 2022; 18:2144048. [PMID: 36411988 DOI: 10.1080/21645515.2022.2144048] [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] [Indexed: 11/23/2022] Open
Abstract
Healthcare workers are a trusted health information source and are uniquely positioned to reduce the burden of the COVID-19 pandemic. The purpose of this sequential exploratory mixed methods study was to understand attitudes of healthcare workers working in Massachusetts during the COVID-19 pandemic regarding strategies to improve COVID-19 vaccine utilization, including vaccine mandates and incentives. Fifty-two individuals completed one-on-one interviews between April 22nd and September 7th, 2021. The survey was developed based on findings from the interviews; 209 individuals completed the online survey between February 17th and March 23rd, 2022. Both the interview and survey asked about attitudes toward COVID-19 vaccine and booster mandates, incentives, and strategies to improve vaccination rates. Most participants were female (79%-interview, 81%-survey), Caucasian (56%, 73%), and worked as physicians (37%, 34%) or nurses (10%, 18%). Overall, nuanced attitudes regarding vaccine and booster mandates were expressed; many supported mandates to protect their patients' health, others emphasized personal autonomy, while some were against mandates if job termination was the consequence of declining vaccines. Similarly, views regarding vaccine incentives differed; some considered incentives helpful, yet many viewed them as coercive. Strategies believed to be most effective to encourage vaccination included improving accessibility to vaccination sites, addressing misinformation, discussing vaccine safety, tailored community outreach via trusted messengers, and one-on-one conversations between patients and healthcare workers. Healthcare workers' experiences with strategies to improve utilization of COVID-19 vaccines and boosters have implications for public health policies. Generally, efforts to improve access and education were viewed more favorably than incentives and mandates.
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Affiliation(s)
- Sharon M Casey
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Shana A B Burrowes
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Taylor Hall
- Graduate of Medical Sciences, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sidney Dobbins
- Epidemiology and Statistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Mengyu Ma
- Epidemiology and Statistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Ruqiyya Bano
- Epidemiology and Statistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Christina Yarrington
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Elissa M Schechter-Perkins
- Department of Emergency Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Christopher Garofalo
- Department of Family Medicine and Department of Obstetrics and Gynecology, Sturdy Memorial Hospital, Attleboro, Massachusetts, USA.,Family Medicine Associates of South Attleboro, South Attleboro, Massachusetts, USA
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA.,Department of Health Law Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Natalie Pierre-Joseph
- Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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Lee YW, Morgan JR, Fiascone S, Perkins RB. Underscreening, overscreening, and guideline-adherent cervical cancer screening in a national cohort. Gynecol Oncol 2022; 167:181-188. [PMID: 36150914 DOI: 10.1016/j.ygyno.2022.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 07/14/2022] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To explore rates of under- and overscreening for cervical cancer among a national cohort. METHODS The MarketScan database, a national administrative database of employee-sponsored insurance, was queried for elements relevant to cervical cancer screening among women aged 21-65 with 6 years of continuous enrollment (2015-2019). Average-risk women were defined as those without high-risk medical conditions or abnormal screening histories, and without evidence of hysterectomy with removal of the cervix for benign indications. Average-risk women were considered adequately screened if they had Pap tests alone at 2.5-3.5 year intervals, or HPV tests or co-tests at 4.5-5.5 year intervals. Logistic regressions were used to predict the odds of receiving guideline-adherent screening, underscreening, and overscreening. RESULTS Among 1,872,809 eligible patients, 1,471,063 (78.5%) qualified for routine screening. Of these, only 18.1% received guideline-adherent screening, and 25.4% were unscreened during the 6-year period. Younger women (aged 21-39) were more likely to be overscreened [OR 1.46]. Older women (aged 50-64) were more likely to be underscreened or unscreened during the study period [OR 2.54]. Guideline-adherent screening was highest with HPV testing alone (80%) followed by co-testing (44%), and lowest with cytology alone (15%). A total of 329,062 women in this general population sample (18%) met high-risk criteria that required increased frequency of screening. CONCLUSIONS High rates of both underscreening and overscreening indicate a need for additional strategies to improve guideline-adherent care. CLINICAL TRIAL REGISTRATION N/A.
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Affiliation(s)
- Yeon Woo Lee
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, United States of America.
| | - Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States of America.
| | - Stephen Fiascone
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, United States of America.
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, United States of America.
