The need for and acceptability of a cancer training course for medical and nursing students in Tanzania: a convergent mixed methods study.

BACKGROUND: The cancer burden in Africa is on the rise. A Cancer Training Course on screening, prevention, care, and community education is crucial for addressing a wide range of cancer health issues. When appropriately educated healthcare providers on cancer provide care, patient care improves, and healthcare costs decrease. However, in Tanzania, doctors and nurses receive little or no training in primary cancer care in their bachelor's program. AIM: This study assessed the need and acceptability of a cancer training course for nursing and medical doctor students at the Muhimbili University of Health and Allied Sciences (MUHAS) in Dar es Salaam, Tanzania. METHODS: This study was a cross-sectional parallel mixed method study during the 3-month follow-up within the larger study on sexual health training for health professionals. The study was a randomized controlled (RCT), single-blind, parallel trial of sexual health training versus a waitlist control among health students at MUHAS in Tanzania. Descriptive analysis was performed to analyze the participants' demographic information, need, and acceptability of the cancer training courseto determine the frequencies and percentages of their distribution between disciplines. In addition, inductive thematic analysis was performed for the qualitative data. The RCT study was registered at Clinical Trial.gov (NCT03923582; 01/05/2021). RESULTS: Data were collected from 408 students (272 medical doctors and 136 nursing students). The median age of the participants was 23 years. Most (86.0%) medical and 78.1% of nursing students reported receiving little to no cancer training. On the other hand, most (92.3%) medical and nursing (92.0%) students were interested in receiving cancer training. Furthermore, 94.1% of medical and 92.0% of nursing students needed a cancer training course in their undergraduate program. In addition, participants said a cancer training course would be important because it would help them improve the quality of cancer care and enhance the quality of life for patients by ensuring early diagnosis and treatment. CONCLUSION: A cancer training course is both highly needed and acceptable to medical and nursing students. Implementation of this cancer training course will improve students' knowledge and skills and eventually improve the quality of cancer care and patients' quality of life by ensuring early diagnosis and management.

Lower human papillomavirus vaccine initiation and completion among Asian American adolescents compared to their peers: National Health and Nutritional Examination Survey 2011-2018.

PURPOSE: To compare human papillomavirus (HPV) vaccination initiation and completion between Asian American adolescents and their peers. METHODS: HPV vaccine initiation and completion of adolescents aged 9-17 years old were analyzed using the National Health and Nutritional Examination Survey data from 2011 to 2018. The outcomes were HPV vaccine initiation percentage among all adolescents and completion percentage among initiators. Odds ratios for initiation or completion among Hispanics, Blacks, and Asians (referred to as racial/ethnic minorities) versus Whites were compared using logistic regression, adjusted for adolescent's age, annual family income, parent education, and insurance coverage. RESULTS: From 2011 to 2018, overall initiation was less than 40% among U.S. adolescents. The initiation increased among boys (from 10% in 2011-12 to over 30% in 2017-2018) but not among girls. Compared to White girls, Black and Hispanic girls were more likely, while Asian girls were less likely to initiate vaccination. Although not statistically significant, Asian girls had ORs ranging from 0.65 to 0.99 for initiation compared to White girls in each of the four survey cycles. Black and Hispanic boys were more likely to initiate vaccination compared to White boys. Initiation among Asian boys increased to 39% in the 2017-2018 survey cycle. Racial/ethnic minority girls were less likely to complete the series compared to White girls, while the opposite was seen in Black boys. CONCLUSION: HPV vaccination status varies among racial/ethnic groups. Future efforts should be made to achieve the Healthy People 2020 goal of 80% vaccination among U.S. adolescents and address the gap among Asian American girls.

A systematic review of the association between smoking exposure and HPV-related cervical cell abnormality among women living with HIV: Implications for prevention strategies.

