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Background: In 2018, Puerto Rico (PR) enacted a Human papillomavirus (HPV) vaccine school-entry requirement for students ages 11 to 12. Using the Consolidated Framework for Implementation Research (CFIR), we aimed to identify potential barriers and facilitators of this implementation.Methods: We conducted a total of 36 qualitative interviews with key informants who were stakeholders from different organizations (Department of Health, Schools, Healthcare Providers, and Community organizations in favor of the requirement) from July 2018 to January 2020. Three researchers performed the interview guide, data coding, and analysis according to the CFIR framework. We evaluated construct rating variability between the organizations to determine barriers and facilitators. Results: The strongest facilitators determined under the CFIR construct include the stakeholder's awareness of the parent's and student's needs to meet the HPV school-entry requirement. Other facilitators include initiatives for school-entry policies and the relative advantage of this requirement over different strategies. The strongest barriers included the cost for private providers to administer the HPV vaccine, the negative influence of social media about the vaccine, which affected parents' acceptance, and the lack of school nurses as available staff resources for the school entry requirement. Conclusions: Findings from this study can be used to improve implementation (adaptations/modifications) and inform other US states and countries in earlier stages of consideration of the adoption of similar immunization policies. Most barriers can be modifiable with the implementation of educational programs/training across schools, considering that they are the first line of response to parents of this school entry requirement.

Human papillomavirus (HPV) knowledge and HPV vaccination uptake remain suboptimal. We assessed sex and educational attainment differences in HPV knowledge and vaccine awareness. Data from a cross-sectional study (2018-2021) in Puerto Rico among adults aged 21-49 was analyzed (

Patients with cancer are among the most vulnerable populations in the aftermath of a disaster. They are at higher risk of medical complications and death due to the collapse of or disruptions in the health care system, the community infrastructure, and the complexity of cancer care. The United Nations' Sendai Framework for Disaster Reduction states that people with life-threatening and chronic diseases should be considered in disaster plans to manage their risks. With extreme weather or disasters becoming more intense and frequent and with the high burden of cancer in the United States and its territories, it is important to develop region-specific plans to mitigate the impact of these events on the cancer patient population. After Hurricanes Irma and Maria hit Puerto Rico and the U.S. Virgin Islands in 2017, the need to develop and implement such plans for patients with cancer was evident. We describe ongoing efforts and opportunities for disseminating and implementing emergency response plans to maintain adequate cancer care for patients during and after disasters. While plans for patients with cancer should be housed within the emergency support function infrastructure of each jurisdiction, the Centers for Disease Control and Prevention's Comprehensive Cancer Control Plans provide excellent community-centered mechanisms to support these efforts.

OBJECTIVE The aim of the study was to evaluate the validity of anal cytology against high-resolution anoscopy in the detection of anal high-grade squamous intraepithelial lesions (HSILs) among women in a clinical setting in Puerto Rico, alone and in combination with high-risk human papillomavirus (HR-HPV) typing. MATERIALS AND METHODS A cross-sectional study was done among 128 eligible women who attended the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Center between 2014 and 2019. Kappa (κ) coefficient, sensitivity, specificity, positive predictive value, and negative predictive value were calculated using high-resolution anoscopy with biopsy as the criterion standard test. Poisson regression was used to estimate the adjusted prevalence ratio of anal HR-HPV infection. RESULTS Overall, 71.1% of women were HIV infected and 78.9% had anal HR-HPV infection. Squamous intraepithelial lesions were detected with anal cytology and histology in 70.3% and 81.3% of women, respectively. The κ statistic between the tests (cytology and histology) was 0.32 (p < .05). Measured against the results from histology, the sensitivity of anal cytology alone to detect HSIL was 85.4% (95% CI = 72.2%-93.9%), whereas specificity was 38.8% (95% CI = 28.1%-50.3%). Although the sensitivity of the 2 tests combined (anal cytology and HR-HPV typing) to detect histologically confirmed HSIL increased (100.0%, 95% CI = 92.6%-100.0%), the specificity decreased (16.3%, 95% CI = 9.0%-26.2%). Meanwhile, women with HSIL had a higher prevalence of anal HR-HPV infection than those with no SIL/LSIL (prevalence ratio = 6.23, 95% CI = 1.50-25.83). CONCLUSIONS Anal cytology in combination with HR-HPV typing for the screening of anal intraepithelial neoplasia improved the detection of HSIL in women.

Objective Obese women have higher cervical cancer incidence and mortality than their counterparts, possibly related to nonadherence to screening recommendations. We assessed the association of body mass index with adherence to cervical cancer screening recommendations in Hispanic women living in Puerto Rico, a minority population with the highest incidence of cervical cancer in the United States. Materials and methods We included 536 Hispanic women aged 21 to 64 years enrolled in a population-based study of human papillomavirus (HPV) infection. Demographic and clinical characteristics and risky behaviors were collected using structured interviews. Weight and height were measured to classify body mass index as underweight, normal, overweight, and obesity (class I, class II, class III). Adherence to cervical cancer screening recommendations was self-reported. Logistic regression models were fit to estimate the odds ratio with 95% CI after adjusting for covariates. Results Nearly one third (29.7%) of women were overweight and 43.5% were obese (class I: 22.6%, class II: 11.0%, class III: 9.9%). Overall adherence to cervical cancer screening within the past 3 years was 78.5%, being lowest among women with class III obesity (60.4%). After multivariable adjustment, only women with class III obesity had significantly higher odds (odds ratio = 2.5, 95% CI: 1.2-5.1) of reporting nonadherence to cervical cancer screening compared with normal weight women. Conclusions Adherence to cervical cancer screening in this population was below the Healthy People 2020 target of 93%, especially for women with morbid obesity. These findings highlight the importance of adequate interventions to decrease cervical cancer screening disparities in these women.

