Marievelisse Soto-Salgado

Sexual behaviors among adults in Puerto Rico: a population-based study.

INTRODUCTION Given changes in sexual behaviors and norms in the United States, there is a need for current and representative data on sexual behaviors with particular interest in gender, age, and racial/ethnic group differences. AIM Given the limited data for Hispanics and for Puerto Rico (PR), we described patterns of sexual behaviors and characteristics among a sexually active sample (n=1,575) of adults aged 21-64 years in PR. MAIN OUTCOME MEASURES The main outcome measures for this study are sexual behaviors including age at sexual initiation, number of sexual partners, vaginal and anal intercourse, and oral sex, among others. METHODS Data from a population-based cross-sectional study in PR (2005-2008) was analyzed. The prevalence of sexual behaviors and characteristics was described by age-group and gender during the lifetime and in the past 12 months. RESULTS Overall, 96.8%, 81.6%, and 60.9% of participants had ever engaged in vaginal, oral and anal sex, respectively, whereas 23.7% were seropositive to any of the sexually transmitted infections under study. Sexual initiation≤15 years was reported by 37.8% of men and 21.4% of women; whereas 47.9% of men and 13.2% of women reported to have had ≥7 sexual partners in their lifetime. Approximately, 3% of women and 6% of men reported same-sex sexual practices, while history of forced sexual relations was reported by 9.6% of women and 2.5% of men. Sexual initiation≤15 years was more common among individuals aged 21-34 years (41.4% men and 33.6% women) as compared with older cohorts. Although having had ≥7 sexual partners over a lifetime among men was similar across age groups, this behavior decreased in older women cohorts. In both genders, the prevalence of oral and anal sex was also lower in the older age cohorts. CONCLUSION This study provides essential information that can help health professionals understand the sexual practices and needs of the population of PR.

Incidence and mortality rates of selected infection-related cancers in Puerto Rico and in the United States.

BackgroundIn 2002, 17.8% of the global cancer burden was attributable to infections. This study assessed the age-standardized incidence and mortality rates of stomach, liver, and cervical cancer in Puerto Rico (PR) for the period 1992-2003 and compared them to those of Hispanics (USH), non-Hispanic Whites (NHW), and non-Hispanic Blacks (NHB) in the United States (US).MethodsAge-standardized rates [ASR(World)] were calculated based on cancer incidence and mortality data from the PR Cancer Central Registry and SEER, using the direct method and the world population as the standard. Annual percent changes (APC) were calculated using the Poisson regression model from 1992-2003.ResultsThe incidence and mortality rates from stomach, liver and cervical cancer were lower in NHW than PR; with the exception of mortality from cervical cancer which was similar in both populations. Meanwhile, the incidence rates of stomach, liver and cervical cancers were similar between NHB and PR; except for NHB women who had a lower incidence rate of liver cancer than women in PR. NHB had a lower mortality from liver cancer than persons in PR, and similar mortality from stomach cancer.ConclusionsThe burden of liver, stomach, and cervical cancer in PR compares to that of USH and NHB and continues to be a public health priority. Public health efforts are necessary to further decrease the burden of cancers associated to infections in these groups, the largest minority population groups in the US. Future studies need to identify factors that may prevent infections with cancer-related agents in these populations. Strategies to increase the use of preventive strategies, such as vaccination and screening, among minority populations should also be developed.

Human papillomavirus infection in women in Puerto Rico: agreement between physician-collected and self-collected anogenital specimens.

