Natural HPV immunity and vaccination strategies

BACKGROUND

the task of preventing premature death in women may be delivered by vaccinating against the high-risk papillomaviruses associated with various malignancies.

OBJECTIVES

we will discuss the immune mechanisms likely to be relevant to the control of an HPV infection in the cervix and assess the limited evidence for such immune recognition in the natural history of infection.

CONCLUSION

the next generation of vaccination strategies should include the use of HPV 16 early (E2 and/or E6 and/or E7) and late gene targets (L1 and L2) expressed as VLPs with their clinical and immunological evaluation aimed at therapy as well as prophylaxis. Important clinical efficacy assessment may be deliverable in relatively short-term studies by targeting patients with HPV 16 associated vulval intraepithelial neoplasia.

Cervical intraepithelial neoplasia outcomes after large loop excision with clear margins

OBJECTIVE

To identify risk factors for residual or recurrent cervical intraepithelial neoplasia (CIN) after large loop excision of the transformation zone with clear margins.

METHODS

We did a case-control study of women treated with loop excision for CIN who had adequate follow-up and in whom margins were believed to be clear. Women with clear margins in whom no subsequent lesions were found (controls) were compared with women who presented with subsequent CIN (cases). Epidemiologic and colposcopic risk factors for recurrence were analyzed. Multiple logistic regression analysis was done to identify independent risk factors.

RESULTS

In 31 of 635 women studied (4.9%), subsequent lesions were diagnosed. Univariate analysis identified glandular involvement, satellite lesions, and age over 40 years in cases as significant. Multiple logistic regression analysis confirmed that these three characteristics were independent risk factors, with odds ratios of 4.9 (95% confidence intervals 1.9, 12.3), 19 (7.5, 48.2), and 6.7 (2.8, 15.8), respectively. Subsequent lesions were identified by colposcopy or cytologic testing during the first postoperative year in all but one case.

CONCLUSION

Age over 40 years, glandular involvement, and satellite lesions were related to the reappearance of CIN after loop excision with clear margins. These findings could be used to define appropriate follow-up protocols.

Requirement for expert histopathological assessment of ovarian cancer and borderline tumors

The distinction between borderline ovarian tumours (BOT) and ovarian carcinoma is made by histopathological assessment. Of 64 patients managed according to institutional BOT protocols, 27 (42%) had been referred with a diagnosis of ovarian carcinoma that was subsequently changed to BOT following histopathological review. The 70% 6-year event-free survival of the patients with a revised diagnosis was not significantly different from those who were referred with a diagnosis of BOT. This change in diagnosis is important as it avoids the need for chemotherapy for most patients and results in patients receiving appropriate information concerning prognosis. Interestingly, 24 patients (38.1%) reported a family history of epithelial cancer, a finding that has not been reported previously. Campaign

The effects of the participation of patients with cancer in teaching communication skills to medical undergraduates: a randomised study with follow-up after 2 years

The importance of good doctor-patient communication is widely recognised. The aims of this study were to evaluate the immediate effects of the participation of patients with cancer on the attitudes and skills of undergraduate medical students receiving an interview skills training programme, and to assess the effects of the participation of patients with cancer on the attitudes and interview performance of students 2 years later. It was hypothesised that the participation of cancer patients would have specific beneficial effects on attitudes and interview performance. Before participating in a 6-session interview methods course in third year, students were randomised to be taught with patients who had cancer (experimental group) or with patients with other diagnoses (control group). Before and after participating in the course, 233 students (94% response rate) completed an Attitudes Questionnaire. When they reached their fifth year, 54 students again completed the Attitudes Questionnaire and, in addition, made a video recording of an interview with a patient who had gynaecological cancer. These recordings were rated independently by two researchers using the Interview Rating Instrument. Immediately after the course, a number of differences were found between the two groups. For example, students in the experimental group were more likely to consider the ability to listen an extremely important characteristic of hospital doctors and to consider more strongly that trust is an essential part of the doctor-patient relationship. 2 years after the course, the ability of hospital doctors to communicate with patients, and the need for clinical decisions to reflect patients' wishes, were considered to be more important by students in the experimental group, although even 96% of controls felt both these issues were very or extremely important. As hypothesised, the experimental group had better ratings in terms of responding empathically, showing regard and concern for the patient, and assessing the impact of the symptoms on the patient's life. The participation of patients with cancer has beneficial and enduring effects on the attitudes and interview performance of medical undergraduates. Medical schools should consider how best patients with cancer can make an important contribution to communication skills training.

