Jason Semprini, Ph.D.

As human papillomavirus (HPV)-associated cancers continue rising in rural America, identifying contributors to rural-urban gaps in HPV vaccination could inform public health priorities and targeted interventions. Analyzing nationally representative data from the 2022 National Health Interview Survey (NHIS), we evaluated rural-urban differences in HPV vaccination among individuals aged 9–29 years (all of whom were recommended to receive the HPV vaccine during adolescence since 2006). Generalized structural equation models adjusted for complex survey design, sociodemographic factors, and other vaccine utilization. Even after adjusting for other vaccine utilization, rural participants were 5.4%-points (CI = −9.7, −1.0) less likely to receive the HPV vaccine than urban participants. Rural-urban disparities in HPV vaccination varied by healthcare access barriers and geography, with the largest gap found in participants who were privately insured. Our work suggests that rural-urban disparities in HPV vaccination are driven by factors distinct from those associated with other vaccines and healthcare access.

For the 0 to 14 or 40 to 59 age groups, we found no differences in thyroid cancer incidence by nitrate exposure. For ages 15 to 39, there were 41.6 (CI: 6.2, 77.1) more cases in high nitrate states, reflecting an 18.5% difference. Stratified by sex, in the 15 to 39 age group of females had 32.7 (CI: 6.3, 59.1) more cases and males had 8.2 (CI: 0.1, 16.4) more cases, reflecting a 17.8% and 20.4% difference respectively.

Nitrates in drinking water, common in agricultural states like Iowa, pose health risks to young infants. This brief first reviews the plausible biological mechanisms linking nitrate exposure to brain and central nervous system (BCNS) cancers in the first year of life. We then linked historic water quality and cancer registry data at the county level to construct linear and quantile regression models estimating the association between a BCNS diagnosis and nitrate measures. We found significantly higher nitrate levels preceding pediatric zero-year-old BCNS cancer diagnoses. These findings support investigating early-life nitrate exposure as a potential risk factor for infant BCNS tumors.

We found that cancer affiliate networks generally aimed to improve access and delivery of high-quality cancer care, with considerable variation in the activities used to achieve and evaluate progress toward these goals. As networks continue to operate and emerge, research is needed to identify best practices for optimizing networks’ influence on the quality of care in resource-constrained hospitals and enabling effective scaling of the cancer affiliate network model.

Between 2010 and 2019, rural HPV-associated cancer was 11.8 cases per 100,000 population. We found significant heterogeneity within male (10.5) and female (13.2) rates. For males, the lowest rate was found in non-Hispanic Asian-American/Pacific-Islander populations (3.7) and Hispanic populations (4.8), and the highest rate was found in non-Hispanic White populations (11.2). For females, the lowest rate was also found in Hispanic Asian-American/Pacific-Islander populations (8.8) and the highest rates were found in non-Hispanic Black (13.8) and non-Hispanic American Indian/Alaska Native populations (14.5). However, these racial/ethnic differences varied across rural subpopulations, geography, and poverty. Appreciating the diversity of the rural cancer burden can be used to effectively develop and implement public health interventions to address HPV-related cancer disparities in rural communities. Actions are needed to prioritize reducing the burden of HPV-associated cancer in AIAN populations in high-poverty rural communities.

Our study reaffirmed the persistent, diverging incidence of HPV-associated cancer in non-metro America. Prioritizing effective risk reduction policies should be considered especially urgent in states with the > 3% annual growth in non-metro HPV-associated cancer incidence (Illinois, Iowa, Kentucky, Louisiana, Texas). We predict that the divergence in rates and rising trends in non-metro regions are due to stagnate declines in smoking rates and lower adherence to recommended preventative measures.

Although smoking is the leading cause of lung cancer, smoking rates have been declining for decades, in part due to increasing cigarette taxes. This study analyzed how states increased and responded to cigarette taxes to determine whether increasing contemporary cigarette taxes could reduce lung cancer incidence in the United States. Centers for Disease Control and Prevention data were used to measure state-level cigarette tax and consumption (pack sales per capita). For each state, the elasticity of demand (change in cigarette consumption percentage/change in state tax) was estimated. Then, each state was classified into 4 mutually exclusive groups based on median change in the state cigarette tax from 1970 to 2019 (high, low) and median elasticity (high, low). Finally, state-level, sex-stratified data from the North American Association of Centralized Cancer Registries (2000-2019) were analyzed to test whether the incidence of small cell and squamous cell lung cancer varied by group. From 1970 to 2019, cigarette tax increases ranged from $0.08 (Missouri) to $4.90 (District of Columbia). The median tax increase was $1.54. The elasticity of demand for cigarettes from state taxes ranged from −0.10 (West Virginia) to −0.64 (Georgia). The median elasticity was −0.40. Among males, the low-elasticity, low–tax change group had the highest incidence of small cell and squamous cell lung cancer. No significant differences in incidence were found across groups among females. Increasing cigarette taxes could reduce the future incidence of lung cancer among males. Other social or environmental policies, however, may be necessary to reduce lung cancer incidence among females.

