An Organized Approach to Multi-Organ Screening in Rural Honduras

Background: Poverty, poor healthcare infrastructure and geographic location contribute to a total lack of cancer screening for most residents of rural Honduras. Three projects built upon each other to develop, with local leaders, multiorgan screening events that mitigated barriers to screening-based early detection of cancers. Targeted barriers included transportation, cost, community perception and convenience. Aim: To test a novel system of multiorgan screening for feasibility, acceptability and effectiveness. Methods: Leveraging well-known brigade-style medical outreach methods, two large-scale weekend programs for women and one for men over four years in the same rural location screened women for cancers of the cervix, breast, oral cavity, thyroid; and men for cancers of the testes, oral cavity, skin, prostate and colon; and connected participants with follow-up care at a Honduran cancer center. Screening methods ranged from simple throat palpation for thyroid lesions to molecular screening for high risk HPV. Generally, screening began with low-tech methods onsite to triage the participants and identify those at high-risk for cancer who should have more technical follow-up at an equipped clinic. Well-trained Honduran medical students provided screening capacity and community leaders were solely responsible for promoting the screening opportunities. Masking was not possible onsite, but data analysis in the U.S. was anonymized. Results: Participants were accrued to each program's capacity (n=400) in 2013 and 2016 and near capacity in 2017 with high levels of participants completing the screening programs, community engagement with the process, and compliance with referrals for clinical follow-up at a collaborating cancer center located three hours away. Participants identified at the screenings for clinical follow-up included for women: breast 2.7% (2013) and 4.2% (2016), thyroid 1.7% (2016), cervix/positive for high risk HPV 8.2% (2013) and 11.8% (2016); and for men all in 2017: skin 0%, testes 7%, colorectal 1%, oropharynx 1 participant, and prostate 6.7%. The dominant local narrative predicted men would not participate in screening, yet 326 participated and of that group, 239 self-identified as having possible colorectal symptoms based on seeing an advertising flyer with questions about symptoms of constipation, bloody stools, or unintended weight loss. That self-identified subset took the initiative to see the local nurse in advance, obtain a colorectal sample kit, collect three days of stool samples, and bring them to the screening event. Conclusion: With community engagement and attention to planning for organized and rapid throughput, large-scale multiorgan cancer screening may be feasible in low-income rural communities. Funding: The Jornada studies were funded by Norris Cotton Cancer Center at Dartmouth's Geisel School of Medicine and a special grant from Geisel's Munck-Pfefferkorn Fund.

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Burden of high-risk oral HPV infection in men in the United States and implications for oropharyngeal cancer screening: NHANES (1999-2012).

Journal of Clinical Oncology ◽

10.1200/jco.2015.33.3_suppl.55 ◽

2015 ◽

Vol 33 (3_suppl) ◽

pp. 55-55

Author(s):

Erin Dunn ◽

Kevin J. Moore ◽

Tulay Koru-Sengul

Keyword(s):

