Cancer risk in people living with HIV and solid organ transplant recipients: a systematic review and meta-analysis.

BACKGROUND: Systematic evaluations of cancer risk in people living with HIV or AIDS (PLHIV) and solid organ transplant recipients provide unique insights into the role of the immune system in cancer development. In this systematic review and meta-analysis, we expand previous analyses of cancer risk for these two immunocompromised populations. METHODS: We considered studies published in English and listed on PubMed or Embase up to July 1, 2022. Studies were eligible for inclusion if they used population-based registries and compared cancer incidence in PLHIV or solid organ transplant recipients with the general population in the same geographical area. We extracted the number of observed site-specific cancers and expected cases and calculated meta-standardised incidence ratios for cancer within PLHIV and solid organ transplant recipients. In solid organ transplant recipients meta-standardised incidence ratios were compared by organ type. This project is registered on PROSPERO, CRD42022366679. FINDINGS: 46 studies in PLHIV and 67 in solid organ transplant recipients were included in the analysis. Meta-standardised incidence ratios for cancers associated with human papillomavirus were increased in both populations; the highest meta-standardised incidence ratio in PLHIV was anal cancer (37·28 [95% CI 23·65-58·75], I2=97·4%), and in solid organ transplant recipients was cutaneous squamous cell carcinoma (45·87 [31·70-66·38], I2=99·0%). Meta-standardised incidence ratios were significantly increased for most non-HPV viral-infection-related cancers in both populations; the highest standard incidence ratios were for Kaposi sarcoma (PLHIV: 801·52 [95% CI 200·25-3208·13], I2=100·0%; solid organ transplant recipients: 47·31 [23·09-96·95], I2=87·7%) and non-Hodgkin lymphoma (32·53 [19·64-53·87], I2=99·8%; 10·24 [8·48-12·35], I2=94·9%). Eight types of cancer with no known viral cause showed an increased risk in solid organ transplant recipients only; no cancer type showed increased risk in PLHIV only. INTERPRETATION: Cancer risk was increased for a range of infection-related cancers in both PLHIV and solid organ transplant recipients, but divergent results in these and other cancers have emerged. The cancer risk patterns probably reflect variances in the degree of impaired immunity, exposure to carcinogenic viruses, and perhaps exposure to carcinogenic immunosuppressive agents. FUNDING: US National Cancer Institute, National Institutes of Health.

Disparities in HPV vaccine knowledge and adolescent HPV vaccine uptake by parental nativity among diverse multiethnic parents in New Jersey.

BACKGROUND: Suboptimal human papillomavirus (HPV) vaccination rates persist among adolescents in the United States (U.S.). New Jersey (NJ), among the top, most racially/ethnically diverse states in the U.S., had among the lowest HPV vaccine initiation rates, prior to 2018. This study examined parental HPV vaccine knowledge and adolescent HPV vaccine initiation among multiethnic parents in NJ, where access to language concordant HPV vaccine information and vaccination services may differ, for immigrant parents. METHODS: We surveyed parents of adolescents (ages 11-18) at community events in NJ to examine parental HPV vaccine knowledge and adolescent HPV vaccine uptake. Vaccine knowledge was assessed using an 11-item question stem that covered vaccine efficacy, gender recommendation, vaccine protection, and myths. Multivariable models assessed the association of parent nativity on HPV vaccine knowledge scores and adolescent HPV vaccine initiation, controlling for sociodemographic factors. RESULTS: Of the 77 parents, most parents (84%) were aware of the HPV vaccine. However, knowledge scores were low and differed by parent nativity. Non-U.S. born parents had significantly lower knowledge scores - 1.7 [- 3.1, - 0.4] and lower odds of adolescent children initiating the HPV vaccine 0.3 [0.1, 0.9] compared to U.S.-born parents after adjusting demographic characteristics. CONCLUSIONS: Our findings reveal that parental HPV vaccine knowledge remains low among suburban dwelling, immigrant parents, even though they have higher education and access to health care. Multilevel strategies to reduce missed opportunities for HPV vaccine education among parents and HPV vaccination for adolescents are needed, including for suburban, immigrant communities.

Patterns of HIV testing among women diagnosed with invasive cervical cancer in the New Jersey Medicaid Program.

