The impact of adjusting for hysterectomy prevalence on cervical cancer incidence rates and trends among women aged 30 years or older-United States, 2001-2019.

Hysterectomy protects against cervical cancer when the cervix is removed. However, measures of cervical cancer incidence often fail to exclude women with a hysterectomy from the population-at-risk denominator, underestimating and distorting disease burden. In this study, we estimated hysterectomy prevalence from the Behavioral Risk Factor Surveillance System surveys to remove the women who were not at risk of cervical cancer from the denominator and combined these estimates with the US Cancer Statistics data. From these data, we calculated age-specific and age-standardized incidence rates for women aged >30 years from 2001-2019, adjusted for hysterectomy prevalence. We calculated the difference between unadjusted and adjusted incidence rates and examined trends by histology, age, race and ethnicity, and geographic region using joinpoint regression. The hysterectomy-adjusted cervical cancer incidence rate from 2001-2019 was 16.7 per 100 000 women-34.6% higher than the unadjusted rate. After adjustment, incidence rates were higher by approximately 55% among Black women, 56% among those living in the East South Central division, and 90% among women aged 70-79 and ≥80 years. These findings underscore the importance of adjusting for hysterectomy prevalence to avoid underestimating cervical cancer incidence rates and masking disparities by age, race, and geographic region. This article is part of a Special Collection on Gynecological Cancers.

Differential utilization of the online patient portal for completion of health-related social needs screening during routine gynecologic cancer care.

BACKGROUND: Telehealth technologies offer efficient ways to deliver health-related social needs (HRSN) screening in cancer care, but these methods may not reach all populations. The authors examined patient characteristics associated with using an online patient portal (OPP) to complete HRSN screening as part of gynecologic cancer care. METHODS: From June 2021 to June 2023, patients in a gynecologic oncology clinic completed validated HRSN screening questions either (1) using the OPP (independently before the visit) or (2) in person (verbally administered by clinic staff). The authors examined the prevalence of HRSN according to activated OPP status and, in a restricted subgroup, used stepwise multivariate Poisson regression to identify associations between patient and visit characteristics and using the OPP. RESULTS: Of 1616 patients, 87.4% (n = 1413) had an activated OPP. Patients with inactive OPPs (vs. activated OPPs) more frequently reported two or more needs (10% vs 5%; p < .01). Of 986 patients in the restricted cohort, 52% used the OPP to complete screening. The final multivariable model indicated that patients were less likely to use the OPP if they were Black (vs. White; adjusted relative risk [aRR], 0.70; 95% confidence interval [CI], 0.59-0.83); not employed (vs. employed; aRR, 0.81; 95% CI, 0.68-0.97), or had low measures of OPP engagement (aRR, 0.80; 95% CI, 0.68-0.92). New versus established patients were 21% more likely to use the OPP (aRR, 1.21; 95% CI, 1.06-1.38). CONCLUSIONS: Differential use of the OPP suggested that over-reliance on digital technologies could limit the ability to reach those populations that have social factors already associated with cancer outcome disparities. Cancer centers should consider using multiple delivery methods for HRSN screening to maximize reach to all populations.

Risk of progression of cervical intraepithelial neoplasia grade 2 in human papillomavirus-vaccinated and unvaccinated women: a population-based cohort study.