In September 2017, Hurricane Maria devastated the Caribbean region, among them the US territory of Puerto Rico (PR). Vaccination distribution and uptake suffered from the impact. This study evaluated the trends in monthly vaccination initiation rates for human papilloma virus (HPV), Tdap and meningococcal conjugate (MenACWY) adolescent vaccines from 2015 to 2019, during which it was possible to observe and analyze the impact of Hurricane Maria on vaccine initiation. Monthly initiation rates were estimated. Age-standardized initiation rate ratio (SRR) and 95% CI were estimated. The analysis included 85,340 adolescents; 52.3% were male, and 47.7% were females. September 2017 showed HPV vaccine initiation had the lower rates of all the studied vaccines, with a rate of 75% after the disaster (from a rate of almost 90% in July 2017). Tdap and MenACWY vaccines rates remained above 90% in the same period. The SRR of HPV vaccine for September and October 2017 showed an estimated reduction of 5% and 8% in vaccine initiation rates, respectively for each month, when 2016 was the reference year (p > .05). The SRR of Tdap and MenACWY vaccines for November 2017 showed significant reductions when 2015 and 2016 were reference years (p

To evaluate human papillomavirus (HPV) infection knowledge, willingness to get vaccinated, and vaccination uptake, following a brief educational activity entitled ¡Habla de VPH! (Let's talk about HPV!) in a sample of college students at the University of Puerto Rico, Bayamón.Participants completed a self-administered questionnaire developed by the research team, which gathered information regarding sociodemographic characteristics, HPV vaccination status, and willingness to receive the vaccine. Once the participant completed the survey, the staff of the Outreach Program conducted an educational activity. Study participants completed a pre- and post-test, which included a scale with items related to knowledge about HPV infection, associated malignancies, and the vaccine. To compute the mean knowledge score for each test, the correct responses were summed; the total scores for each test ranged from 0 to 11. Follow-up interviews (3 and 6 months) explored knowledge changes and-in the previously unvaccinated students-vaccine uptake.A total of forty students answered the questionnaire. A significant difference between the average knowledge before (7.6 ± 2.1) and after the intervention (10.6 ±0.6) (P.001) was observed. Of the non-vaccinated group, 59.3% reported being interested in receiving the vaccine. By the 3- and 6-month follow-ups, only 2 students had started the vaccine series.Knowledge about HPV and associated malignancies increased significantly. However, few students initiated the vaccine after either of the followups. Future efforts should line up the vaccine promotion and outreach activities with immunization services, making the vaccine available in the communities to be impacted.

This cohort study examines rates of cervical cancer screening in Puerto Rico among women with Medicaid health coverage following the 2017 hurricanes, earthquakes in late 2019-2020, and the 2020 COVID-19 lockdown.

Background The Human papillomavirus vaccine (HPV) is an essential tool for the prevention of HPV-related cancers. In Puerto Rico, the Secretary of Health established a school entry requirement of at least one dose of HPV vaccination in girls and boys aged 11 and 12 years, taking effect in August 2018. Our study aimed to examine parents’ and guardians’ views of unvaccinated children about the process of implementation of the new HPV vaccination school entry policy in Puerto Rico and identify potential barriers and facilitators related to the implementation of this requirement. Methods During April through November 2019, we conducted three focus groups (n = 12) and eight in-depth semi-structured interviews with parents of children aged 11 and 12 who had not yet initiated the HPV vaccine series. The interview topics addressed were: perception of vaccination, HPV vaccine and it is inclusion as new school entry requirement practice, procedure of the sources of information, influencers, and willingness to change. The interviews were recorded and transcribed by our staff members. We identified emergent themes through thematic analysis. Results The participants’ perspective on the HPV vaccine school requirement was mixed. Lack of information of the HPV vaccines and lack of communication about the school-entry requirement were the themes most mentioned in the interviews. Moreover, previous negative experiences from friends or family members and adverse effects deterred some participants from vaccinating their kids. We discussed barriers in the process of soliciting an exemption. Conclusion Most barriers mentioned by study participants are modifiable. Information about the HPV vaccine mandate’s implementation and educational materials regarding HPV vaccine safety need to be provided to address parents’ concerns related to the vaccine’s side effects. Schools (teachers, principal directors, and administrative staff), the government, and parent organizations need to be part of these efforts. This multilevel approach will help to improve disseminating information about HPV vaccination to clarify doubts and misinformation among parents.

The Hispanic/Latino population is the second largest racial/ethnic group in the continental United States and Hawaii, accounting for 18% (60.6 million) of the total population. An additional 3 million Hispanic Americans live in Puerto Rico. Every 3 years, the American Cancer Society reports on cancer occurrence, risk factors, and screening for Hispanic individuals in the United States using the most recent population-based data. An estimated 176,600 new cancer cases and 46,500 cancer deaths will occur among Hispanic individuals in the continental United States and Hawaii in 2021. Compared to non-Hispanic Whites (NHWs), Hispanic men and women had 25%-30% lower incidence (2014-2018) and mortality (2015-2019) rates for all cancers combined and lower rates for the most common cancers, although this gap is diminishing. For example, the colorectal cancer (CRC) incidence rate ratio for Hispanic compared with NHW individuals narrowed from 0.75 (95% CI, 0.73-0.78) in 1995 to 0.91 (95% CI, 0.89-0.93) in 2018, reflecting delayed declines in CRC rates among Hispanic individuals in part because of slower uptake of screening. In contrast, Hispanic individuals have higher rates of infection-related cancers, including approximately two-fold higher incidence of liver and stomach cancer. Cervical cancer incidence is 32% higher among Hispanic women in the continental US and Hawaii and 78% higher among women in Puerto Rico compared to NHW women, yet is largely preventable through screening. Less access to care may be similarly reflected in the low prevalence of localized-stage breast cancer among Hispanic women, 59% versus 67% among NHW women. Evidence-based strategies for decreasing the cancer burden among the Hispanic population include the use of culturally appropriate lay health advisors and patient navigators and targeted, community-based intervention programs to facilitate access to screening and promote healthy behaviors. In addition, the impact of the COVID-19 pandemic on cancer trends and disparities in the Hispanic population should be closely monitored.

Anal cancer incidence is higher in persons living with HIV/AIDS (PLWHA) than in the general population. Participation of PLWHA in anal cancer clinical trials (CTs) is essential; Hispanic PLWHA are underrepresented in CTs. We conducted a behavioral CT among 305 PLWHA in Puerto Rico to measure the efficacy of an educational video in increasing calls and screening into an anal cancer CT. Participants received printed educational materials on anal cancer and CTs; the intervention group also received an educational video. Outcome assessment based on follow-up interviews showed that printed materials increased awareness about CTs and high-resolution anoscopy (HRA), and willingness to participate in an anal cancer CT in both groups. However, the addition of the video increased the likelihood of participants to call the CT for orientation (RRadjusted = 1.66, 95% CI 1.00–2.76; p = 0.05) and pre-screening evaluation (RRadjusted = 1.70, 95% CI 0.95–3.03; p = 0.07). This intervention could help increase participation of Hispanics into anal cancer-related CTs.