Survivors in nonmetropolitan compared to metropolitan areas had less perceived change in cancer follow-up and treatment schedules. It will be important to assess whether shifts in follow-up and preventive care to telehealth for cancer survivors in need of care during the COVID-19 pandemic affect their long-term outcomes.

Rising levels of nitrate in our drinking water pose a threat to public health. Emerging evidence suggests a possible association between early prenatal exposure to nitrate in drinking water and adverse birth outcomes. Understanding this association has proved challenging, as there is currently no regulatory guidance on safe levels of nitrate during the early prenatal period and many factors contribute to adverse birth outcomes. Focusing on Iowa, a state with some of the highest levels of ground water nitrate in the country, this study linked public water quality data to more than 350,000 birth records. During the study period (1970–1988), nitrate levels increased 8% annually. Mean nitrate levels were 4.2 mg/L, well below the 10 mg/L regulatory threshold. Interestingly, exposure to nitrate above the 10 mg/L threshold had no association with birth outcomes. Rather, the study showed that prenatal exposure to lower levels of nitrate were adversely associated with gestational age and low birthweight. These results suggest that current regulatory standards, which have not been updated since 1992, may be inadequate.

We found that, unlike the stagnate trends in older females between 2019 to 2022, in 25-29-year-old females, cervical cancer incidence declined 2.1 cases/100,000 (CI = -2.7, -1.6): a 48% reduction from baseline trends. Although tempered by uneven adherence, after fifteen years we finally appear to be realizing quantifiable benefits from this cancer prevention vaccine.

Treatment at an accredited hospital appeared to increase time-to-treatment differences between high-and low-income counties and low-income counties. This heterogeneity may reflect access challenges facing low-income cancer patients. Health systems seeking to provide high quality, timely care must overcome these access challenges as they navigate patients through the cancer care continuum. While a 2.6-day delay in treatment may not impact outcomes, future research should understand why patients from lower-resource communities wait longer than patients in affluent communities.

We analyzed Puerto Rico cancer incidence and mortality rate data for male and female residents aged 85+. Since 2001, for both males and females aged 85 + in Puerto Rico, cancer incidence and mortality rates declined as the proportion of distant stage cancers increased.

St. Jude's Children's Hospital presents progress on priority action items and showcases successful efforts to promote HPV cancer prevention with rural communities.

Presentation at annual Public Health in Iowa Conference. The 60-minute presentation to 55+ public health professionals showed evidence that exposure to nitrate levels below the regulatory threshold are associated with adverse birth outcomes.

The American Cancer Society (ACS) and The National HPV Vaccination Roundtable (HPVRT) are partnering with rural healthcare partners to expand knowledge and increase on-time HPV vaccination.

The ACA has been associated with increased HPV vaccination uptake, especially among racial/ethnic minorities, gains likely driven by an increase in vaccination-enabling factors such as decreased uninsurance and increased access to physician visits.

Cancer Causes & Control - By highlighting state and Tribal CCC plans’ best practices and incorporating Tribal priorities within state and district CCC plans and programs, we underscore the importance of addressing cancer in Tribal populations across the U.S. and offer examples of inclusive CCC plan development and implementation.

Rural life is a choice made by 1 in 5 people, but they do not choose to be at higher risk of cancers, including HPV cancers. HPV vaccination is cancer prevention. This virtual seminar will explore progress to prevent HPV cancers with rural communities in the U.S.

Vaccine - The ACA has been associated with increased HPV vaccination uptake, especially among racial/ethnic minorities, gains likely driven by an increase in vaccination-enabling factors such as decreased uninsurance and increased access to physician visits.

The Laryngoscope - The recent scoping review by Tomescu et al. on the effects of rurality on head and neck cancer brings a helpful focus to an important topic. There are many disparate effects of rurality on treatment and outcomes that must be better studied in a targeted manner.