Efficacy of cervical-smear collection devices: a systematic review and meta-analysis

BACKGROUND

Few randomised controlled trials have sufficient power to show clear advantages of different designs of cervical-smear collection devices. We studied by systematic review whether the design of cervical-smear devices affects rates of inadequate smears and detection of disease and whether the presence of endocervical cells in the smear affects detection of disease.

METHODS

We sought relevant randomised controlled trials by computer literature review by MEDLINE backed up by a manual search of 16 journals. Each trial was classified according to methodological quality criteria. Odds ratios were calculated where data allowed.

FINDINGS

34 randomised controlled trials investigating cervical Papanicolaou smear collection devices were identified. All 34 trials compared the ability of devices to collect endocervical cells, and 19 compared the ability of devices to detect dyskaryosis. Meta-analyses showed that compared with other collection devices, the Ayre's spatula is an ineffective device for collecting endocervical cells (for example, odds ratio for comparison of extended-tip spatulas vs Ayre's spatula 2.25 [95% CI 2.06-2.44]) and also gives a lower yield of dyskaryosis (odds ratio for comparison of extended-tip spatulas vs Ayre's spatula 1.21 [1.20-1.33]). Devices that effectively collect endocervical cells also detect a higher proportion of abnormal cytology than those that do not.

INTERPRETATION

The widely used Ayre's spatula is the least effective device for cervical sampling and should be superseded by extended-tip spatulas for primary screening and investigation of women before and after treatment for cervical intraepithelial neoplasia. The presence of endocervical cells is a valid and convenient surrogate for the ability to detect dyskaryosis.

The effects of the participation of patients with cancer in teaching communication skills to medical undergraduates: a randomised study with follow-up after 2 years

The importance of good doctor-patient communication is widely recognised. The aims of this study were to evaluate the immediate effects of the participation of patients with cancer on the attitudes and skills of undergraduate medical students receiving an interview skills training programme, and to assess the effects of the participation of patients with cancer on the attitudes and interview performance of students 2 years later. It was hypothesised that the participation of cancer patients would have specific beneficial effects on attitudes and interview performance. Before participating in a 6-session interview methods course in third year, students were randomised to be taught with patients who had cancer (experimental group) or with patients with other diagnoses (control group). Before and after participating in the course, 233 students (94% response rate) completed an Attitudes Questionnaire. When they reached their fifth year, 54 students again completed the Attitudes Questionnaire and, in addition, made a video recording of an interview with a patient who had gynaecological cancer. These recordings were rated independently by two researchers using the Interview Rating Instrument. Immediately after the course, a number of differences were found between the two groups. For example, students in the experimental group were more likely to consider the ability to listen an extremely important characteristic of hospital doctors and to consider more strongly that trust is an essential part of the doctor-patient relationship. 2 years after the course, the ability of hospital doctors to communicate with patients, and the need for clinical decisions to reflect patients' wishes, were considered to be more important by students in the experimental group, although even 96% of controls felt both these issues were very or extremely important. As hypothesised, the experimental group had better ratings in terms of responding empathically, showing regard and concern for the patient, and assessing the impact of the symptoms on the patient's life. The participation of patients with cancer has beneficial and enduring effects on the attitudes and interview performance of medical undergraduates. Medical schools should consider how best patients with cancer can make an important contribution to communication skills training.

Human papillomavirus type 16 and 18 detection in the management of mild dyskaryosis

OBJECTIVE

To determine if semi-quantitative human papillomavirus (HPV) types 16 and 18 detection by polymerase chain reaction can increase the sensitivity and specificity of repeat cytology alone for underlying high grade cervical intraepithelial neoplasia (CIN).

DESIGN

Prospective randomised study of immediate treatment and surveillance.

SETTING

A dedicated colposcopy clinic serving a regional population.

SAMPLE

Three hundred and four women with smears reported as mild dyskaryosis.

METHODS

Repeat cytology, HPV 16 and 18 tests, and colposcopy were performed at study entry. Women were randomised to either immediate treatment or surveillance with repeated tests at 6 and 12 months. Unless all study smears were negative, women were treated at study exit by large loop excision of the transformation zone.