Cancer is the leading cause of death among Hispanics/Latinos, who represent the largest racial/ethnic minority group in the United States, accounting for 17.8% (57.5 million) of the total population in the continental United States and Hawaii in 2016. In addition, more than 3 million Hispanic Americans live in the US territory of Puerto Rico. Every 3 years, the American Cancer Society reports on cancer occurrence, risk factors, and screening for Hispanics in the United States based on data from the National Cancer Institute, the North American Association of Central Cancer Registries, and the Centers for Disease Control and Prevention. For the first time, contemporary incidence and mortality rates for Puerto Rico, which has a 99% Hispanic population, are also presented. An estimated 149,100 new cancer cases and 42,700 cancer deaths will occur among Hispanics in the continental United States and Hawaii in 2018. For all cancers combined, Hispanics have 25% lower incidence and 30% lower mortality compared with non-Hispanic whites, although rates of infection-related cancers, such as liver, are up to twice as high in Hispanics. However, these aggregated data mask substantial heterogeneity within the Hispanic population because of variable cancer risk, as exemplified by the substantial differences in the cancer burden between island Puerto Ricans and other US Hispanics. For example, during 2011 to 2015, prostate cancer incidence rates in Puerto Rico (146.6 per 100,000) were 60% higher than those in other US Hispanics combined (91.6 per 100,000) and 44% higher than those in non-Hispanic whites (101.7 per 100,000). Prostate cancer is also the leading cause of cancer death among men in Puerto Rico, accounting for nearly 1 in 6 cancer deaths during 2011-2015, whereas lung cancer is the leading cause of cancer death among other US Hispanic men combined. Variations in cancer risk are driven by differences in exposure to cancer-causing infectious agents and behavioral risk factors as well as the prevalence of screening. Strategies for reducing cancer risk in Hispanic populations include targeted, culturally appropriate interventions for increasing the uptake of preventive services and reducing cancer risk factor prevalence, as well as additional funding for Puerto Rico-specific and subgroup-specific cancer research and surveillance.

OBJECTIVE: Anal cancer screening has been recommended for women with lower genital tract neoplasia (LGTN), lupus, Crohn’s disease, human immunodeficiency virus (HIV) and/or organ transplantation recipients. This study described and compared knowledge, attitudes, and experiences related to anal cancer and anal cancer screening between women at high-risk for anal cancer and their counterparts. METHODS: This is a Cross-sectional study within colposcopy and gynecology oncology clinics in Puerto Rico; 283 women aged ≥21 years or older and with prior diagnosis of gynecological neoplasia completed an interviewer-administered questionnaire. Women were categorized according to their medical history as being high-risk or non-high-risk for anal cancer. The high-risk group included women with history of lower genital tract neoplasia, lupus, Crohn’s disease, HIV and/or organ transplantation. RESULTS: Overall, 40.7% of the study population were at high-risk of developing anal cancer. History of anal cancer screening was low among high-risk and non-high-risk women (11.5 vs. 5.6%, p>0.05). Less than 1% of all women reported to have had a high-resolution anoscopy. Most women (87.6%) had little knowledge about anal Pap: test but were willing to have one if their doctors recommended it (96.5%). No major differences in knowledge, attitudes or screening history were observed between high-risk and non-high-risk women. CONCLUSION: Although experts do not recommend routine anal cancer screening for the general population, they do recommend it for women within certain high-risk groups. Study findings highlight the importance of increasing education and awareness of anal cancer among high-risk patients and physicians, to promote better preventive methods, achieve early detection and improve disease outcomes.

PURPOSE Squamous cell carcinoma of the anus (SCCA) is common among persons living with HIV (PLWH). We described SCCA incidence and survival among the general population and among PLWH in Puerto Rico (PR), along with mortality of anal cancer. METHODS PR HIV/AIDS Surveillance Program and the PR Central Cancer Registry databases were linked (2000-2016). Incidence rates (IRs) and trends (annual percent change [APC]) in SCCA and mortality rates and trends for anal cancer were estimated. Relative survival and relative excess risk (RER) of death were calculated. RESULTS From 2000 to 2016, 991 individuals in PR were diagnosed with anal cancer; 73% of cases were SCCA 9.1% of SCCA and 1.5% of non-SCCA cases were in PLWH ( P < .0001). SCCA incidence was higher among PLWH than the general population (IR = 27.7/100,000). Among PLWH, SCCA incidence (per 100,000) was the highest among men who have sex with men (IR = 60.5). From 2001-2016, SCCA incidence increased among the general population (APC: 4.90, P < .05); however, no significant change was observed among PLWH (APC = 0.19 and P = .96). The APC for anal cancer mortality in the general population was positive (3.9%) from 2000 to 2016, but not significant ( P > .05). The 5-year relative survival of SCCA was 56.9% among PLWH and 66.8% among the general population. In multivariate analysis, the RER of death for SCCA 5 years postdiagnosis was affected by stage at diagnosis (distant: RER = 7.6, 95% CI, 2.36 to 24.25) but not by PLWH status (RER = 1.4, 95% CI, 0.67 to 3.01). CONCLUSION Our findings highlight the relevance of anal cancer screening in PLWH and HPV vaccination in both PLWH and the general population in PR, which could have an impact on the disease trend in the next few decades.

This cohort study examines recent trajectories in the incidence of cervical cancer in Puerto Rico by age and among birth cohorts.

Background In September 2017, hurricanes Irma and Maria affected Puerto Rico (PR) and the US Virgin Islands (USVI), causing major disruptions in basic services and health care. This study documented the stressors and experiences of patients with gynecologic cancer receiving oncology care in PR following these hurricanes. Methods We conducted 4 focus groups (December 2018-April 2019) among women aged ≥21 years from PR who were diagnosed with gynecological cancer between September 2016 and September 2018 (n = 24). Using the same eligibility criteria, we also interviewed patients from the USVI (n = 2) who were treated in PR. We also conducted key-informant interviews with oncology care providers and administrators (n = 23) serving gynecologic cancer patients in PR. Discussions were audio-recorded, transcribed verbatim, and coded to identify emergent themes using a constant comparison method. Results Analyses of focus group discussions and interviews allowed us to identify the following emergent themes: 1) disruptions in oncology care were common; 2) communication between oncology providers and patients was challenging before and after the hurricanes hit; 3) patient resilience was key to resume care; and 4) local communities provided much-needed social support and resources. Conclusions This study provides firsthand information about the disruptions in oncology care experienced by and the resiliency of women with gynecologic cancer following hurricanes Irma and Maria. Our findings underscore the need to incorporate oncology care in the preparedness and response plans of communities, health systems, and government agencies to maintain adequate care for cancer patients during and after disasters such as hurricanes.

