INTRODUCTION: Variations in cervical cancer incidence rates and trends have been reported by sociodemographic characteristics. However, research on economic characteristics is limited especially among younger women in the United States. METHODS: We analyzed United States Cancer Statistics data to examine age-standardized cervical cancer incidence rates among women aged 15-29 years during 2007-2020. We used an index-based county-level economic classification to rank counties in the top 25 %, middle 25 %-75 %, and bottom 25 %. We assessed differences in incidence using rate ratios and trends using annual percent changes (APCs) from joinpoint regression. Due to impact from the COVID-19 pandemic, trend analysis excluded 2020 data. Analyses were conducted during August-October 2023. RESULTS: During 2007-2020, incidence rates were lower in the top 25 % counties economically than the bottom 25 % or middle 25 %-75 % (1.6 vs 2.1 vs 1.9 per 100,000, respectively). Rates were higher in nonmetropolitan than metropolitan counties across economic groups. Overall, rates declined in all county-level economic strata, especially in the bottom 25 % during 2015-2019 (APC -10.6 %). Rates appeared to decrease in metropolitan counties and women of all races across economic categories. decreases were most evident in the top 25 % of non-Hispanic White women during 2016-2019 and nonmetropolitan counties during 2017-2019. CONCLUSIONS: In women aged 15-29 years, declining rates of cervical cancer during 2007-2019 across county-level economic strata may partly reflect effects of human papillomavirus vaccination and cervical cancer screening. Further observed differences by race and rurality may help inform efforts to increase implementation of preventive measures in populations with the highest burden.

In addition to oropharyngeal cancers, evidence suggests there may be an etiologic role for human papillomavirus (HPV) in some other head and neck cancers arising from the oral cavity and larynx. We estimated the burden of HPV16-attributable cancers of the oral cavity (ICD-O-3 site codes C02.0-C02.3, C02.9, C03.0, C03.1, C03.9, C04.0, C04.1, C04.8, C04.9, C05.0, C05.8, C05.9, C06.0-C06.2, C06.8, C06.9) and larynx (C32.0-C32.3, C32.8, C32.9) in the United States by pooling estimates from published case studies to calculate HPV16-attributable fractions (HPV16-AFs) and applying the HPV16-AFs to 2016-2020 US Cancer Statistics data. During 2016-2020, of an average annual number of 12,612 oral cavity cancers, 3.9% (n = 497) were estimated to be attributable to HPV16. Of an average annual number of 11,170 laryngeal cancers, 2.8% (n = 309) were estimated to be attributable to HPV16. This information can improve surveillance of HPV16-attributable cancers in the US population and inform our understanding of the potential impact of HPV vaccination on cancers at these two sites.

IMPORTANCE: The World Health Organization has called for eliminating cervical cancer as a public health problem. Accurate and up-to-date estimates of population-based cervical cancer incidence are essential for monitoring progress toward elimination and informing local cancer control strategies, but these estimates are lacking for the US-Affiliated Pacific Islands (USAPI). OBJECTIVE: To calculate age-standardized incidence rates for cervical cancer in the 6 USAPI and compare these rates with rates in the US (50 states and the District of Columbia). DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used population-based data from the Pacific Regional Central Cancer Registry for women aged 20 years or older who were diagnosed with invasive cervical cancer from January 1, 2007, to December 31, 2020. The registry comprises data on all cervical cancers from the USAPI, which include 3 US territories (American Samoa, Commonwealth of the Northern Mariana Islands, and Guam) and 3 freely associated states (Federated States of Micronesia [FSM], Republic of the Marshall Islands [RMI], and Republic of Palau). Data were analyzed from July 10, 2023, to November 28, 2023. MAIN OUTCOMES AND MEASURES: The main outcome was age-standardized cervical cancer incidence rates, stratified by age, stage, and histologic code for the USAPI using population estimates from 3 different sources (US Census Bureau International Database, United Nations Population Division, and Pacific Data Hub). Rate ratios were calculated to compare incidence rates between the USAPI and the US. RESULTS: From 2007 to 2020, 409 cases of cervical cancer were diagnosed in the USAPI (median age at diagnosis, 46.0 years [25th-75th percentile, 39.0-55.0 years]), with an age-standardized incidence rate ranging from 21.7 (95% CI, 19.6-23.9) to 22.1 (95% CI, 20.0-24.4) per 100 000 women, depending on the population estimate. Incidence rates were highest in RMI, ranging from 58.1 (95% CI, 48.0-69.7) to 83.4 (95% CI, 68.3-101.0) per 100 000 women, followed by FSM, ranging from 28.7 (95% CI, 23.4-34.9) to 29.8 (95% CI, 24.3-36.3) per 100 000 women. Compared with the US, incidence rates were highest in RMI (rate ratio, 5.7 [95% CI, 4.7-6.8] to 8.2 [95% CI, 6.7-9.9]) and FSM (rate ratio; 2.8; 95% CI, 2.3-3.4). Of all cases in the USAPI, 213 (68.2%) were diagnosed at a late stage. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, cervical cancer remained a major public health issue in some USAPI, with RMI reporting the highest incidence rates. The findings suggest that improvements in human papillomavirus vaccination and cancer screening coverage through efforts tailored to the unique geographic, sociocultural, economic, and health care landscape of the USAPI may reduce the burden of cervical cancer.