MAIN OUTCOME MEASURES

Sensitivity and specificity of HPV testing for types 16 and 18 in conjunction with cytology for high grade CIN.

RESULTS

Combining repeat cytology with HPV 16 and 18 testing had a sensitivity of 94% and a specificity of 26%, a positive predictive value of 71%, and a negative predictive value of 71%, for underlying high grade CIN. If used to secondary screen in conjunction with repeat cytology for mild dyskaryosis, 88% of women would have been referred for colposcopy on the basis of either test being positive.

CONCLUSION

Combining repeat cytology and HPV 16 and 18 detection would result in the majority of women being referred for immediate colposcopy. Taken with an overall default rate of 17%, immediate referral of all women with mild dyskaryosis for colposcopic assessment still appears to be a more effective clinical strategy.

Spontaneous evolution of human papillomavirus infection in the uterine cervix

BACKGROUND

Little is known about the natural history and the malignant potential of low-grade cervical intraepithelial neoplasia associated with human papillomavirus (HPV) infection. Cervical cancer remains the second most frequent cause of death in women across the world. Epidemiologic and molecular studies have shown that human papillomavirus (HPV) is associated with cervical carcinogenesis. In this prospective study we examined the behavior of low-grade cervical intraepithelial lesions associated with HPV infection over a 6-year period.

MATERIAL AND METHODS

During 1992, women with Papanicolaou smears reporting koilocytotic atypia (HPV effect) with or without grade 1 cervical intraepithelial neoplasia (HPV +/- CINI, low grade squamous intraepithelial lesions, LgSIL), along with colposcopic impression of LgSIL were included to the study. Between 1992 and 1998 all women underwent repeat Papanicolaou smears, colposcopic evaluation and HPV DNA testing every six months. HPV typing of cervical scrapes was done by PCR.

RESULTS

A total of 330 women completed at least 6 years of follow up. Among women with high-risk HPV types (16/18), the presence of dysplasia (grade 1 cervical intraepithelial neoplasia) was significantly correlated with the progression of the lesion; 29% of cases with HPV + CINI (15 out of 75) progressed to more severe lesions versus only 9% of cases with HPV infection (18 out of 225), P < 0.001, chi-square test. The incidence of histologically confirmed progressive lesions was significantly greater in women with mild dysplasia (18 out of 75, 24%) compared to women without dysplasia (13 out of 255, 5%), P < 0.001, chi-square test.

CONCLUSIONS

In our study HPV typing was not predictive of the evolution of low-grade intraepithelial lesions associated with HPV infection. Standard cytologic screening and colposcopy are the most effective means of monitoring low-grade lesions.

A protective role for common p21WAF1/Cip1 polymorphisms in human ovarian cancer

The objective of this study was to compare the frequency of two common p21WAF1/Cip1 gene polymorphisms in ovarian cancer patients with that in age-matched controls, from a population originating from Eastern Scotland. Both polymorphisms were found significantly less frequently in both the constitutive and tumour tissue DNA of ovarian cancer patients (3/65; 4.6%), than in that from geographically and age-matched controls (25/186; 13.4%) (p=0.0495, chi2). Furthermore, we found no p21WAF1/Cip1 gene mutations in any of the tumours, reflected by a relatively low degree of loss of heterozygosity (LOH) at the chromosomal region where the gene maps, providing further evidence that the p21WAF1/Cip1 gene is not mutated in ovarian cancer. The data suggest however, that there may potentially be a protective function for the two p21WAF1/Cip1 gene polymorphisms in the population under study.

Recurrent borderline ovarian tumours after conservative management in women wishing to retain their fertility

OBJECTIVE

To evaluate the rate of recurrence after conservative treatment of Stage 1 borderline ovarian tumors.

METHODS

Retrospective case note review of all women with borderline ovarian tumours diagnosed at Aberdeen, U.K. and loannina, Greece between 1981-1993. Outcome measures comprised initial surgery, stage of disease, histological type, pregnancy rate, recurrence rate and disease-free interval.

RESULTS

Conservative surgery for borderline tumours in young women permitted high conception rates. Recurrence of tumour was high in this group, 71%, and presented late.