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Wesselink AK, Hatch EE, Rothman KJ, Wang TR, Willis MD, Yland J, Crowe HM, Geller RJ, Willis SK, Perkins RB, Regan AK, Levinson J, Mikkelsen EM, Wise LA. A Prospective Cohort Study of COVID-19 Vaccination, SARS-CoV-2 Infection, and Fertility. Am J Epidemiol 2022; 191:1383-1395. [PMID: 35051292 PMCID: PMC8807200 DOI: 10.1093/aje/kwac011] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [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: 09/24/2021] [Revised: 01/07/2022] [Accepted: 01/13/2022] [Indexed: 01/28/2023] Open
Abstract
Some reproductive-aged individuals remain unvaccinated against coronavirus disease 2019 (COVID-19) because of concerns about potential adverse effects on fertility. Using data from an internet-based preconception cohort study, we examined the associations of COVID-19 vaccination and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with fertility among couples trying to conceive spontaneously. We enrolled 2,126 self-identified female participants aged 21-45 year residing in the United States or Canada during December 2020-September 2021 and followed them through November 2021. Participants completed questionnaires every 8 weeks on sociodemographics, lifestyle, medical factors, and partner information. We fit proportional probabilities regression models to estimate associations between self-reported COVID-19 vaccination and SARS-CoV-2 infection in both partners with fecundability (i.e., the per-cycle probability of conception), adjusting for potential confounders. COVID-19 vaccination was not appreciably associated with fecundability in either partner (female fecundability ratio (FR) = 1.08, 95% confidence interval (CI): 0.95, 1.23; male FR = 0.95, 95% CI: 0.83, 1.10). Female SARS-CoV-2 infection was not strongly associated with fecundability (FR = 1.07, 95% CI: 0.87, 1.31). Male infection was associated with a transient reduction in fecundability (for infection within 60 days, FR = 0.82, 95% CI: 0.47, 1.45; for infection after 60 days, FR = 1.16, 95% CI: 0.92, 1.47). These findings indicate that male SARS-CoV-2 infection may be associated with a short-term decline in fertility and that COVID-19 vaccination does not impair fertility in either partner.
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Affiliation(s)
- Amelia K Wesselink
- Correspondence to Amelia K. Wesselink, Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, T3E, Boston, MA 02118 (e-mail: )
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36
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Perkins RB, Saslow D, Oliver K. Long-Term Effectiveness of Human Papillomavirus Vaccination: Implications for Future Reduction in Cancer. Ann Intern Med 2022; 175:1037-1038. [PMID: 35576588 DOI: 10.7326/m22-1309] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Debbie Saslow
- Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia
| | - Kristin Oliver
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York
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37
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Egemen D, Perkins RB, Clarke MA, Guido R, Huh W, Saraiya M, Saslow D, Smith R, Unger ER, Garcia F, Wentzensen N, Cheung LC. Risk-Based Cervical Consensus Guidelines: Methods to Determine Management if Less Than 5 Years of Data Are Available. J Low Genit Tract Dis 2022; 26:195-201. [PMID: 35763610 PMCID: PMC9232276 DOI: 10.1097/lgt.0000000000000685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In the 2019 ASCCP Risk-Based Management Consensus Guidelines, clinical management decisions are based on immediate and 5-year cervical intraepithelial neoplasia (CIN) 3+ risk estimates. However, data for technologies other than human papillomavirus testing and cytology may be limited to clinical trials and observational studies of shorter duration than 5 years. To enable decisions about 1- or 3-year intervals, 3-year CIN 3+ risk equivalents to 5-year CIN 3+ risk thresholds were generated. MATERIALS AND METHODS We examined screening test result scenarios around the 5-year risk thresholds of 0.15% and 0.55% and calculated the average percent increase in CIN 3+ risk from 3 to 5 years. Using this average increase, we obtained estimates of corresponding risk thresholds at 3 years. We then validated whether use of the 3-year risk threshold would have resulted in equivalent management per the 2019 recommendations. RESULTS Around the 5-year CIN 3+ risk threshold of 0.55%, the average increase in risk from 3 to 5 years was 0.16%. Therefore, the equivalent threshold for 3-year risk was estimated as 0.39%. We found no difference in recommendations to return in 1 or 3 years using the 3-year or 5-year risk thresholds in 66 of the 67 scenarios (98.5%) in follow-up in 2019 guidelines. CONCLUSIONS In this methodological addendum, the Enduring Guidelines Committee adopted the use of the 0.39% 3-year CIN 3+ risk threshold as equivalent of the 0.55% 5-year CIN 3+ risk threshold for technologies with fewer than 5 years of follow-up data. This allows evidence-based guidance for surveillance intervals of 1 or 3 years for new technologies with limited longitudinal data.