Objective This study aimed to describe the prevalence and concordance between cervical and anal human papillomavirus (HPV) infection and compare cervicovaginal and anal self-collection methods for HPV testing between physician and self-collected specimens in women in Puerto Rico. Materials and Methods Specimens for HPV-DNA testing were obtained from 100 women aged 18 to 34 years attending a general gynecology clinic for a routine Pap smear. Human papillomavirus testing was performed using polymerase chain reaction MY09/MY11 primers. Positive samples were typed for 39 genotypes. Agreement between sampling methods was determined by percent agreement and the &kgr; statistic. Results For the 39 genotypes evaluated, 38.4% (38/99) of cervicovaginal and 33.7% (30/89) of anal physician-collected samples were HPV+, whereas 35.1% (34/97) of cervicovaginal and 32.0% (31/97) of anal self-collected samples were positive. Human papillomavirus type 16 was the most common type identified in the cervix (8.3%, 8/97) and the anus (5.6%, 5/89) of physician-collected samples, with similar prevalence in self-collected samples. Concordance between cervical and anal HPV infection was high (>90%) for all types evaluated. There was a strong percent agreement between physician- and self-collected cervicovaginal and anal samples (>95% for all HPV types) and good to excellent agreement (&kgr; > 0.60) for most HPV types. Conclusions The clinic-based prevalence of anal and cervicovaginal HPV infection was high, with a strong concordance between cervical and anal infection and good to excellent agreement between physician- and self-collected samples. This study supports the feasibility of using cervical and anal self-sampling methods in future population-based studies of HPV infection in Puerto Rico and as an HPV screening method in women.

Penile Cancer Disparities in Puerto Rican Men as compared to the United States Population

PURPOSE This study compares incidence and mortality of penile cancer in Puerto Rico (PR) with other racial/ethnic groups in the United States (US) and evaluates the extent in which socioeconomic position index (SEP) or its components influence incidence and mortality in PR. MATERIALS AND METHODS Age-standardized rates were calculated for incidence and mortality based on data from the PR Cancer Registry and the US National Cancer Institutes Surveillance, Epidemiology and End Results program, using the direct method. RESULTS PR men had approximately 3-fold higher incidence of penile cancer as compared to non-Hispanic white (Standardized rate ratio [SRR]: 3.33; 95%CI=2.80-3.95). A higher incidence of penile cancer was also reported in PR men as compared to non-Hispanic blacks and Hispanics men. Mortality from penile cancer was also higher for PR men as compared to all other ethnic/racial groups. PR men in the lowest SEP index had 70% higher incidence of penile cancer as compared with those PR men in the highest SEP index. However, the association was marginally significant (SRR: 1.70; 95%CI=0.97, 2.87). Only low educational attainment was statistically associated with higher penile cancer incidence (SRR: 2.18; 95%CI=1.42-3.29). CONCLUSIONS Although penile cancer is relatively uncommon, our results support significant disparities in the incidence and mortality rates among men in PR. Low educational attainment might influence the high incidence of penile cancer among PR men. Further studies are strongly recommended to explore these disparities.

Correlates of the Metabolic Syndrome Among a Sample of Women in the San Juan Metropolitan Area of Puerto Rico

BACKGROUND The metabolic syndrome is an interaction of risk factors that may lead to cardiovascular disease and type 2 diabetes. METHODS Given the need for data in Puerto Rico, this cross-sectional study aimed to determine the association between demographic, lifestyles, and reproductive characteristics and the metabolic syndrome among a sample of women (N = 564) in the San Juan Metropolitan Area. The metabolic syndrome was defined based on the revised National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. RESULTS In multivariate logistic regression models, women aged 40-59 and 60-79 years were 3.03 [95% confidence interval (CI), 1.70, 5.40] and 7.05 (95% CI, 3.69, 13.49) times more likely, respectively, to have the metabolic syndrome as compared to those aged 21-39 years. A dose-response relationship was also observed between body mass index (BMI) and metabolic syndrome. Physical activity reduced the odds for metabolic syndrome [prevalence odds ratios (POR) = 0.64; 95% CI, 0.41, 1.01]; however, this association was marginally significant (P = 0.05). Among reproductive characteristics, only women who had a history of gestational diabetes (GDM) were 2.14 (95% CI, 1.02, 4.51) times more likely to have metabolic syndrome. CONCLUSIONS Consistent with previous studies, increased age and BMI, physical inactivity, and GDM are associated with the metabolic syndrome in this population. This information is relevant for the development of preventive interventions for the metabolic syndrome.