PURPOSE: Practice-based guidelines recommend HIV testing during initial invasive cervical cancer (ICC) workup. Determinants of HIV testing during diagnosis of AIDS-defining cancers in vulnerable populations, where risk for HIV infection is higher, are under-explored. METHODS: We examine factors associated with patterns of HIV testing among Medicaid enrollees diagnosed with ICC. Using linked data from the New Jersey State Cancer Registry and New Jersey Medicaid claims and enrollment files, we evaluated HIV testing among 242 ICC cases diagnosed from 2012 to 2014 in ages 21-64 at (a) any point during Medicaid enrollment (2011-2014) and (b) during cancer workup 6 months pre ICC diagnosis to 6 months post ICC diagnosis. Logistic regression models identified factors associated with HIV testing. RESULTS: Overall, 13% of women had a claim for HIV testing during ICC workup. Two-thirds (68%) of women did not have a claim for HIV testing (non-receipt of HIV testing) while enrolled in Medicaid. Hispanic/NH-API/Other women had lower odds of non-receipt of HIV testing compared with NH-Whites (OR: 0.40; 95% CI: 0.17-0.94). Higher odds of non-receipt of HIV testing were observed among cases with no STI testing (OR: 4.92; 95% CI 2.27-10.67) and < 1 year of Medicaid enrollment (OR: 3.07; 95% CI 1.14- 8.26) after adjusting for other factors. CONCLUSIONS: Few women had HIV testing claims during ICC workup. Opportunities for optimal ICC care are informed by knowledge of HIV status. Further research should explore if lack of HIV testing claims during ICC workup is an accurate indicator of ICC care, and if so, to assess testing barriers during workup.

Risk of hepatocellular carcinoma in people with HIV in the United States, 2001-2019.

BACKGROUND: People with HIV have higher risk of hepatocellular carcinoma than the general population, partly because of higher prevalence of coinfection with hepatitis B virus (HBV) or hepatitis C virus (HCV). METHODS: We calculated standardized incidence ratios for hepatocellular carcinoma in people with HIV by comparing rates from people with HIV in the HIV/AIDS Cancer Match Study, a population-based HIV and cancer registry linkage, to those in the general population. We used multivariable Poisson regression to estimate adjusted incidence rate ratios among people with HIV and linked the Texas HIV registry with medical claims data to estimate adjusted odds ratios (AORs) of HBV and HCV in hepatocellular carcinoma patients with logistic regression. RESULTS: Compared with the general population, hepatocellular carcinoma rates in people with HIV were elevated 2.79-fold (n = 1736; 95% confidence interval [CI] = 2.66 to 2.92). Hepatocellular carcinoma rates decreased statistically significantly from 2001-2004 to 2015-2019 (P < .001). Compared with men who have sex with men, hepatocellular carcinoma risk was elevated 4.28-fold among men who injected drugs (95% CI = 3.72 to 4.93) and 1.83-fold among women who injected drugs (95% CI = 1.49 to 2.26). In Texas, 146 hepatocellular carcinoma cases among people with HIV were linked to claims data: 25% HBV positive, 59% HCV positive, and 13% coinfected with HBV and HCV. Compared with men who had sex with men, people who inject drugs had 82% decreased odds of HBV (AOR = 0.18, 95% CI = 0.05 to 0.63) and 2 times the odds of HCV (AOR = 20.4, 95% CI = 3.32 to 125.3). CONCLUSIONS: During 2001-2019, hepatocellular carcinoma risk declined among people with HIV, though rates remain statistically significantly elevated compared with the general population, particularly among people who inject drugs. Prevention and treatment of HBV/HCV are needed to reduce hepatocellular carcinoma risk among people with HIV.

Cancer Treatment Disparities in People With HIV in the United States, 2001-2019.

