Changing Inequalities in Cervical Cancer: Modeling the Impact of Vaccine Uptake, Vaccine Herd Effects, and Cervical Cancer Screening in the Post-Vaccination Era

Malagón, Talía; Drolet, Mélanie; Boily, Marie‐Claude; Laprise, Jean-François; Brisson, Marc

doi:10.1158/1055-9965.epi-14-1052

Cited by 15 publications

(7 citation statements)

References 70 publications

(101 reference statements)

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“…Socioeconomic factors such as education, income, and health insurance were important variables in our model, and are likely to be positively associated with both HPV vaccination and cervical screening. One modeling study suggests that HPV vaccination will reduce overall screening rates, but that current inequities will persist as long as some populations have low rates of vaccination and screening (Malagon et al, 2015). Future studies to determine factors in screening by HPV vaccination status may elucidate additional important findings.…”

Section: Discussionmentioning

confidence: 99%

National assessment of HPV and Pap tests: Changes in cervical cancer screening, National Health Interview Survey

Watson

Benard

King

et al. 2017

Preventive Medicine

103

108

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Background Major organizations recommend cytology screening (Pap test) every 3 years for women aged 21–65; women aged 30 to 65 have the option of adding the HPV test (co-test) every 5 years. We examined national percentages of cervical cancer screening, and we examined use of co-testing as an option for screening. Methods We used 2015 U.S. National Health Interview Survey (NHIS) data to examine recent cervical cancer screening (Pap test within 3 years among women aged 21–65without a hysterectomy; N = 10,596) and co-testing (N = 9,125). We also conducted a multivariable analysis to determine odds of having had a Pap test or co-test by demographic variables. To evaluate changes in screening over time, we examined Pap testing during the years 2000, 2005, 2008, 2010, 2013 and 2015. Analysis completed in Atlanta, GA during 2016. Results Overall, 81.1% of eligible women reported having a Pap test within 3 years; percentages declined over time among all age groups. An estimated 14 million women aged 21–65 had not been screened within the past 3 years. Recent immigrants to the United States, women without insurance, and women without a usual source of healthcare had lower odds of being up to date with screening. About 1/3 of women up to date on Pap testing reported having a co-test with their most recent Pap test. Conclusions Declines in screening among women aged 21–65 are cause for concern. More research is needed on co-testing practices. Provider and patient education efforts may be needed to clarify recommended use of HPV tests.

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Section: Discussionmentioning

confidence: 99%

National assessment of HPV and Pap tests: Changes in cervical cancer screening, National Health Interview Survey

Watson

Benard

King

et al. 2017

Preventive Medicine

103

108

View full text Add to dashboard Cite

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“…This work builds on a number of other studies that have raised the question of how differences in uptake of vaccination and cervical screening will affect equality in HPV-related disease outcomes. Initial explorations considered hypothetical cases of increasing assortative mixing (assortativity) in partner choice, 14 , 15 , 16 , 17 others used ethnicity-specific data on vaccination and screening uptake but did not consider sexual mixing. 18 , 19 The strength of this study lies in the data-grounded modelling approach: by using an individual-based transmission dynamic model, we have been able to incorporate heterogeneity in both sexual and health-protective behaviour by ethnicity, including detailed data on partner choice by ethnicity and age, and to track an individual's life history of infection, vaccination, and disease.…”

Section: Discussionmentioning

confidence: 99%

“…To understand the complicated nature of infection dynamics and disease progression, and the multiple behavioural and demographic factors such as those associated with HPV and cervical cancer, mathematical models are often used. 12 , 13 , 14 Recent studies have considered the hypothetical effect of HPV vaccination on health inequality 14 , 15 , 16 , 17 and others have questioned the implications of difference in vaccination uptake by ethnicity; 18 , 19 however, none to our knowledge have made a data-based evaluation of the implicit dependency of sexual mixing and health-care-seeking behaviour.…”

Section: Introductionmentioning

confidence: 99%

Effect of HPV vaccination and cervical cancer screening in England by ethnicity: a modelling study