Cancer Screening ◽

High Risk ◽

Oropharyngeal Cancer ◽

The United States ◽

Hpv Infection ◽

Population Based ◽

Infection Prevalence ◽

Hpv 16 ◽

Screening Programs ◽

High Risk Hpv

55 Background: In men high-risk human papilloma viruses (HPVs) have been implicated in causing cancer of the penis, anus, and oropharynx. HPV infection, specifically HPV 16, is currently one of the most common causes of oropharyngeal cancer. National population-based surveys provide estimates of population-specific prevalence, trend, and determinants to identify the burden of high-risk HPV in the oropharynx of men. Methods: We calculated HPV infection prevalence by oral testing in the US from 1999-2012 National Health and Nutrition Examination Survey (NHANES) to obtain a representative sample of non-institutionalized civilian population. We provided epidemiology of HPV infection for both females and males with prevalence estimates, unadjusted odds ratio (OR) with 95% confidence interval (95%CI). Analysis was performed by SAS v9.3 with complex sampling design. Results: Among HPV-positive persons, high-risk HPV infection (16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 73, 82) was more prevalent for men (79.4%) than for women (20.6%). Men also had the highest prevalence for each high-risk type tested. Notably, men held 84.9% of the HPV 16 burden, which has the highest risk for orophargyngeal cancer. Mexican-American men had lower odds of high-risk HPV infection than White men (OR=0.47; 95%CI=0.261, 0.86). Further, divorced/separated/widowed men had lower (0.48; 0.26, 0.88) and never married men had greater (1.76; 1.01, 3.07) odds of high-risk HPV compared to men who are married/living with partner. Conclusions: Using a large population-based survey, our results show increased prevalence of high-risk HPV infection in men. Stratification by ethnicity and marital status will increase understanding and awareness of the burden and demographic disparities of potentially oncogenic HPV infections in men and may provide a base for culturally and gender competent oropharyngeal cancer screening programs. Recognizing demographic disparities and behaviors could guide further research into risk factors and conditions that guide the prevalence of HPV infection and oropharyngeal cancer in specific male populations.

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Introduction of primary screening using high-risk HPV DNA detection in the Dutch cervical cancer screening programme: a population-based cohort study

BMC Medicine ◽

10.1186/s12916-019-1460-0 ◽

2019 ◽

Vol 17 (1) ◽

Cited By ~ 14

Author(s):

Clare A. Aitken ◽

Heleen M. E. van Agt ◽

Albert G. Siebers ◽

Folkert J. van Kemenade ◽

Hubert G. M. Niesters ◽

...

Keyword(s):

Cervical Cancer ◽

Cancer Screening ◽

High Risk ◽

Cervical Cancer Screening ◽

Screening Programme ◽

Referral Rate ◽

Cancer Screening Programme ◽

Cervical Cancer Screening Programme ◽

High Risk Hpv

Abstract Background In January 2017, the Dutch cervical cancer screening programme transitioned from cytomorphological to primary high-risk HPV (hrHPV) DNA screening, including the introduction of self-sampling, for women aged between 30 and 60 years. The Netherlands was the first country to switch to hrHPV screening at the national level. We investigated the health impact of this transition by comparing performance indicators from the new hrHPV-based programme with the previous cytology-based programme. Methods We obtained data from the Dutch nationwide network and registry of histo- and cytopathology (PALGA) for 454,573 women eligible for screening in 2017 who participated in the hrHPV-based programme between 1 January 2017 and 30 June 2018 (maximum follow-up of almost 21 months) and for 483,146 women eligible for screening in 2015 who participated in the cytology-based programme between 1 January 2015 and 31 March 2016 (maximum follow-up of 40 months). We compared indicators of participation (participation rate), referral (screen positivity; referral rate) and detection (cervical intraepithelial neoplasia (CIN) detection; number of referrals per detected CIN lesion). Results Participation in the hrHPV-based programme was significantly lower than that in the cytology-based programme (61% vs 64%). Screen positivity and direct referral rates were significantly higher in the hrHPV-based programme (positivity rate: 5% vs 9%; referral rate: 1% vs 3%). CIN2+ detection increased from 11 to 14 per 1000 women screened. Overall, approximately 2.2 times more clinical irrelevant findings (i.e. ≤CIN1) were found in the hrHPV-based programme, compared with approximately 1·3 times more clinically relevant findings (i.e. CIN2+); this difference was mostly due to a national policy change recommending colposcopy, rather than observation, of hrHPV-positive, ASC-US/LSIL results in the hrHPV-based programme. Conclusions This is the first time that comprehensive results of nationwide implementation of hrHPV-based screening have been reported using high-quality data with a long follow-up. We have shown that both benefits and potential harms are higher in one screening round of a well-implemented hrHPV-based screening programme than in an established cytology-based programme. Lower participation in the new hrHPV programme may be due to factors such as invitation policy changes and the phased roll-out of the new programme. Our findings add further to evidence from trials and modelling studies on the effectiveness of hrHPV-based screening.