Background In August 2018, Puerto Rico (PR) became the 4th state or territory in the United States to adopt a human papillomavirus (HPV) vaccine school-entry requirement, for students 11–12 years old. Evidence suggests that the content of media coverage may impact people’s perception of HPV vaccine and their willingness to vaccinate. This study aimed to analyze the content of digital news coverage related to the implementation of the policy in PR. Methods A content review was conducted of digital media published from January 2017 through December 2018. The content reviewed was carried out in two steps: 1) creating a matrix to summarize each article’s content about the policy and 2) qualitative analysis using a grounded theory approach. Results The search resulted in 34 articles obtained from 17 online local and international news outlets that reported the policy's implementation. Analyses showed that 61% of the news articles did not mention the number of required doses, and 79% discussed the new policy concerning cancer prevention. In 2017, news coverage focused mostly on describing the policy, while 2018 coverage focused on controversies surrounding the implementation. Neutral emergent codes included: 1) Description of the policy; 2) Information about HPV related cancers; and 3) General information about HPV vaccine. Negative emergent codes included: 1) infringement to patient and parental autonomy; 2) Hesitancy from the political sector, and 3) Hesitancy from groups and coalitions. Positive content included: 1) knowledge and acceptance of HPV vaccine for cancer prevention; 2) importance of education and protective sexual behaviors; and 3) new vaccination law proposal. Conclusions Most of the media coverage in PR was neutral and included limited information related to the vaccine, HPV, and HPV-related cancers. Neutral and negative themes could influence public concerns regarding the new policy, as well as HPV vaccination rates in PR.

OBJECTIVE: There is a high prevalence of human papillomavirus (HPV) infection in Puerto Rico, but little is known about the prevalence of Chlamydia trachomatis (CT) infection in healthy Puerto Rican women. Thus we aimed to evaluate the seroprevalence and association and the association between HPV and CT. METHODS: This was a secondary data analysis from a cross-sectional, population-based, study of HPV infection in women aged 16-64 years in Puerto Rico (2010-2013). Enzyme-linked immunosorbent assays (ELISA) were used to detect serum antibodies to CT and HPV. Logistic regression models were used to estimate the odds ratio (OR) for the association between HPV and CT serostatus. RESULTS: The study included 524 women; mean age was 42 years. Overall, 97 (18.5%) women were CT-seropositive, 251 (47.0%) were HPV seropositive, and 57 (10.9%) had antibodies for both CT and HPV. Women who were CT-seropositive were more likely (p

OBJECTIVE To assess HPV knowledge as well as knowledge and acceptance of HPV vaccines. METHODS The present cross-sectional study surveyed women with cervical cytology anomalies referred to colposcopy clinics at the University of Puerto Rico and San Juan City Hospital between November 1, 2013, and November 30, 2015. The data were analyzed using descriptive statistics and multivariate logistic regression models. RESULTS Of 418 participants, 333 had heard of HPV. Of these, 273 of 331 (82.5%) knew it causes cervical cancer and 284 of 332 (85.8%) knew it is sexually transmitted; 313 were aware of the vaccine(s). Of 278 participants, 270 (97.1%) were willing to vaccinate their children and 125 of 285 (43.9%) desired vaccination. Only 13 (10.9%) of 119 age-eligible women had been vaccinated. Women who had completed high school had increased odds of having heard of HPV (adjusted OR 2.3, 95% CI 1.2-4.4; P=0.014), with a similar increase in the odds of having heard of the vaccine(s). Women who knew about HPV had greatly increased odds of knowing about the vaccine(s) (adjusted OR 19.7, 95% CI 9.8-41.6). CONCLUSION Knowledge of HPV and HPV vaccine(s) was high, but vaccine uptake was low in the study population. Physicians' active roles in HPV education and vaccination are crucial.

The aim of the study was to estimate the magnitude of the association between HPV-related gynecological neoplasms and secondary anal cancer among women in Puerto Rico (PR).We identified 9,489 women who had been diagnosed with a primary cervical, vaginal, or vulvar tumor during 1987-2013. To describe the trends of invasive cervical, vulvar, vaginal, and anal cancer, the age-adjusted incidence rates were estimated using the direct method (2000 US as Standard Population). Standardized incidence ratios (observed/expected) were computed using the indirect method; expected cases were calculated using 2 methods based on age-specific rates of anal cancer in PR. The ratio of standardized incidence ratios of anal cancer was estimated using the Poisson regression model to estimate the magnitude of the association between HPV-gynecologic neoplasms and secondary anal cancer.A significant increase in the incidence trend for anal cancer was observed from 1987 to 2013 (annual percent change = 1.1, p.05), whereas from 2004 to 2013, an increase was observed for cervical cancer incidence (annual percent change = 3.3, p.05). The risk of secondary anal cancer among women with HPV-related gynecological cancers was approximately 3 times this risk among women with non-HPV-related gynecological cancers (relative risk = 3.27, 95% CI = 1.37 to 7.79).Anal cancer is increasing among women in PR. Women with gynecological HPV-related tumors are at higher risk of secondary anal cancer as compared with women from the general population and with those with non-HPV-related gynecological cancers. Appropriate anal cancer screening guidelines for high-risk populations are needed, including women with HPV-related gynecological malignancies and potentially other cancer survivors.

Background Despite limited data, research suggests that marijuana use is associated with oral HPV infection and periodontitis, two potential oropharyngeal cancer risk factors. We assessed these associations in a Hispanic adult population in Puerto Rico. Methods A cross-sectional study of 735 adults assessed marijuana use, determined through an audio computer-assisted self-interview, and periodontitis and self-collection of oral HPV samples following the National Health and Nutrition Examination Survey methodology. The Centers of Disease Control and Prevention/American Academy of Periodontology definition was used for periodontitis. HPV typing was performed using polymerase chain reaction with modified L1 consensus primers (MY09/MY11). Results 26.5% of adults reported lifetime use of marijuana, 2.7% were frequent users (lifetime use ≥ 26 times, past year use ≥ 6 times, and past 30-day use ≥2 times), 5.7% had oral HPV infection, and 20.1% had severe periodontitis. The multivariate logistic regression analysis showed that frequent marijuana users were more likely to have severe periodontitis (OR = 2.91, 95%CI = 1.06 – 7.96) than never/once lifetime users after adjusting for age, sex, healthcare coverage, smoking, binge drinking, number of oral sex partners, and oral HPV infection. However, frequent marijuana use was not associated with oral HPV infection. Conclusion Marijuana use was associated with periodontitis, but not with oral HPV infection. Further evaluation of the role of marijuana use in oral HPV infection and periodontitis may inform novel preventive public health strategies, as marijuana users could be at increased risk of oral cancer. This article is protected by copyright. All rights reserved