BACKGROUND: Many countries have implemented active surveillance (ie, leaving the lesion untreated) as an option among younger women with cervical intraepithelial neoplasia grade 2 because regression rates are high and excisional treatment increases the risk for preterm birth in subsequent pregnancies. However, early identification of women at increased risk for progression to cervical intraepithelial neoplasia grade 3 or worse is important to ensure timely treatment. Because women who have received a human papillomavirus vaccine have a lower risk for cervical cancer, they may have a lower risk for progression of untreated cervical intraepithelial neoplasia grade 2 to cervical intraepithelial neoplasia grade 3 or worse. OBJECTIVE: This study aimed to investigate if women who received a human papillomavirus vaccine and who are undergoing active surveillance for cervical intraepithelial neoplasia grade 2 are less likely to progress to cervical intraepithelial neoplasia grade 3 or worse when compared with women who did not receive the vaccine. STUDY DESIGN: We conducted a population-based cohort study in Denmark using data from national health registers. We identified all women aged 18 to 40 years who were undergoing active surveillance for cervical intraepithelial neoplasia grade 2 from January 1, 2007, to December 31, 2020. Women with a previous record of cervical intraepithelial neoplasia grade 2 or worse, hysterectomy, or a loop electrosurgical excision procedure were excluded. Exposure was defined as having received ≥1 dose of a human papillomavirus vaccine at least 1 year before the cervical intraepithelial neoplasia grade 2 diagnosis. We used cumulative incidence functions to estimate the risk for progression to cervical intraepithelial neoplasia grade 3 or worse within 28 months using hysterectomy, emigration, and death as competing events. We used modified Poisson regression to calculate crude and adjusted relative risks of progression during the 28-month surveillance period. Results were stratified by age at vaccination and adjusted for index cytology, disposable income, and educational level. RESULTS: The study population consisted of 7904 women of whom 3867 (48.9%) were vaccinated at least 1 year before a diagnosis of cervical intraepithelial neoplasia grade 2. At the time of cervical intraepithelial neoplasia grade 2 diagnosis, women who were vaccinated were younger (median age, 25 years; interquartile range, 23-27 years) than those who were not (median age, 29 years; interquartile range, 25-33 years). The 28-month cumulative risk for cervical intraepithelial neoplasia grade 3 or worse was significantly lower among women who were vaccinated before the age of 15 years (22.9%; 95% confidence interval, 19.8-26.1) and between the ages of 15 and 20 years (31.5%; 95% confidence interval, 28.8-34.3) when compared with women who were not vaccinated (37.6%; 95% confidence interval, 36.1-39.1). Thus, when compared with women who were not vaccinated, those who were vaccinated before the age of 15 years had a 35% lower risk for progression to cervical intraepithelial neoplasia grade 3 or worse (adjusted relative risk, 0.65; 95% confidence interval, 0.57-0.75), whereas women who were vaccinated between the ages of 15 and 20 years had a 14% lower risk (adjusted relative risk, 0.86; 95% confidence interval, 0.79-0.95). For women who were vaccinated after the age of 20 years, the risk was comparable with that among women who were not vaccinated (adjusted relative risk, 1.02; 95% confidence interval, 0.96-1.09). CONCLUSION: Women who were vaccinated and who were undergoing active surveillance for cervical intraepithelial neoplasia grade 2 had a lower risk for progression to cervical intraepithelial neoplasia grade 3 or worse during 28 months of follow-up when compared with women who were not vaccinated but only if the vaccine was administered by the age of 20 years. These findings may suggest that the human papillomavirus vaccination status can be used for risk stratification in clinical management of cervical intraepithelial neoplasia grade 2.

Contemporary provider perspectives on how to address HPV vaccine hesitancy in the US: A qualitative study.

Introduction: Despite over 15 years of real-world data that supports the safety and efficacy of the human papillomavirus (HPV) vaccine, in the United States vaccine hesitancy persists. Many studies have focused on vaccine-hesitant parents, but fewer have examined provider perspectives on how to address HPV vaccine hesitancy. Methods: Between July 2021-April 2022, we recruited providers in Maryland and the broader Mid-Atlantic region who practiced pediatrics, primary care, family medicine, or adolescent medicine and who provided outpatient care for children ages 10-17. Semi-structured virtual interviews focused on provider-reported strategies to address HPV vaccine-hesitant parents, as well as perceived barriers to successful vaccination and provider perspectives on specific interventions to address parental hesitancy. Audio recordings were transcribed and analyzed via a combination of deductive and inductive coding. Higher-level themes within the domains of strategies, barriers, and perspectives on specific proposed interventions were identified. Results and discussion: A total of sixteen providers completed an interview. Within the domain of provider-reported strategies, the following themes emerged: 1) leveraging continuity of care and established parental trust, 2) supporting parental autonomy, 3) tailoring the approach to specific concerns of vaccine-hesitant parents, 4) normalizing the HPV vaccine, and 5) focusing on health prevention and cancer prevention. Barriers providers identified were: 1) limited time, 2) lack of common ground with parents, 3) parent-child decision discordance, 4) availability of misinformation, and 5) parental concerns such as safety and necessity. In the domain for proposed interventions, providers favored interventions that saved time or were not resource-intense, that did not single out the HPV vaccine as different, were patient friendly, and leveraged efficiency through the electronic medical record. The insights from this study can help inform the development of provider-acceptable and feasible tools and interventions to address parental HPV vaccine hesitancy.