This study aims to evaluate the association between smoking exposure and human papillomavirus (HPV)-related cervical abnormalities among women living with HIV (WLWH). By conducting a systematic review of the current literature, we evaluated the association between current active smoking and/or exposure to secondhand smoke (SHS) and the risk of cervical HPV incidence, prevalence, and clearance, as well as high-grade cervical intraepithelial neoplasm (HGCIN) incidence, prevalence, progression, and regression among WLWH. We conducted the literature search in Ovid Medline, Embase, and Scopus following the PRISMA guidelines. We determined the risk of bias of included studies using the Risk of Bias Assessment Tool for Nonrandomized Studies. Studies with the same effect measure were combined for a pooled estimate. We identified 15 studies that met the inclusion criteria for the final analysis, with a limited number of studies evaluating each study question. Among WLWH, current active smoking is associated with an increased risk of new HPV infections (HR = 1.33, 95% CI 1.10-1.60), HPV prevalence (ORpooled = 1.55, 95% CI 1.26-1.91), HGCIN incidence (HR = 1.5, 95% CI 1.2-2.0), and HGCIN prevalence (PR = 3.69, 95% CI 1.54-8.78). There was no significant association between current active smoking and HPV clearance. We did not identify any study that evaluated the association between SHS exposure and HPV-related cervical abnormalities among WLWH. Active smoking increases the risk of HPV infection and pre-cancer lesion development in WLWH. Considering smoking as an additional risk factor when designing tailored cervical cancer screening programs for WLWH is necessary in high smoking prevalence regions.

Quantifying social contact patterns in Minnesota during stay-at-home social distancing order.

SARS-CoV-2 is primarily transmitted through person-to-person contacts. It is important to collect information on age-specific contact patterns because SARS-CoV-2 susceptibility, transmission, and morbidity vary by age. To reduce the risk of infection, social distancing measures have been implemented. Social contact data, which identify who has contact with whom especially by age and place are needed to identify high-risk groups and serve to inform the design of non-pharmaceutical interventions. We estimated and used negative binomial regression to compare the number of daily contacts during the first round (April-May 2020) of the Minnesota Social Contact Study, based on respondent's age, gender, race/ethnicity, region, and other demographic characteristics. We used information on the age and location of contacts to generate age-structured contact matrices. Finally, we compared the age-structured contact matrices during the stay-at-home order to pre-pandemic matrices. During the state-wide stay-home order, the mean daily number of contacts was 5.7. We found significant variation in contacts by age, gender, race, and region. Adults between 40 and 50 years had the highest number of contacts. The way race/ethnicity was coded influenced patterns between groups. Respondents living in Black households (which includes many White respondents living in inter-racial households with black family members) had 2.7 more contacts than respondents in White households; we did not find this same pattern when we focused on individual's reported race/ethnicity. Asian or Pacific Islander respondents or in API households had approximately the same number of contacts as respondents in White households. Respondents in Hispanic households had approximately two fewer contacts compared to White households, likewise Hispanic respondents had three fewer contacts than White respondents. Most contacts were with other individuals in the same age group. Compared to the pre-pandemic period, the biggest declines occurred in contacts between children, and contacts between those over 60 with those below 60.

Challenges related to human papillomavirus (HPV) vaccine uptake in Minnesota: clinician and stakeholder perspectives.

BACKGROUND: Human papillomavirus (HPV) vaccination rates among adolescents are increasing in Minnesota (MN) but remain below the Healthy People 2020 goal of 80% completion of the series. The goal of this study was to identify messaging and interventions impacting HPV vaccine uptake in MN through interviews with clinicians and key stakeholders. METHODS: We conducted semi-structured key participant interviews with providers and stakeholders involved in HPV vaccination efforts in MN between 2018 and 2019. Provider interview questions focused on messaging around the HPV vaccine and clinic-based strategies to impact HPV vaccine uptake. Stakeholder interview questions focused on barriers and facilitators at the organizational or state level, as well as initiatives and collaborations to increase HPV vaccination. Responses to interviews were recorded and transcribed. Thematic content analysis was used to identify themes from interviews. RESULTS: 14 clinicians and 13 stakeholders were interviewed. Identified themes were grouped into 2 major categories that dealt with messaging around the HPV vaccine, direct patient-clinician interactions and external messaging, and a third thematic category involving healthcare system-related factors and interventions. The messaging strategy identified as most useful was promoting the HPV vaccine for cancer prevention. The need for stakeholders to prioritize HPV vaccination uptake was identified as a key factor to increasing HPV vaccination rates. Multiple providers and stakeholders identified misinformation spread through social media as a barrier to HPV vaccine uptake. CONCLUSION: Emphasizing the HPV vaccine's cancer prevention benefits and prioritizing it among healthcare stakeholders were the most consistently cited strategies for promoting HPV vaccine uptake. Methods to combat the negative influence of misinformation about HPV vaccines in social media are an urgent priority.