Background: Hurricanes are the immediate ways that people experience climate impacts in the Caribbean. These events affect socio-ecological systems and lead to major disruptions in the healthcare system, having effects on health outcomes. In September 2017, Puerto Rico (PR) and the United States Virgin Islands (USVI) experienced one of the most catastrophic hurricane seasons in recent history (Hurricane Irma was a Category 5 and Hurricane María was a Category 4 when they hit PR). Objective: This study examines environmental stressors experienced by women with gynecologic (GYN) cancers from PR and USVI who received oncologic cancer care in PR, in the aftermath of the hurricanes. Methods: A descriptive qualitative study design was used to obtain rich information for understanding the context, barriers, knowledge, perspectives, risks, vulnerabilities, and attitudes associated to these hurricanes. We performed focus groups among GYN cancer patients (n = 24) and key-informant interviews (n = 21) among health-care providers and administrators. Interviews were conducted from December 2018–April 2019. Results: Environmental health stressors such as lack of water, heat and uncomfortable temperatures, air pollution (air quality), noise pollution, mosquitos, and rats ranked in the top concerns among cancer patients and key-informants. Conclusions: These findings are relevant to cancer patients, decision-makers, and health providers facing extreme events and disasters in the Caribbean. Identifying environmental secondary stressors and the most relevant cascading effects is useful for decision-makers so that they may address and mitigate the effects of hurricanes on public health and cancer care.

Objectives: Puerto Rico (PR), is the fifth highest jurisdiction of the United States of America (US) with respect to HIV prevalence and the leading in cervical cancer incidence. This cross-sectional study describes the prevalence and correlates of cervical HPV infection among a clinic-based sample of 302 women living with HIV/AIDS in PR. Methods: Data collection included questionnaires, blood and cervical samples. Multivariable logistic regression models were used to estimate the magnitude of association (adjusted Prevalence odds ratio [aPOR]) between HPV cervical infection and other covariates. Results: Mean age of participants was 40.3 years (± 10.3 SD). The prevalence of HPV infection was 50.3%; 41.1% for low-risk types and 29.5% for high-risk types. Having ⥠10 lifetime sexual partners (aPOR = 2.10, 95% CI:1.02â4.29), an abnormal Pap (aPOR = 3.58, 95% CI:1.93â6.62), active genital warts (aPOR = 3.45, 95% CI:1.60â7.42), and CD4 counts ⤠200 (aPOR = 4.24, 95% CI: 1.67â10.78) were positively associated with any cervical HPV infection. Similar results were observed for HR HPV infection. Conclusions: A high burden of HPV co-infection exists among women living with HIV/AIDS in this population. Given the high incidence of HIV in PR and the higher risk of cervical cancer among women living with HIV/AIDS, HPV vaccination should be promoted in this population. Keywords: HIV, HPV, Cervix, Hispanic women, Puerto Rico

Background Research on the physical and mental health profiles and patterns of health care use among women veterans receiving health care from the Department of Veterans Affairs (VA) on the island of Puerto Rico is lacking. Methods This cross-sectional study examines differences in physical and mental health conditions, and patterns of VA health care use, between women veterans of the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) era who were using VA facilities in Puerto Rico (n = 897) and those using U.S.-based VA facilities (n = 117,216) from 2002 to 2015. Results Results of fully adjusted logistic regression models revealed that OIF/OEF women in Puerto Rico had heightened risk for global pain-related disorders (i.e., any pain) (adjusted odds ratio [AOR], 1.45; 95% confidence interval [CI], 1.22–1.71), back pain (AOR, 1.83; 95% CI, 1.56–2.14), diabetes (AOR, 1.42; 95% CI, 1.03–1.95), hyperlipidemia (AOR, 3.34; 95% CI, 2.80–3.98), major depression (AOR, 1.78; 95% CI, 1.53–2.06), and bipolar depression (AOR, 1.66; 95% CI, 1.34–2.04). They also evidenced greater risk for a host of reproductive health conditions and had higher average annual use of VA health care than their U.S. counterparts. Conclusions OIF/OEF women receiving VA health care in Puerto Rico evidenced a greater burden of physical illness, depression, and heightened use of VA health care services relative to their U.S. counterparts. Providers’ increased awareness of the physical and mental health care needs of this population is warranted. Research efforts that help to identify efficient and effective strategies to provide culturally tailored and/or personalized health care for this population could also be useful.

Cervical cancer remains a major burden for women around the world. In 2018, the World Health Organization called for the elimination of cervical cancer worldwide (

Background No study has estimated the potential impact of Human Papillomavirus (HPV) vaccination in Puerto Rico, a population with considerable burden of HPV-related morbidities. We evaluated the health and economic impacts of implementing a vaccination strategy for females and males in Puerto Rico, with the quadrivalent HPV (HPV4) vaccine, under different vaccination scenarios. Methods We adapted a mathematical model which estimates the direct and indirect health benefits and costs of HPV4 vaccination in a dynamic population. The model compared three vaccination scenarios against screening only (no-vaccination) for three doses of HPV4 vaccine among individuals aged 11–15 years in Puerto Rico: 1) 34% for females and 13% for males (34%F/13%M), 2) 50% for females and 40% for males (50%F/40%M), and 3) 80% for female and 64% for male (80%F/64%M). Data specific to Puerto Rico was used. When not available, values from the United States were used. Input data consisted of demographic, behavioral, epidemiological, screening, and economic parameters. Results The model predicted decreases in: 1) HPV infection prevalence for females and males, 2) cervical intraepithelial neoplasia and cervical cancer incidence for females, 3) genital warts incidence for females and males, and 4) cervical cancer deaths among females, when various vaccination program scenarios were considered. In addition, when the vaccination percentage was increased in every scenario, the reduction was greater and began earlier. The analysis also evidenced an incremental cost effectiveness ratio (ICER) of $1,964 per quality–adjusted life year gained for the 80%F/64%M uptake scenario. Conclusions HPV vaccine can prove its cost effectiveness and substantially reduce the burden and costs associated to various HPV-related conditions when targeted to the adequate population together with an organized HPV vaccination program.