JAMA Network Open - Did female biennial mammography screening rates change after the US Preventive Services Task Force (USPSTF) 2009 policy update? This cross-sectional study of 1.6 million females found reduced mammography rates after the USPSTF 2009 update for those no longer recommended to complete a biennial mammogram. These decreases varied by age, race and ethnicity, binge drinking status, and state of residence. The findings of this study suggest that patient-level variables related to breast cancer risk are associated with differences in how women responded to the 2009 USPSTF mammography guidance.

Journal of Rural Health - Although preventable, nonmetropolitan Americans have shouldered a growing burden of HPV-associated cancers. To address these cervical, anal, and oropharyngeal cancer disparities, it is imperative that HPV vaccination programs are effectively implemented at scale.

Pediatric Blood & Cancer - Despite the pandemic’s impact on adult cancer prevention and control, there appears to have been minimal impact on cancer surveillance in common pediatric cancers within pediatric populations. We may have reason to be hopeful given the persistent declining incidence of pediatric cancer in the U.S. since 2018. The trends in the AYA population also appear quite steady, especially relative to the adult cancers. Although we still observe some differences related to the accreditation status and the magnitude of declining trends in pediatric and AYA cancer incidence, we still have no explanation as to why. Whether these differences are a result of surveillance, data issues, or access differences warrants further investigation.

Oral Oncology Reports - HNC patients overall, but HPV+ Oropharynx cancer patients especially, experienced treatment delays in 2021. These delays, and their consequences, warrant policymaking attention.

JNCI - In this issue of the Journal, Mani et al. reminded us of the elevated risk from COVID-19 facing people living with cancer. Analyzing population-based data, the authors showed that people with cancer have a 2.3 times higher mortality from COVID-19 than the rest of the US population. The authors also compared relative mortality from COVID-19 across age groups, sex, race and ethnicity, and other factors. We worry, however, that these comparisons may underestimate the death toll we witnessed during 2020.

Lifestyle Medicine - Smoking prevalence continues to decline in the United States, and the pandemic appeared to have been associated with lower smoking rates. However, our results suggest that the pandemic was also associated with greater intensity and fewer quit attempts among smokers warranting greater attention from policymakers and researchers.

Healthcare Management Science - NSCLC disparities are complex and multifaceted. Yet, even when accounting for age and stage at diagnosis, non-Hispanic Black patients with NSCLC are less often recommended to have surgery than non-Hispanic White patients. Machine learning models amplified the racial/ethnic disparities across the cancer care continuum (which are reflected in the data used to make model decisions). Excluding race/ethnicity lowered the bias of the models but did not affect disparate impact. Developing analytical strategies to improve fairness would in turn improve the utility of machine learning approaches analyzing population-based cancer data.

Rural & Remote Health - HPV-associated cancer can be prevented by a vaccine. However, HPV vaccination rates are lower in non-metro than metro counties. Again, however, there is likely variation within non-metro counties. Given low historical adherence to HPV-vaccine schedules and the negative trends in this current study, I predict that the rising rural burden of HPV-associated cancer will intensify in the coming decade without effective prevention and control strategies in rural America.

JTO Clinical & Research Reports - Receiving GCIT considerably improves survival across all races, though disparities in receipt are observed. Interventions are needed to ensure equitable access to guideline-concordant care and reduce survival disparities for patients.

Pediatric Blood & Cancer - We explore whether the COVID-19 pandemic disrupted trends of common pediatric and AYA cancers.

Cancer Epidemiology - The USPSTF’s 2008 recommendation was associated with reduced colonoscopies, especially in adults over age 85. Whether this recommendation, or the 2021 updated guidance, optimizes population health by reducing the burden of CRC screening in older adults remains unknown.

Oral Oncology Reports - Given the importance of timely pharyngeal cancer treatment, health systems must identify and address the drivers of treatment delays to advance cancer equity.

The Gazette - Letter to the editor.

Learning Health Systems - As rural hospitals continue to face resource constraints, multisectoral efforts informed by data from centralized public health surveillance systems can promote quality improvement initiatives across rural communities. While our work remains preliminary, we predict that analytic support provided by the Iowa Cancer Registry will enable the rural network hospitals to focus their capacity toward developing the infrastructure necessary to deliver high-quality care and serve the unique needs of rural cancer patients.

St. Jude’s Children's Hospital HPV Cancer Prevention Program - Quarterly Meeting