BACKGROUND: Breast cancer is the most common cancer diagnosed among women globally and in the United States (US); however, its incidence in the six US-Affiliated Pacific Islands (USAPI) remains less characterized. METHODS: We analyzed data from a population-based cancer registry using different population estimates to calculate incidence rates for breast cancer among women aged >20 years in the USAPI. Rate ratios and 95 % confidence intervals (CI) were calculated to compare incidence rates between the USAPI and the US (50 states and the District of Columbia). RESULTS: From 2007-2020, 1118 new cases of breast cancer were diagnosed in the USAPI, with 66.3 % (n = 741) of cases reported in Guam. Age-standardized incidence rates ranged from 66.4 to 68.7 per 100,000 women in USAPI and 101.1-110.5 per 100,000 women in Guam. Compared to the US, incidence rates were lower in USAPI, with rate ratios ranging from 0.38 (95 % CI: 0.36, 0.40) to 0.39 (95 % CI: 0.37, 0.42). The proportion of late-stage cancer was significantly higher in the USAPI (48.7 %) than in the US (34.0 %), particularly in the Federated States of Micronesia (78.7 %) and Palau (73.1 %). CONCLUSIONS: Breast cancer incidence rates were lower in the USAPI than in the US; however, late-stage diagnoses were disproportionately higher. Low incidence and late-stage cancers may signal challenges in screening, cancer surveillance, and health care access and resources. Expanding access to timely breast cancer screening, diagnosis, and treatment could reduce the proportion of late-stage cancers and improve survival in the USAPI.

OBJECTIVE: To examine population-level scrotal cancer incidence rates and trends among adult men in the United States. METHODS: Data from the United States Cancer Statistics, covering approximately 96% of the United States population, were analyzed to calculate age-standardized incidence rates of scrotal cancer among men aged 18 years and older from 1999 to 2020. Trends in incidence rates were evaluated by age, race and ethnicity, Census region, and histology using joinpoint regression. RESULTS: Overall, 4669 men were diagnosed with scrotal cancer (0.20 per 100,000). Incidence rates were highest among men aged 70 years and older (0.82 per 100,000). Rates were higher among non-Hispanic Asian or Pacific Islander men (0.31 per 100,000) compared to other race and ethnicity groups. The most common histologic subtypes were squamous cell carcinoma (35.9%), extramammary Paget disease (20.8%), and sarcoma (20.5%). Incidence rates decreased by 2.9% per year from 1999 to 2019 for non-Hispanic Asian or Pacific Islander men, decreased by 8.1% per year from 1999 to 2006 for basal cell carcinomas, and increased by 1.8% per year from 1999 to 2019 for extramammary Paget disease; otherwise, rates remained stable for all other variables examined. CONCLUSION: While scrotal cancer incidence rates were higher than previously reported, rates were still low and stable over time.

The U.S.-affiliated Pacific Islands (USAPI) have higher cervical cancer incidence and mortality rates and lower screening coverage compared with the United States. This is likely because of economic, geographical, health care delivery, and cultural barriers for women living in these resource-constrained, isolated regions. The most recent U.S. and World Health Organization cervical cancer screening guidelines recommended primary human papillomavirus (HPV) testing as one screening option or the preferred screening modality. Primary HPV screening-based strategies offer several advantages over current screening methods in the USAPI. However, adoption of this newer screening modality has been slow in the United States and not yet incorporated into USAPI screening programs. The U.S. Centers for Disease Control and Prevention and partners initiated the Pacific Against Cervical Cancer (PACe) project in 2019 to evaluate the feasibility, acceptability, and cost-effectiveness of primary HPV testing-based strategies in Guam and in Yap, Federated States of Micronesia. This report provides an overview of the PACe project and outlines the approaches we took in implementing primary HPV testing as a new cervical cancer screening strategy (including the option of self-sampling in Yap), encompassing four core components: (1) community engagement and education, (2) medical and laboratory capacity building, (3) health information and system improvement, and (4) modeling and cost-effectiveness analysis. The PACe project provides examples of systematic implementation and resource appropriate technologies to the USAPI, with broader implications for never screened and under-screened populations in the United States and Pacific as they face similar barriers to accessing cervical cancer screening services.

BACKGROUND: Incidence of anal squamous cell carcinoma is increasing, but vaccination against human papillomavirus (HPV) and removal of precancerous anal lesions could prevent new cases. The overall HPV-associated cancer incidence is reported to be higher in rural populations and in counties with lower economic status. We assessed these differences specifically for HPV-associated anal squamous cell carcinoma and described the geographic, county-level economic, and sociodemographic variations in incidence rates and trends. METHODS: We analyzed data from the US Cancer Statistics to assess age-standardized incidence rates of HPV-associated squamous cell carcinomas among adults aged 18 years and older from 2001 to 2019. We calculated rate ratios and 95% confidence intervals to examine differences in incidence rates. We also quantified changes in incidence rates over time using joinpoint regression. RESULTS: From 2001 to 2019, 72 421 new cases of HPV-associated anal squamous cell carcinoma were diagnosed among women (2.8 per 100 000) and 37 147 among men (1.7 per 100 000). Age-standardized incidence rates were higher in the South compared with other census regions and in counties ranked in the bottom 25% and 25%-75% economically than in the top 25%. The overall incidence rate increased in women but remained stable in men during 2009-2019. Incidence rates increased in adults aged 50 years and older but decreased among those aged 40-44 years from 2001 to 2019 in women and from 2007 to 2019 in men. CONCLUSIONS: There were inequities in HPV-associated anal squamous cell carcinoma incidence by geographic and county-level economic characteristics. Failure to improve vaccine and treatment equity may widen existing disparities.

