Objective
Human papillomavirus (HPV) vaccination should reduce the risk for high-grade cervical intraepithelial neoplasia (CIN2+) among women with abnormal Papanicolau tests by reducing the proportion with HPV16/18, provided vaccination was prior to HPV exposure. Limited data support this concept. We aimed to estimate the prevalence of self-reported vaccination among women referred for colposcopy and to assess the vaccine impact on the prevalence of CIN2+ on final pathology.
Study Design
We reviewed a retrospective cohort of women who were age eligible for the HPV vaccine (26 years old or younger in 2006 when the vaccine was approved by the Food and Drug Administration) and were undergoing colposcopy at Barnes-Jewish Hospital (St Louis, MO) between 2008 and 2013. Vaccine history was obtained by self-report. Vaccine trends were compared using the Cochran-Armitage trend test. Stepwise logistic regression was used to evaluate correlates of HPV vaccination and the association between HPV vaccine and high-grade CIN2+.
Study Design
We reviewed a retrospective cohort of women who were age eligible for the HPV vaccine (26 years old or younger in 2006 when the vaccine was approved by the Food and Drug Administration) and were undergoing colposcopy at Barnes-Jewish Hospital (St Louis, MO) between 2008 and 2013. Vaccine history was obtained by self-report. Vaccine trends were compared using the Cochran-Armitage trend test. Stepwise logistic regression was used to evaluate correlates of HPV vaccination and the association between HPV vaccine and high-grade CIN2+.
Results
Among 701 patients with recorded vaccine histories, 102 (15%) reported HPV vaccination, although the median number of doses received was 1. Over 6 years, vaccination rates increased from 13% to 26% ( P = .0063). Sociodemographic and clinical characteristics by self-reported HPV vaccination status are listed in the Table . Among vaccinated women, 54% were white, median number of lifetime sexual partners was 7, 45% were cigarette smokers, and 6% were human immunodeficiency virus positive. Most were referred for cytology read as low-grade squamous intraepithelial lesion (47%), followed by atypical squamous cells of undetermined significance and high-risk HPV (25%) and high-grade squamous intraepithelial lesion (18%). Compared with unvaccinated women, vaccinees were younger (mean age 24 years vs 25 years, P = .037) and more often white ( P = .02), with fewer pregnancies (median gravidity 1 vs 2, P = .001). A total of 470 biopsies and 430 endocervical curettages were performed. In the vaccinated group, 24% had CIN2+ on colposcopic biopsy compared with 27% in the unvaccinated cohort ( P = .928). Self-reported vaccination was not associated with a lower risk of CIN2+ (odds ratio [OR], 0.86, 95% confidence interval [CI], 0.53–1.41, P = .546]. Compared with women with lesser results, a higher proportion of women with CIN2+ were white (48% vs 37%, OR, 1.57, 95% CI, 1.12–2.20, P = .008) and presented with higher-grade abnormal Papanicolau smears (OR, 5.96, 95% CI, 3.92–9.06, P < .001). After adjusting for those factors that were significant (race, abnormal Papanicolau) or marginally significant (age and smoking), self-reported vaccination remained not associated with a lower risk of CIN2+ (OR, 0.81, 95% CI, 0.48–1.38, P = .438).
| Characteristics | HPV vaccinated (n = 102) | Unvaccinated (n = 599) | P value |
|---|---|---|---|
| Age, mean, y | 24 ± 3.1 | 25 ± 3.5 | .037 b |
| Race | .020 b | ||
| White | 55 (54) | 226 (38) | |
| Black | 46 (45) | 360 (60) | |
| Asian/Pacific Islander | 0 (0) | 3 (1) | |
| Other | 1 (1) | 10 (2) | |
| Insurance status | .367 | ||
| Public | 57 (56) | 378 (63) | |
| Private | 9 (8) | 48 (8) | |
| Self-pay/others | 36 (35) | 173 (29) | |
| Gravidity, median, IQR | 1 (0-3) | 2 (1-3) | .001 b |
| Age at first intercourse, mean, y | 16 ± 2.2 | 16 ± 2.2 | .473 |
| Lifetime number of sexual partners, median, IQR | 7 (4-10) | 6 (4-10) | .801 |
| HPV positive | 63 (74) | 396 (76) | .773 |
| HIV positive | 6 (6) | 42 (7) | .693 |
| Cigarette smoking | 46 (45) | 261 (44) | .963 |
| Packs per week, median, IQR | 3.5 (3.5-7) | 3.5 (1.75-7) | .272 |
| Lifetime number of abnormal Papanicolau test(s), median, IQR | 1 (1-2) | 1 (1-2) | .695 |
| Abnormal Papanicolau result at presentation | |||
| ASCUS | 1 (1) | 6 (1) | .886 |
| ASCUS HR HPV | 26 (25) | 165 (28) | |
| ASC-H | 7 (7) | 35 (6) | |
| LSIL | 48 (47) | 288 (48) | |
| HSIL | 18 (18) | 83 (14) | |
| AGC | 1 (1) | 18 (3) | |
| Unknown | 1 (1) | 3 (1) | |
| History of prior LEEP | 6 (6) | 39 (7) | .811 |
| Method of contraception | .269 | ||
| Pill, patch, ring, condom | 41 (40) | 200 (33) | |
| LARC | 41 (40) | 227 (38) | |
| Sterilization | 4 (4) | 35 (6) | |
| No method | 16 (16) | 137 (23) | |
| Adequate colposcopy | 72 (73) | 382 (65) | .084 |
| Colposcopic impression | .619 | ||
| Benign | 30 (31) | 197 (33) | |
| Low-grade | 63 (64) | 344 (58) | |
| High-grade | 5 (5) | 47 (8) | |
| Invasive cancer | 0 (0) | 1 (0) | |
| Biopsy performed | 70 (69) | 400 (67) | .730 |
| Number of biopsies performed | .099 | ||
| 1 | 42 (60) | 253 (64) | |
| 2 | 21 (30) | 127 (32) | |
| 3 | 7 (10) | 14 (4) | |
| 4 | 0 (0) | 3 (1) | |
| ECC performed | 59 (58) | 371 (62) | .409 |
| Pathology results a | .928 | ||
| Benign | 56 (57) | 314 (52) | |
| CIN1 | 21 (21) | 121 (20) | |
| CIN2 | 12 (12) | 66 (11) | |
| CIN3/CIS | 12 (12) | 96 (16) | |
| AIS | 0 (0) | 1 (0) | |
| Invasive cancer | 0 (0) | 1 (0) |
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