PURPOSE: People with HIV (PWH) have worse cancer outcomes, partially because of inequities in cancer treatment. We evaluated cancer treatment disparities among PWH, including an assessment of changes in disparities over time. METHODS: We used data from the HIV/AIDS Cancer Match Study, a population-based HIV and cancer registry linkage to examine diffuse large B-cell lymphoma (DLBCL), Hodgkin lymphoma (HL), and cancers of the cervix, lung, anus, prostate, colon, and female breast. Outcomes included receipt of (1) any cancer treatment and (2) standard therapy among patients with local-stage cancer. We assessed associations between HIV and each outcome by estimating adjusted prevalence odds ratios (aORs) with 95% CI and trends over time. We identified predictors of nonreceipt of cancer treatment in PWH. RESULTS: From 2001 to 2019, compared with people with cancer without HIV (n = 2,880,955), PWH (n = 16,334) were more likely to not receive cancer treatment for cervical cancer (aOR, 2.03 [95% CI, 1.52 to 2.70]), DLBCL (aOR, 1.53 [95% CI, 1.38 to 1.70]), HL (aOR, 1.39 [95% CI, 1.19 to 1.63]), lung cancer (aOR, 1.79 [95% CI, 1.65 to 1.93]), prostate cancer (aOR, 1.32 [95% CI, 1.21 to 1.44]), colon cancer (aOR, 1.73 [95% CI, 1.43 to 2.08]), and breast cancer (aOR, 1.38 [95% CI, 1.07 to 1.77]). Similar associations were observed in PWH with local-stage cancers although no difference was observed for anal cancers. The association between HIV and nonreceipt of cancer treatment significantly decreased over time for breast, colon, and prostate cancers (all P trend <.0001), but PWH remained less likely to receive treatment in 2014-2019 for DLBCL, cervix, and lung cancers. Among PWH, Black individuals, people who inject drugs, and those 65 years and older were less likely to receive cancer treatment. CONCLUSION: Disparities in receipt of cancer treatment persist for PWH in the United States in contemporary time periods. Solutions to address inequitable receipt of cancer treatment among PWH are urgently needed.

Severe housing cost burden and premature mortality from cancer.

Unaffordable housing has been associated with poor health. We investigated the relationship between severe housing cost burden and premature cancer mortality (death before 65 years of age) overall and by Medicaid expansion status. County-level severe housing cost burden was measured by the percentage of households that spend 50% or more of their income on housing. States were classified on the basis of Medicaid expansion status (expanded, late-expanded, nonexpanded). Mortality-adjusted rate ratios were estimated by cancer type across severe housing cost burden quintiles. Compared with the lowest quintile of severe housing cost burden, counties in the highest quintile had a 5% greater cancer mortality rate (mortality-adjusted rate ratio = 1.05, 95% confidence interval = 1.01 to 1.08). Within each severe housing cost burden quintile, cancer mortality rates were greater in states that did not expand Medicaid, though this association was significant only in the fourth quintile (mortality-adjusted rate ratio = 1.08, 95% confidence interval = 1.03 to 1.13). Our findings demonstrate that counties with greater severe housing cost burden had higher premature cancer death rates, and rates are potentially greater in non-Medicaid-expanded states than Medicaid-expanded states.

Clinical Multiteam System Composition and Complexity Among Newly Diagnosed Early-Stage Breast, Colorectal, and Lung Cancer Patients With Multiple Chronic Conditions: A SEER-Medicare Analysis.

PURPOSE: Sixty percent of adults have multiple chronic conditions at cancer diagnosis. These patients may require a multidisciplinary clinical team-of-teams, or a multiteam system (MTS), of high-complexity involving multiple specialists and primary care, who, ideally, coordinate clinical responsibilities, share information, and align clinical decisions to ensure comprehensive care needs are managed. However, insights examining MTS composition and complexity among individuals with cancer and comorbidities at diagnosis using US population-level data are limited. METHODS: Using SEER-Medicare data (2006-2016), we identified newly diagnosed patients with breast, colorectal, or lung cancer who had a codiagnosis of cardiopulmonary disease and/or diabetes (n = 75,201). Zaccaro's theory-based classification of MTSs was used to categorize clinical MTS complexity in the 4 months following cancer diagnosis: high-complexity (≥ 4 clinicians from ≥ 2 specialties) and low-complexity (1-3 clinicians from 1-2 specialties). We describe the proportions of patients with different MTS compositions and quantify the incidence of high-complexity MTS care by patient groups. RESULTS: The most common MTS composition was oncology with primary care (37%). Half (50.3%) received high-complexity MTS care. The incidence of high-complexity MTS care for non-Hispanic Black and Hispanic patients with cancer was 6.7% (95% CI, -8.0 to -5.3) and 4.7% (95% CI, -6.3 to -3.0) lower than non-Hispanic White patients with cancer; 13.1% (95% CI, -14.1 to -12.2) lower for rural residents compared with urban; 10.4% (95% CI, -11.2 to -9.5) lower for dual Medicaid-Medicare beneficiaries compared with Medicare-only; and 16.6% (95% CI, -17.5 to -15.8) lower for colorectal compared with breast cancer. CONCLUSION: Incidence differences of high-complexity MTS care were observed among cancer patients with multiple chronic conditions from underserved populations. The results highlight the need to further understand the effects of and mechanisms through which care team composition, complexity, and functioning affect care quality and outcomes.

