Knowledge, Attitudes, Willingness to Pay, and Patient Preferences About Genetic Testing and Subsequent Risk Management for Cancer Prevention.

Knowledge, attitudes, and patient preferences about genetic testing and subsequent risk management for cancer prevention among average risk populations are understudied, especially among Hispanics. This study was to assess these items by conducting an in-person survey in this understudied population. We conducted in-person surveys using a self-administered, structured questionnaire among young women in 2017. Survey questions were adapted from other validated surveys. This study had 677 participants in the final analyses. Data were collected in 2017 and analyzed in 2018 and 2019. Participants had little knowledge about genes or breast cancer risk, but most felt that genetic testing for cancer prevention is "a good idea" (87.0%), "a reassuring idea" (84.0%), and that "everyone should get the test" (87.7%). Most (64.0%) of these women would pay up to $25 for the test, 29.3% would pay $25-$500, and < 10% would pay more than $500 for the test. When asked about a hypothetical scenario of high breast cancer risk, 34.2% Hispanics and 24.5% non-Hispanics would choose chemoprevention. Women would be less likely to choose risk reduction procedures, such as mastectomy (19.6% among Hispanics and 15.1% among non-Hispanics) and salpingo-oophorectomy (11.8% among Hispanics and 10.7% among non-Hispanics). In this low-income, mostly Hispanic population, knowledge about genetic testing and cancer risk is poor, but most have positive opinions about genetic testing for cancer prevention. However, their strong preference for chemoprevention and lesser preference for prophylactic surgeries in a hypothetical scenario underscore the importance of genetic counseling and education.

Quantitative and qualitative assessment of an all-inclusive postpartum human papillomavirus vaccination program.

BACKGROUND: A postpartum human papillomavirus vaccination program was locally implemented to address low initiation rates among young adults. Within 20 months, the program achieved high vaccine initiation and series completion rates. Based on the program's success, it was expanded to all 36 counties served by a public hospital. OBJECTIVE: This study aimed to conduct a quantitative and qualitative evaluation to examine the success and limitations of the program when expanded from 1 county to 36 counties, many of which are home to rural and medically underserved communities. STUDY DESIGN: Patient navigators reviewed the electronic medical records and immunization registry records of women aged ≤26 years, who delivered an infant at the public hospital, to determine whether they needed to initiate or complete the human papillomavirus vaccine series. Eligible women were counseled and offered the human papillomavirus vaccine during their hospital stay. Patient navigators scheduled follow-up injections in addition to the mother's postpartum or her infant's well-child visits, made reminder phone calls, and rescheduled missed appointments. Descriptive statistics, including frequencies and proportions, were used for patients approached in the initial and expansion programs. Frequencies from the initial and expansion programs were examined separately. Qualitative interviews were conducted with the clinic staff to evaluate the program. The qualitative analyses were conducted using NVivo (QSR International, Melbourne, Australia, version 10). RESULTS: Both initial and expanded programs achieved vaccine completion rates above 70%. Of the 2631 eligible postpartum women enrolled in the initial program, 785 (30%) had already been fully vaccinated. Of the remaining 1846 women, 1265 (69%) women received their first dose, and 196 (11%) women received their second or third dose on the postpartum unit. Of the 1461 women who received at least 1 dose through the initial program, 1124 (77%) completed all 3 doses. Of the 4330 eligible postpartum women enrolled in the expanded program, 886 (21%) had already been fully vaccinated. Of the remaining 3444 women, 2284 (66%) received their first dose, and 343 (10%) received their second or third dose on the postpartum unit. Of the 2627 women receiving at least 1 dose through the expanded program, 1932 (74%) completed all 3 doses. Clinic staff interviewed felt the program benefited the postpartum unit and clinics, because it increased patient knowledge of the vaccine, increased patient volume for vaccination, and gave healthcare providers more time to focus on other tasks. CONCLUSION: Human papillomavirus vaccination on the postpartum unit is an effective way to increase catchup rates and is well accepted by healthcare providers. High completion rates can be achieved if adequate support is provided, even among patients residing in rural or underserved areas who need extensive support to access primary healthcare services. Although this particular program may be considered costly, it is overall effective because the vaccine prevents 5 different types of cancer in women. The inclusion of human papillomavirus vaccination in routine postpartum care is a relatively easy way to reach many adults not vaccinated at a younger age and could help address low vaccination rates among young women in the United States, including hard-to-reach populations.

Geographical disparities in human papillomavirus herd protection.