CONCLUSION

Prolonged intensive follow-up is required for women treated conservatively for borderline malignant ovarian tumours.

Gynaecological cancer

Gynaecological cancer encompasses a number of tumours with different epidemiology, pathology and treatment strategies. This article reviews the principal clinical advances and areas of development in cancer of the ovary, cervix, endometrium and vulva.

Abdominopelvic CT scan findings after surgery for ovarian cancer

AIMS

To evaluate abdomino-pelvic changes in patients who had total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) for stage I ovarian cancer.

METHOD

The postoperative computed tomographic (CT) scans of 23 patients who had undergone TAH and BSO for stage I ovarian tumours between 3 and 14 weeks previously were assessed, providing there had been no treatment with chemotherapy or radiotherapy and that each patient had normal tumour marker (CA125) levels after surgery. After the CT scan patients were followed up and had no clinical or biochemical (CA125) evidence of relapse for a median of 27 months (range 11 to 78 months). The following sites were assessed by two observers: the vaginal vault, round ligaments, bladder, rectum, perirectal fat, pelvic sidewalls, omentum, surgical scar and abdominal wall. Any abnormality was recorded, with re-evaluation on follow-up CT scans in ten patients (between three and 17 months).

RESULTS

The following abnormalities were seen: (1) Thickened round ligaments (n=12) with bulbous masses at the surgically transected ends (n=7). This was bilateral in eight patients. (2) Vaginal vault thickening (n=11) either uniform (n=6) or bulbous bilaterally (n=2) or unilaterally (n=3). (3) Subtle omental bed stranding or nodularity (n=11). (4) Peritoneal thickening underlying the scar (n=4). (5) Asymmetrical rectus abdominis muscles (n=3) adjacent to the surgical scar or thickened scar tissue in the anterior abdominal wall (n=4). No significant bladder, rectal, perirectal or nodal abnormalities were found.

CONCLUSION

Pseudotumours at the transected ends of the round ligaments, or uniformly swollen round ligaments, may be identified in patients who have had TAH and BSO, as may vaginal vault thickening. Other changes which may be observed in the abdomen and pelvis are peritoneal thickening adjacent to the scar and omental bed stranding.

Admission-discharge policies for hysteroscopic surgery: a randomised comparison of day case with in-patient admission

OBJECTIVE

To study the effectiveness and acceptability of day case hysteroscopic surgery.

DESIGN

Prospective randomised controlled trial.

SETTING

Aberdeen Royal Infirmary.

SUBJECTS

One hundred and ninety four consecutive women who underwent hysteroscopic endometrial ablation.

INTERVENTION

Seventy three women were allocated to day case surgery and 37 to inpatient admission; 84 women though otherwise fit for day case surgery were scheduled for in-patient admission as they lived more than 20 miles away. All women completed a questionnaire 24 h after their operations. Readmission rates were obtained from case notes. Satisfaction rates 12 months after the operation were recorded by means of a follow-up questionnaire.

RESULTS

Post-operative pain was absent or slight in 48 (75%) of the women in the day case group 27 (84%) of women in the in-patient group, and 55 (82%) in the non-randomised in-patient group. Post-operative analgesia was necessary in 34 (52%) women in the day case group, 24 (75%) women in the in-patient group and 36 (53%) women in the non-randomised in-patient group. Hospital costs were significantly less in the day case group. Satisfaction with stay 92% in the day case group, and 100% in the other two groups.

CONCLUSION

In this setting, day care is a safe acceptable and less expensive alternative to in-patient care for hysteroscopic endometrial ablation.

Immediate colposcopy or cytological surveillance for women with mild dyskaryosis: a cost effectiveness analysis

BACKGROUND

The aim of the study was to compare the cost effectiveness of immediate diagnosis and treatment of mild dyskaryosis compared with the usual policy of cytological surveillance.

METHODS

A cost effectiveness analysis was carried out alongside a randomized clinical trial.