Disparities in geospatial patterns of cancer care within urban counties and structural inequities in access to oncology care.

OBJECTIVE: To examine geospatial patterns of cancer care utilization across diverse populations in New Jersey-a state where most residents live in urban areas. DATA SOURCES/STUDY SETTING: We used data from the New Jersey State Cancer Registry from 2012 to 2014. STUDY DESIGN: We examined the location of cancer treatment among patients 20-65 years of age diagnosed with breast, colorectal, or invasive cervical cancer and investigated differences in geospatial patterns of care by individual and area-level (e.g., census tract-level) characteristics. DATA COLLECTION/EXTRACTION METHODS: Multivariate generalized estimating equation models were used to determine factors associated with receiving cancer treatment within residential counties, residential hospital service areas, and in-state (versus out-of-state) care. PRINCIPAL FINDINGS: We observed significant differences in geospatial patterns of cancer treatment by race/ethnicity, insurance type, and area-level factors. Even after adjusting for tumor characteristics, insurance type, and other demographic factors, non-Hispanic Black patients had a 5.6% higher likelihood of receiving care within their own residential county compared to non-Hispanic White patients (95% CI: 2.80-8.41). Patients insured with Medicaid and those without insurance had higher likelihoods of receiving care within their residential county compared to privately insured individuals. Patients living in census tracts with the highest quintile of social vulnerability were 4.6% more likely to receive treatment within their residential county (95% CI: 0.00-9.30) and were 2.7% less likely to seek out-of-state care (95% CI: -4.85 to -0.61). CONCLUSIONS: Urban populations are not homogenous in their geospatial patterns of cancer care utilization, and individuals living in areas with greater social vulnerability may have limited opportunities to access care outside of their immediate residential county. Geographically tailored efforts, along with socioculturally tailored efforts, are needed to help improve equity in cancer care access.

Human Papillomavirus Awareness by Educational Level and by Race and Ethnicity.

Importance: Understanding disparities in human papillomavirus (HPV) awareness is crucial, given its association with vaccine uptake. Objective: To investigate differences in HPV awareness by educational attainment, race, ethnicity, and their intersectionality. Design, Setting, and Participants: This cross-sectional study used the Health Information National Trends Survey (HINTS) 5 cycles 1 to 4 data (January 26, 2017, to June 15, 2020). The data were analyzed from December 12, 2022, to June 20, 2023. A sample of the noninstitutionalized civilian US population 18 years or older was included in the analysis. Main Outcomes and Measures: Weighted prevalence of HPV awareness, HPV vaccine awareness, and knowledge that HPV causes cancer, stratified by educational attainment and by race and ethnicity. Interaction between educational attainment and race and ethnicity was assessed using a Wald test. Results: A total of 15 637 participants had educational attainment data available; of these, 51.2% were women, and the median age was 58 (IQR, 44-69) years. A total of 14 444 participants had race and ethnicity information available; of these, 4.6% were Asian, 13.9% were Black, 15.3% were Hispanic, 62.6% were White, and 3.6% were of other race or ethnicity (including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and more than 1 race or ethnicity). Awareness of HPV by educational attainment ranged from 40.4% for less than high school to 78.2% for college or higher; awareness by race and ethnicity ranged from 46.9% among Asian individuals to 70.2% among White individuals. Awareness of HPV vaccines across educational attainment ranged from 34.7% among those with less than high school to 74.7% among those with a college degree or higher and by race and ethnicity from 48.4% among Asian individuals to 68.2% among White individuals. Among adults who were aware of HPV, knowledge that HPV causes cervical cancer differed by educational attainment, ranging from 51.7% among those with less than high school to 84.7% among those with a college degree or higher, and by race and ethnicity, ranging from 66.0% among Black individuals to 77.9% among Asian individuals. The interaction between educational attainment and race and ethnicity on HPV awareness and HPV vaccine awareness was not significant; however, within each educational attainment level, awareness differed by race and ethnicity, with the lowest awareness consistently among Asian individuals regardless of educational attainment. Within each racial and ethnic group, HPV awareness and HPV vaccine awareness significantly decreased with decreasing educational attainment. Conclusions and Relevance: Disparities in HPV awareness were evident across social factors, with the lowest awareness among Asian individuals and individuals with lower educational attainment. These results emphasize the importance of considering social factors in HPV awareness campaigns to increase HPV vaccination.