Disparities in breast cancer in Puerto Rico and among Hispanics, non-Hispanic whites, and non-Hispanics blacks in the United States, 1992-2004.

To the Editor: Breast cancer (BC) is the most common cancer type and the most common cause of cancer death among women in Puerto Rico (PR) (1). Historical studies suggest a lower incidence of BC in PR as compared to the United States (US) (2,3); however, limited data exists regarding the current burden of this malignancy in PR and how it compares with other racial ⁄ ethnic groups. This study assessed the age-standardized incidence and mortality rates of BC in PR and compared them to those of Hispanics (USH), Non-Hispanic whites (NHW), and Non-Hispanic blacks (NHB) in the US for the period 1992–2004. Incident and death cases of invasive BC (ICD-O-3: C50.0–C50.9) were obtained from the PR Central Cancer Registry (PRCCR) (4,5) and the Surveillance, Epidemiology and End Results Program (SEER) (6,7), respectively. Annual age-standardized [ASR(world)] incidence and mortality rates (per 100,000) were calculated for each racial ⁄ ethnic group using the direct method (world population). The annual percent change (APC) of the ASR(World) was estimated using the Joinpoint Regression Program from SEER. To assess differences in BC incidence and mortality rates between PR as compared to other racial ⁄ ethnic groups, the ASR(World) were grouped from 2000 to 2004. Then, the standardized rate ratio (SRR) was estimated with its 95% confidence interval. Although the BC incidence ASR(World) in PR was lower than in other racial ⁄ ethnic groups in the US, the incidence of BC increased during the study period in PR (APC = 1.41%, p < 0.05), whereas it remained stable for USH (APC = 0.08%), NHW ()0.18%), and NHB ()0.40%) (p > 0.05) (Fig. 1). Compared to women in PR, USH, NHW, and NHB women had a 14%, 88%, and 57% higher risk of BC, respectively (Table 1). Meanwhile, women in PR had similar BC mortality ASR(World) than USH women (p > 0.05); whereas, NHW and NHB women had a 56% and a 98% higher risk of dying from BC than women in PR, respectively. In addition to these differences, a decreasing trend in BC mortality was observed in all US racial ⁄ ethnic groups (Fig. 1), while trends for PR remained stable (p > 0.05). The lower burden of BC in PR than in the continental US population is consistent with previous studies (2,3). Nonetheless, the similar age-adjusted mortality rates of BC among USH and PR suggests a potential health disparity between these groups, as the incidence of the disease was in fact lower in PR. It could be hypothesized that this disparity may be the result of differences in access to treatment between these groups. However, further research is warranted. No study has assessed the reasons for the increasing trend of BC incidence in PR, although our data is consistent with trends observed since the 1950s (1,3). The stabilization of the incidence trends in all racial ⁄ ethnic groups in the US is also consistent with previous reports, although their reasons are not yet well understood (8,9). Even though an increase in BC mortality in PR was reported from 1950 to 1990 (3), it seems to have stabilized since then. This is supported by previous reports of the PRCCR (1). Meanwhile, although in the US (8) it is hypothesized that the decline in BC mortality is due to improvements in access to early detection and treatment services, this decline is not yet observed in PR. Overall, the observed incidence and mortality trends from BC in PR might also be explained by factors such as acculturation, changes in lifestyle, screening practices, genetic factors, and access to care. As previously described for Puerto Ricans and Hispanics (3,10,11), these populations have acquired western habits that mirror those of industrialized nations, Address correspondence and reprints request to: Ana P. Ortiz, PhD, MPH, Department of Biostatistics and Epidemiology, Graduate School of Public Health & University of Puerto Rico Comprehensive Cancer Center, UPR, or e-mail: ana.ortiz7@upr.edu. Financial support: Grants U54CA96297, G12RR03051, 5P20RR011126, and U58DP000782-01.