RESULTS

Immediate diagnosis and treatment increased total costs by 50 per cent from 54.42 pounds per treated woman [95 per cent confidence interval (CI) 48.85 pounds-59.98 pounds] in the surveillance group to 82.02 pounds per woman in the immediate diagnosis and treatment group with an incremental cost of 27.60 pounds (95 per cent CI 22.04 pounds-33.17 pounds). However, the number of cases of CIN III detected increased by 69 per cent for the policy of immediate diagnosis and treatment. This led to an average cost effectiveness ration of 180.18 pounds for the immediate diagnosis and treatment group and 199.94 pounds per case of CIN III detected for the surveillance group, with a marginal cost effectiveness ratio of 148.22 pounds (95 per cent CI 94.01 pounds-309.33 pounds) for the immediate diagnosis and treatment group.

CONCLUSION

Immediate diagnosis and treatment increases the total cost of managing mildly dyskaryotic smears but this increased cost is offset by a sharp increase in the number of cases of CIN III detected.

A pragmatic randomised comparison of transcervical resection of the endometrium with endometrial laser ablation for the treatment of menorrhagia

OBJECTIVE

To compare endometrial laser ablation (ELA) with transcervical resection of the endometrium (TCRE) in the treatment of menorrhagia.

DESIGN

Randomised controlled trial.

SETTING

Gynaecology department of a large teaching hospital.

PARTICIPANTS

Women with menorrhagia due to dysfunctional uterine bleeding (n = 372) were randomly allocated to ELA (n = 188) or TCRE (n = 184).

MAIN OUTCOME MEASURES

Operative complications, post-operative recovery, relief of menstrual and other symptoms, need for further surgical treatment, satisfaction with treatment after 6 and 12 months, and differential resource use.

RESULTS

TCRE was significantly quicker, with lower rates of fluid overload. Perioperative morbidity was low and similar in both groups. Outcome at 12 months was also similar: 72 women (45%) had either amenorrhoea or brown discharge in the ELA group compared with 71 (49%) in the TCRE group; 79 (49%) versus 68 (46%) had lighter periods. Thirty (16%) versus 36 (20%) had received further surgical treatment: 9 (5%) compared with 25 (14%) had had a hysterectomy and 21 (11%) versus 11 (6%) had received repeat ablation. Anxiety and depression, dysmenorrhoea and pre-menstrual symptoms were improved by both procedures and bladder symptoms were affected by neither. At 12 months 148 (90%) women in the ELA group and 140 (91%) women in the TCRE group were satisfied with their treatment. The estimated additional cost of ELA was Pound 145 per procedure.

CONCLUSIONS

At one year there was no clear difference in clinical outcome between ELA and TCRE. Both procedures were associated with low morbidity. ELA was the more costly procedure. Despite the need for further surgery for about one in six women, satisfaction rates were high following both ELA and TCRE.

The case for stopping cervical screening at age 50

OBJECTIVE

To determine the pattern of abnormal cervical cytology in women aged 50 to 60 years and to determine whether the development of cervical neoplasia in this age group is confined to women who have been inadequately screened.

DESIGN

Retrospective case analysis study.

POPULATION

An 11-year birth cohort of women in Grampian Region born between 2/10/33 and 1/10/44, and those who had significant cytological abnormalities in the 5 year period 1/10/89 to 30/9/94.

MAIN OUTCOME MEASURES

Cytological and histological outcome for women with significant cytological abnormalities between 50 to 60 years of age and the interval between three consecutive smears taken up to 50 years of age for those women.

RESULTS

Of 23,440 women aged 50 to 60 years ever screened in Grampian Region, 229 (1%) had significant cytological abnormalities. Seventy had CIN 3 and 15 had invasive disease of the cervix. Among approximately 9000 women with adequate smear histories prior to age 50, one case of CIN 3 and one case of invasion were detected. The prevalence of invasive disease in the whole cohort during this five year period was 59/100,000. Among the previously well screened women the prevalence was 11/100,000.

CONCLUSION

The incidence of preinvasive disease of the cervix is low over the age of 50 and is seen almost exclusively in inadequately screened women. There would appear to be little benefit in continuing cervical screening over the age of 50 in women who have had regular negative smears. The release of this low risk group from the cervical screening programme could alleviate anxiety and could enable reallocation of resources to target better high risk women who default from regular screening and to reduce screening intervals where necessary to three years.

Invasive cervical cancer after conservative therapy for cervical intraepithelial neoplasia

BACKGROUND

Conservative outpatient therapy for cervical intraepithelial neoplasia (CIN) by ablative or excisional techniques is widely used. The main objective of this treatment is the prevention of invasive cervical cancer. We assessed the rate of invasive disease and the duration of the risk of developing invasive cervical cancer after such treatment.

