Introduction: Allogeneic hematopoietic cell transplantation (alloHCT) survivors are at risk for secondary malignancies (SM), such as cervical cancer (CC) and breast cancer (BC). A recent study (n=440) reported low clinician adherence rate to guidelines for CC (40%) and BC (49%) screening, and high patient non-adherence for CC screening recommendation (24%) [Bhatt N et al, 2024 & 2025]. Oregon Health & Science University is the only allogeneic transplant center (TC) in the state with a large catchment area. We conducted a single-center, retrospective study, to evaluate the rates and predictors of CC and BC screening among women survivors after alloHCT.

Methods: Electronic medical records (EMR) of female patients who received alloHCT between 2012-2023 (N=190) were reviewed. Patients assigned female at birth, with a cervix, age 21-65 years, with at least 1 year of follow-up (F/U) were included. Data was collected on demographics, malignancy, alloHCT, gynecologic health, CC (papanicolaou smear, PS) and BC (mammogram) screenings. The primary aim was to assess the rate of CC screening post-HCT. Due to variable F/U time among patients, we used cox proportional hazards regression modeling to find predictors of CC screening completion. In a sub analysis of this sample (age > 40 years), we reviewed mammogram completion patterns in the pre- and post-alloHCT setting.

Results: The median age was 46.0 years (20.0-63.0) and the median F/U time after HCT was 1,578.0 days (396.0-4721.0). The median distance to the TC was 24.4 miles (1.9 – 2594.0) and 25.8% lived >100 miles away from the TC. There was a predominance of private insurance (67.9%), followed by Medicaid (22.1%) and Medicare (5.8%); 63.7% were married, 96.3% were English speaking, and 70% were never smokers. There was a predominance of MDS/AML (59.5%), myeloablative conditioning (84.7%), non- total body irradiation (TBI) based conditioning regimen (72.6%), peripheral blood grafts (89.5 %) and non-post-transplant cyclophosphamide (PTCY) based graft vs. host disease (GVHD) prophylaxis (91.1%). Incidence of acute GVHD (grade 1-4) was 43.7% and chronic GVHD (mild-severe) was 63.7%, with 25.8 % of vaginal involvement.

In this cohort, 77.4% had pre-HCT CC screening, and 57.89% of patients completed CC screening post-HCT, of which 37.3% completed within 1 year, 30% completed in the second year and 32.7% after 2 years. The median F/U time was significantly higher in patients who completed their post-HCT PS (1,993.5 days) than those without a post-HCT PS (1,053.0 days, p =<0.001). In patients 40 years and above (n=122), 74.6% of patients had a pre-HCT mammogram, 66.4% had a post-HCT mammogram, of which 49.5% were completed within 1 year, 28.4% in second year and 22.2% after 2 years. In this cohort, the completion rate of both mammogram and PS testing was 44.3%, mammogram alone was 22.1%, PS alone 9.0% and neither 24.6%.

A multivariable analysis was conducted using age, distance to TC, chronic GVHD with vaginal involvement, history of abnormal PS test and Medicaid insurances. Younger age and prior history of abnormal PS were significantly associated with receipt of CC screening after controlling for other covariates (aHR 0.97 [0.96-0.99]; 2.55 [1.73-3.76]). Patients with history of chronic GVHD with vaginal involvement had higher rates of CC screening after HCT, but this relationship did not reach statistical significance (aHR 1.52 [0.92-2.51]). While distance >100 miles was associated with a lower rate of CC screening in the bivariate model (HR 0.62 [0.40-0.97], this relationship was no longer significant in the multivariable model (aHR 0.83 [0.57-1.34]).

Conclusion: Despite post-HCT recommendations defined by our TC, our retrospective study identifies suboptimal CC and BC screening rates, similar to that cited in the literature. Younger age and a prior history of abnormal PS findings were predictors of post-alloHCT CC screening completion. Presence of chronic GVHD with vaginal involvement and distance < 100 miles from the TC showed trends towards post-alloHCT CC screening completion. These findings offer an insight into CC screening patterns and potential gaps in survivorship care. Future work includes a qualitative study on patient perspectives and a feasibility pilot study of novel approaches to improve CC screening. Data from this work will help establish a patient-centered survivorship care program that includes effective strategies for promoting SM screenings.

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2025
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