INTRODUCTION: Integration of screening data into routine cancer surveillance systems can create more robust data systems to inform cancer prevention and control activities. Currently, state central cancer registries do not routinely collect breast and cervical cancer screening data as part of state cancer surveillance activities. Florida conducted a pilot study involving: (1) linkage of breast and cervical cancer screening data from the Florida Breast and Cervical Cancer Early Detection Program (FBCCEDP) from 2009 to 2021 to the Florida Cancer Data System (FCDS) database to capture screening data for matched cancer cases in the FCDS; and (2) evaluation of the feasibility of developing a population-based breast and cervical cancer screening surveillance system by capturing electronic screening data from private health care providers. METHODS: In 2018, the FCDS worked with the Florida Department of Health to identify data partners for the 5-year cancer screening pilot project funded by the Centers for Disease Control and Prevention. Engagement of project partners required extensive review of available screening data; data standards and formatting; data transmission schedules and methods; and processing procedures. The FCDS developed a database to integrate multiple source data sets into a single database whereby linkage to the central cancer registry could be performed. RESULTS: The FCDS worked with Suncoast Health Systems, a clinical practice in the Hillsborough region of Florida, and the FBCCEDP to evaluate data availability, standardization of data sets, and data submission schedules for the pilot project. Extensive meetings and data reviews were conducted with both partners in the first phase of the project. The FCDS developed automated data processing procedures to integrate the data into a single cancer screening database and then linked records to the central cancer registry data set. DISCUSSION: Registry collaboration with the FBCCEDP and Suncoast team on data quality and standardization has produced positive results. The project required extensive review of data and produced many lessons learned for development of a cancer screening surveillance system. Our pilot project depended on partnership building, commitment to data quality, and consistency in data submission practices.

PURPOSE: The objective of this study was to examine patterns of mammography screening prior to breast cancer diagnosis in all women with breast cancer in a Kansas community. METHODS: The study population included 508 women in the Kansas Cancer Registry database diagnosed with breast cancer between 2013-2014 who were patients and residents of a defined area at the time of diagnosis. Screening history within 4 years of diagnosis was obtained. Poisson regression analysis was used to examine the relationship between sociodemographic factors and biennial screening. RESULTS: About 41.5% of women received at least biennial screening, while 22.1% received less than biennial screening and 36.4% had no screening. About 40% of women aged 50-64, 50.4% aged 65-74, and 48.3% aged 75-84 received biennial screening (p=0.002). Women diagnosed with in-situ and localized breast cancers had significantly higher proportions of biennial screening (46.7% and 48.6%, respectively; p < 0.001). Average tumor size was 15.7, 17.4, and 24.4 mm, for women who received at least biennial, some, and no screening, respectively (p < 0.001). Results from Poisson regression analysis showed the adjusted relative risk associated with rural/mixed residence at diagnosis and Medicaid beneficiary was 0.45 and 0.40 (p=0.003 and p=0.032) respectively. CONCLUSIONS: Biennial mammography screening was associated with lower breast cancer stage and smaller tumor size, illustrating the importance of screening as early detection. Different outreach strategies may be necessary to reach women within varied age groups or geographical regions to help increase the number of women who remain up-to-date with mammography screening.

BACKGROUND: Cancer survival has improved for the most common cancers. However, less improvement and lower survival has been observed in some groups perhaps due to differential access to cancer care including prevention, screening, diagnosis, and treatment. METHODS: To further understand contemporary relative cancer survival (one- and five- year), we used survival data from CDC's National Program of Cancer Registries (NPCR) for cancers diagnosed during 2007-2016. We examined overall relative cancer survival by sex, race and ethnicity, age, and county-level metropolitan and non-metropolitan status. Relative cancer survival by metropolitan and non-metropolitan status was further examined by sex, race and ethnicity, age, and cancer type. RESULTS: Among persons with cancer diagnosed during 2007-2016 the overall one-year and five-year relative survival was 80.6% and 67.4%, respectively. One-year relative survival for persons living in metropolitan counties was 81.1% and 77.8% among persons living in non-metropolitan counties. We found that persons who lived in non-metropolitan counties had lower survival than those who lived in metropolitan counties, and this difference persisted across sex, race and ethnicity, age, and most cancer types. CONCLUSION: Further examination of the differences in cancer survival by cancer type or other characteristics might be helpful for identifying potential interventions, such as programs that target screening and early detection or strategies to improve access to high quality cancer treatment and follow-up care, that could improve long-term outcomes. IMPACT: This analysis provided a high-level overview of contemporary cancer survival in the United States.

BACKGROUND: Cancer incidence and death rates in the United States are often published at the county or statelevels; examining cancer statistics at the congressional district (CD) level allows decision makers to better understand how cancer is impacting the specific populations they represent. METHODS: Cancer incidence data were obtained from the Centers for Disease Control and Prevention's National Program of Cancer Registries and the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. Mortality data were obtained from the National Center for Health Statistics. CD rates were estimated by assigning the county-level age-adjusted rates to the census block and weighting those by the block population proportion of the CD. Those weighted rates were then aggregated over the blocks within the CD to estimate the district rate. Incidence rate estimates for 406 CDs and death rate estimates for 436 CDs were reported according to the boundaries for the 115th Congress of the United States. Maps showing rate estimates for all cancers combined, lung/bronchus, colorectal, female breast, cervical, and prostate cancer are presented by sex and race/ethnicity. RESULTS: The distribution of cancer incidence and death rates by CDs show similar patterns to those that have been observed at the county and state levels, with the highest cancer incidence and death rates observed in CDs in the South and Eastern regions. CONCLUSION: This examination of cancer rates at the CD-level provides data that can be used to inform cancer control strategies at the local and national levels. Displaying the data with the Data Visualizations tool makes it easily accessible to the public and decision makers.