Historical and projected hysterectomy rates in the USA: Implications for future observed cervical cancer rates and evaluating prevention interventions.

BACKGROUND: SEER-reported cervical cancer incidence rates reflect the total female population including women no longer at risk due to hysterectomy. Hysterectomy rates have been declining in the United States as alternative treatments have become available, which could result in an apparent increase in SEER-reported cervical cancer rates. We aimed to obtain nationally representative historical data on hysterectomy rates in USA, use trends analysis to project rates back to 1935 and forward to 2035, and then predict the impact of changing hysterectomy rates on SEER-reported cervical cancer rates. METHODS: We performed a systematic search of Medline, Embase, Premedline, Cochrane Central databases and extracted nationally-representative hysterectomy incidence data from 1965 to 2009, including data on the number of cervix-preserving (subtotal) procedures. We then projected rates back to 1935, and forward to 2035 based on trends from joinpoint regression. These rates were then used to estimate hysterectomy prevalence out to 2035, and then to predict the impact of changing hysterectomy rates on SEER-reported cervical cancer rates to 2035. We examined alternative assumptions regarding projected hysterectomy incidence rates out to 2035, including a scenario in which rates decline no further from 2009 rates, and a scenario where rates decline at twice the baseline rate. RESULTS: Estimated age-standardized hysterectomy incidence increased from 2.4 to 10.6 per 1000 women between 1935 and 1975. Thereafter, rates are predicted to fall to 3.9 per 1000 by 2035. Subtotal hysterectomy procedures declined from being the predominant method in 1935 to less than 12% of procedures from 1970 onwards. Consequently, holding all else constant, an increase in SEER-reported age-standardized cervical cancer incidence rates (ages 0-85+) of 9% is expected from 2009 to 2035. The predictions were minimally impacted by alternative scenarios for future hysterectomy rates. CONCLUSIONS: Declining hysterectomy rates have implications for the interpretation of SEER-reported cervical cancer rates. A background increase in cervical cancer rates due to decreasing population hysterectomy exposure may partially offset expected decreases from recent cervical screening changes recommended by the US Preventive Services Task Force. Evaluations of new cervical cancer prevention opportunities should consider the background impact of historical and projected hysterectomy rates.

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer.

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from 6 working groups, and a recent symposium cosponsored by the ACS, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (eg, the management of screen positives and screening intervals for screen negatives) of women after screening, the age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16 and HPV18 infections.

Risk-Taking Behaviors and Sexual Violence Among Secondary School Students in Tanzania.

There is limited district level data on drug or alcohol use as well as sex and reproductive history among secondary school students in Tanzania to inform prevention efforts. To address this, we conducted a survey of 2523 secondary school students in 2 districts (Bahi and Mpwapwa) and the Dodoma municipal area in Tanzania. Overall, fifty three percent were female and 67% were between the ages of 15 and 17 years old. Students in the Dodoma Municipality district self-reported the highest prevalence of forced sex, sex for gifts or money, and drug use. Students in the Bahi district reported the highest prevalence of alcohol use. Males reported a higher prevalence of consensual sex, contraception use, and alcohol and drug use compared to females, the latter of whom reported a higher prevalence of forced sex. Most students' indicated that their primary source of sex and reproductive health information was their teachers. These results suggest the need for tailored interventions among secondary school students in the Dodoma region in Tanzania.

Concordance of Self- and Clinician-Collected Anal Swabs to Detect Human Papillomavirus in a Sample of HIV-Negative Men.