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Affiliation(s)
- Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Rebecca B. Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA
| | - Megan A. Clarke
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Richard Guido
- Department of Obstetrics and Gynecology, Magee-Women's Hospital, Pittsburgh, PA
| | - Warner Huh
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Mona Saraiya
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | - Francisco Garcia
- Community and Health Services, Chief Medical Officer, Pima County, AZ
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Li C. Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
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38
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Smith DL, Perkins RB. Low rates of HPV vaccination and cervical cancer screening: Challenges and opportunities in the context of the COVID-19 pandemic. Prev Med 2022; 159:107070. [PMID: 35461955 PMCID: PMC9022394 DOI: 10.1016/j.ypmed.2022.107070] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Abstract
This invited commentary discusses the article by Richards et al. describing differences in rates of on-time HPV vaccination and cervical cancer screening in 2018 among enrollees in different insurance plans. The commentary focuses on the larger problem of low vaccination HPV rates and decreasing cervical cancer screening rates seen across all sectors. We outline challenges posed by the COVID-19 pandemic on HPV vaccination and cervical cancer screening, and discuss opportunities to improve cervical cancer prevention.
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Affiliation(s)
- Debi L Smith
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Rebecca B Perkins
- Boston University School of Medicine/ Boston Medical Center, Boston, MA, USA.
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39
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Saraiya M, Colbert J, Bhat GL, Almonte R, Winters DW, Sebastian S, O'Hanlon M, Meadows G, Nosal MR, Richards TB, Michaels M, Townsend JS, Miller JW, Perkins RB, Sawaya GF, Wentzensen N, White MC, Richardson LC. Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity. J Womens Health (Larchmt) 2022; 31:462-468. [PMID: 35467443 PMCID: PMC9206487 DOI: 10.1089/jwh.2022.0100] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cervical cancer is highly preventable when precancerous lesions are detected early and appropriately managed. However, the complexity of and frequent updates to existing evidence-based clinical guidelines make it challenging for clinicians to stay abreast of the latest recommendations. In addition, limited availability and accessibility to information technology (IT) decision supports make it difficult for groups who are medically underserved to receive screening or receive the appropriate follow-up care. The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC), is leading a multiyear initiative to develop computer-interpretable ("computable") version of already existing evidence-based guidelines to support clinician awareness and adoption of the most up-to-date cervical cancer screening and management guidelines. DCPC is collaborating with the MITRE Corporation, leading scientists from the National Cancer Institute, and other CDC subject matter experts to translate existing narrative guidelines into computable format and develop clinical decision support tools for integration into health IT systems such as electronic health records with the ultimate goal of improving patient outcomes and decreasing disparities in cervical cancer outcomes among populations that are medically underserved. This initiative meets the challenges and opportunities highlighted by the President's Cancer Panel and the President's Cancer Moonshot 2.0 to nearly eliminate cervical cancer.
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Affiliation(s)
- Mona Saraiya
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jean Colbert
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Geeta L Bhat
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Rose Almonte
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - David W Winters
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Sharon Sebastian
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Michael O'Hanlon
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Ginny Meadows
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Michael R Nosal
- MITRE Healthcare Federally Funded Research and Development Center, McLean, Virginia, USA
| | - Thomas B Richards
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maria Michaels
- Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Julie S Townsend
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jacqueline W Miller
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rebecca B Perkins
- Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - George F Sawaya
- UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA.,Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Mary C White
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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40
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Demarco M, Egemen D, Hyun N, Chen X, Moscicki AB, Cheung L, Carter-Pokras O, Hammer A, Gage JC, Clarke MA, Castle PE, Befano B, Chen J, Dallal C, He X, Desai K, Lorey T, Poitras N, Raine-Bennett TR, Perkins RB, Wentzensen N, Schiffman M. Contribution of Etiologic Cofactors to CIN3+ Risk Among Women With Human Papillomavirus-Positive Screening Test Results. J Low Genit Tract Dis 2022; 26:127-134. [PMID: 35249974 PMCID: PMC8940696 DOI: 10.1097/lgt.0000000000000667] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The US screening and management guidelines for cervical cancer are based on the absolute risk of precancer estimated from large clinical cohorts and trials. Given the widespread transition toward screening with human papillomavirus (HPV) testing, it is important to assess which additional factors to include in clinical risk assessment to optimize management of HPV-infected women. MATERIALS AND METHODS We analyzed data from HPV-infected women, ages 30-65 years, in the National Cancer Institute-Kaiser Permanente Northern California Persistence and Progression study. We estimated the influence of HPV risk group, cytology result, and selected cofactors on immediate risk of cervical intraepithelial neoplasia grade 3 or higher (CIN 3+) among 16,094 HPV-positive women. Cofactors considered included, age, race/ethnicity, income, smoking, and hormonal contraceptive use. RESULTS Human papillomavirus risk group and cytology test result were strongly correlated with CIN 3+ risk. After considering cytology and HPV risk group, other cofactors (age, race/ethnicity, income, smoking, and hormonal contraceptive use) had minimal impact on CIN 3+ risk and did not change recommended management based on accepted risk thresholds. We had insufficient data to assess the impact of long-duration heavy smoking, parity, history of sexually transmitted infection, or immunosuppression. CONCLUSIONS In our study at the Kaiser Permanente Northern California, the risk of CIN 3+ was determined mainly by HPV risk group and cytology results, with other cofactors having limited impact in adjusted analyses. This supports the use of HPV and cytology results in risk-based management guidelines.
