Cervical Cancer: Formulation and Implementation of Govt of India Guidelines for Screening and Management

Inhibition of NF-kB and COX-2 by andrographolide regulates the progression of cervical cancer by promoting PTEN expression and suppressing PI3K/AKT signalling pathway

In the face of recent advances in Cervical cancer (CC) treatment, therapeutic and surgical procedures for CC management are still inadequate. In the current study for the first time Andrographolide (Andro) has been explored for its multitarget therapeutic efficacy on NF-kB, COX-2, and PI3K/AKT expressions together in CC. The expression levels of NF-kB, COX-2, PI3K and PTEN in the CC patient samples, both at mRNA and protein levels have shown significant association with poor survival and increased tumor aggressiveness. The binding efficacy of Andro was investigated using molecular docking and molecular dynamic simulations, and the protein and ligand complex for NF-kB and COX-2 has shown high binding energy. Andro displayed cytotoxicity by impeding the in-vitro proliferation of CC cells. Andro significantly supressed the NF-kB, COX-2, and PI3K expression and enhanced the expression levels of PTEN at protein levels in-vitro. Andro induced apoptosis in a dose dependent manner and significantly inhibited the migration and invasion of CC cells. Andro exhibited similar activity in-vivo and suppressed the CC tumor growth in xenograft C57BL/6 mice model. The anti-tumor activity of Andro, both in-vitro and in-vivo has shown considerable downregulation of NF-kB and COX-2 and induced apoptosis through impeding the PI3K/AKT signalling pathway. These findings from the above study projects, administration of Andro as an effective alternate safe compound to curtail and impede cervical cancer progression.

Survival of patients with cervical cancer in India - findings from 11 population based cancer registries under National Cancer Registry Programme

Background

Cancer survival data from Population Based Cancer Registries (PBCR) reflect the average outcome of patients in the population, which is critical for cancer control efforts. Despite decreasing incidence rates, cervical cancer is the second most common female cancer in India, accounting for 10% of all female cancers. The objective of the study is to estimate the five-year survival of patients with cervical cancer diagnosed between 2012 and 2015 from the PBCRs in India.

Methods

A single primary incidence of cervical cancer cases of 11 PBCRs (2012-2015) was followed till June 30, 2021 (n = 5591). Active follow-ups were conducted through hospital visits, telephone calls, home or field visits, and public databases. Five-year Observed Survival (OS) and Age Standardised Relative Survival (ASRS) was calculated. OS was measured by age and clinical extent of disease for cervical cancers.

Findings

The five-year ASRS (95% CI) of cervical cancer was 51.7% (50.2%-53.3%). Ahmedabad urban (61.5%; 57.4%-65.4%) had a higher survival followed by Thiruvananthapuram (58.8%; 53.1%-64.3%) and Kollam (56.1%; 50.7%-61.3%). Tripura had the lowest overall survival rate (31.6%; 27.2%-36.1%). The five-year OS% for pooled PBCRs was 65.9%, 53.5%, and 18.0% for localised, regional, and distant metastasis, respectively.

Interpretation

We observed a wide variation in cervical cancer survival within India. The findings of this study would help the policymakers to identify and address inequities in the health system. We re-emphasise the importance of awareness, early detection, and increase the improvement of the health care system.

Funding

The National Cancer Registry Programme is funded through intra-mural funding by Indian Council of Medical Research, Department of Health Research, India, Ministry of Health & Family Welfare.

A comprehensive review on the functional role of miRNA clusters in cervical cancer

Cervical cancer (CC) poses a significant health threat in women globally. MicroRNA clusters (MCs), comprising multiple miRNA-encoding genes, are pivotal in gene regulation. Various factors, including circular RNA and DNA methylation, govern MC expression. Dysregulated MC expression correlates strongly with CC development via promoting the acquisition of cancer hallmarks. Certain MCs show promise for diagnosis, prognosis and therapy selection due to their distinct expression patterns in normal, premalignant and tumor tissues. This review explains the regulation and biological functions of MCs and highlights the clinical relevance of abnormal MC expression in CC.

