Vicki B. Benard

Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature.

IMPORTANCE Since licensure of the human papillomavirus (HPV) vaccine in 2006, HPV vaccine coverage among US adolescents has increased but remains low compared with other recommended vaccines. OBJECTIVE To systematically review the literature on barriers to HPV vaccination among US adolescents to inform future efforts to increase HPV vaccine coverage. EVIDENCE REVIEW We searched PubMed and previous review articles to identify original research articles describing barriers to HPV vaccine initiation and completion among US adolescents. Only articles reporting data collected in 2009 or later were included. Findings from 55 relevant articles were summarized by target populations: health care professionals, parents, underserved and disadvantaged populations, and males. FINDINGS Health care professionals cited financial concerns and parental attitudes and concerns as barriers to providing the HPV vaccine to patients. Parents often reported needing more information before vaccinating their children. Concerns about the vaccines effect on sexual behavior, low perceived risk of HPV infection, social influences, irregular preventive care, and vaccine cost were also identified as potential barriers among parents. Some parents of sons reported not vaccinating their sons because of the perceived lack of direct benefit. Parents consistently cited health care professional recommendations as one of the most important factors in their decision to vaccinate their children. CONCLUSIONS AND RELEVANCE Continued efforts are needed to ensure that health care professionals and parents understand the importance of vaccinating adolescents before they become sexually active. Health care professionals may benefit from guidance on communicating HPV recommendations to patients and parents. Further efforts are also needed to reduce missed opportunities for HPV vaccination when adolescents interface with the health care system. Efforts to increase uptake should take into account the specific needs of subgroups within the population. Efforts that address system-level barriers to vaccination may help to increase overall HPV vaccine uptake.

Burden of cervical cancer in the United States, 1998-2003.

Recent interest in human papillomavirus (HPV)‐associated cancers and the availability of several years of data covering 83% of the US population prompted this descriptive assessment of cervical cancer incidence and mortality in the US during the years 1998 through 2003. This article provides a baseline for monitoring the impact of the HPV vaccine on the burden of cervical cancer over time.

Cervical Cancer Screening With Both Human Papillomavirus and Papanicolaou Testing vs Papanicolaou Testing Alone: What Screening Intervals Are Physicians Recommending?

BACKGROUND Guidelines recommend screening for cervical cancer among women 30 years or older 3 years after a normal Papanicolaou test (hereinafter referred to as Pap test) result or a combined normal screening result (normal Pap/negative human papillomavirus [HPV] test results). We assessed reported recommendations by US primary care physicians (PCPs) on screening intervals that incorporate HPV cotesting compared with Pap testing alone. METHODS From September 1, 2006, through May 31, 2007, we conducted a mailed survey of a representative sample of 1212 PCPs, of whom 950 performed Pap tests and recommended the HPV test for screening or management. The main outcome measure included self-reported data on timing of screening intervals for women with normal results using clinical vignettes. RESULTS Among Pap test providers who recommend HPV testing, 31.8% reported that they would conduct the next Pap test in 3 years for a 35-year-old woman with 3 normal Pap test results. For a 35-year-old woman with a normal Pap test result and a negative HPV test finding, only 19.0% would conduct the next Pap test in 3 years. Most remaining physicians would conduct the Pap test more frequently. Most PCPs did not recommend a second HPV test or recommended the next HPV test at the same frequency as the Pap test. Physician specialty was strongly associated with guideline-consistent recommendations for the next Pap or HPV test. CONCLUSIONS A lower proportion of PCPs recommend extending screening intervals to 3 years with an HPV cotest than those screening with the Pap test alone. Implementation of effective interventions and strategies that improve physician adherence to recommendations will be important for efficient screening practices.

Race-specific results of Papanicolaou testing and the rate of cervical neoplasia in the National Breast and Cervical Cancer Early Detection Program, 1991–1998 (United States)

AbstractObjective: To describe differences in cervical screening and biopsy results by race or ethnicity from women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Methods: We examined the percentage of abnormalities detected by Papanicolaou (Pap) tests and the rate of biopsy-diagnosed high-grade precancerous or cancerous lesions by racial or ethnic group. Results: Almost half the 628,085 women screened were members of racial or ethnic minority groups. American Indian or Alaska Native women were more likely than others to report never having had a prior Pap test. American Indian or Alaska Native women had the highest proportion of abnormal Pap tests for first program screens (4.4%), followed by blacks (3.2%), whites (3.0%), Hispanics (2.7%), and Asians or Pacific Islanders (1.9%). Whites had the highest biopsy detection rate of high-grade lesions for first program screens (9.9 per 1000 Pap tests), followed by Hispanics (7.6), blacks (7.1), American Indians or Alaska Natives (6.7), and Asians or Pacific Islanders (5.4). Conclusions: This program provides important data on the prevalence of cervical neoplasia among diverse populations. Our findings that black women with a high-grade Pap test were less likely to get a work-up are disconcerting and merit further study and ultimate correction.