Introduction: Research on the association between periodontitis and oral human papilloma virus (HPV) infection is inconsistent. The cross-sectional association of severe periodontitis with oral HPV infection was investigated in a sample of Hispanic adults. Methods: Data from the 2014–2016 San Juan Overweight Adults Longitudinal Study (n = 740) was analyzed. Periodontitis assessment and self-collection of oral HPV samples followed the National Health and Nutrition Examination Survey methodology. Periodontitis was defined using the Centers of Disease Control and Prevention/American Academy of Periodontology definition. HPV typing was performed using polymerase chain reaction. Multivariate logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Results: 5.7% of participants had oral HPV infection and 20.3% had severe periodontitis. Adults with severe periodontitis had higher odds of oral HPV infection than those with none/mild disease (OR=2.9, 95% CI: 1.0–8.4, p

ObjectivesThe objective of this study was to investigate the factors associated with HPV awareness among women aged 16 to 64years, among underserved minority Hispanic women living in Puerto Rico.MethodsA population-based, cross-sectional sample of 566 women, ages 16 to 64years, living in the San Juan metropolitan area were surveyed regarding sexual behavior, HPV knowledge, and HPV vaccine uptake. Data was analyzed using descriptive statistics and multivariate logistic regression.ResultsOverall, 64.8% of the women in the sample had heard about the HPV vaccine. Among those in the recommended catch-up vaccination age range (16-26years, n = 86), 4.7% had received at least one dose of the HPV vaccine. Of those aware of the availability of the HPV vaccine, most had learned about it through the media, whereas, only 39.6% had learned about it from a physician. Multivariate logistic regression analysis showed that HPV awareness (OR 8.6; 95% CI 5.0-14.8) and having had an abnormal Pap smear (OR 2.0; 95% CI 1.2-3.4) were associated with HPV vaccine awareness (p

To assess the prevalence of cervical cancer screening through Papanicolaou (Pap) test utilization and its association with sexual behaviors among a population-based sample of Hispanic women in Puerto Rico (PR).This study was a secondary data analysis of the database of a cross-sectional study of HPV infection in PR (2010-2013; n = 554 women). Pap test utilization (past 3 years) was self-reported and sexual risky behavior was defined as an index that considered the following sexual behaviors: early age of sexual debut (≤16 years), 11 or more lifetime sexual partners, and 2 or more sexual partners in the last year. Multivariable logistic regression was used to estimate the magnitude of the association between sexual risk behavior and Pap test utilization, after adjusting for socioeconomic and lifestyles characteristics.The overall prevalence of Pap test utilization was 78.0%. Pap test screening varied with sexual behavior, with women with none or one risky sexual behavior having higher odds of Pap test utilization in the past 3 years (odds ratio [OR], 1.74; 95% CI, 1.03-2.93) compared with those with two or three risky sexual behaviors. This difference remained marginally significant (p.10) after adjusting for age, educational attainment, smoking status and STI history (OR, 1.72; 95% CI, 0.96-3.08).The prevalence of cervical cancer screening in this population (78%) is still below Healthy People 2020 recommendations (93%). Also, women with risky sexual behaviors are less likely to have been screened. Efforts to promote cervical screening programs should focus on these high-risk women as a method for cervical cancer prevention and control.

Women with inflammatory bowel disease (IBD) may be at increased risk of human papilloma virus (HPV) infection and HPV-related malignancies, as many are immunocompromised secondary to the use of immunosuppressant agents. Several studies have addressed the knowledge about cervical cancer risk factors in different populations, particularly HPV infection and its association with cervical malignancies; most of these studies show poor patient knowledge. The purpose of this study is to describe the knowledge of females with IBD about HPV infection and the HPV vaccine. We performed a cross-sectional study in 147 consecutive patients attending the clinics of the University of Puerto Rico Center for IBD from 2009 to 2010. An interviewer-administered questionnaire was used to collect information on demographics, lifestyles, and HPV-related knowledge of participants. Bivariate analysis using the chi-square statistics and Fisher’s exact test was used to examine factors associated with HPV awareness. The mean age of participants was 36.6 years (SD = 13.91 years). Three fourth (77 %) of women had awareness of the existence of HPV, and 58 % did know about the existence of HPV vaccines. Among those who had heard about HPV, 79.6 % knew that HPV can cause cervical cancer, and 57.5 % knew that the virus is sexually transmitted. Among those who knew of the vaccine, 75.3 % learned about its existence through the media, while only 15.3 %, through their health-care provider. Only three women within recommended ages (2 %) had been vaccinated against HPV, although 50 % of participants indicated that they would definitely/probably vaccinate against HPV in the future. A significant trend was observed, where more educated women were more likely to have heard of HPV (p for trend = 0.0017). Women who were high school graduates/some college (OR = 6.63, 95 % CI = 1.71–25.66) and those with at least an associate degree (OR = 11.69, 95 % CI = 3.05–45.89) were more likely to be aware of the HPV vaccine than women without a high school degree. Our study documents poor knowledge of HPV and HPV vaccine in this population of IBD patients in Puerto Rico. Although vaccination coverage is low in this population, women are receptive to the possibility of vaccination in the future. Given that this population may be at an increased risk of HPV infection and related morbidities, education and vaccination programs should be promoted among them.

This study compared the incidence of lung cancer among Puerto Ricans (PRs) with that of Whites, Blacks, and Hispanics in the United States. We computed age-standardized rates of lung cancer during 1992–2010 and percentages of change over time. Standardized rate ratios (SRR) were estimated to assess racial/ethnic and gender differences. All men groups showed a significant decline in lung cancer over time but PRs observed the smallest change (−1.2 %). For both men and women, PRs had lower incidence rates compared to other racial/ethnic groups (SRR < 1; P < 0.05). Among all groups, men reported higher incidence rates than women but PRs showed the largest gender disparity (SRR = 2.29). This study showed that although PRs exhibited lower incidence rates of lung cancer, this subgroup of Hispanics faced an important burden of lung cancer, principally because PR men had the smallest decline over time and the largest gender difference among all groups.

Background Despite substantial advances in the era of highly active antiretroviral therapy, HIV-positive persons are at high risk of tobacco-related disease and mortality. This study describes the prevalence and sociodemographic factors associated with current tobacco use among HIV-positive men and women 18 years and older receiving HIV care in Puerto Rico. Methods Data from the 2009 Medical Monitoring Project (MMP) was used. A three-stage sampling design was conducted to obtain annual cross-sectional probability samples of HIV-infected adults in care. Factors associated with current tobacco use were identified using logistic regression models. All analyses were performed using STATA version 11.0. Results The estimated prevalence of current cigarette use among the population was 29.0% (95%CI: 23.5%-35.2%), daily smoking was reported in 76.7% of them. Multivariate logistic regression models, showed that male drug users (injected and noninjected) were up to nine times more likely to be current smokers (OR = 9.9; 95%CI = 3.1, 31.5) as compared to nonusers. Conclusion Findings highlight the need for smoking cessation strategies in this population, particularly among male HIV+ drug users.