OBJECTIVE: The aim of this study was to determine the concordance of self- and clinician-collected anorectal swabs for the detection of human papillomavirus (HPV) DNA in a population of HIV-negative men who have sex with men (MSM). METHODS: This cross-sectional study involved recruitment of HIV-negative MSM in a Midwestern US metropolitan area to collect paired sequential self- and clinician-collected anorectal swabs using illustrated instructions. Swabs were tested for type-specific HPV DNA with a comparison of type-specific HPV categories detected by each method. The sensitivity and specificity of self-collection were calculated assuming clinician collection as the criterion standard. McNemar's test and κ statistics were used to determine percent agreement and concordance of self- and clinician-collected swab results. RESULTS: Seventy-eight participants had paired anorectal swab samples of adequate quality for analyses. The sensitivity and specificity of self-collected swabs for detection of all high-risk HPV DNA types were 69.8% and 91.4%, respectively. Similar degrees of sensitivity and specificity of self-collection were seen for other groups of high-risk HPV types. Percent agreement and κ statistic for self- and clinician-collected swabs for all high-risk HPV types were 80.8% and 0.53, respectively. CONCLUSIONS: Self-collected anorectal swab samples showed lower sensitivity but moderate to high specificity for detection of high-risk and vaccine-preventable HPV types compared with clinician-collected swab samples. Self-collection instructional details and the thoroughness of clinician collection of samples may have impacted sensitivity and specificity, suggesting a need to optimize and standardize instructions.

Effect of an Electronic Health Record Decision Support Alert to Decrease Excess Cervical Cancer Screening.

OBJECTIVE: Cervical cancer screening is often conducted in excess of current screening guidelines. The objective of this study was to evaluate the effect of an electronic health record (EHR) clinical decision support alert to decrease guideline-nonadherent cervical cancer screening beyond the age limits of screening or posthysterectomy. MATERIALS AND METHODS: The proportion of guideline-nonadherent Pap tests in women younger than 21 years or older than 65 years or posthysterectomy were compared 4 months before and 3 months after implementation of an EHR clinical decision support alert warning providers that a Pap test is not indicated. Providers could cancel the Pap test or override the alert and place the order. Provider characteristics and Pap test indications were summarized by preintervention/postintervention period using descriptive statistics. The proportions of nonindicated Pap tests were compared by intervention period and provider characteristics using generalized estimating equation models. RESULTS: In women beyond the screening age limits or posthysterectomy, a total of 388 Pap tests were ordered before intervention, and 313 tests were ordered after intervention. Proportion of guideline-nonadherent tests was similar before (62%) and after intervention (63%); thus, implementation of the clinical decision support alert did not change the proportion of guideline-nonadherent Pap tests ordered (OR = 1.08, 95% CI = 0.77-1.52). It is notable that 52% of guideline-nonadherent tests were ordered by 11 providers. Even when controlling for providers who ordered more than 1 test during the study period, multivariate analysis showed that male providers were more likely to order guideline-nonadherent Pap tests (OR = 2.30, 95% CI = 1.36-3.89); no other differences by provider characteristics were observed. CONCLUSIONS: An EHR clinical decision support alert does not decrease guideline-nonadherent cervical cancer screening. These data suggest efforts to optimize clinical decision support should be focused on other aspects of cervical cancer prevention.

Age at last screening and remaining lifetime risk of cervical cancer in older, unvaccinated, HPV-negative women: a modelling study.