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Human Papillomavirus Laboratory Testing: the Changing Paradigm

Clinical Microbiology Reviews ◽

10.1128/cmr.00013-15 ◽

2016 ◽

Vol 29 (2) ◽

pp. 291-319 ◽

Cited By ~ 59

Author(s):

Eileen M. Burd

Keyword(s):

High Risk ◽

Human Papillomaviruses ◽

Screening Tests ◽

Screening Methods ◽

Hpv Testing ◽

Normal Cytology ◽

Ongoing Research ◽

Screening Programs ◽

Molecular Tests ◽

High Risk Hpv

SUMMARYHigh-risk human papillomaviruses (HPVs) cause essentially all cervical cancers, most anal and oropharyngeal cancers, and some vaginal, vulvar, and penile cancers. Improved understanding of the pathogenesis of infection and the availability of newer tests are changing the approach to screening and diagnosis. Molecular tests to detect DNA from the most common high-risk HPVs are FDA approved for use in conjunction with cytology in cervical cancer screening programs. More-specific tests that detect RNA from high-risk HPV types are now also available. The use of molecular tests as the primary screening tests is being adopted in some areas. Genotyping to identify HPV16 and -18 has a recommended role in triaging patients for colposcopy who are high-risk HPV positive but have normal cytology. There are currently no recommended screening methods for anal, vulvar, vaginal, penile, or oropharyngeal HPV infections. HPV testing has limited utility in patients at high risk for anal cancer, but p16 immunohistochemistry is recommended to clarify lesions in tissue biopsy specimens that show moderate dysplasia or precancer mimics. HPV testing is recommended for oropharyngeal squamous cell tumors as a prognostic indicator. Ongoing research will help to improve the content of future guidelines for screening and diagnostic testing.

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Cohort Profile: African Collaborative Center for Microbiome and Genomics Research (ACCME)

Journal of Global Oncology ◽

10.1200/jgo.2016.003822 ◽

2016 ◽

Vol 2 (3_suppl) ◽

pp. 40s-40s

Author(s):

Sally N. Adebamowo ◽

Eileen O. Dareng ◽

Ayotunde O. Famooto ◽

Rasheed A. Bakare ◽

Clement A. Adebamowo ◽

...

Keyword(s):

Cervical Cancer ◽

High Risk ◽

Rrna Gene ◽

Screening Programs ◽

Vaginal Ph ◽

Hpv Types ◽

The Mean ◽

Study Participants ◽

High Risk Hpv

Abstract 65 Background: Cervical cancer is the second most common cancer in Africa. Much remains unknown about the prevalence and pathogenicity of human papillomavirus (HPV) types and the mechanism of disease, and there is a need for new biomarkers for screening programs. Methods: ACCME is a multicenter prospective cohort study of host germline, somatic and HPV genomics and epigenomics, and vaginal microenvironment; and their association with cervical cancer in 10,000 HIV negative women in Nigeria. Data on demographic, lifestyle, medical history, serum, germline DNA, HPV genotype, and vaginal pH are collected at baseline and during follow up visits every 6 months. Samples of exfoliated cervical cells are analyzed for high risk HPV with Roche LINEAR ARRAY and vaginal bacterial composition and abundance are characterized by deep sequencing of barcoded 16S rRNA gene fragments (V4) on a Illumina MiSeq platform. Colposcopies and biopsies are conducted on participants with clinical lesions and those with persistent high risk HPV infections. Results: By December 2015, 10,000 participants had been enrolled in the ACCME cohort. The mean (SD) age of the study participants at baseline was 40 (10) years. Most of the participants were married (76%), attended university (44%), and had professional jobs (37%). All the study participants have had vaginal sex, 17% have had oral sex, and only 2% have ever had anal sex. We found 30% of the study participants were HPV positive and 70% were HPV negative. The mean (SD) vaginal pH in the study population was 5.2 (0.5). Further analyses to characterize high-risk HPV types and determine persistence will be conducted at each follow up visit. Also, characterization of cervical cytokines and vaginal microbiome will be conducted after the follow up visits for all participants have been conducted. Conclusions: ACCME is a paradigm for translational research in biomarker discovery that addresses high impact public health challenges affecting women's health in Africa and the rest of the world. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: No COIs from the authors.