INTRODUCTION: Since human papillomavirus vaccine introduction, incidence rates of cervical precancers have decreased; however, the vaccine's impact on noncervical anogenital precancers has not been shown. These precancers are identified opportunistically and are not collected routinely by most cancer registries. METHODS: This study examined the incidence rates of high-grade (intraepithelial lesions grade 3) vulvar, vaginal, and anal precancers among persons aged 15-39 years using 2000-2017 data from select cancer registries covering 27.8% of the U.S. population that required reporting of these precancers. Trends in incidence rates were evaluated with Joinpoint regression. Analyses were conducted in 2020. RESULTS: High-grade vulvar precancer rates declined by 21.0% per year after human papillomavirus vaccine introduction among females aged 15-19 years. In addition, high-grade vaginal precancer rates declined by 19.1% per year among females aged 15-29 years after human papillomavirus vaccine introduction. Compared with that in the prevaccine period when high-grade anal precancer rates were increasing, anal precancer rates after human papillomavirus vaccine introduction were stable among females aged 15-29 years and among males aged 30-39 years. Among males aged 15-29 years, the rates increased over the entire period but less so after human papillomavirus vaccine introduction. CONCLUSIONS: Opportunistically-detected high-grade vulvar and vaginal precancers among females aged 15-29 years decreased and anal precancers stabilized in years after the introduction of the human papillomavirus vaccine, which is suggestive of the impact of the vaccine on noncervical human papillomavirus cancers.

BACKGROUND: Screening and timely follow-up have lowered cervical cancer incidence in the US; however, screening coverage, incidence, and death rates have remained fairly stable in recent years. Studies suggest that half of women diagnosed with cervical cancer don't receive appropriate screening prior to diagnosis; cervical cancer survivors can provide crucial insight into barriers and facilitators to screening. METHODS: Participants were cervical cancer survivors ≥21 years, identified through population-based central cancer registries (CR) in 3 US states or a social network (SN), Cervivor. CR participants completed a mailed survey on screening history, barriers, and facilitators to screening and sociodemographic data. SN participants completed the same survey online. RESULTS: CR participants (N = 480) were older, with a lower proportion of non-Hispanic white, married, and insured women compared to SN participants (N = 148). Fifty percent of CR and 79% of SN participants were screened 5 years prior to their diagnoses. Of those screened, 28% in both groups reported not following-up on abnormal results. For both groups, the most frequently identified screening barrier was that participants never imagined they would develop cervical cancer (percent agree CR = 76%; SN = 86%), and the facilitator was wanting to take care of their bodies (CR = 95%; SN = 94%). CONCLUSION: Addressing key barriers to obtaining screening and timely follow-up related to lack of knowledge of cervical cancer risk and screening tests and addressing insurance coverage in the design or modification of interventions may increase cervical cancer screening and lower cervical cancer incidence in the US.

BACKGROUND: Despite advances to prevent and detect cervical cancer, national targets for screening have not been met in the United States. Previous studies suggested that approximately half of women who developed cervical cancer were not adequately screened. This study aimed to provide an updated examination of women's screening and diagnostic practices five years prior to an invasive cervical cancer diagnosis. METHODS: The study included women age 21 years and older diagnosed with invasive cervical cancer in 2013-2016 from three population-based state cancer registries in the United States. Medical records abstraction identified screening history and diagnostic follow-up. A mailed survey provided sociodemographic data. Screening was a Pap or human papillomavirus (HPV) test between 6 months and 5 years before diagnosis. Adequate follow-up was defined per management guidelines. RESULTS: Of the 376 women, 60% (n = 228) had not been screened. Among women who received an abnormal screening result (n = 122), 67% (n = 82) had adequate follow-up. Predictors of: (a) being screened were younger age, having a higher income, and having insurance; (b) adequate follow-up were having a higher income, and (c) stage 1 cervical cancer were being screened and younger age. CONCLUSION: Unlike other cancer patterns of care studies, this study uses data obtained from medical records supplemented with self-report information to understand a woman's path to diagnosis, her follow-up care, and the stage of her cervical cancer diagnosis. This study provides findings that could be used to reach more unscreened or under screened women and to continue lowering cervical cancer incidence in the United States.

Human papillomavirus (HPV) causes most cervical cancers and some cancers of the penis, vulva, vagina, oropharynx, and anus. Cervical precancers can be detected through screening. HPV vaccination with the 9-valent HPV vaccine (9vHPV) can prevent approximately 92% of HPV-attributable cancers (1).* Previous studies have shown lower incidence of HPV-associated cancers in non-Hispanic American Indian and Alaska Native (AI/AN) populations compared with other racial subgroups (2); however, these rates might have been underestimated as a result of racial misclassification. Previous studies have shown that cancer registry data corrected for racial misclassification resulted in more accurate cancer incidence estimates for AI/AN populations (3,4). In addition, regional variations in cancer incidence among AI/AN populations suggest that nationally aggregated data might not adequately describe cancer outcomes within these populations (5). These variations might, in part, result from geographic disparities in the use of health services, such as cancer screening or vaccination (6). CDC analyzed data for 2013-2017 from central cancer registries linked with the Indian Health Service (IHS) patient registration database to assess the incidence of HPV-associated cancers and to estimate the number of cancers caused by HPV among AI/AN populations overall and by region. During 2013-2017, an estimated 1,030 HPV-associated cancers were reported in AI/AN populations. Of these cancers, 740 (72%) were determined to be attributable to HPV types targeted by 9vHPV; the majority were cervical cancers in females and oropharyngeal cancers in males. These data can help identify regions where AI/AN populations have disproportionately high rates of HPV-associated cancers and inform targeted regional vaccination and screening programs in AI/AN communities.