Cancer mortality rates by racial and ethnic groups in the United States, 2018-2020.

BACKGROUND: Starting in 2018, national death certificates included a new racial classification system that accounts for multiple-race decedents and separates Native Hawaiian and Pacific Islander (NHPI) individuals from Asian individuals. We estimated cancer death rates across updated racial and ethnic categories, sex, and age. METHODS: Age-standardized US cancer mortality rates and rate ratios from 2018 to 2020 among individuals aged 20 years and older were estimated with national death certificate data by race and ethnicity, sex, age, and cancer site. RESULTS: In 2018, there were approximately 597 000 cancer deaths, 598 000 in 2019, and 601 000 in 2020. Among men, cancer death rates were highest in Black men (298.2 per 100 000; n = 105 632), followed by White (250.8; n = 736 319), American Indian/Alaska Native (AI/AN; 249.2; n = 3376), NHPI (205.6; n = 1080), Latino (177.2; n = 66 167), and Asian (147.9; n = 26 591) men. Among women, Black women had the highest cancer death rates (206.5 per 100 000; n = 104 437), followed by NHPI (192.1; n = 1141), AI/AN (189.9; n = 3239), White (183.0; n = 646 865), Latina (128.4; n = 61 579), and Asian (111.4; n = 26 396) women. The highest death rates by age group occurred among NHPI individuals aged 20-49 years and Black individuals aged 50-69 and 70 years and older. Asian individuals had the lowest cancer death rates across age groups. Compared with Asian individuals, total cancer death rates were 39% higher in NHPI men and 73% higher in NHPI women. CONCLUSIONS: There were striking racial and ethnic disparities in cancer death rates during 2018-2020. Separating NHPI and Asian individuals revealed large differences in cancer mortality between 2 groups that were previously combined in vital statistics data.

Trends in Mortality From Poisonings, Firearms, and All Other Injuries by Intent in the US, 1999-2020.

Importance: Although deaths due to external causes are a leading cause of mortality in the US, trends over time by intent and demographic characteristics remain poorly understood. Objective: To examine national trends in mortality rates due to external causes from 1999 to 2020 by intent (homicide, suicide, unintentional, and undetermined) and demographic characteristics. External causes were defined as poisonings (eg, drug overdose), firearms, and all other injuries, including motor vehicle injuries and falls. Given the repercussions of the COVID-19 pandemic, US death rates for 2019 and 2020 were also compared. Design, Setting, and Participants: Serial cross-sectional study using national death certificate data obtained from the National Center for Health Statistics and including all external causes of 3 813 894 deaths among individuals aged 20 years or older from January 1, 1999, to December 31, 2020. Data analysis was conducted from January 20, 2022, to February 5, 2023. Exposures: Age, sex, and race and ethnicity. Main Outcomes and Measures: Trends in age-standardized mortality rates and average annual percentage change (AAPC) in rates calculated by intent (suicide, homicide, unintentional, and undetermined), age, sex, and race and ethnicity for each external cause. Results: Between 1999 and 2020, there were 3 813 894 deaths due to external causes in the US. From 1999 to 2020, poisoning death rates increased annually (AAPC, 7.0%; 95% CI, 5.4%-8.7%). From 2014 to 2020, poisoning death rates increased the most among men (APC, 10.8%; 95% CI, 7.7%-14.0%). During the study period, poisoning death rates increased in all the racial and ethnic groups examined; the most rapid increase was among American Indian and Alaska Native individuals (AAPC, 9.2%; 95% CI, 7.4%-10.9%). During the study period, death rates for unintentional poisoning had the most rapid rate of increase (AAPC, 8.1%; 95% CI, 7.4%-8.9%). From 1999 to 2020, firearm death rates increased (AAPC, 1.1%; 95% CI, 0.7%-1.5%). From 2013 to 2020, firearm mortality increased by an average of 4.7% annually (95% CI, 2.9%-6.5%) among individuals aged 20 to 39 years. From 2014 to 2020, mortality from firearm homicides increased by an average of 6.9% annually (95% CI, 3.5%-10.4%). From 2019 to 2020, mortality rates from external causes accelerated further, largely from increases in unintentional poisoning, and homicide due to firearms and all other injuries. Conclusions and Relevance: Results of this cross-sectional study suggest that from 1999 to 2020, death rates due to poisonings, firearms, and all other injuries increased substantially in the US. The rapid increase in deaths due to unintentional poisonings and firearm homicides is a national emergency that requires urgent public health interventions at the local and national levels.