Human Papillomavirus-Related Cancers Among People Living With AIDS in Puerto Rico

The objective of this study was to estimate the incidence of cancer and human papillomavirus (HPV)–related cancers and the risk of death (by cancer status) among people living with AIDS (PLWA) in Puerto Rico. We used data from the Puerto Rico AIDS Surveillance Program and Central Cancer Registry (1985–2005). Cancers with highest incidence were cervix (299.6/100,000) for women and oral cavity/oropharynx for men (150.0/100,000); the greatest excess of cancer incidence for men (standardized incidence ratio, 86.8) and women (standardized incidence ratio, 52.8) was for anal cancer. PLWA who developed a cancer had decreased survival and increased risk of death compared with those who did not have cancer. Cancer control strategies for PLWA will be essential for improving their disease survival.

Risk of Colorectal and Other Cancers in Patients With Serrated Polyposis

Patients with serrated polyposis develop multiple colorectal hyperplastic and/or serrated sessile adenomas/polyps. We investigated the risk of colorectal and other cancers by analyzing data from 64 patients with serrated polyposis (mean age at diagnosis, 54 y; 41% men; 92% white) listed in the Johns Hopkins Polyposis Registry. Medical, endoscopic, and histopathology reports were evaluated. Six patients (9.4%) had a history of colorectal cancer, diagnosed at a mean age of 56 years; 6 additional patients (9.4%) had at least 1 advanced colorectal adenoma. Extracolonic cancers were found in 16% of the study population. The standard incidence ratio for colorectal cancer in patients with serrated polyposis was 18.72 (95% confidence interval, 6.87-40.74) and for extracolonic cancer was 31.20 (95% confidence interval, 14.96-57.37), compared with the Surveillance, Epidemiology, and End Results population. Patients with serrated polyposis therefore have a high risk for colorectal cancer and require vigilant colorectal surveillance, starting at the time of diagnosis of serrated polyposis. The risk of extracolonic cancer also appears to be increased, but this requires further evaluation.

Cross-sectional study of HPV-16 infection in a population-based subsample of Hispanic adults

Objective This study aimed to estimate the prevalence and correlates of seropositivity to human papillomavirus (HPV)-16 in a subsample of adults who participated in the parent study Epidemiology of Hepatitis C in the adult population of Puerto Rico (PR). Setting The parent study was a population-based household survey aimed to estimate the seroprevalence of hepatitis C and other viral infections (hepatitis A, hepatitis B, HIV, and herpes simplex type 2) in PR (n=1654) between 2005 and 2008. Participants A subsample of the last 450 consecutive adults aged 21–64 years, recruited between February 2007 and January 2008, who participated in the parent study and agreed to participate in HPV testing. Primary and secondary outcome measures The samples were tested by ELISA for HPV-16 viral-like particle-specific immunoglobulin G. Information on sociodemographic, health, and lifestyle characteristics was collected. Logistic regression modelling was used to estimate the prevalence odds ratio (POR) to assess factors associated to HPV-16 seropositivity. Results Prevalence of seropositivity to HPV-16 was 11.3%. Seroprevalence was higher in women (15.8%) than men (5.6%; p=0.001). After adjusting for age and sex, ever smokers (POR 2.06, 95% CI 1.08 to 3.92) and participants with at least five lifetime sexual partners (POR 2.91, 95% CI 1.24 to 6.81) were more likely to be HPV-16 seropositive. Conclusions HPV-16 seropositivity is similar to that reported in the USA (10.4%) for NHANES 2003–2004 participants, although different assays were used in these studies. While future studies should evaluate HPV seroprevalence using a larger population-based sample, our results highlight the need to further understand the burden of HPV infection and HPV-related malignancies in PR, population with a low vaccine uptake.

Seroprevalence of Helicobacter pylori in Hispanics living in Puerto Rico: A population-based study

Helicobacter pylori is an important etiologic factor for peptic ulcers and gastric cancer, one of the top ten leading causes of cancer death in Puerto Rico. However, the prevalence of H. pylori infections in this population was previously unknown. The aim of this study was to examine the seroprevalence of H. pylori and its associated risk factors in Puerto Rico.