Cancer-related mortality in the US-Affiliated Pacific Island (USAPI) jurisdictions is unknown. This is the first ever reporting of cancer-related mortality in the USAPI using cancer registry data. The individual USAPI jurisdictions collected incident cancer data and submitted it to the Pacific Regional Central Cancer Registry (PRCCR). All cases reported to PRCCR (n = 3,118) with vital status of dead (n = 1,323) during 2008-2013 were examined. Cause of death was coded based on clinical information provided in the cancer registry. Incidencebased mortality (IBM) rates were calculated using SEER*Stat software and age adjusted to the US standard population. Total cancer IBM rates among males were highest in Palau (151.5 per 100,000), Republic of the Marshall Islands (RMI, 142.0), and Guam (133.2); rates were lowest in American Samoa (21.7), the Commonwealth of the Northern Mariana Islands (CNMI, 22.7), and the Federated States of Micronesia (FSM, 28.9). Total cancer IBM rates among females were highest in RMI (120.3 per 100,000), Palau (107.7), and Guam (72.2); rates were lowest in CNMI (19.0), FSM (23.2), and American Samoa (42.8). The median time from cancer diagnosis to death was 8-28 days in the Freely Associated States and 102-128 days in the Flag Territories. IBM rates were higher among individuals in USAPI jurisdictions than among Asian/ Pacific Islanders in Hawai'i for many cancers preventable through vaccination, smoking cessation, overweight and obesity prevention, and cancer screening. Geographic remoteness, underreporting, delay in reporting, and challenges with accurate death registration and certification led to lower IBM rates for some jurisdictions. These mortality data can help prioritize evidence-based interventions to reduce cancer-related deaths through risk factor reduction, early detection, and improved quality of life after a cancer diagnosis through palliative care.

India's cervical cancer screening was launched in 2016 and we evaluated baseline facility readiness using nationally representative data from the 2012-13 District Level Household and Facility Survey on 4 tiers of the public health care system - 18,367 sub-health centres (SHC's), 8540 primary health centres (PHC's), 4810 community health centres and 1540 district/sub-divisional hospitals. To evaluate facility readiness we used the Improving Data for Decision Making in Global Cervical Cancer Programmes toolkit on six domains - potential staffing, infrastructure, equipment and supplies, infection prevention, medicines and laboratory testing, and data management. Composite scores were created by summing responses within domains, standardizing scores across domains at each facility level, and averaging across districts/states. Overall, readiness scores were low for cervical cancer screening. At SHC's, the lowest scores were observed in 'infrastructure' (0.55) and 'infection prevention' (0.44), while PHC's had low 'potential staffing' scores (0.50) due to limited manpower to diagnose and treat (cryotherapy) potential cases. Scores were higher for tiers conducting diagnostic work-up and treatment/referral. The highest scores were in 'potential staffing' except for PHC's, while the lowest scores were in 'infection & prevention' and 'medicines and laboratory'. Goa and Maharashtra were consistently top 5 ranking states for readiness. Substantial heterogeneity in facility readiness for cervical cancer screening spans states and tiers of India's public healthcare system. Infrastructure and staffing are large barriers to screening at PHCs, which are crucial for referral of high-risk patients. Our results suggest focus areas in cervical cancer screening at the district level for policy makers.

Cancers of the oral cavity and pharynx account for 3% of cancers diagnosed in the United States* each year. Cancers at these sites can differ anatomically and histologically and might have different causal factors, such as tobacco use, alcohol use, and infection with human papillomavirus (HPV) (1). Incidence of combined oral cavity and pharyngeal cancers declined during the 1980s but began to increase around 1999 (2,3). Because tobacco use has declined in the United States, accompanied by a decrease in incidence of many tobacco-related cancers, researchers have suggested that the increase in oral cavity and pharynx cancers might be attributed to anatomic sites with specific cell types in which HPV DNA is often found (4,5). U.S. Cancer Statistics(dagger) data were analyzed to examine trends in incidence of cancers of the oral cavity and pharynx by anatomic site, sex, race/ethnicity, and age group. During 2007-2016, incidence rates increased for cancers of the oral cavity and pharynx combined, base of tongue, anterior tongue, gum, tonsil, oropharynx, and other oral cavity and pharynx. Incidence rates declined for cancers of the lip, floor of mouth, soft palate and uvula, hard palate, hypopharynx, and nasopharynx, and were stable for cancers of the cheek and other mouth and salivary gland. Ongoing implementation of proven population-based strategies to prevent tobacco use initiation, promote smoking cessation, reduce excessive alcohol use, and increase HPV vaccination rates might help prevent cancers of the oral cavity and pharynx.