BACKGROUND: Human papillomavirus (HPV) vaccination has occurred unequally across the United States, potentially contributing to uneven vaccine-type HPV prevalence between regions. We examined whether emerging vaccine-related herd protection exhibits regional differences among unvaccinated girls and women. METHODS: We evaluated the prevalence of vaginal HPV among women 14-59 years of age from 2003 to 2014 using repeated cross-sectional data from the National Health and Nutrition Examination Survey (NHANES). Women who provided an adequate vaginal swab sample were included. Vaginal prevalence of vaccine-type HPV (types 6, 11, 16, 18) were examined in four regions of the United States between 2003 and 2014. We examined vaccine-type HPV prevalence in 2007-2014 in each US census region among younger participants (14-34 years old) stratified by vaccination status to determine whether one or both groups contributed to uneven HPV prevalence. RESULTS: A total of 12 175 participants 14-59 years of age met inclusion criteria. Vaccine-type HPV prevalence decreased in all regions. Vaccine-type HPV varied by region only among unvaccinated 14-34 year olds, with a higher prevalence in the Midwest (13.8%, 95% confidence interval (CI): 10.7-17.0) and South (12.5%, 95% CI: 10.2-14.8) compared to the Northeast (8.9%, 95% CI: 6.5-11.2). No regional variation in vaccine-type HPV prevalence was observed among vaccinated participants. CONCLUSIONS: Higher prevalence of vaccine-type HPV among unvaccinated women in the South and Midwest may contribute to regional disparities in HPV-related cancer incidence, as emerging herd immunity may not be as strong in those regions.

Variations in reason for intention not to vaccinate across time, region, and by race/ethnicity, NIS-Teen (2008-2016).

BACKGROUND: Human papillomavirus (HPV) vaccination is expected to reduce HPV-related disease and cancer in the US. However, many parents are hesitant to obtain the vaccine for their children. The purpose of this study is to examine how the reasons for refusing the HPV vaccine vary across regions of the US, across time, and by race/ethnicity. METHODS: This study used data on 13-17 year old adolescents collected by the National Immunization Survey - Teen (NIS-Teen) annually between 2008 and 2016. We evaluated the frequencies of parents who did not intend to vaccinate their children in the next year among unvaccinated children. Among these non-intenders, we evaluated how reasons for HPV vaccine hesitancy changed across time, by region of the US, and race/ethnicity. RESULTS: The proportion of non-intenders among unvaccinated decreased from 72% in 2010 to 58% in 2016. The most frequent reason for vaccine hesitancy was that parents felt HPV vaccination was not necessary (22.4%), followed by lack of provider recommendation (16.2%), and lack of knowledge (15.6%). Lack of provider recommendation increased in frequency as a reason for HPV vaccine hesitancy until 2012, then decreased in frequency through 2016. Cost was one reason that was elevated in all regions compared to the Northeast. Black non-intenders were less likely to report safety, costs, or their children's fear as reasons for not intending to vaccinate their children compared to white non-intenders. Hispanic non-intenders were more likely to report lack of knowledge and that the vaccine is not a school requirement as reasons not to vaccinate their children compared to white non-intenders. CONCLUSIONS: National advocacy for improving provider recommendation for HPV vaccination likely contributed to a sharp decline in HPV vaccine hesitancy due to lack of provider recommendation. Results indicate the need for multifaceted interventions to increase HPV vaccination.

HPV Vaccination Among Foreign-Born Women: Examining the National Health Interview Survey 2013-2015.

INTRODUCTION: Human papillomavirus vaccination is less prevalent among foreign-born than U.S.-born women and may lead to disparities in human papillomavirus-related cancers in the future. There is limited research on factors associated with vaccination uptake between these two groups. This study examined the association between place of birth and human papillomavirus vaccine uptake, and what determinants of vaccination attenuate this relationship. METHODS: The 2013-2015 National Health Interview Survey data on women was analyzed in 2016, to determine differences in prevalence of human papillomavirus vaccination between foreign- and U.S.-born women. Multivariate binary logistic regression analysis was used to examine the association between foreign-born status and human papillomavirus vaccine initiation, after controlling for health insurance status, having a usual source of care, obstetrician/gynecologist visits, Pap tests, length of U.S. residency, and citizenship. RESULTS: Human papillomavirus vaccination prevalence varied significantly among women born in different regions of the world. European and South-American women had the highest vaccination rates among all foreign-born women. Compared with U.S.-born women, foreign-born women were significantly less likely to report human papillomavirus vaccine initiation. This relationship was partially attenuated after adjusting for the covariates. Among foreign-born women, Asians were significantly less likely to report human papillomavirus vaccination uptake than white women. Additionally, living in the U.S. for >5 years was significantly associated with vaccine initiation, but attenuated by U.S. citizenship status. CONCLUSIONS: Public health interventions to improve human papillomavirus vaccination need to be developed to address multicultural audiences with limited access to health insurance and health care.

Use of BRCA Mutation Test in the U.S., 2004-2014.

