Kimberly K. Vesco

Liquid-Based Cytology and Human Papillomavirus Testing to Screen for Cervical Cancer: A Systematic Review for the U.S. Preventive Services Task Force

BACKGROUND Screening programs using conventional cytology have successfully reduced cervical cancer, but newer tests might enhance screening. PURPOSE To systematically review the evidence on liquid-based cytology (LBC) and high-risk human papillomavirus (HPV) screening for U.S. Preventive Services Task Force use in updating its 2003 recommendation. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, and PsycINFO from January 2000 through September 2010. STUDY SELECTION Two independent reviewers selected fair- to good-quality English-language studies that compared LBC or HPV-enhanced primary screening with conventional cytology in countries with developed population-based screening for cervical cancer. DATA EXTRACTION At least 2 independent reviewers critically appraised and rated the quality of studies and used standardized abstraction forms to extract data about test performance for detecting cervical intraepithelial neoplasia (CIN) and cancer and screening-related harms. DATA SYNTHESIS On the basis of 4 fair- to good-quality studies (141 566 participants), LBC had equivalent sensitivity and specificity to conventional cytology. Six fair- to good-quality diagnostic accuracy studies showed that 1-time HPV screening was more sensitive than cytology for detecting CIN3+/CIN2+ but was less specific. On the basis of 2 fair- to good-quality randomized, controlled trials (RCTs) (120 533 participants), primary HPV screening detected more cases of CIN3 or cancer in women older than 30 years. Four fair- to good-quality diagnostic accuracy studies and 4 fair- to good-quality RCTs showed mixed results of cotesting (HPV plus cytology) in women aged 30 years or older compared with cytology alone, with no clear advantage over primary HPV screening. Incomplete reporting of results for all screening rounds, including detection of disease and colposcopies, limits our ability to determine the net benefit of HPV-enhanced testing strategies. LIMITATION Resources were insufficient to gather unpublished data, short-term trial data showed possible ascertainment bias, and most RCTs used protocols that differed from current U.S. practice. CONCLUSION Evidence supports the use of LBC or conventional cytology for cervical cancer screening, but more complete evidence is needed before HPV-enhanced primary screening is widely adopted for women aged 30 years or older.

Excessive Gestational Weight Gain and Postpartum Weight Retention Among Obese Women

OBJECTIVE: To evaluate the incremental effect of weight gain above that recommended for term pregnancy (15 pounds) on postpartum weight retention at 1 year among obese women. METHODS: In a retrospective cohort study, we identified 1,656 singleton gestations resulting in live births among obese women (body mass index at or above 30 kg/m2) between January 2000 and December 2005 in Kaiser Permanente Northwest. Pregnancy weight change (last available predelivery weight minus weight at pregnancy onset) was categorized as less than 0, 0–15, greater than 15 to 25, greater than 25 to 35, and greater than 35 pounds. Postpartum weight change (weight at 1 year postpartum minus weight at pregnancy onset) was defined as less than 0, 0–10, and greater than 10 pounds. RESULTS: Total gestational weight gain was –33.2 (weight loss) to +98.0 pounds (weight gain). Nearly three fourths gained greater than 15 pounds, and they were younger and weighed less at baseline than women who gained 15 pounds or less. Pregnancy-related weight change showed a significant relationship with postpartum weight change. For each pound gained during pregnancy, there was a 0.4-pound increase above baseline weight at 1 year postpartum. In adjusted logistic regression models, the risk of a postpartum weight greater than 10 pounds over baseline was twofold higher for women gaining greater than 15 to 25 pounds compared with women gaining 0–15 pounds (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.54–3.10), fourfold higher for women gaining greater than 25 to 35 pounds (OR 3.91, 95% CI 2.75–5.56), and almost eightfold higher for women gaining greater than 35 pounds (OR 7.66, 95% CI 5.36–10.97). CONCLUSION: Incremental increases in gestational weight gain beyond the current recommendation for obese women substantially increase the risk of weight retention at 1 year postpartum. LEVEL OF EVIDENCE: II

Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy.

OBJECTIVE: To estimate trends in postpartum glucose testing in a cohort of women with gestational diabetes mellitus (GDM). METHODS: A validated computerized algorithm using Kaiser Permanente Northwest automated data systems identified 36,251 live births or stillbirths from 1999 through 2006. The annual percentage of pregnancies complicated by gestational diabetes with clinician orders for and completion of a fasting plasma glucose (FPG) test within 3 months of delivery was calculated. Logistic regression with generalized estimating equations was used to test for statistically significant trends. RESULTS: The percentages of pregnancies affected by GDM increased from 2.9% in 1999 to 3.6% in 2006 (P<.01). Clinician orders for postpartum tests increased from 15.9% in 1999 to 79.3% in 2004 (P<.01), and then remained stable through 2006. Completed FPG tests increased from 9.0% in 1999 to 57.8% in 2004 (P<.01), and then remained stable through 2006. No oral glucose tolerance tests were ordered. From 2004 to 2006, the practice site where women received care was the factor most strongly associated with the clinician order, but it was not predictive of test completion. Among women with clinician orders, those who were Asian or Hispanic or who attended the 6-week postpartum examination were more likely to complete the test than their counterparts. CONCLUSION: Postpartum glucose testing in women with GDM-affected pregnancies increased over time. However, even in recent years, 42% of women with GDM-affected pregnancies failed to have a postpartum FPG test, and no test was ordered for 21% of GDM-affected pregnancies. LEVEL OF EVIDENCE: II