METHODS

Four UK centres have used life-table methods to analyse the long-term results of conservative treatment of CIN. We combined and updated data from these studies to investigate the rate of invasive disease after treatment and the duration of that risk.

FINDINGS

The data comprised 44 699 woman-years of follow-up, with 2116 women under observation 8 years after treatment. 33 women developed invasive cancer, 14 of whom had microinvasion. The cumulative rate of invasion 8 years after treatment was 5.8 per 1000 women and the rate of invasive cancer during this period was 85 (95% CI 60-119) per 100,000 woman-years. The risk of developing cancer did not change throughout the 8 years of follow-up.

INTERPRETATION

These data show that conservative outpatient therapy in women with CIN reduces the risk of invasive cancer of the cervix by 95% during the first 8 years after treatment. However, even with careful, long-term follow-up, the risk of invasive cervical cancer among these women is about five times greater than that among the general population of women throughout that period. Careful follow-up is essential for at least 10 years after conservative treatment of CIN.

A comparison of bladder and ovarian function two years following hysterectomy or endometrial ablation

OBJECTIVE

To test the hypothesis that at two years bladder and ovarian function function are no different following either simple hysterectomy or endometrial ablation (transcervical resection/laser ablation).

DESIGN

Randomised controlled trial comparing hysterectomy with endometrial ablation. Two years after trial entry bladder and ovarian function were evaluated subjectively by means of questionnaires and objectively by means of cystometry and estimation of serum follicle stimulating hormone respectively.

SETTING

Aberdeen Royal Infirmary.

PARTICIPANTS

Tow hundred and four women with dysfunctional uterine bleeding who, when recruited to the initial study two years previously, were aged less than 50 years, weighed less than 100 kg, and who would otherwise have undergone hysterectomy.

RESULTS

Of the 204 women originally recruited, 101 re-attended the clinic and underwent cystometry and follicle stimulating hormone estimation. These, together with a further 59 women, completed postal questionnaires (79% of original cohort). Rates of stress incontinence (44% vs 44%, 95% CI of difference -16% to +15%), urge incontinence (21% vs 19% 95% CI of difference -11% to +14%), and hot flushes (30% vs 44%, 95% CI of difference -25% to +7%) were similar in the hysterectomy and endometrial ablation groups, respectively. Cystometry revealed 14 (31%) cases of bladder dysfunction after hysterectomy and 17 (35%) after hysteroscopic surgery (95% CI of difference -23% to +15%). Serum follicle stimulating hormone levels > 40 IU/L [corrected] were found in three (6%) women following hysterectomy and five (10%) of women after endometrial ablation.

CONCLUSION

This study suggests that in comparison with endometrial ablation, simple hysterectomy for dysfunctional uterine bleeding does not compromise bladder or ovarian function, at least at two years after the operation. Due to lack of power the estimates of any differences are imprecise, and clinically significant effects cannot be ruled out.

Mature results of a randomized trial of two doses of cisplatin for the treatment of ovarian cancer. Scottish Gynecology Cancer Trials Group

PURPOSE

In 1992, we reported the first results of a randomized study in ovarian cancer, comprising two doses of cisplatin and indicated a significant difference (P = .0008) in median survival. Four years later, we now describe the results of this trial.

PATIENTS AND METHODS

After a median follow-up of 4 years and 9 months, 115 of 159 cases of advanced ovarian cancer, originally randomized to receive six cycles of cyclophosphamide 750 mg/m2 and either a high dose (HD) of 100 mg/m2 cisplatin or a low dose (LD) of 50 mg/m2 (LD) cisplatin, have now died.

RESULTS

The overall survival for HD and LD patients is 32.4% and 26.6%, respectively, and the overall relative death rate is 0.68 (P = .043). This represents a reduction in overall benefit with longer follow-up compared with the first 2 years (relative death rate of 0.52). Toxicity, particularly neurotoxicity, is still evident in the fourth year (10/31 on HD compared with 1/24 on LD).

CONCLUSION

Our recommended dose of cisplatin in combination schedule is therefore 75 mg/m2, representing the optimal balance between efficacy and toxicity.