Timeliness of Breast Cancer Diagnosis and Initiation of Treatment in the National Breast and Cervical Cancer Early Detection Program, 1996–2005

OBJECTIVES To determine the effects of program policy changes, we examined service delivery benchmarks for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS We analyzed NBCCEDP data for women with abnormal mammogram or clinical breast examination (n=382 416) from which 23 701 cancers were diagnosed. We examined time to diagnosis and treatment for 2 time periods: 1996 to 2000 and 2001 to 2005. We compared median time for diagnostic, treatment initiation, and total intervals with the Kruskal-Wallis test. We calculated adjusted proportions (predicted marginals) with logistic regression to examine diagnosis and treatment within program benchmarks (<or=60 days) and time from screening to treatment (<or=120 days). RESULTS Median diagnostic intervals decreased by 2 days (25 vs 23; P<.001). Median treatment initiation intervals increased by 2 days (12 vs 14; P<.001). Total intervals decreased by 3 days (43 vs 40; P<.001). Women meeting the 60-day benchmark for diagnosis improved the most for women with normal mammograms and abnormal clinical breast examinations from 77% to 82%. CONCLUSIONS Women screened by the NBCCEDP received diagnostic follow-up and initiated treatment within preestablished program guidelines.

Breast Cancer Screening Beliefs, Recommendations, and Practices Primary Care Physicians in the United States

Primary care physicians (PCPs) play a key role in breast cancer screening, yet no current data exist regarding PCP practices.

Adherence to guidelines for follow-up of low-grade cytologic abnormalities among medically underserved women.

OBJECTIVE: To determine whether women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) who had findings on a Papanicolaou (Pap) test of atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL) were followed up in accordance with the interim guidelines for management of abnormal cervical cytology METHODS: For this study period, the guidelines for a Pap result of ASC-US or LSIL specified follow-up by Pap tests repeated every 4 to 6 months for 2 years. If a second report of ASC-US or LSIL was made, the patient was to have colposcopy. We analyzed data from 10,004 women who had a result of ASC-US or LSIL followed by a second ASC-US or LSIL from 1991–2000 RESULTS: As judged by the guidelines, 44% of women who had 2 low-grade abnormalities were followed up appropriately with colposcopy. Among women with 2 ASC-US results, those aged less than 30 years were more likely to receive colposcopy than the other age groups, while women who were aged 60 years and older were more likely to be followed up with a third Pap test. For each of the 4 result groups, American Indian or Alaska Native women had the highest percentages of a third Pap test, whereas Black or African-American women had a higher percentage of no follow-up CONCLUSION: More than one half of the women studied were not followed up in accordance with the established guidelines for managing abnormal cervical cytology. Factors such as age and race or ethnicity influence whether women with cytologic abnormalities receive appropriate follow-up. LEVEL OF EVIDENCE: II-3

Cervical screening in the National Breast and Cervical Cancer Early Detection Program, 1995-2001.

OBJECTIVE: To describe results of cervical cytology screening among low-income and uninsured women in the National Breast and Cervical Cancer Early Detection Program. METHODS: We analyzed data from 750,591 women who received their first Papanicolaou (Pap) test in the program between July 1995 and March 2001. RESULTS: Nearly 85% of the women were aged 40 years or older. Almost half were members of racial or ethnic minority groups. Overall, the percentage of abnormal Pap test results decreased with increasing age. The rates of cervical intraepithelial neoplasia (CIN) were highest in the younger age groups but the rate of invasive cancer increased with age. White women had the highest age-adjusted percentage of abnormal Pap test results and the highest rate of biopsy-confirmed CIN 2 or worse. CONCLUSIONS: In this nationwide screening program, only 7% of all biopsy-confirmed high-grade cervical lesions (CIN 2 or worse) were invasive cancer. This underscores the success of Pap screening in identifying preinvasive disease and preventing cancer. LEVEL OF EVIDENCE: II-3

Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States

OBJECTIVE Guidelines recommend when the human papillomavirus (HPV) and Papanicolaou tests are used together (HPV co-test) for routine cervical cancer screening, screening intervals can be extended to 3 years. We assessed HPV test practices and Papanicolaou test screening interval recommendations of US providers. STUDY DESIGN Using a multistage probability design, we analyzed nationally representative data that were collected in 2006 through the Centers for Disease Control and Preventions National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. RESULTS Approximately 51% of providers ordered the HPV co-test; however, clinical vignettes found that <15% of providers who ordered the HPV test recommend the next Papanicolaou test in 3 years for women with concurrent normal HPV co-test results and a documented normal screening history. CONCLUSION Overall, annual cervical cancer screening continues to be a common recommendation, regardless of whether a screening history has been established or an HPV test has been ordered.

Cervical Carcinoma Rates Among Young Females in the United States

OBJECTIVE: All national organizations now recommend that women be screened for cervical cancer beginning at age 21 years, regardless of age of sexual initiation; however, studies have shown that providers continue to screen much earlier than recommended. Two federal cancer surveillance systems were used to quantify the burden of invasive cervical carcinoma among women younger than 40 years of age. METHODS: We examined combined data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results Program covering 92% of the U.S. population. We calculated the age-adjusted incidence of cervical carcinoma among women younger than age 40 years by age, race, ethnicity, and histology for the time period of 1999–2008. RESULTS: For women younger than age 40 years, 78% of the cervical cancer cases were diagnosed in women aged 30–39, 21% were diagnosed in women 20–29 years of age, and 1% was diagnosed in women younger than age 20 years. There was an average of 3,063 cases of invasive cervical carcinomas annually from 1999 through 2008, with an average of 14 carcinomas per year (rate of 0.15 per 100,000 females) among those aged 15–19 years, and 125 carcinomas per year (rate of 1.4 per 100,000 females) among those aged 20–24 years. CONCLUSION: Cervical cancer is very rare in young women. Widespread implementation of Pap testing over the past four decades has detected very few cases of cervical cancer in women younger than 25 while potentially causing harm with unnecessary follow-up interventions. LEVEL OF EVIDENCE: III