Health information correlates of fruit and vegetable intake and of knowledge of the fruit and vegetable recommendations were examined using bivariate and multivariate regressions with data from the 2007-2008 U.S. National Cancer Institute's Health Information National Trends Survey in the United States and in Puerto Rico. Residents from Puerto Rico had the lowest reported fruit and vegetable intake and the lowest knowledge of the recommended servings of fruits and vegetables to maintain good health, compared with U.S. Hispanics, non-Hispanic Whites, and Blacks. Sixty-seven percent of Puerto Rican residents and 62% of U.S. Hispanics reported never seeking information on health or medical topics. In multivariate analysis, those who never sought information on health or medical topics reported significantly lower fruit and vegetable intake (coefficient = -0.24; 95% CI [-0.38, -0.09]), and were less likely to know the fruit and vegetable recommendations (OR = 0.32; 95% CI [0.20, 0.52]), compared with those who obtained information from their health care providers. Health promotion initiatives in the United States and Puerto Rico have invested in mass media campaigns to increase consumption of and knowledge about fruit and vegetables, but populations with the lowest intake are less likely to seek information. Strategies must be multipronged to address institutional, economic, and behavioral constraints of populations who do not seek out health information from any sources.

This study examined the prevalence and association of diabetes mellitus (DM) and prediabetes with cardiovascular risk factors among Puerto Ricans adults. Data from a household survey of 857 adults aged 21–79 years who underwent interviews, physical exams, and blood draws were analyzed. Prevalence of total DM and prediabetes was estimated using American Diabetes Association diagnostic criteria of fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c). Poisson regression models were used to estimate the prevalence ratio for each cardiovascular risk factor under study. Age-standardized prevalence of total DM and prediabetes, detected by FPG and/or HbA1c, was 25.5 and 47.4 %, respectively. Compared with participants with normoglycemia, those with previously diagnosed DM, undiagnosed DM, and prediabetes had more adverse cardiovascular risk factor profiles, characterized by a higher prevalence of general and abdominal obesity, hypertension, low HDL cholesterol, elevated LDL cholesterol, elevated triglycerides, and elevated plasminogen activator inhibitor 1 (p < 0.05). The high prevalence of DM and prediabetes calls for public health actions to plan and implement lifestyle interventions to prevent or delay the onset of DM and cardiovascular disease.

The incidence of anal cancer is increasing, particularly among HIV and men who have sex with men (MSM) groups. The vast majority of cases are associated with human papillomavirus (HPV), the most common sexually transmitted infection. Epidemiological studies have also documented low survival, which might be linked to lack of appropriate screening, access, and utilization of pertinent health care services. Our objective was to assess the relative survival (1 and 3 years) of anal cancer in Puerto Rico for men and women during the period from 2000–2007. All histological types of cancer of anus, anal canal, and anorectum (ICD-O-3 codes C210-C218), except for sarcomas, were included. Relative survival was estimated with the use of life tables from the population of Puerto Rico. In addition, the excess survival was compared by age at diagnosis, histology, and stage (defined as local, regional, or distant), using the Poisson regression model. The overall 3-year relative survival in Puerto Rico was the same (53 %) for men and women. Our findings establish baseline survival data for anal cancer in Hispanics from Puerto Rico. Since now, the national guidelines for anal cancer screening and treatment are on their way to be determined; baseline information about survival will allow monitoring the efficacy that standardized screening programs may eventually have in increasing anal cancer survival in this population.

This study assessed the association of the hypertriglyceridemic waist (HTGW) phenotype with prediabetes and diabetes (DM) in a group of Hispanics. Analysis of a cross-sectional study of 858 adults residing in Puerto Rico that collected data on blood pressure, biochemical, and anthropometric measurements was performed. HTGW phenotype was defined as elevated triglycerides and elevated waist circumference. Prediabetes was defined as a fasting glucose of 100-125 mg/dL and DM as a fasting glucose ≥126 mg/dL or prior diagnosis. Prevalence of HTGW, prediabetes, and DM was 27.9, 38.0, and 21.6 %, respectively. Subjects with the HTGW phenotype had higher adjusted odds of prediabetes (POR 5.55; 95 % CI 3.38-9.13) and DM (POR 7.28; 95 % CI 3.63-14.63) compared to those without the phenotype. The association for prediabetes was stronger for women than among men. HTGW phenotype was strongly associated with prediabetes and DM, reinforcing the need to further assess its performance as a screening tool to identify at-risk individuals for cardiometabolic conditions.

Background: Metabolic syndrome (MetSyn) is related to an increased risk for type 2 diabetes and cardiovascular disease. Smokers are at greater risk than nonsmokers of becoming insulin resistant and to develop cardiovascular disease. This study aimed to explore the association between cigarette smoking, MetSyn, and its components among Puerto Rican adults. Methods: A representative sample of 856 persons aged 21-79 years from the San Juan Metropolitan area participated in this study. Demographic and lifestyle characteristics, including smoking habits, were gathered from a self-reported questionnaire. MetSyn was defined according to the revised NCEP-ATP III criteria and measured using biochemical measurements and anthropometric indices. Logistic regression models were used to estimate prevalence odds ratios (POR) and its 95% confidence intervals (CI). Results: MetSyn was significantly (P < 0.001) more prevalent in former smokers (48.4%) as compared to current (42.7%) and never smokers (40.0%). However, after adjusting for possible confounders, current smokers who used more than 20 cigarettes per day were 2.24 (95% CI = 1.00-4.99) times more likely to have MetSyn as compared to never smokers. Heavy smokers were also more likely to have high triglyceride levels (POR = 2.22, 95% CI = 1.12-4.38) and low HDL-cholesterol levels (POR = 2.49, 95% CI = 1.28-4.86) as compared to never smokers. Conclusion: This study supports previous reports of an increased risk of MetSyn among current smokers, particularly those with a heavier consumption. Tobacco control strategies, such as preventing smoking initiation and disseminating evidence-based cessation programs, are necessary to reduce the burden of MetSyn in Puerto Rico.