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Factors associated with high-risk HPV infection and cervical cancer screening methods among rural Uyghur women aged > 30 years in Xinjiang

BMC Cancer ◽

10.1186/s12885-018-5083-1 ◽

2018 ◽

Vol 18 (1) ◽

Cited By ~ 2

Author(s):

Sulaiya Husaiyin ◽

Lili Han ◽

Lin Wang ◽

Chunhua Ma ◽

Zumurelaiti Ainiwaer ◽

...

Keyword(s):

Cervical Cancer ◽

Cancer Screening ◽

High Risk ◽

Cervical Cancer Screening ◽

Hpv Infection ◽

Screening Methods ◽

Factors Associated ◽

High Risk Hpv

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High-Risk HPV Genotypes Identified in Northern Honduras: Evidence for Prevention

Journal of Global Oncology ◽

10.1200/jgo.18.85200 ◽

2018 ◽

Vol 4 (Supplement 2) ◽

pp. 211s-211s

Author(s):

S. Turner ◽

C. Studwell ◽

S. Deharvengt ◽

K.D. Lyons ◽

J.A. Plata ◽

...

Keyword(s):

Cervical Cancer ◽

High Risk ◽

Cervical Screening ◽

Dartmouth College ◽

Cancer Center ◽

Hpv 16 ◽

Pap Tests ◽

Abnormal Pap Tests ◽

High Risk Hpv

Background: Cervical cancer is one of the most prevalent cancers in Honduran women. Lacking national or population-based registries, we rely on hospital registries to establish incidence: San Felipe General Hospital in 2012 diagnosed 38% of 998 women and The League against Cancer Hospital (LCC) in 2016 diagnosed 54.4% of 695 women with cervical cancer CC. According to PAHO's Honduras Profile 2013, screening coverage with Pap was 48.1%. Bruni in 2010 reported a prevalence of high risk HPV (hrHPV) infection for Central America of 13%, identifying genotypes 16, 18, 52, 31 and 58 as most frequent. Information about pathogenesis of hrHPV to induce cervical lesions is based on models of genotypes 16 and 18 only. Aim: Inform evidence of hrHPV genotypes collected in Honduras from an urban and a rural population, generate discussion and subsequent improvement of cervical cancer control strategies in our country. Methods: In 2016, 2 clinical studies funded by Norris Cotton Cancer Center at Dartmouth College and the LCC accrued 913 women: 401 in Locomapa Valley (rural), 111 in La Mosquitia (remote rural), and 401 in a textile factory in San Pedro Sula (urban). Women were consented, to obtain 3 cervical samples, during a cervical cancer screening brigade. One sample for conventional cytology, and 2 for hrHPV by PCR genotyping. One local with our customized PCR device and the second at Dartmouth. An educational component and survey were included. Positive patients identified with hrHPV, pre or invasive cancer were referred to LCC for treatment and follow-up. Results: In Locomapa and the factory (rural and urban sites) 13% of participants were positive for hrHPV. Only 15% had HPV 16. The following common genotypes varied by location: urban factory HPV 59, 12% in rural location HPV 58, 10%; HPV 31, 9%; HPV 39 8%; HPV 35 and 66, 7%; HPV 45 and 51, 6%; HPV 18 and 56, 3%; HPV 33 and 52, 1%. 17% of women had multiple hrHPV coinfection. 7.7% had abnormal Pap tests. In La Mosquitia (remote rural), 24% of women were positive for hrHPV: HPV 52, 29%; HPV 16, 23%; HPV 39, 10%; HPV 68, 6%; HPV 58, 6%; HPV 45, 6%; HPV 51 and HPV 31, 18, 66, 59 and 35, 3% each. 1.8% had abnormal Pap tests; all participants identified with hrHPV were referred for follow-up. The average age was 40.3 years, parity, 3 children, education 6.0 years; and 15% were first-time users of a cervical screening program. Conclusion: Associate the burden of disease, with risk factors, will help us to generate models of prevention and care that are reproducible and effective to reduce morbi-mortality. Brigade-type screening models, with trained providers working at a community location over a single day, can offer improved access for women at risk and facilitate educational activities for health promotion. Introducing tests as hrHPV DNA detection, effectively reduces the volume of women to follow. Strengthening the capacity of primary care with novel screening techniques and ensure diligent follow-up is essential.