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Affiliation(s)
- Maria Demarco
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Noorie Hyun
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Xiaojian Chen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | | | - Li Cheung
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Olivia Carter-Pokras
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | | | - Julia C. Gage
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Megan A. Clarke
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Philip E. Castle
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Brian Befano
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Jie Chen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Cher Dallal
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Xin He
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Kanan Desai
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Thomas Lorey
- Kaiser Permanente Northern California, San Francisco, CA
| | - Nancy Poitras
- Kaiser Permanente Northern California, San Francisco, CA
| | | | | | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
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41
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Perkins RB, Werner C, Wentzensen N. What Contributes to Pregnancy Complications Among Women With Cervical Intraepithelial Neoplasia Grade 3? Ann Intern Med 2022; 175:293-294. [PMID: 35130047 DOI: 10.7326/m21-4666] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Claudia Werner
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicolas Wentzensen
- Department of Clinical Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
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42
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Casey SM, Jansen E, Drainoni ML, Schuch TJ, Leschly KS, Perkins RB. Long-Term Multilevel Intervention Impact on Human Papillomavirus Vaccination Rates Spanning the COVID-19 Pandemic. J Low Genit Tract Dis 2022; 26:13-19. [PMID: 34928249 DOI: 10.1097/lgt.0000000000000648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the long-term sustainability of a multilevel intervention and the COVID-19 pandemic impact on adolescent human papillomavirus (HPV) vaccination coverage. MATERIALS AND METHODS In 2016, a pediatric and family medicine practice within a federally qualified health center completed a multilevel intervention, Development of Systems and Education for Human Papillomavirus Vaccination. We examined the intervention impact on HPV vaccine initiation and completion rates among adolescents 10-18 years between March 2016 and October 2020. We determined the total number of HPV vaccine doses administered monthly. Data were plotted on statistical process control charts. RESULTS Vaccine initiation increased from an average of 14% to an average of 42% for 10-year-old patients and from an average of 72% to an average of 92% for 11- to 12-year-old patients between March 2016 and January 2017 and remained stable through March 2020. Complete vaccination by age 13 years increased from 62% to 88% through October 2020. CONCLUSIONS This intervention led to continued improvement for on-time HPV vaccination coverage 4 years after intervention completion.Clinical Trial Registration: This trial has been registered at http://www.clinicaltrials.gov (identifier NCT02812732).
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Affiliation(s)
- Sharon M Casey
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA
| | - Emily Jansen
- Continuing Medical Education Office, Boston University School of Medicine, Boston, MA
| | | | | | | | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA
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43
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Perkins RB, Adcock R, Benard V, Cuzick J, Waxman A, Howe J, Melkonian S, Gonzales J, Wiggins C, Wheeler CM. Clinical follow-up practices after cervical cancer screening by co-testing: A population-based study of adherence to U.S. guideline recommendations. Prev Med 2021; 153:106770. [PMID: 34416221 PMCID: PMC8595756 DOI: 10.1016/j.ypmed.2021.106770] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/07/2021] [Accepted: 08/15/2021] [Indexed: 01/01/2023]
Abstract
Failure to follow-up women after abnormal cervical screening could lead to cervical cancers, yet little is known about adherence to recommended follow-up after abnormal co-testing [cytology and high-risk human papillomavirus (hrHPV) testing]. We documented clinical management following cervical screening by co-testing in a diverse population-based setting. A statewide surveillance program for cervical screening, diagnosis, and treatment was used to investigate all cytology, hrHPV and biopsy reports in the state of New Mexico from January 2015 through August 2019. Guideline-adherent follow-up after co-testing required 1) biopsy within 6 months for low-grade cytology if positive for hrHPV, for high-grade cytology irrespective of hrHPV, and for HPV 16/18 positive results irrespective of cytology and; 2) repeat co-testing within 18 months if cytology was negative and hrHPV test was positive (excluding types 16/18). Screening co-tests (2015-2017) for 164,522 women were analyzed using descriptive statistics, Kaplan Meier curves, and pairwise comparisons between groups. Guideline adherence was highest when both cytology and hrHPV tests were abnormal, ranging from 61.7% to 80.3%. Guideline-adherent follow-up was lower for discordant results. Women with high-grade cytology were less likely to receive a timely biopsy when hrHPV-testing was negative (48.1%) versus positive (83.3%) (p < 0.001). Only 47.9% of women received biopsies following detection of HPV16/18 with normal cytology, and 30.8% received no follow-up within 18-months. Among women with hrHPV-positive normal cytology without evidence of HPV 16/18 infection, 51% received no follow-up within 18 months. Provider education and creation of robust recall systems may help ensure appropriate follow-up of abnormal screening results.