Human papillomavirus (HPV) causes nearly all cervical cancers and some cancers of the vagina, vulva, penis, anus, and oropharynx (1).* Most HPV infections are asymptomatic and clear spontaneously within 1 to 2 years; however, persistent infection with oncogenic HPV types can lead to development of precancer or cancer (2). In the United States, the 9-valent HPV vaccine (9vHPV) is available to protect against oncogenic HPV types 16, 18, 31, 33, 45, 52, and 58 as well as nononcogenic types 6 and 11 that cause genital warts. CDC analyzed data from the U.S. Cancer Statistics (USCS)(dagger) to assess the incidence of HPV-associated cancers and to estimate the annual number of cancers caused by HPV, overall and by state, during 2012-2016 (3,4). An average of 43,999 HPV-associated cancers were reported annually, and an estimated 34,800 (79%) of those cancers were attributable to HPV. Of these 34,800 cancers, an estimated 32,100 (92%) were attributable to the types targeted by 9vHPV, with 19,000 occurring among females and 13,100 among males. The most common were cervical (9,700) and oropharyngeal cancers (12,600). The number of cancers estimated to be attributable to the types targeted by 9vHPV ranged by state from 40 to 3,270 per year. HPV vaccination is an important strategy that could prevent these cancers, but during 2018, only half of adolescents were up to date on HPV vaccination (5). These surveillance data from population-based cancer registries can be used to inform the planning for, and monitor the long-term impact of, HPV vaccination and cancer screening efforts nationally and within states.

Background: Despite advances in cervical cancer screening, a significant number of women in the United States have not received adequate screening. Studies have suggested that approximately half of the women who developed cervical cancer were not adequately screened. The Centers for Disease Control and Prevention (CDC) Case Investigation of Cervical Cancer (CICC) Study took a unique approach to reconstruct the time before a woman's cervical cancer diagnosis and understand the facilitators and barriers to screening and care. This article provides an overview of the study. Methods: This study included all cervical cancer survivors diagnosed with invasive cervical cancer aged 21 years and older in three U.S. states from 2014-2016. The study design consisted of three different data collection methods, including comprehensive registry data, a mailed survey, and medical chart abstraction. This overview compares the characteristics of cervical cancer survivors in the three states by study participation and eligibility status. Results: Registries identified 2,748 women diagnosed with invasive cervical cancer. Of these, 1,730 participants were eligible for participation, 28% (n = 481) enrolled in the study and 23% (n = 400) consented to the medical chart abstraction. Conclusion: The CICC Study is unique in that it addresses, with medical record verification, the medical history of woman 5 years before their cervical cancer diagnosis as well as provides information from the woman on her health care behaviors. This study provides data on a general population of cervical cancer survivors in three states that could be used to guide interventions to increase cervical cancer screening.

From 1970 to 2010 the foreign-born population in the United States has rapidly increased from 9.6 to 40.0 million individuals. Historically, differences in cancer rates have been observed between US-born and foreign-born individuals. However, comprehensive and up-to-date data on US cancer rates by birth place is lacking. To compare cancer mortality rates among foreign and US-born individuals, population-based cancer mortality data were obtained from the CDC's National Center for Health Statistics. Utilizing data recorded on death certificates, individuals were categorized as US-born or foreign-born. Annual population estimates were obtained from the American Community Survey. Age-adjusted mortality rates and rate ratios (RRs) for all cancer sites were calculated using SEER*Stat. A total of 5,670,535 deaths from malignant cancers were recorded in the US from 2005 to 2014 and 9% of deaths occurred among foreign-born individuals. Overall, foreign-born individuals had a 31% lower cancer mortality rate when compared to US-born individuals (Rate Ratio (RR): 0.69 (95% CI: 0.68-0.69)), and similar results were observed when stratifying by sex, race/ethnicity, age, and geographic region. However, foreign-born individuals did have significantly elevated cancer mortality rates for seven cancers sites, of which five were infection-related, including: nasopharynx (RR: 2.01), Kaposi Sarcoma (RR: 1.94), stomach (RR: 1.82), gallbladder (RR: 1.47), acute lymphocytic leukemia (RR: 1.27), liver and intrahepatic bile duct (RR: 1.24), and thyroid (RR: 1.22) cancers. Many of these deaths could be avoided through improved access to prevention, screening, and treatment services for immigrant populations in the US or in their country of origin.

INTRODUCTION: Historically, foreign-born women in the U.S. are less likely to be screened and are more likely to die from cervical cancer when compared with their U.S.-born counterparts. In order to inform prevention efforts and reduce this health disparity, mortality data were obtained from the National Center for Health Statistics to describe cervical cancer mortality among U.S.- and foreign-born women. METHODS: Annual population estimates were obtained from the U.S. Census Bureau's American Community Survey from 2005 to 2014. From 2017 to 2018, age-adjusted mortality rates and rate ratios were calculated by nativity status, race/ethnicity, age, geographic region, and country of birth. RESULTS: From 2005 to 2014, a total of 5,924 deaths from cervical cancer were recorded among the foreign-born population, compared with 33,893 deaths among U.S.-born women. Overall, foreign-born women had a lower cervical cancer mortality rate when compared with the U.S.-born women (rate ratio=0.95, 95% CI=0.92, 0.97). However, older foreign-born women had significantly higher mortality rates compared with U.S.-born women: aged 65-79 years (rate ratio=1.15, 95% CI=1.09, 1.22) and >/=80 years (rate ratio=1.43, 95% CI=1.32, 1.55). Women born in Mexico had significantly elevated rates of cervical cancer mortality (rate ratio=1.35, 95% CI=1.27, 1.42) when compared with U.S.-born women. CONCLUSIONS: Efforts that work to increase cervical cancer screening access and guideline compliance might further reduce the cervical cancer deaths in the U.S., and the excess burden observed among older foreign-born women.