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Partnering for Success: Expanding Breast and Cancer Screening in Rural Honduras One Clinic at a Time

Journal of Global Oncology ◽

10.1200/jgo.2016.003848 ◽

2016 ◽

Vol 2 (3_suppl) ◽

pp. 24s-25s

Author(s):

Derek S. Stenquist ◽

Suyapa Bejarano ◽

Linda S. Kennedy ◽

Silvia Portillo ◽

Ana Barrientos ◽

...

Keyword(s):

Cervical Cancer ◽

Cancer Screening ◽

High Risk ◽

Rural Communities ◽

Cervical Cancer Screening ◽

Conflicts Of Interest ◽

Cancer Education ◽

Cancer Center ◽

Breast And Cervical Cancer

Abstract 36 Background: Women in rural Honduras have limited access to cancer education, screening, and care. With village leaders, we piloted breast and cervical cancer screening in El Rosario, Honduras. Our objectives were to improve awareness and access, mitigate barriers, connect community and Honduran providers, and link patients with abnormal findings to cancer treatment. In 2013, health professionals and staff from Norris Cotton Cancer Center at Dartmouth- Hitchcock joined Honduran clinicians and medical students from La Liga Contra el Cáncer for two days of rural cancer screening. Peer educators taught 475 participants from 31 rural communities how to conduct self-breast exams. Of these participants, 238 chose clinical breast exams; 5% were clinically abnormal and 2.9% were referred for services at La Liga with 100% compliance. 34% reported barriers to cervical cancer screening due to distance and lack of transportation. 14.5% tested positive for HPV and 8% were positive for high risk HPV genotypes including 11 of 13 known high risk types. This group has been retested periodically by Pap. The collaborators will return in April 2016 to repeat the study, adding oral and thyroid screening. Genotyping for hrHPV will be onsite with a novel assay for PCR developed at Dartmouth-Hitchcock. Reflex testing with Pap will follow as needed. Follow up will be at La Liga where care is offered for free or at a reduced cost. A similar project for 400 urban factory-workers will also take place in April 2016. Methods: 2-day, multi-modal education and screening outreach run brigade-style combining low-tech primary screening with onsite molecular pathology. Conclusions: Partnerships between local leaders and clinicians are predicted to be essential to project implementation. Targeting populations with education and screening plus building connections to follow up care will provide earlier detection of breast and cervical cancer. We predict that community leadership will be critical to preventing loss to follow-up. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: Derek S. Stenquist No relationship to disclose Suyapa Bejarano No relationship to disclose Linda S. Kennedy No relationship to disclose Silvia Portillo No relationship to disclose Ana Barrientos No relationship to disclose Suzanne P. Burgos No relationship to disclose Roberto Armando Elvir Zelaya No relationship to disclose Christine Averill No relationship to disclose Emmeline Liu No relationship to disclose Francine de Abreau No relationship to disclose Paul Burchard No relationship to disclose Torrey Gallagher No relationship to disclose Martha Goodrich No relationship to disclose Scottie Eliassen No relationship to disclose Julie Weiss No relationship to disclose Camilo Mandujano No relationship to disclose Jennifer Alford-Teaster No relationship to disclose Gregory J. Tsongalis Research Funding: Illumina, Qiagen, Thermofisher Tracy Onega No relationship to disclose Mary D. Chamberlin No relationship to disclose

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