Background: Oncogenic HPV infection is associated to anogenital cancer. We estimate the prevalence and correlates of anogenital HPV infection among a population-based sample of women aged 16–64 years living in the metropolitan area of Puerto Rico. Methods: 564 women completed face-to-face and computer assisted interviews and self-collected anal and cervical specimens. HPV DNA testing used MY09/MY11 consensus HPV L1 primers and beta-globin as an internal control for sample amplification. Positive specimens were typed by dot-blot hybridization. Results: Weighted prevalence of cervical, anal, and cervical/anal co-infection was 29.4%, 38.6%, and 17.1%, respectively. The commonest oncogenic HPV types detected in the cervix and anus were: 68 (8% vs. 7%) and 16 (5.5% vs. 5.1%), correspondingly. Having ≥3 lifetime sexual partners (OR: 2.3; 95% CI: 1.5–3.5) and last year anal intercourse (OR: 1.6; 95% CI: 1.1–2.5) increased the odds of anogenital HPV infection. Cervical infection was independently associated to anal infection (OR: 3.0; 95% CI: 2.0–4.6). Conclusions: Similar to others, our results confirm the burden of anogenital HPV infection in women and its relationship with sexual behavior. As vaccination increases, future studies should monitor changing trends in HPV infection in this population, and the relationship between anal and cervical HPV-related disease. Keywords: Anogenital HPV infection, Women, Hispanics, Puerto Rico

This study characterized the prevalence of overweight and obesity and assessed their cardiometabolic comorbidities in the population aged 21–79 years living in the San Juan Metropolitan Area of Puerto Rico. We analyzed data from a household survey conducted in Puerto Rico between 2005 and 2007 that used a representative sample of 840 non-institutionalized adults living in the San Juan Metropolitan Area. Body mass index categories were classified as normal weight, overweight and obese. Poisson regression model with robust variance was used to estimate the prevalence ratio to assess the association of each cardiometabolic comorbidity (hypertension, dyslipidemia, diabetes, prediabetes, systemic inflammation, prothrombotic state, and coronary heart disease) with overweight and obesity. Age-standardized prevalence of overweight and obesity was 35.9% and 41.5%, respectively, figures higher than the combined prevalence for the U.S. adult population (68.8%) but similar to all mainland Hispanics (78.8%). Men were more likely to be overweight than women (40.4% versus 33.4%), whereas more women than men were obese (43.7% versus 37.6%). Prevalence of all cardiometabolic comorbidities was significantly (p

Information on the impact of hormone receptor status subtypes in breast cancer (BC) prognosis is still limited for Hispanics. We aimed to evaluate the association of BC molecular subtypes and other clinical factors with survival in a hospital-based female population of BC cases in Puerto Rico. We analyzed 663 cases of invasive BC diagnosed between 2002 and 2005. Information on HER-2/neu (HER-2) overexpression, estrogen (ER), and progesterone (PR) receptor status and clinical characteristics were retrieved from hospitals cancer registries and record review. Survival probabilities by covariates of interest were described using the Kaplan-Meier estimators. Cox proportional hazards models were employed to assess factors associated with risk of BC death. Overall, 17.3% of BC cases were triple-negative (TN), 61.8% were Luminal-A, 13.3% were Luminal-B, and 7.5% were HER-2 overexpressed. In the multivariate Cox model, among patients with localized stage, women with TN BC had higher risk of death (adjusted hazard ratio [HR]: 2.57, 95% confidence interval [CI]: 1.29-5.12) as compared to those with Luminal-A status, after adjusting for age at diagnosis. In addition, among women with regional/distant stage at diagnosis, those with TN BC (HR: 5.48, 95% CI: 2.63-11.47) and those HER-2+, including HER-2 overexpressed and Luminal-B, (HR: 2.73, 95% CI:1.30-5.75) had a higher mortality. This is the most comprehensive epidemiological study to date on the impact of hormone receptor expression subtypes in BC survival in Puerto Rico. Consistent to results in other populations, the TN subtype and HER-2+ tumors were associated with decreased survival.

Purpose This study compares incidence and mortality of penile cancer in Puerto Rico (PR) with other racial/ethnic groups in the United States (US) and evaluates the extent in which socioeconomic position index (SEP) or its components influence incidence and mortality in PR. Materials and Methods Age-standardized rates were calculated for incidence and mortality based on data from the PR Cancer Registry and the US National Cancer Institute's Surveillance, Epidemiology and End Results program, using the direct method. Results PR men had approximately 3-fold higher incidence of penile cancer as compared to non-Hispanic white (Standardized rate ratio [SRR]: 3.33; 95%CI=2.80-3.95). A higher incidence of penile cancer was also reported in PR men as compared to non-Hispanic blacks and Hispanics men. Mortality from penile cancer was also higher for PR men as compared to all other ethnic/racial groups. PR men in the lowest SEP index had 70% higher incidence of penile cancer as compared with those PR men in the highest SEP index. However, the association was marginally significant (SRR: 1.70; 95%CI=0.97, 2.87). Only low educational attainment was statistically associated with higher penile cancer incidence (SRR: 2.18; 95%CI=1.42-3.29). Conclusions Although penile cancer is relatively uncommon, our results support significant disparities in the incidence and mortality rates among men in PR. Low educational attainment might influence the high incidence of penile cancer among PR men. Further studies are strongly recommended to explore these disparities.

Objective: In this study, we examine factors associated with the use of the emergency room (ER) as an entry point into the health-care system to initiate a cancer diagnosis among Puerto Rico’s Government Health Plan (GHP) patients and compare the 1-year survival of GHP patients that initiated cancer diagnosis in the emergency room (ER) presentation with those that initiated the diagnosis in a physician’s office. Methods: Data for patients with colorectal cancer (CRC) aged 50 to 64 years and diagnosed in 2012 were obtained from the Puerto Rico Central Cancer Registry and linked to the Puerto Rico Health Insurance Administration database (n = 190). Crude odds ratio, adjusted odds ratio, and their 95% confidence intervals were reported. We used the Kaplan-Meier method to generate survival curves. Multivariate Cox regression analysis was performed to evaluate the association between ER presentation and 1-year cause-specific survival. Results: We found that 37.37% of the study population had an ER presentation. Male patients had a higher occurrence of having an ER presentation (66.20%), while 76.06% of the patients with an ER presentation were diagnosed in late stage. Emergency room presentation was a highly predictive factor for cancer mortality in the year following the diagnosis. These patients had between 3.99 to 4.24 times higher mortality risk than non-ER presentation patients ( P < .05). Conclusion: Late presentation for CRC diagnosis through an ER visit is a significant concern that influences negatively on the patient’s outcome. Efforts at increasing primary care visits and routine screening tests among GHP beneficiaries could improve survival.