Ethnicity & Disease

The Impact of Fibroids and Histologic Subtype on the Performance of US Clinical Guidelines for the Diagnosis of Endometrial Cancer among Black Women

Objective: To assess the predicted performance of the American College of Obstetrics and Gynecology (ACOG)’s recommended endometrial thickness (ET) of ≥4mm via transvaginal ultrasound (TVUS) for a simulated cohort of US Black women with postmenopausal bleeding (PMB).Methods: We used endometrial cancer parameters from ET studies upon which guidelines are based, as well as documented population characteristics of US Black wom­en, to simulate a cohort of US Black women with PMB. Annual endometrial cancer (EC) prevalence overall and by histology type (I and II), history and current diagnosis of uterine fibroids, and visibility of endometria were estimated. Sensitivity analyses were performed to assess performance changes with quality of baseline parameters and impact of fibroids on ET visibility.Main Outcome Measures: Performance characteristics of 3+, 4+, and 5+mm ET thresholds were assessed including sensitiv­ity, specificity, positive predictive value (PPV), negative predictive value (NPV), Receiver Operator Characteristic (ROC) curves, and the area under the curve (AUC).Results: In the main model with the 4+mm recommended threshold, TVUS ET showed a sensitivity of 47.5% (95% CI: 46.0-49.0%); specificity of 64.9% (95% CI: 64.4-65.3%); PPV of 13.1% (95% CI: 12.5-13.6%); NPV of 91.7% (95% CI: 91.4-92.1%), and AUC of .57 (95% CI: .56-.57).Conclusions: Among a simulated cohort of US Black women, the recommended 4+mm ET threshold to trigger diagnostic biopsy for EC diagnosis performed poorly, with more than 50% of cases missed and an 8-fold higher frequency of false nega­tive results than reported for the general population. Ethn Dis. 2021;30(4):543-552; doi:10.18865/ed.30.4.543

Commentary: Advancing the Science of Implementation for Resource-Limited Settings through Bidirectional Learning Around Cervical Cancer Screening

In 2020, the highest rates of cervical cancer incidence and mortality were reported in Asian and African regions of the world. Across the globe, growing evidence confirms cancer disparities among racial and ethnic minorities, low socioeconomic status groups, sexual and gender minorities, uninsured individuals, and rural residents. Recognition of these stark disparities has led to increased global efforts for improv­ing screening rates overall and, in medically underserved populations, highlighting the urgent need for research to inform the suc­cessful implementation of cervical cancer screening. Implementation science, defined as the study of methods to promote the integration of research evidence into health care practice, is well-suited to address this challenge. With a multilevel, implementa­tion focus, we present key research direc­tions that can help address cancer dispari­ties in resource-limited settings. First, we describe several global feasibility studies that acknowledge the effectiveness of self-sam­pling as a strategy to improve screening cov­erage. Second, we highlight Project ECHO as a strategy to improve providers’ knowl­edge through an extended virtual learning community, thereby building capacity for health care settings to deliver screening. Third, we consider community health work­ers, who are a cornerstone of implement­ing public health interventions in global communities. Finally, we see tremendous learning opportunities that use contextually relevant strategies to advance the science of community engagement and adaptations that could further enhance the uptake of screening in resource-limited settings. These opportunities provide future directions for bidirectional exchange of knowledge between local and global resource-limited settings to advance implementation science and address disparities. Ethn Dis. 2022; 32(4):269-274; doi:10.18865/ed.32.4.269

HPV Vaccination Hesitancy Among Latina Immigrant Mothers Despite Physician Recommendation

Purpose: Human papillomavirus (HPV) vaccination uptake continues to be low in the United States. While a recommenda­tion from a health care provider (HCP) has been shown to be associated with vaccine acceptability among parents, little is known about factors associated with hesitancy despite HCP recommendation. We exam­ined factors associated with HPV vaccine hesitancy, despite a physician recommenda­tion, among Latina immigrant mothers of daughters aged 9-12 years.Methods: As part of a group randomized trial to promote HPV vaccination between 2013 and 2016, we conducted a baseline interviewer-administered survey of mothers to assess sociodemographics, knowledge and perceived risk of cervical cancer/HPV infection, self-efficacy, and intention to vaccinate their unvaccinated daughters. Hesitancy was defined as “don’t know/not sure” (DK/NS) in response to the question: “If your daughter’s doctor recommended that she gets the HPV vaccine, would you let her get it?”Results: Of the 317 participants, 35.3% indicated hesitancy to vaccinate their daughters if their physician recommended it. Although a number of variables were as­sociated with HPV vaccine hesitancy in the univariate model, five remained significant in the final multivariable model: daughter’s health insurance status; HPV awareness; perceived risk of HPV infection for their daughters; perceived self-risk of cervical cancer; and a self-efficacy score of ability to complete the HPV vaccination series.Conclusions: A recommendation by a health care provider may be not enough to motivate Latina immigrant mothers to vaccinate their daughters. Further efforts should focus on increasing awareness re­garding HPV and cervical cancer, heighten­ing perceived risk of HPV infection among daughters and boosting self-efficacy to get their children vaccinated against HPV.Ethn Dis. 2020; 30(4):661-670; doi:10.18865/ed.30.4.661