Risk Factors and Other Epidemiologic Considerations for Cervical Cancer Screening: A Narrative Review for the U.S. Preventive Services Task Force

Despite the success of cervical cancer screening programs, questions remain about the appropriate time to begin and end screening. This review explores epidemiologic and contextual data on cervical cancer screening to inform decisions about when screening should begin and end. Cervical cancer is rare among women younger than 20 years. Screening for cervical cancer in this age group is complicated by lower rates of detection and higher rates of false-positive results than in older women. Methods used to diagnose and treat cervical intraepithelial neoplasia have important potential adverse effects. High-risk human papillomavirus infections and abnormalities on cytologic and histologic examination have relatively high rates of regression. Accordingly, cervical cancer screening in women younger than 20 years may be harmful. The incidence of, and mortality rates from, cervical cancer and the proportion of U.S. women aged 65 years or older who have had a Papanicolaou smear within 3 years have decreased since 2000. Available evidence supports discontinuation of cervical cancer screening among women aged 65 years or older who have had adequate screening and are not otherwise at high risk. Further reductions in the burden of cervical cancer in older women are probably best achieved by focusing on screening those who have not been adequately screened.

Excess Gestational Weight Gain : Modifying Fetal Macrosomia Risk Associated With Maternal Glucose

OBJECTIVE: To estimate how maternal weight gain and maternal glucose relate to fetal macrosomia risk (greater than 4,000 g) among a population universally screened for gestational diabetes mellitus (GDM). METHODS: Between 1995 and 2003, 41,540 pregnant women in two regions (Northwest/Hawaii) of a large U.S. health plan had GDM screening using the 50-g glucose challenge test; 6,397 also underwent a 3-hour, 100-g oral glucose tolerance test. We assessed the relationship between level of maternal glucose with glucose screening and fetal macrosomia risk after adjustment for potential confounders, including maternal age, parity, and ethnicity and sex of the newborn. We stratified by maternal weight gain (40 lb or fewer compared with more than 40 lb) because excessive maternal weight gain modified results. RESULTS: Among women with both normal and abnormal GDM screenings, increasing level of maternal glucose was linearly related to macrosomia risk (P<.001 for trend in all groups). Women with excessive weight gain (more than 40 lb) had nearly double the risk of fetal macrosomia for each level of maternal glucose compared with those with gestational weight gain of 40 lb or fewer. For example, among women with normal post–glucose challenge test glucose levels (less than 95 mg/dL) and excessive weight gain, 16.5% had macrosomic newborns compared with 9.3% of women who gained 40 lb or fewer. Moreover, nearly one third of women (29.3%) with GDM who gained more than 40 lb had a macrosomic newborn compared with only 13.5% of women with GDM who gained 40 lb or fewer during pregnancy (P=.018). CONCLUSION: Excessive pregnancy weight gain nearly doubles the risk of fetal macrosomia with each increasing level of maternal glucose, even among women with GDM. LEVEL OF EVIDENCE: II

Newborn Size Among Obese Women With Weight Gain Outside the 2009 Institute of Medicine Recommendation

OBJECTIVE: To estimate risk of delivering macrosomic, large-for-gestational-age and small-for-gestational-age neonates in obese women with gestational weight gain outside the 2009 Institute of Medicine recommendation (11–20 pounds). METHODS: In a retrospective cohort study, we evaluated 2,080 obese women (body mass index 30 or higher) with singleton pregnancies that resulted in term live births within one health maintenance organization between 2000 and 2005; women with diabetes or hypertensive disorders were excluded. Gestational weight gain was categorized as less than 0, 0 to less than 11, 11–20 (referent), greater than 20–30, greater than 30–40, and greater than 40 pounds and as above, below, or within Institute of Medicine recommendations. We conducted multivariable logistic regression to estimate the odds of large for gestational age and small for gestational age (birth weights greater than the 90th percentile and less than the 10th percentile for gestational age, respectively) and macrosomia (greater than 4,500 g) adjusting for potential confounders. RESULTS: Eighteen percent gained below, 25% within, and 57% above Institute of Medicine recommendations. Prevalence of macrosomia, large for gestational age, and small for gestational age were 4.3%, 19.8%, and 4.3%, respectively. Compared with weight gain of 11–20 pounds, weight gain above recommendations did not significantly decrease small-for-gestational-age risk but was associated with increased odds of macrosomia (adjusted odds ratio [OR] 3.36; 95% confidence interval [CI] 1.74–6.51; 6.0% compared with 2.1%) and large for gestational age (adjusted OR 1.80; 95% CI 1.36–2.38; 23.8% compared with 16.6%). Weight gain below recommendations was associated with increased odds of small for gestational age (adjusted OR 3.94; 95% CI 2.04–7.61; 8.8% compared with 2.7%) and decreased odds of large for gestational age (adjusted OR 0.56; 95% CI 0.37–0.84; 11.2% compared with 16.6%). CONCLUSION: Regarding small for gestational age and large for gestational age, there is no benefit of weight gain above Institute of Medicine recommendations. Weight gain below recommendations decreases large for gestational age but increases small-for-gestational-age risk. LEVEL OF EVIDENCE: II