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Affiliation(s)
- Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
| | - Rachael Adcock
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Vicki Benard
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Alan Waxman
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM, USA
| | - Jean Howe
- Obstetrics and Gynecology, Northern Navajo Medical Center, Shiprock, NM, USA
| | - Stephanie Melkonian
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Albuquerque, NM, USA
| | - Janis Gonzales
- Division of Public Health, Family Health Bureau, New Mexico Department of Health, USA
| | - Charles Wiggins
- New Mexico Tumor Registry, University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA
| | - Cosette M Wheeler
- Center for HPV Prevention, New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA..
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Wentzensen N, Clarke MA, Perkins RB. Impact of COVID-19 on cervical cancer screening: Challenges and opportunities to improving resilience and reduce disparities. Prev Med 2021; 151:106596. [PMID: 34217415 PMCID: PMC8241689 DOI: 10.1016/j.ypmed.2021.106596] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/26/2021] [Accepted: 05/01/2021] [Indexed: 12/13/2022]
Abstract
The COVID-19 pandemic has a major impact on a wide range of health outcomes. Disruptions of elective health services related to cervical screening, management of abnormal screening test results, and treatment of precancers, may lead to increases in cervical cancer incidence and exacerbate existing health disparities. Modeling studies suggest that a short delay of cervical screening in subjects with previously negative HPV results has minor effects on cancer outcomes, while delay of management and treatment can lead to larger increases in cervical cancer. Several approaches can mitigate the effects of disruption of cervical screening and management. HPV-based screening has higher accuracy compared to cytology, and a negative HPV result provides longer reassurance against cervical cancer; further, HPV testing can be conducted from self-collected specimens. Self-collection expands the reach of screening to underserved populations who currently do not participate in screening. Self-collection and can also provide alternative screening approaches during the pandemic because testing can be supported by telehealth and specimens collected in the home, substantially reducing patient-provider contact and risk of COVID-19 exposure, and also expanding the reach of catch-up services to address backlogs of screening tests that accumulated during the pandemic. Risk-based management allows prioritizing management of patients at highest risk of cervical cancer while extending screening intervals for those at lowest risk. The pandemic provides important lessons for how to make cervical screening more resilient to disruptions and how to reduce cervical cancer disparities that may be exacerbated due to disruptions of health services.
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Affiliation(s)
- Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.
| | - Megan A Clarke
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Rebecca B Perkins
- Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
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Fisher-Borne M, Isher-Witt J, Comstock S, Perkins RB. Understanding COVID-19 impact on cervical, breast, and colorectal cancer screening among federally qualified healthcare centers participating in "Back on track with screening" quality improvement projects. Prev Med 2021; 151:106681. [PMID: 34217422 PMCID: PMC8241686 DOI: 10.1016/j.ypmed.2021.106681] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/05/2021] [Accepted: 06/06/2021] [Indexed: 11/17/2022]
Abstract
The COVID-19 pandemic has contributed to decreases in breast, colorectal, and cervical cancer screenings between 86 and 94% compared to three-year averages. These postponed screenings have created backlogs that systems will need to address as healthcare facilities re-open for preventive care. The American Cancer Society is leading a 17-month intervention with 22 federally qualified health centers (FQHCs) across the United States aimed at reducing cancer incidence and mortality disparities and alleviating additional strain caused by COVID-19. This study describes COVID-related cancer screening service disruptions reported by participating FQHCs. Selected FQHCs experienced service disruptions and/or preventive care cancellations due to COVID-19 that varied in severity and duration. Fifty-nine percent stopped cancer screenings completely. Centers transitioned to telehealth visits or rescheduled for the future, but the impact of these strategies may be limited by continued pandemic-related disruptions and the inability to do most screenings at home; colon cancer screening being the exception. Most centers have resumed in-person screening, but limited in person appointments and high levels of community transmission may reduce FQHC abilities to provide catch-up services. FQHCs provide critical cancer prevention services to vulnerable populations. The delivery of culturally competent, high-quality healthcare can mitigate and potentially reverse racial and ethnic disparities in cancer prevention testing and treatment. Ensuring and expanding access to care as we move out of the pandemic will be critical to preventing excess cancer incidence and mortality in vulnerable populations.