BACKGROUND: There is a paucity of empirical evidence to inform the age at which to stop cervical cancer screening. The recommended age to stop screening generally varies between age 50-70 years worldwide. However, cervical cancer incidence and mortality remain high in older women. We used a Markov model of cervical cancer screening to estimate the remaining lifetime risk of cervical cancer at different ages and with different exit screening tests, with the aim of informing recommendations of the age at which to stop cervical cancer screening in developed countries. METHODS: For this modelling study, we developed a state transition (Markov) model of cervical cancer natural history and screening. We developed, calibrated, and validated our model using Canadian provincial registries and survey data. To simulate an age-structured population in the model, a new cohort of 236 564 women (one fifth of the population of Canadian women aged 20-24 years in 2012) entered the model every year and were successively modelled in parallel. Successive cohorts entered the model at age 10 years, creating an age-structured population of women aged 10-100 years. Women who had a total hysterectomy were excluded from the analyses. We calibrated our model to human papillomavirus (HPV) infection and cancer incidence with data from Statistics Canada, which compiles the data from 13 individual provincial registries. We chose a three-stage progressive cervical intraepithelial neoplasia model to include differences in management and treatment decisions depending on lesion severity. We modelled infections with four high-risk HPV groups: HPV16 and HPV18; HPV31, HPV33, HPV45, HPV52, and HPV58; HPV35, HPV39, HPV51, HPV56, HPV59, HPV66, and HPV68; and a generic group of other potentially oncogenic HPVs. We estimated 5-year, 10-year, and remaining lifetime risk of cervical cancer for older, unvaccinated women who stopped screening at different ages and underwent different screening tests. FINDINGS: Cervical cancer incidence excluding women with hysterectomies underestimated the incidence of cervical cancer in women with a cervix by up to 71% in women aged 80-84 years. Our model predicted that women without HPV vaccination who have been never screened have a 1 in 45 (95% percentile interval 1 in 32 to 1 in 64) lifetime risk of cervical cancer. Perfect adherence (100% of women screened) to cytology screening every 3 years between the ages of 25 years and 69 years could reduce the lifetime risk of cervical cancer to 1 in 532 women (95% percentile interval 1 in 375 to 1 in 820) without HPV vaccination. Increasing the age at which women stopped cytology screening from 55 years to 75 years led to incremental decreases in cancer risk later in life. A 70-year old woman whose screening history was unknown had an average remaining lifetime risk of 1 in 588 (<1%; 95% percentile interval 1 in 451 to 1 in 873) if she stopped screening. Her remaining lifetime risk at age 70 years was reduced to 1 in 1206 (2·0 times reduction; 95% percentile interval 1 in 942 to 1 in 1748) if she had a negative cytology test, 1 in 6525 (12·9 times reduction; 95% percentile interval 1 in 3167 to 1 in 18 664) if she had a negative HPV test, and 1 in 9550 (18·1 times reduction; 95% percentile interval 1 in 4928 to 1 in 23 228) if she had a negative co-test for cytology and HPV. INTERPRETATION: Cervical cancer risk reductions might be achieved by screening with cytology up to age 75 years, although with diminishing returns. A negative exit oncogenic HPV test or negative HPV test plus cytology correlates with a low remaining lifetime cervical cancer risk for unvaccinated women with a cervix after the age of 55 years. FUNDING: Canadian Institutes of Health Research.

Optimizing Screening for Sexually Transmitted Infections in Men Using Self-Collected Swabs: A Systematic Review.

BACKGROUND: Sexually transmitted infection (STI) rates are increasing in the United States while funding for prevention and treatment programs has declined. Sample self-collection for STI testing in men may provide an acceptable, easy, rapid, and potentially cost-effective method for increasing diagnosis and treatment of STIs. METHODS: We conducted a systematic review of articles assessing self-collection of anal, oral, or genital swab samples among adult men for detection of STIs and/or human papillomavirus-related dysplasia. We searched for English-language articles in which men 18 years or older were recruited to participate. RESULTS: Our literature search resulted in 1053 citations, with 20 meeting inclusion criteria. Self-collection methods were highly sensitive and comparable with clinician collection for detection of multiple STI pathogens. However, self-collected samples were less likely to be of adequate quality for anorectal cytology and less sensitive for detection of anal intraepithelial neoplasia than clinician-collected samples. Self-collection was highly acceptable. Overall, studies were small and heterogeneous and used designs providing lower levels of evidence. CONCLUSIONS: Self-collection methods are a viable option for collecting samples for STI testing in adult men based on their high feasibility, acceptability, and validity. Implementation of self-collection procedures in STI testing venues should be performed to expand opportunities for STI detection and treatment.

Pertussis and the Minnesota State Fair: Demonstrating a Novel Setting for Efficiently Conducting Seroepidemiologic Studies.

Seroepidemiologic studies, which measure serum antibody levels produced in response to infection and/or vaccination, can be valuable tools for gaining insight into population level dynamics of infectious diseases. However, because seroepidemiologic studies are expensive and logistically challenging, they are not routinely conducted for surveillance purposes. We have identified a novel venue, state fairgrounds, in which annual sera samples from a population may be rapidly collected with minimal recruitment expenses. We conducted a pilot pertussis seroepidemiologic study over the course of 3 days at the 2016 Minnesota State Fair to determine if this setting, which hosts nearly 2 million visitors over 12 days each year, is viable for facilitating larger seroepidemiologic studies. A total of 104 adults and children were enrolled to provide a finger stick blood sample for serologic testing and to take a written survey regarding recent cough illness and pertussis vaccination. The survey was used to distinguish between antibodies induced by vaccination and pertussis infection. Elevated antibodies suggestive of recent infection were found among two adults. The prevalence of undetectable antibodies, suggestive of susceptibility, was 72.3% (95% CI 59.6, 85.1%) among 7-17 year olds, 53.8% (95% CI 26.7, 80.9%) among 1-6 year olds, and 23.3% (95% CI 8.2, 38.5%) among adults. Our ability to rapidly enroll participants and collect satisfactory specimens suggests that seroepidemiologic studies with 1000-2000 participants could efficiently be completed over the 12-day course of the Minnesota State Fair. This setting raises the possibility of efficiently conducting annual population-based seroepidemiologic studies to supplement traditional public health surveillance in estimating disease prevalence, monitoring vaccine impact, and identifying at-risk groups.