INTRODUCTION: BRCA mutation testing has been used for screening women at high risk of breast and ovarian cancer and for selecting the best treatment for those with breast cancer. To optimize the infrastructure and medical resources allocation for genetic testing, it is important to understand the use of BRCA mutation testing in the U.S. health system. METHODS: This retrospective cohort study included 53,254 adult women with insurance claims for BRCA mutation testing between 2004 and 2014 from ClinformaticsTM Data Mart Database. Data analysis was performed in 2016. This study assessed trends in the use of BRCA mutation testing in women with previously diagnosed breast or ovarian cancer and those without (unaffected women). RESULTS: Between 2004 and 2014, of those receiving BRCA testing, the proportion of BRCA tests performed in unaffected women increased significantly (p<0.001), from 24.3% in 2004 to 61.5% in 2014. An increase in the proportion of BRCA tests used in unaffected women was found in each characteristic subgroup. In 2014, most subgroups had a proportion surpassing 50%, except for those aged 51-65 years and those without a family history of breast cancer. There was a much lower proportion of those aged 20-40 years among tested women with previously diagnosed breast or ovarian cancer than in unaffected women (17.6% vs 41.7%, p<0.001). CONCLUSIONS: During the past decade, the role of BRCA testing has gradually shifted from being used primarily in cancer patients to being used in unaffected women in the U.S.

Complications and continuation of intrauterine device use among commercially insured teenagers.

OBJECTIVE: Many U.S. health care providers remain reluctant to prescribe intrauterine devices (IUDs) to teenagers as a result of concerns about serious complications. This study examined whether 15-19-year-old IUD users were more likely to experience complications, failure, or early discontinuation than adult users aged 20-24 years and 25-44 years and whether there were differences in these outcomes between users of levonorgestrel-releasing intrauterine systems and copper IUDs. METHODS: A retrospective cohort study was conducted using health insurance claims obtained from a private insurance company of 90,489 women who had an IUD inserted between 2002 and 2009. Logistic regression models were used to estimate the odds of experiencing complications, method failure, or early discontinuation within 12 months of insertion by age group and type of IUD inserted. RESULTS: Serious complications, including ectopic pregnancy and pelvic inflammatory disease, occurred in less than 1% of patients regardless of age or IUD type. Women aged 15-19 years were more likely than those aged 25-44 years to have a claim for dysmenorrhea (odds ratio [OR] 1.4, confidence interval [CI] 1.1-1.6), amenorrhea (OR 1.3, CI 1.1-1.5), or normal pregnancy (OR 1.4, CI 1.1-1.8). Overall, early discontinuation did not differ between teenagers and women aged 25-44 years (13% compared with 11%, P>.05). However, use of the levonorgestrel-releasing intrauterine system was associated with fewer complications and less early discontinuation than the copper IUD in all age groups. CONCLUSIONS: The IUD is as appropriate for teenagers to use as it is for older women, with serious complications occurring infrequently in all groups. The levonorgestrel-releasing intrauterine system may be a better choice than the copper IUD as a result of lower odds of complications, discontinuation, and failure. LEVEL OF EVIDENCE: II.

Completion of the human papillomavirus (HPV) vaccine series among males with private insurance between 2006 and 2009.

Little is known about initiation and completion among males who received the HPV vaccine on an off-label basis before 2009. This study utilized administrative claims data from a private insurance company to examine completion of the 3 dose HPV series among 514 males who initiated the vaccine between 2006 and May of 2009. Frequencies of HPV vaccination were examined and multivariate logistic regression estimated the odds of completing the entire series within 365 days of initiation. We found that only 21% of male initiators completed all 3 vaccine doses within 12 months and completion decreased over time. Series completion did not vary significantly by provider type. These findings suggest that difficulties may be encountered in fully vaccinating enough males to achieve adequate herd immunity in the future.

Completion of the human papillomavirus vaccine series among insured females between 2006 and 2009.

BACKGROUND: Completion of the human papillomavirus (HPV) vaccine in a large percentage of young females is an important goal to prevent anogenital cancers associated with HPV. The current study examined whether the percentage of insured women who complete the vaccine series has changed across time, and how provider type and age at initiation affects rates of completion. METHODS: This retrospective cohort study used administrative data from a private insurance company. The study included 271,976 females in whom the HPV vaccine series was initiated and who had been continuously enrolled in their respective insurance plan for 365 days after vaccine initiation. Multivariate logistic regression was used to determine the odds of completing the vaccine series within 365 days after initiation. RESULTS: Females aged 13 years to 18 years, 19 years to 26 years, and ≥ 27 years were found to be less likely than those ages 9 years to 12 years to complete their HPV vaccine series. Obstetricians/gynecologists were more likely to administer vaccines to completers than pediatricians, whereas clinics, nurses, family care practitioners, and specialists were less likely to administer initial vaccines to completers compared with pediatricians. The results of the current study also found that females aged 9 years to 12 years and 13 years to 18 years had lower odds of completing the HPV vaccine series for each subsequent year compared with those aged 19 years to 26 years and ≥ 27 years. CONCLUSIONS: Among insured females in the United States, the percentage of females who complete the HPV vaccine series is dropping over time, especially among younger females, who are specifically targeted to receive the vaccine. Physicians need to stress the importance of completing all 3 vaccinations to their patients.