Trends in Cancer Mortality Among Black Individuals in the US From 1999 to 2019.

Importance: Cancer is the second leading cause of mortality in the US. Despite national decreases in cancer mortality, Black individuals continue to have the highest cancer death rates. Objective: To examine national trends in cancer mortality from 1999 to 2019 among Black individuals by demographic characteristics and to compare cancer death rates in 2019 among Black individuals with rates in other racial and ethnic groups. Design, Setting, and Participants: This serial cross-sectional study used US national death certificate data obtained from the National Center for Health Statistics and included all cancer deaths among individuals aged 20 years or older from January 1999 to December 2019. Data were analyzed from June 2021 to January 2022. Exposures: Age, sex, and race and ethnicity. Main Outcomes and Measures: Trends in age-standardized mortality rates and average annual percent change (AAPC) in rates were estimated by cancer type, age, sex, and race and ethnicity. Results: From 1999 to 2019, 1 361 663 million deaths from cancer occurred among Black individuals. The overall cancer death rate significantly decreased among Black men (AAPC, -2.6%; 95% CI, -2.6% to -2.6%) and women (AAPC, -1.5%; 95% CI, -1.7% to -1.3%). Death rates decreased for most cancer types, with the greatest decreases observed for lung cancer among men (AAPC, -3.8%; 95% CI, -4.0% to -3.6%) and stomach cancer among women (AAPC, -3.4%; 95% CI, -3.6% to -3.2%). Lung cancer mortality also had the largest absolute decreases among men (-78.5 per 100 000 population) and women (-19.5 per 100 000 population). We observed a significant increase in deaths from liver cancer among men (AAPC, 3.8%; 95% CI, 3.0%-4.6%) and women (AAPC, 1.8%; 95% CI, 1.2%-2.3%) aged 65 to 79 years. There was also an increasing trend in uterus cancer mortality among women aged 35 to 49 years (2.9%; 95% CI, 2.3% to 2.6%), 50 to 64 years (2.3%; 95% CI, 2.0% to 2.6%), and 65 to 79 years (1.6%; 95% CI, 1.2% to 2.0%). In 2019, Black men and women had the highest cancer mortality rates compared with non-Hispanic American Indian/Alaska Native, Asian or Pacific Islander, and White individuals and Hispanic/Latino individuals. Conclusions and Relevance: In this cross-sectional study, there were substantial decreases in cancer death rates among Black individuals from 1999 to 2019, but higher cancer death rates among Black men and women compared with other racial and ethnic groups persisted in 2019. Targeted interventions appear to be needed to eliminate social inequalities that contribute to Black individuals having higher cancer mortality.

Justice-Involved Women and Cervical Cancer Disparities: Issues of Surveillance, Education, and Policy.

Incarceration affects an increasing number of women in the United States. For current and formerly incarcerated women (justice-involved women), incarceration has implications for health, particularly the reproductive health of women, long after incarceration is over. Currently, justice-involved women have a high cervical cancer burden relative to the general population, resulting in substantial disparities in incidence and outcomes. In this article, we review the surveillance, education, and resulting policy issues that contribute to incarceration being a determinant of cervical cancer disparities and present a potential model for continuity of care to reduce such inequity.