BACKGROUND: Historically, foreign-born individuals in the US have had an elevated risk of dying from gastric cancer when compared to US-born individuals. This is primarily due to factors that occur prior to their immigration to the US, including diet and underlying risk of H. pylori infection. METHODS: National mortality data from 2005 to 2014 were obtained from the CDC's National Center for Health Statistics. Annual population estimates were obtained from the US Census Bureau's American Community Survey for foreign-born and US-born persons. Age-adjusted gastric cancer mortality rates and rate ratios (RR) were calculated stratified by birth place, age, race/ethnicity, and geographic location. RESULTS: From 2005 to 2014, 111,718 deaths from malignant gastric cancer occurred in the US, of which 24,583 (22%) occurred among foreign-born individuals. Overall, foreign-born individuals had higher mortality rates compared with US-born individuals (RR 1.82; 95% CI 1.80, 1.85) and this difference remained after stratifying by sex, age, and geographic location. However, this finding was primarily driven by the low rate of gastric cancer mortality among US-born whites, with similar mortality rates observed among all other foreign-born and US-born groups. Gastric cancer mortality rates significantly decreased during the study period overall (AAPC - 2.50; 95% CI - 3.21, - 1.79) with significant declines observed among US-born (AAPC - 2.81; 95% CI - 3.55, - 2.07) and the foreign-born (AAPC - 2.53; 95% CI - 3.20, - 1.86) population. CONCLUSIONS: Efforts directed at reducing the prevalence of gastric cancer risk factors could help reduce the elevated burden observed among foreign-born individuals and US-born minority groups.

Cervical cancer is the second leading cause of new cancer cases and cancer-related deaths among women in India, with an estimated 96,922 new cases and 60,078 deaths each year.* Despite the availability of effective low-cost screening options in India, limited access to screening and treatment services, diagnosis at a later stage, and low investment in health care infrastructure all contribute to the high number of deaths (1). In 2016 the Ministry of Health and Family Welfare of India recommended cervical cancer screening using visual inspection with acetic acid every 5 years for women aged 30-65 years (per World Health Organization [WHO] guidelines) (2,3). To establish a baseline for cervical cancer screening coverage, survey data were analyzed to estimate the percentage of women aged 30-49 years who had ever been screened for cervical cancer (defined as ever having had a cervix examination). Cervical cancer screening was estimated using data from the Fourth National Family Health Survey(dagger) (NFHS-4), a nationally representative survey conducted at the district level during 2015-2016, which included 699,686 Indian women aged 15-49 years. Lifetime cervical cancer screening prevalence was low (29.8%) and varied by geographic region, ranging from 10.0% in the Northeast Region to 45.2% in the Western Region. Prevalence of screening was higher among women with higher levels of education and household wealth, those who had ever been married, and urban residents. This screening prevalence can be used as a baseline indicator for cervical cancer screening in India in accordance with the WHO Noncommunicable Diseases Global Monitoring Framework during state-based programmatic rollout and program evaluation (4).

BACKGROUND: Since the mid-1980s, the burden of liver cancer in the United States has doubled, with 31,411 new cases and 24,698 deaths occurring in 2014. Foreign-born individuals may be more likely to die of liver cancer than individuals in the general US-born population because of higher rates of hepatitis B infection, a low socioeconomic position, and language barriers that limit the receipt of early cancer detection and effective treatment. METHODS: To determine whether liver cancer mortality rates were higher among foreign-born individuals versus US-born individuals in the United States, population-based cancer mortality data were obtained from the National Center for Health Statistics of the Centers for Disease Control and Prevention. Annual population estimates were obtained from the US Census Bureau's American Community Survey. Age-adjusted mortality rates and rate ratios (RRs) for liver cancer stratified by birth place were calculated, and the average annual percent change (AAPC) was used to evaluate trends. RESULTS: A total of 198,557 deaths from liver and intrahepatic bile duct cancer were recorded during 2005-2014, and 16% occurred among foreign-born individuals. Overall, foreign-born individuals had a 24% higher risk of liver cancer mortality than US-born individuals (RR, 1.24; 95% confidence interval [CI], 1.22-1.25). Foreign-born individuals did not have any significant changes in liver cancer mortality rates overall, but among US-born individuals, liver cancer mortality rates significantly increased (AAPC, 2.7; 95% CI, 2.1-3.3). CONCLUSIONS: Efforts that address the major risk factors for liver cancer are needed to help to alleviate the health disparities observed among foreign-born individuals and reverse the increasing trend observed in the US-born population.

Cancer is one of the leading causes of morbidity and mortality worldwide. In 2012, there were > 14 million new cancer cases and > 8 million cancer deaths, with 70% of these deaths occurring in low- and middle-income countries (LMICs). Part of the success of cancer prevention and control efforts requires the development and strengthening of the public health workforce, particularly in LMICs where the cancer burden is the greatest. The US Centers for Disease Control and Prevention (CDC) supports workforce capacity development globally through Field Epidemiology Training Programs (FETPs) established in ministries of health in > 70 countries. To enhance training in cancer prevention and control in FETPs, the CDC has developed an open-access curriculum in applied cancer epidemiology and supports FETP trainees who conduct cancer-related planned projects. The curriculum contains modules on cancer registration, screening, and comprehensive cancer control that are particularly relevant to current cancer control efforts in many LMICs. Pilot testing of the curriculum showed an increase in trainees' cancer knowledge and covered content trainees found to be relevant to their field epidemiology training and projects and future work in cancer prevention and control. Since 2013, the CDC has supported 13 trainees with cancer-related projects; two have published articles, two have presented their results at international conferences, and others are writing manuscripts on their project outcomes. Through the development of an open-access applied cancer epidemiology curriculum and by supporting cancer-related projects for FETP trainees, the CDC provided technical assistance for LMICs to build capacity for cancer prevention and control efforts.