WHO absolute fracture risk models (FRAX): Do clinical risk factors improve fracture prediction in older women without osteoporosis?

Bone mineral density (BMD) is a strong predictor of fracture, yet most fractures occur in women without osteoporosis by BMD criteria. To improve fracture risk prediction, the World Health Organization recently developed a country‐specific fracture risk index of clinical risk factors (FRAX) that estimates 10‐year probabilities of hip and major osteoporotic fracture. Within differing baseline BMD categories, we evaluated 6252 women aged 65 or older in the Study of Osteoporotic Fractures using FRAX 10‐year probabilities of hip and major osteoporotic fracture (ie, hip, clinical spine, wrist, and humerus) compared with incidence of fractures over 10 years of follow‐up. Overall ability of FRAX to predict fracture risk based on initial BMD T‐score categories (normal, low bone mass, and osteoporosis) was evaluated with receiver‐operating‐characteristic (ROC) analyses using area under the curve (AUC). Over 10 years of follow‐up, 368 women incurred a hip fracture, and 1011 a major osteoporotic fracture. Women with low bone mass represented the majority (n = 3791, 61%); they developed many hip (n = 176, 48%) and major osteoporotic fractures (n = 569, 56%). Among women with normal and low bone mass, FRAX (including BMD) was an overall better predictor of hip fracture risk (AUC = 0.78 and 0.70, respectively) than major osteoporotic fractures (AUC = 0.64 and 0.62). Simpler models (eg, age + prior fracture) had similar AUCs to FRAX, including among women for whom primary prevention is sought (no prior fracture or osteoporosis by BMD). The FRAX and simpler models predict 10‐year risk of incident hip and major osteoporotic fractures in older US women with normal or low bone mass.

Efficacy of a group‐based dietary intervention for limiting gestational weight gain among obese women: A randomized trial

Observational studies suggest that minimal gestational weight gain (GWG) may optimize pregnancy outcomes for obese women. This trial tested the efficacy of a group‐based weight management intervention for limiting GWG among obese women.

Efficacy of a group-based dietary intervention for limiting gestational weight gain among obese women

Observational studies suggest that minimal gestational weight gain (GWG) may optimize pregnancy outcomes for obese women. This trial tested the efficacy of a group‐based weight management intervention for limiting GWG among obese women.

Early Term Delivery and Health Care Utilization in the First Year of Life

OBJECTIVE To assess health care utilization during the first year of life among early term-born infants. STUDY DESIGN We assessed health care utilization of 22420 singleton term infants (37-42 weeks gestational age [GA]) without major birth defects, fetal growth restriction, or exposure to diabetes or hypertension in utero, delivered between 1998 and 2007 and continuously enrolled at Kaiser Permanente Northwest for 12 months after delivery. GA, duration of delivery hospitalization, and postdelivery rehospitalizations and sick/emergency room visits in the first year of life were obtained from electronic medical records. Logistic regression models were used to estimate associations between GA and number of hospitalizations and length of stay. Generalized linear models were used to estimate the adjusted mean number of sick/emergency visits. RESULTS Overall, 20.9% of term infants were born early. Infants delivered vaginally at 37 weeks GA had a 2.2 greater odds (95% CI, 1.6-3.1) of staying 4 or more days compared with those born at 39-40 weeks GA. Similar association was found among infants delivered by cesarean delivery at 37 or 38 weeks GA. Infants born at 37 weeks GA had increased odds of being rehospitalized within 2 weeks of delivery (OR, 2.6; 95% CI, 1.9-3.6). The adjusted mean number of sick/emergency room visits was higher for infants born at 37 and 38 weeks GA than for those born at 39-40 weeks GA (8.1, 7.7, and 7.3, respectively; P < .0001). CONCLUSIONS Early term-born infants had greater health care utilization during their entire first year of life than infants born at 39-40 weeks GA.