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Affiliation(s)
- Marcie Fisher-Borne
- Office of Cancer Research and Implementation, American Cancer Society, Atlanta, GA, USA.
| | - Jennifer Isher-Witt
- Office of Cancer Research and Implementation, American Cancer Society, Atlanta, GA, USA
| | - Sara Comstock
- Office of Cancer Research and Implementation, American Cancer Society, Atlanta, GA, USA
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
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Perkins RB, Foley S, Hassan A, Jansen E, Preiss S, Isher-Witt J, Fisher-Borne M. Impact of a Multilevel Quality Improvement Intervention Using National Partnerships on Human Papillomavirus Vaccination Rates. Acad Pediatr 2021; 21:1134-1141. [PMID: 34023489 DOI: 10.1016/j.acap.2021.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a multilevel intervention using national partnerships on human papillomavirus (HPV) vaccination rates. METHODS The American Cancer Society's Vaccinate Adolescents against Cancer program is a multilevel intervention focusing on systems and providers. The 2017 cohort introduced national partnerships to deliver intervention elements and Maintenance of Certification and continuing medical education credits for physicians. Eleven federally qualified health center (FQHC) systems completed interventions in 2017. Interventions included provider training and ≥1 other evidence-based systems improvement. We compared adolescent vaccination rates in the preintervention period (2016) and intervention period (2017) among adolescents who turned 13 during the calendar year. Intervention effectiveness was assessed using repeated measures paired t tests and Cohen's d effect size for vaccination rate change. RESULTS All FQHC systems implemented provider training plus an average of 2.3 additional systems improvements. Series initiation increased by an average of 23.6 percentage points (47.2%-70.8%). HPV completion rates increased by an average of 22.7 percentage points (24.6%-46.3%). Meningococcal and Tdap vaccination rates increased by 23.3 and 25.9 percentage points respectively (47.9%-71.2% and 48.8%-74.7%). All changes were statistically significant (all P < .05) and indicated large effect sizes (Cohen's d3 1.15). Among clinicians completing postintervention surveys, 90% reported making changes to their health care system or direct patient care based on what they had learned. CONCLUSIONS Multilevel interventions focusing on provider training and systems changes can substantially improve on-time adolescent vaccination coverage and can be successfully performed using national partnerships and a train-the-trainer model.
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Affiliation(s)
- Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center (RB Perkins), Boston, Mass
| | - Shaylen Foley
- American Cancer Society, Vaccinate Adolescents Against Cancer Program (S Foley, A Hassan, S Preiss, JI Witt, and M Fisher-Borne), Atlanta, Ga
| | - Anna Hassan
- American Cancer Society, Vaccinate Adolescents Against Cancer Program (S Foley, A Hassan, S Preiss, JI Witt, and M Fisher-Borne), Atlanta, Ga
| | - Emily Jansen
- Boston University School of Medicine, Continuing Medical Education Office (E Jansen), Boston, Mass
| | - Sandy Preiss
- American Cancer Society, Vaccinate Adolescents Against Cancer Program (S Foley, A Hassan, S Preiss, JI Witt, and M Fisher-Borne), Atlanta, Ga
| | - Jennifer Isher-Witt
- American Cancer Society, Vaccinate Adolescents Against Cancer Program (S Foley, A Hassan, S Preiss, JI Witt, and M Fisher-Borne), Atlanta, Ga.
| | - Marcie Fisher-Borne
- American Cancer Society, Vaccinate Adolescents Against Cancer Program (S Foley, A Hassan, S Preiss, JI Witt, and M Fisher-Borne), Atlanta, Ga
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Drainoni ML, Biancarelli D, Jansen E, Bernstein J, Joseph N, Eun TJ, Fenton AHTR, Clark JA, Hanchate A, Legler A, Schuch TJ, Leschly K, Perkins RB. Provider and Practice Experience Integrating the Dose-HPV Intervention into Clinical Practice. J Contin Educ Health Prof 2021; 41:195-201. [PMID: 33973928 PMCID: PMC8881994 DOI: 10.1097/ceh.0000000000000363] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Few studies have rigorously evaluated the drivers of successful implementation of interventions to improve human papillomavirus (HPV) vaccination rates. The aim of this study was to evaluate the implementation of Development of Systems and Education for HPV Vaccination (DOSE HPV), a performance improvement intervention. METHODS Primary care providers (PCPs), nurses, and individuals with leadership roles from pediatric and family medicine practices who attended DOSE HPV intervention sessions participated in qualitative interviews immediately following intervention completion. The study team professionally transcribed interviews and performed qualitative coding using inductive methods. Final analysis employed the Promoting Action on Research implementation in Health Services (PARiHS) model. RESULTS Twenty-six individuals participated: 12 PCPs, 5 nurses, and 9 individuals with dual leadership and PCP roles. Participants described five factors that they felt contributed to program success: (1) evidence-based, goal-directed education; (2) personalized data feedback; (3) clinical leadership support; (4) collaborative facilitation; (5) repeated contacts/longitudinal structure of the intervention. Barriers to implementing the intervention included: (1) inability to standardize workflow across practices; (2) low pediatric volume, (3) competing priorities/lack of incentives, (4) ineffective involvement of nurses, (5) poor communication between clinical leadership and staff. DISCUSSION Although many HPV testing interventions have been implemented, findings have been mixed. It is clear that having an effective, evidence-based intervention by itself is not enough to get it into practice. Rather, it is crucial to consider implementation factors to ensure consistent implementation and sustainability. Key factors for the success of the DOSE HPV intervention appear to include a collaborative approach, provision of useful evidence to motivate behavior change, and repeated contacts to ensure accountability for implementing changes. Workflow issues, ineffective lines of communication, and competing priorities at both the visit and the patient and population management levels can hinder implementation.