A Cross-Sectional Review of Cervical Cancer Messages on Twitter During Cervical Cancer Awareness Month.

OBJECTIVES: The objectives of this study were to quantify personal stories about cervical cancer and to determine the proportion and sentiment (positive vs negative) of messages ("tweets") that discussed cervical cancer prevention strategies on Twitter. METHODS: This study was a cross-sectional Twitter review of English-language top tweets about cervical cancer during the Cervical Cancer Awareness month, January 2016. Theme categories were identified, and tweets were independently coded by 2 reviewers; discrepancies in coding were resolved by a third reviewer. Descriptive statistical analyses were performed. RESULTS: During January 2016, approximately 348 top tweets about cervical cancer were identified. Professional health organizations produced 20.7% of tweets, and individuals identifying themselves as health-care professionals contributed an additional 4%. In addition to the tweet, 45.1% attached a photo or video; 54.6% included links to a larger article. Only 11.2% of tweets included personal stories from cervical cancer patients. Among the top tweets, 70.3% were focused on prevention through screening and/or HPV vaccination, with 97.4% recommending such practices. A substantial proportion of the Twitter traffic (24.7%) referenced the #SmearForSmear campaign by the patient-advocate organization Jo's Cervical Cancer Trust, based in the United Kingdom. CONCLUSIONS: Analysis of top tweets during the cervical cancer awareness month showed that, although personal stories about cervical cancer were rare, cervical cancer prevention was a popular topic during the cervical cancer awareness month. This was largely driven by a picture-based twitter campaign from a single advocacy organization.

Excess Cost of Cervical Cancer Screening Beyond Recommended Screening Ages or After Hysterectomy in a Single Institution.

OBJECTIVE: The aim of the study was to estimate the excess cost of guideline nonadherent cervical cancer screening in women beyond the recommended screening ages or posthysterectomy in a single healthcare system. MATERIALS AND METHODS: All Pap tests performed between September 1, 2012, and August 31, 2014, in women younger than 21 years, older than 65 years, or after hysterectomy, were coded as guideline adherent or nonadherent per the 2012 America Society of Colposcopy and Clinical Pathology guidelines. We assumed management of abnormal results per the 2013 America Society of Colposcopy and Clinical Pathology management guidelines. Costs were obtained from a literature review and Center for Medicare and Medicaid Services data and applied to nonadherent screening and subsequent diagnostic tests. RESULTS: During this period, 1,398 guideline nonadherent Pap tests were performed (257 in women <21 years, 536 in women >65 years, and 605 after hysterectomy), with 88 abnormal results: 35 (13.5%) in women younger than 21 years, 14 (2.6%) in women older than 65 years, and 39 (6.5%) in women after hysterectomy. The excess cost for initial screening, diagnostic tests, and follow-up was US $35,337 for 2 years in women younger than 21 years, US $54,378 for 5 years in women older than 65 years, and US $77,340 for 5 years in women after hysterectomy, resulting in a total excess cost of US $166,100 for 5 years. Of the 1,398 women who underwent guideline nonadherent screening, there were only 2 (0.1%) diagnoses of high-grade dysplasia (VaIN3). CONCLUSIONS: Guideline nonadherent cervical cancer screening in women beyond the recommended screening ages and posthysterectomy resulted in costs exceeding US $160,000 for screening, diagnostic tests, and follow-up with minimal improvement in detection of high-grade dysplasia.

Using Multiple Outcomes of Sexual Behavior to Provide Insights Into Chlamydia Transmission and the Effectiveness of Prevention Interventions in Adolescents.