OBJECTIVE: The aim of the study was to provide national estimates of Pap test receipt, by birthplace, and percent of lifetime in the United States (US). MATERIALS AND METHODS: Pooled nationally representative data (2005, 2008, 2013, 2015) from the National Health Interview Survey were used to examine differences in Pap test receipt among adult US women by birthplace and percent of lifetime in the US. Descriptive estimates were age-adjusted. Regression models were adjusted for selected sociodemographic and healthcare access and utilization factors and presented as predicted margins. RESULTS: Foreign-born women 18 years and older were more than twice as likely to have never received a Pap test compared with US-born women (18.6% vs 6.8%). Regression models showed that foreign-born women from Mexico (9.8%), South America (12.6%), Caribbean (14.6%), Southeast Asia (13.7%), Central Asia (20.4%), South Asia (22.9%), Middle East (25.0%), Africa (27.8%), Europe (16.4%), and Former Soviet Union (28.2%) were more likely to be unscreened compared with US-born women (7.6%). Foreign-born women who spent less than 25% of their life in the US had higher prevalence of never having a Pap test (20%) compared with foreign-born who spent more than 25% of their life in the US (12.7%). CONCLUSIONS: Using national survey, we found that where a woman is born and the percent of her lifetime spent residing in the US do impact whether she gets screened at least once in her lifetime. IMPACT: These findings may inform cervical cancer screening efforts targeting foreign-born women.

Cervical cancer incidence and mortality rates are high, particularly in developing countries. Most cervical cancers can be prevented by human papillomavirus (HPV) vaccination, screening, and timely treatment. The US Centers for Disease Control and Prevention (CDC) provides global technical assistance for implementation and evaluation of HPV vaccination pilot projects and programs and laboratory-related HPV activities to assess HPV vaccines. CDC collaborates with global partners to develop global cervical cancer screening recommendations and manuals, implement screening, create standardized evaluation tools, and provide expertise to monitor outcomes. CDC also trains epidemiologists in cancer prevention through its Field Epidemiology Training Program and is working to improve cancer surveillance by supporting efforts of the World Health Organization in developing cancer registry hubs and assisting countries in estimating costs for developing population-based cancer registries. These activities contribute to the Global Health Security Agenda action packages to improve immunization, surveillance, and the public health workforce globally.

BACKGROUND: Cervical cancer incidence in the US-Affiliated Pacific Islands (USAPIs) is double that of the US mainland. American Samoa, Commonwealth of Northern Mariana Islands (CNMI), Guam and the Republic of Palau receive funding from the Centers for Disease Control (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to implement cervical cancer screening to low-income, uninsured or under insured women. The USAPI grantees report data on screening and follow-up activities to the CDC. MATERIALS AND METHODS: We examined cervical cancer screening and follow-up data from the NBCCEDP programs in the four USAPIs from 2007 to 2015. We summarized screening done by Papanicolaou (Pap) and oncogenic human papillomavirus (HPV) tests, follow-up and diagnostic tests provided, and histology results observed. RESULTS: A total of 22,249 Pap tests were conducted in 14,206 women in the four USAPIs programs from 2007-2015. The overall percentages of abnormal Pap results (low-grade squamous intraepithelial lesions or worse) was 2.4% for first program screens and 1.8% for subsequent program screens. Histology results showed a high proportion of cervical intraepithelial neoplasia grade 2 or worse (57%) among women with precancers and cancers. Roughly one-third (32%) of Pap test results warranting follow-up had no data recorded on diagnostic tests or follow-up done. CONCLUSION: This is the first report of cervical cancer screening and outcomes of women served in the USAPI through the NBCCEDP with similar results for abnormal Pap tests, but higher proportion of precancers and cancers, when compared to national NBCCEDP data. The USAPI face significant challenges in implementing cervical cancer screening, particularly in providing and recording data on diagnostic tests and follow-up. The screening programs in the USAPI should further examine specific barriers to follow-up of women with abnormal Pap results and possible solutions to address them.

United Nation's Sustainable Development Goals and the World Health Organization's Global Monitoring Framework support a strong global commitment to reducing the high burden of cervical and breast cancers among low- and middle-income countries. Strategies include vaccination, screening, and early diagnosis. Population-based surveys, such as those conducted by the Demographic and Health Surveys (DHS) Program, can collect the information needed to guide cancer control efforts in a standardized comparable manner. We identified and evaluated the breadth of breast and cervical cancer screening information that was collected by the DHS from 1984 through 2015. Then, we determined if these surveys currently provide the specific and measurable data about both the quantity and quality of cancer screening needed to guide national efforts to reduce the overall effects of cervical and breast cancers. We searched the DHS website to identify surveys conducted between the start of the DHS Program in 1984 and November 2015 that included questions about breast and cervical cancer screening. The relevant questions were extracted from the questionnaire, translated into English, and grouped by themes. Of the 90 countries where DHS surveys have been implemented, cervical cancer screening questions were included in 22 countries (24.4%) and breast cancer screening questions in 18 countries (20.0%). The common themes identified were disease knowledge, screening knowledge, screening practice, and screening outcomes. Most countries with survey questionnaires available for review addressed at least one aspect of screening practice (88.9% of cervical and 87.5% of breast), although few countries queried knowledge and outcomes. Questions that assess varied aspects of breast and cervical cancer screening have been incorporated into relatively few DHS surveys. The themes identified could guide the design of a standard set of questions for use in future population-based surveys and enable evaluation beyond the existence of screening, which would include assessment of the quality and impact of cervical and breast cancer screening.