Overweight and obese women's symptoms, knowledge, and preferences regarding endometrial biopsy for endometrial cancer detection: A threshold technique survey.

Background: The incidence of endometrial cancer (EC) in the United States continues to rise, driven mainly by the obesity epidemic. We sought to determine overweight and obese women's cancer risk knowledge and preferences regarding diagnostic endometrial biopsy (EMB) for EC detection. Methods: An online survey was administered to overweight and obese women without EC recruited through the electronic medical record's online patient portal. Baseline questions queried gynecologic history, cancer risk knowledge, and factors potentially influencing decision-making for EMB. We used the threshold survey technique to identify the minimum acceptable risk (MAR) threshold at which each respondent would be willing to undergo an EMB to detect EC. Results: Of 357 respondents (median age 45 years (interquartile range [IQR]: 38-54); median BMI 39 [IQR: 36.0-44.6]), fewer than half (48.7 %) were aware that obesity is a risk factor for EC, and 10 % considered their risk of EC to be high. Almost half (42 %) of respondents reported MAR thresholds characterized as very low (0-1 %), and these were more common among respondents with higher BMIs. Forty percent identified their weight as a factor influencing their MAR threshold decision, while 76 % identified their perceived personal risk as a factor. Less than half cited immediate risks of the procedure. Conclusion: Many patients reported being willing to undergo an EMB at very low risk thresholds for EC. Perceived personal risk is a stronger factor in decision-making than immediate procedural risks. Providers should focus on communicating patients' risk to motivate EMB to detect EC where appropriate.

Integrating Social Needs Screening and Resource Referral Into Standard Ambulatory Oncology Care: A Quality Improvement Project.

PURPOSE: We previously implemented paper-based screening for health-related social resource needs (HRSN) in our gynecologic oncology clinic and found that 36% of patients who completed the screening reported HRSN. We identified two primary deficiencies with our process. First, only 52% of patients completed the screening. Second, 37% of patients with needs failed to indicate if they desired resource referral or not. Therefore, we conducted a quality improvement project to integrate screening and referral processes into the electronic medical record (EMR) and routine clinic workflow to achieve at least 90% screening compliance and 90% elicited referral preference. METHODS: A multidisciplinary team consisting of physicians, a health outcomes researcher, a computer programmer, project assistants, and the staff of a partner community organization designed and implemented an intervention that screened for HRSN online via the EMR patient platform or in person during visits. The primary outcome was the percentage of eligible patients who completed the HRSN screening (ie, reach). Outcomes were reviewed weekly, and feedback was provided to stakeholders monthly. Iterative changes were incorporated into five successive Plan-Do-Study-Act (PDSA) cycles completed from January 2021 to March 2023. RESULTS: Screening compliance increased from the baseline of 52% (paper-based) to 97% in PDSA 4. Completion via the online patient portal increased from 17% in prelaunch to 49% in PDSA 4. Of patients who reported needs, 100% had a documented referral preference. CONCLUSION: Compared with paper-based screening, an EMR-integrated HRSN screening and referral system significantly improved reach to patients at a gynecologic oncology clinic. Implementation efforts to expand to other ambulatory clinic settings are in process.

State of the Science of Scale-Up of Cancer Prevention and Early Detection Interventions in Low- and Middle-Income Countries: A Scoping Review.