Johnson

Lafferty

Eggo

et al. 2018

The Lancet Public Health

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SummaryBackgroundHealth equality is increasingly being considered alongside overall health gain when assessing public health interventions. However, the trade-off between the direct effects of vaccination and herd immunity could lead to unintuitive consequences for the distribution of disease burden within a population. We used a transmission dynamic model of human papillomavirus (HPV) to investigate the effect of ethnic disparities in vaccine and cervical screening uptake on inequality in disease incidence in England.MethodsWe developed an individual-based model of HPV transmission and disease, parameterising it with the latest data for sexual behaviour (from National Survey of Sexual Attitudes and Lifestyles [Natsal-3]) and vaccine and screening uptake by ethnicity (from Public Health England [PHE]) and fitting it to data for HPV prevalence (from ARTISTIC, PHE, Natsal-3) and HPV-related disease incidence (from National Cancer Registry [ONS]). The outcome of interest was the age-adjusted incidence of HPV-related cancer (both cervical and non-cervical) in all women in England in view of differences and changes in vaccination and screening uptake by ethnicity in England, over time. We also studied three potential public health interventions aimed at reducing inequality in HPV-related disease incidence: increasing uptake in black and Asian females to match that in whites for vaccination; cervical screening in women who turn 25 in 2018 or later; and cervical screening in all ages.FindingsIn the pre-vaccination era, before 2008, women from ethnic minorities in England reported a disproportionate share of cervical disease. Our model suggests that Asian women were 1·7 times (95% credibility interval [CI] 1·1–2·7) more likely to be diagnosed with cervical cancer than white women (22·8 vs 13·4 cases per 100 000 women). Because HPV vaccination uptake is lower in ethnic minorities, we predict an initial widening of this gap, with cervical cancer incidence in Asian women up to 2·5 times higher (95% CI 1·3–4·8) than in white women 20 years after vaccine introduction (corresponding to an additional 10·8 [95% CI 10·1–11·5] cases every year). In time, we predict that herd immunity benefits will diffuse from the larger white sub-population and the disparity will narrow. Increased cervical screening uptake in vaccinated women from ethnic minorities would lead to rapid improvement in equality with parity in incidence after 20 years of HPV vaccination.InterpretationOur study suggests that the introduction of HPV vaccination in England will initially widen a pre-existing disparity in the incidence of HPV-related cancer by ethnicity, partly due to herd immunity disproportionately benefiting subgroups with high vaccination rates. Although in time this induced disparity will narrow, increasing cervical screening uptake in girls from ethnic minorities should be encouraged to eliminate the inequality in cervical cancer incidence in the medium term. We recommend that dynamic effects should be considered when estimating the effect of publi...

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“…It is a disease that disproportionately burdens disadvantaged ethnic minorities and women living in poverty in affluent countries, and the poorest women in poor countries [ 1 – 4 ]. Acknowledging population disparities in cervical cancer incidence is not new; cervical cancer has a long reputation of being a disease that disproportionately affects women of low socioeconomic status (SES) [ 1 , 4 – 7 ]. Much of this cancer incidence is, in theory, preventable.…”

Section: Introductionmentioning

confidence: 99%

“…However while organised programs aim to provide equality of opportunity, equality of outcome is rarely achieved. Disparities in screening uptake also exist; even in countries with equal and free access to screening there have been differences in uptake along SES lines with testing rates decreasing as SES decreases [ 1 , 3 , 10 ]. Despite extensive research on underscreened populations and the barriers to participation those communities face [ 11 – 13 ], discrepancies in uptake remain [ 8 , 14 ].…”

Section: Introductionmentioning

confidence: 99%

An empirical study of the ‘underscreened’ in organised cervical screening: experts focus on increasing opportunity as a way of reducing differences in screening rates

Williams

Carter

2016

BMC Med Ethics

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BackgroundCervical cancer disproportionately burdens disadvantaged women. Organised cervical screening aims to make cancer prevention available to all women in a population, yet screening uptake and cancer incidence and mortality are strongly correlated with socioeconomic status (SES). Reaching underscreened populations is a stated priority in many screening programs, usually with an emphasis on something like ‘equity’. Equity is a poorly defined and understood concept. We aimed to explain experts’ perspectives on how cervical screening programs might justifiably respond to ‘the underscreened’.MethodsThis paper reports on a grounded theory study of cervical screening experts involved in program organisation. Participants were 23 experts from several countries and a range of backgrounds: gynecology; epidemiology; public health; pathology; general practice; policy making. Data were gathered via semi-structured interview and concepts developed through transcript coding and memo writing.ResultsMost experts expressed an intuitive commitment to reducing systematic differences in screening participation or cancer outcomes. They took three different implicit positions, however, on what made organised programs justifiable with respect to underscreened populations. These were: 1) accepting that population screening is likely to miss certain disenfranchised groups for practical and cultural reasons, and focusing on maximising mainstream reach; 2) identifying and removing barriers to screening; and 3) providing parallel tailored screening services that attended to different cultural needs. Positions tended to fall along country of practice lines.ConclusionsExperts emphasised the provision of opportunity for underscreened populations to take up screening. A focus on opportunity appeared to rely on tacit premises not supported by evidence: that provision of meaningful opportunity leads to increased uptake, and that increased uptake of an initial screening test by disadvantaged populations would decrease cervical cancer incidence and mortality. There was little attention to anything other than the point of testing, or the difficulties disadvantaged women can have in accessing follow up care. The different approaches to ‘improving equity’ taken by participants are differently justified, and differently justifiable, but none attend directly to the broader conditions of disadvantage.Electronic supplementary materialThe online version of this article (doi:10.1186/s12910-016-0143-z) contains supplementary material, which is available to authorized users.

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Changing Inequalities in Cervical Cancer: Modeling the Impact of Vaccine Uptake, Vaccine Herd Effects, and Cervical Cancer Screening in the Post-Vaccination Era

Cited by 15 publications

References 70 publications

National assessment of HPV and Pap tests: Changes in cervical cancer screening, National Health Interview Survey

National assessment of HPV and Pap tests: Changes in cervical cancer screening, National Health Interview Survey

Effect of HPV vaccination and cervical cancer screening in England by ethnicity: a modelling study

An empirical study of the ‘underscreened’ in organised cervical screening: experts focus on increasing opportunity as a way of reducing differences in screening rates

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