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Affiliation(s)
- Mari-Lynn Drainoni
- Dr. Drainoni: Research Professor, Boston University Schools of Medicine and Public Health, Boston, MA; Codirector, Evans Center for Implementation and Improvement Sciences, Boston, MA. Ms. Biancarelli: Consultant, Accenture, Boston, MA. Ms. Jansen: Senior Program Manager, Boston University School of Medicine, Boston, MA. Dr. Bernstein: Emeritus Professor, Boston University School of Public Health; Professor of Emergency Medicine, Boston University School of Medicine, Boston, MA. Dr. Joseph: Clinical Associate Professor of Adolescent Medicine and Pediatrics, Boston University School of Medicine, Boston, MA. Ms. Eun: PhD Student, Department of Sociology, Stanford University, Boston, MA. Dr. Fenton: Postdoctoral Fellow, Center for Outcomes Research & Evaluation, Maine Medical Center Research Institute, Boston, MA. Dr. Clark: Professor, Boston University School of Public Health, Boston, MA. Dr. Hanchate: Associate Professor, Boston University Schools of Medicine and Public Health; Health Economist, VA Boston Healthcare System, Boston, MA. Mr. Legler: Senior Healthcare Statistician, Boston VA Healthcare System, Boston, MA. Dr. Schuch: Chief Information Officer, Pediatrician at South Boston Community Health Center, Boston, MA. Dr. Leschly: Assistant Professor, Boston University School of Medicine; Medical Director, East Boston Neighborhood Health Center, Boston, MA. Dr. Perkins: Associate Professor, Boston University School of Medicine, Boston, MA
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Mills JM, Morgan JR, Dhaliwal A, Perkins RB. Eligibility for cervical cancer screening exit: Comparison of a national and safety net cohort. Gynecol Oncol 2021; 162:308-314. [PMID: 34090706 DOI: 10.1016/j.ygyno.2021.05.035] [Citation(s) in RCA: 10] [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: 03/22/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine eligibility for discontinuation of cervical cancer screening. METHODS Women aged 64 with employer-sponsored insurance enrolled in a national database between 2016 and 2018, and those aged 64-66 receiving primary care at a safety net health center in 2019 were included. Patients were evaluated for screening exit eligibility by current guidelines: no evidence of cervical cancer or HIV-positive status and no evidence of cervical precancer in the past 25 years, and had evidence of either hysterectomy with removal of the cervix or evidence of fulfilling screening exit criteria, defined as two HPV screening tests or HPV plus Pap co-tests or three Pap tests within the past 10 years without evidence of an abnormal result. RESULTS Of the 590,901 women in the national claims database, 131,059 (22.2%) were eligible to exit due to hysterectomy (1.6%) or negative screening (20.6%). Of the 1544 women from the safety net health center, 528 (34.2%) were eligible to exit due to hysterectomy (9.3%) or negative screening (24.9%). Most women did not have sufficient data available to fulfill exit criteria: 382,509 (64.7%) in the national database and 875 (56.7%) in the safety net hospital system. Even among women with 10 years of insurance claims data, only 41.5% qualified to discontinue screening. CONCLUSIONS Examining insurance claims in a national database and electronic medical records at a safety net institution led to remarkably similar findings: two thirds of women fail to qualify for screening exit. Additional steps to ensure eligibility prior to screening exit may be necessary to decrease preventable cervical cancers among women aged >65. CLINICAL TRIAL REGISTRATION N/A.
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Affiliation(s)
- Jacqueline M Mills
- Department of Obstetrics and Gynecology, Boston University School of Medicine/ Boston Medical Center, Boston, MA, United States of America.
| | - Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States of America.
| | - Amareen Dhaliwal
- Boston University School of Medicine, Boston, MA, United States of America.