PURPOSE: Cancer deaths in low- and middle-income countries (LMICs) will nearly double by 2040. Available evidence-based interventions (EBIs) for cancer prevention and early detection can reduce cancer-related mortality, yet there is a lack of evidence on effectively scaling these EBIs in LMIC settings. METHODS: We conducted a scoping review to identify published literature from six databases between 2012 and 2022 that described efforts for scaling cancer prevention and early detection EBIs in LMICs. Included studies met one of two definitions of scale-up: (1) deliberate efforts to increase the impact of effective intervention to benefit more people or (2) an intervention shown to be efficacious on a small scale expanded under real-world conditions to reach a greater proportion of eligible population. Study characteristics, including EBIs, implementation strategies, and outcomes used, were summarized using frameworks from the field of implementation science. RESULTS: This search yielded 3,076 abstracts, with 24 studies eligible for inclusion. Included studies focused on a number of cancer sites including cervical (67%), breast (13%), breast and cervical (13%), liver (4%), and colon (4%). Commonly reported scale-up strategies included developing stakeholder inter-relationships, training and education, and changing infrastructure. Barriers to scale-up were reported at individual, health facility, and community levels. Few studies reported applying conceptual frameworks to guide strategy selection and evaluation. CONCLUSION: Although there were relatively few published reports, this scoping review offers insight into the approaches used by LMICs to scale up cancer EBIs, including common strategies and barriers. More importantly, it illustrates the urgent need to fill gaps in research to guide best practices for bringing the implementation of cancer EBIs to scale in LMICs.

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.

Availability and Geographic Access to Hospital-Based Breast Cancer Diagnostic Services in Ghana.

PURPOSE: Breast cancer is the most frequent cancer and second most common cause of cancer-related death in Ghana. Early detection and access to diagnostic services are vital for early treatment initiation and improved survival. This study characterizes the geographic access to hospital-based breast cancer diagnostic services in Ghana as a framework for expansion. METHODS: A cross-sectional hospital-based survey was completed in Ghana from November 2020 to October 2021. Early diagnostic services, as defined by the National Comprehensive Cancer Network (NCCN) Framework for Resource Stratification, was assessed at each hospital. Services were characterized as available >80% of the time in the previous year, <80%, or not available. ArcGIS was used to identify the proportion of the population within 20 and 45 km of services. RESULTS: Most hospitals in Ghana participated in this survey (95%; 328 of 346). Of these, 12 met full NCCN Basic criteria >80% of the time, with 43% of the population living within 45 km. Ten of the 12 met full NCCN Core criteria, and none met full NCCN Enhanced criteria. An additional 12 hospitals were identified that provide the majority of NCCN Basic services but lack select services necessary to meet this criterion. Expansion of services in these hospitals could result in an additional 20% of the population having access to NCCN Basic-level early diagnostic services within 45 km. CONCLUSION: Hospital-based services for breast cancer early diagnosis in Ghana are available but sparse. Many hospitals offer fragmented aspects of care, but only a limited number of hospitals offer the full NCCN Basic or Core level of care. Understanding current availability and geographical distribution of services provides a framework for potential targeted expansion of services.

Availability and geographic access to breast cancer pathology services in Ghana.

INTRODUCTION: Breast cancer poses a significant health challenge in Sub-Saharan Africa, particularly in Ghana, where late-stage diagnoses and limited healthcare access contribute to elevated mortality rates. This study focuses on the crucial role of pathology and laboratory medical (PALM) services in the timely diagnosis of breast cancer within Ghana. METHODS: A cross-sectional survey of hospitals was completed from November 2020 to October 2021, with 94.8% of identified in-country hospitals participating. Pathology service-related parameters assessed included whether pathology was available for the diagnosis of breast cancer on-site or via external referral, the number of pathology personnel, additional breast cancer diagnostic capabilities including estrogen and progesterone and/or HER2 testing, and the time from biopsy to patients receiving their results. Geospatial mapping was used to identify areas of limited access. RESULTS: Of the 328 participating hospitals, 136 (41%) reported breast cancer pathology services, with only 6 having on-site capabilities. Pathology personnel, comprising 15 consultants and 15 specialists, were concentrated in major referral centers, particularly in Greater Accra and Kumasi. An assessment of referral patterns suggested that 75% of the population reside within an hour of breast cancer pathology services. Among the 136 hospitals with access to breast cancer pathology, only a limited number reported that results included ER/PR (38%) and HER2 testing (33%). CONCLUSION: Ghana has been able to ensure significant pathology service availability through robust referral pathways with centralized labs. Despite this, difficulties persist with the majority of pathology results not including hormone receptor testing which is important in providing tumor specific treatment.