BACKGROUND: Mathematical models are important tools for assessing prevention and management strategies for sexually transmitted infections. These models are usually developed for a single infection and require calibration to observed epidemiological trends in the infection of interest. Incorporating other outcomes of sexual behavior into the model, such as pregnancy, may better inform the calibration process. METHODS: We developed a mathematical model of chlamydia transmission and pregnancy in Minnesota adolescents aged 15 to 19 years. We calibrated the model to statewide rates of reported chlamydia cases alone (chlamydia calibration) and in combination with pregnancy rates (dual calibration). We evaluated the impact of calibrating to different outcomes of sexual behavior on estimated input parameter values, predicted epidemiological outcomes, and predicted impact of chlamydia prevention interventions. RESULTS: The two calibration scenarios produced different estimates of the probability of condom use, the probability of chlamydia transmission per sex act, the proportion of asymptomatic infections, and the screening rate among men. These differences resulted in the dual calibration scenario predicting lower prevalence and incidence of chlamydia compared with calibrating to chlamydia cases alone. When evaluating the impact of a 10% increase in condom use, the dual calibration scenario predicted fewer infections averted over 5 years compared with chlamydia calibration alone [111 (6.8%) vs 158 (8.5%)]. CONCLUSIONS: While pregnancy and chlamydia in adolescents are often considered separately, both are outcomes of unprotected sexual activity. Incorporating both as calibration targets in a model of chlamydia transmission resulted in different parameter estimates, potentially impacting the intervention effectiveness predicted by the model.

Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians.

DESCRIPTION: The purpose of this best practice advice article is to describe the indications for screening for cervical cancer in asymptomatic, average-risk women aged 21 years or older. METHODS: The evidence reviewed in this work is a distillation of relevant publications (including systematic reviews) used to support current guidelines. BEST PRACTICE ADVICE 1: Clinicians should not screen average-risk women younger than 21 years for cervical cancer. BEST PRACTICE ADVICE 2: Clinicians should start screening average-risk women for cervical cancer at age 21 years once every 3 years with cytology (cytologic tests without human papillomavirus [HPV] tests). BEST PRACTICE ADVICE 3: Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years. BEST PRACTICE ADVICE 4: Clinicians may use a combination of cytology and HPV testing once every 5 years in average-risk women aged 30 years or older who prefer screening less often than every 3 years. BEST PRACTICE ADVICE 5: Clinicians should not perform HPV testing in average-risk women younger than 30 years. BEST PRACTICE ADVICE 6: Clinicians should stop screening average-risk women older than 65 years for cervical cancer if they have had 3 consecutive negative cytology results or 2 consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years. BEST PRACTICE ADVICE 7: Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.

Adherence to the 2012 national cervical cancer screening guidelines: a pilot study.

OBJECTIVE: The goal of this pilot study was to evaluate adherence to the 2012 cervical cancer screening guidelines among health care providers in a large health maintenance organization. STUDY DESIGN: A cross-sectional survey evaluating knowledge, reported practices, and views of the 2012 cervical cancer screening guidelines was distributed to 325 health care providers within HealthPartners. The survey was divided into 3 sections: (1) provider demographics; (2) knowledge of the 2012 age-specific cancer screening guidelines; and (3) provider practice. Comparisons based on appropriate knowledge and practice of the guidelines were made using Fisher exact tests. RESULTS: The response rate was 42%. Of 124 respondents, 15 (12.1%) reported they were not aware of the 2012 guideline changes. Only 7 (5.7%) respondents answered all the knowledge questions correctly. A majority of respondents reported correct screening practices in the 21-29 year patient age group (65.8%) and in the >65 year patient age group (74.3%). Correct screening intervals in the 30-65 year patient age group varied by modality, with 89.3% correctly screening every 3 years with Pap smear alone, but only 57.4% correctly screening every 5 years with Pap smear + human papillomavirus cotesting. The most frequently cited reasons for not adhering were lack of knowledge of the guidelines and patient demand for a different screening interval. CONCLUSION: Adherence to the 2012 cervical cancer screening guidelines is poor due, in part, to a lack of knowledge of the guidelines. Efforts should focus on improved provider and patient education, and methods that facilitate adherence to the guidelines such as electronic health record order sets.