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/ Boston Medical Center, Boston, MA, United States of America.
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Perkins RB, Guido RL, Saraiya M, Sawaya GF, Wentzensen N, Schiffman M, Feldman S. Summary of Current Guidelines for Cervical Cancer Screening and Management of Abnormal Test Results: 2016-2020. J Womens Health (Larchmt) 2021; 30:5-13. [PMID: 33464997 DOI: 10.1089/jwh.2020.8918] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Cervical cancer can be prevented through routine screening and follow-up of abnormal results. Several guidelines have been published in the last 4 years from various medical societies and organizations. These guidelines aim to personalize screening and management, reducing unnecessary testing in low-risk patients and managing high-risk patients with more intensive follow-up. However, the resulting complexity can lead to confusion among providers. The CDC, NCI, and obstetrician-gynecologists involved in guideline development summarized current screening and management guidelines. For screening, guidelines for average-risk and high-risk populations are summarized and presented. For management, differences between the 2012 and 2019 consensus guidelines for managing abnormal cervical cancer screening tests and cancer precursors are summarized. Current screening guidelines for average-risk individuals have minor differences, but are evolving toward an HPV-based strategy. For management, HPV testing is preferred to cytology because it is a more sensitive test for cancer precursor detection and also allows for precise risk stratification. Current risk-based screening and management strategies can improve care by reducing unnecessary tests and procedures in low-risk patients and focusing resources on high-risk patients. Knowledge of screening and management guidelines is important to improve adherence and avoid both over- and under-use of screening and colposcopy.
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Affiliation(s)
- Rebecca B Perkins
- Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - Richard L Guido
- University of Pittsburgh/Magee-Women's Hospital, Pittsburgh, Pennsylvania, USA
| | - Mona Saraiya
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - George F Sawaya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics and Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Sarah Feldman
- Department of Obstetrics/Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Saraiya M, Cheung LC, Soman A, Mix J, Kenney K, Chen X, Perkins RB, Schiffman M, Wentzensen N, Miller J. Risk of cervical precancer and cancer among uninsured and underserved women from 2009 to 2017. Am J Obstet Gynecol 2021; 224:366.e1-366.e32. [PMID: 33035473 DOI: 10.1016/j.ajog.2020.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 08/02/2020] [Revised: 09/24/2020] [Accepted: 10/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND New guidelines for managing cervical precancer among women in the United States use risk directly to guide clinical actions for individuals who are being screened. These risk-based management guidelines have previously only been based on risks from a large integrated healthcare system. We present here data representative of women of low income without continuous insurance coverage to inform the 2019 guidelines and ensure applicability. OBJECTIVE We examined the risks of high-grade precancer after human papillomavirus and cytology tests in underserved women and assessed the applicability of the 2019 guidelines to this population. STUDY DESIGN We examined cervical cancer screening and follow-up data among 363,546 women enrolled in the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program from 2009 to 2017. We estimated the immediate (prevalent) risks of cervical intraepithelial lesion grade 3 or cancer by using prevalence-incidence mixture models. Risks were estimated for each combination of human papillomavirus and cytology result and were stratified by screening history. We compared these risks with published estimates used in new risk-based management guidelines. RESULTS Women who were up-to-date with their screening, defined as being screened with cytology within the past 5 years, had immediate risks of cervical intraepithelial neoplasia grade 3 or higher similar to that of women at Kaiser Permanente Northern California, whose data were used to develop the management guidelines. However, women in the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program had greater immediate risks if they were never screened or not up-to-date with their screening. CONCLUSION New cervical risk-based management guidelines are applicable for underinsured and uninsured women with a low income in the United States who are up-to-date with their screening. The increased risk observed here among women who received human papillomavirus-positive, high-grade cytology results, who were never screened, or who were not up-to-date with their cervical cancer screening, led to a recommendation in the management guidelines for immediate treatment among these women.
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Affiliation(s)
- Mona Saraiya
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlanta, GA.
| | - Li C Cheung
- National Cancer Institute, Division of Cancer Epidemiology and Genetics, Rockville, MD
| | - Ashwini Soman
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlanta, GA
| | - Jacqueline Mix
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlanta, GA
| | - Kristy Kenney
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlanta, GA
| | - Xiaojian Chen
- National Cancer Institute, Division of Cancer Epidemiology and Genetics, Rockville, MD
| | | | - Mark Schiffman
- National Cancer Institute, Division of Cancer Epidemiology and Genetics, Rockville, MD
| | - Nicolas Wentzensen
- National Cancer Institute, Division of Cancer Epidemiology and Genetics, Rockville, MD
| | - Jacqueline Miller
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlanta, GA
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