Comparison of Colposcopy and Histopathology in Abnormal Cervix

Cervicovaginal cancer (CVC) is the most common malignancy of the genital tract. Colposcopy is a diagnostic procedure that is used to examine the cervix and tissue samples of the urethra and vulva in a magnified view. The colposcopy and histological findings of unhealthy cervixes in a tertiary care hospital were compared. This comparative cross-sectional study was conducted from November 2022 to March 2023 among women with a variety of gynecological complaints who visited the Department of Obstetricians and Gynecologists in a tertiary care facility. One hundred participants were included in this study. The data collected were analyzed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, United States). Participants had an average age of 35.22 ± 7.18 years, and white discharge was the most reported ailment (73%). Comparing the results of the colposcopy with the histological findings revealed a sensitivity of 91.5% and a specificity of 72.2%. The high sensitivity of colposcopy highlights the need to combine it with histological techniques to obtain better results.

Cervical Cancer Screening Coverage at Tertiary Care Institutes Across India

OBJECTIVES

The 70% screening coverage target proposed in the global cervical cancer elimination strategy is not achieved even at tertiary centres in India. A situational analysis was done to assess the currently existing facilities and barriers in tertiary care institutes.

METHODS

This cross sectional multicentric study was conducted from August to September 2021 in six tertiary care institutes across India. Women aged 30-49 years attending outpatient services (OPD) were invited for cervical screening. Women and health care professionals (HCPs) were administered structured questionnaires to assess knowledge, attitude and practices regarding cervical cancer screening services.

RESULTS

Out of 6709 eligible women who attended OPD, 1666 (24.8%; range:19-57%) received screening. Availability of screening kits was limited to 10-25 Pap/HPV tests per day. Visual inspection with acetic acid (VIA) and HPV testing were offered only at certain centres. Colposcopy and treatment facilities were optimal at all centres. Knowledge, attitude and practices were analysed for 1800 women: 45.7% had heard of cervical cancer, 78.0% did not know that it is preventable, 75.8% never heard about screening. Common symptoms correctly identified included postmenopausal bleeding (4.8%), postcoital bleeding (5.7%), intermenstrual bleeding (5.8%) and vaginal discharge (12.4%). Risk factors were identified by minority: poor menstrual hygiene (6.6%), oral contraceptive pill use (6.4%), multiparity (4.4%), and HPV infection (3.0%). Out of 21, mean total knowledge score (MTKS) was 2.07± 2.67. Out of 317 HCPs, 96.5% knew that cervical cancer is caused by HPV infection, is preceded by premalignant stage, and that it is preventable by screening and treatment (80.1%). Knowledge about screening modalities was present in 87.4% for cytology, 75.1% for VIA, 68.8% for HPV test. MTKS of HCPs was 20.88±6.61 out of 32.

CONCLUSION

Even at tertiary centres, limited availability of HPV tests, reluctance to implement VIA and lack of awareness among women remain the major barriers.

Epidemiology, Molecular Pathogenesis, Immuno-Pathogenesis, Immune Escape Mechanisms and Vaccine Evaluation for HPV-Associated Carcinogenesis

Human papillomavirus (HPV) is implicated in over 90% of cervical cancer cases, with factors like regional variability, HPV genotype, the population studied, HPV vaccination status, and anatomical sample collection location influencing the prevalence and pathology of HPV-induced cancer. HPV-16 and -18 are mainly responsible for the progression of several cancers, including cervix, anus, vagina, penis, vulva, and oropharynx. The oncogenic ability of HPV is not only sufficient for the progression of malignancy, but also for other tumor-generating steps required for the production of invasive cancer, such as coinfection with other viruses, lifestyle factors such as high parity, smoking, tobacco chewing, use of contraceptives for a long time, and immune responses such as stimulation of chronic stromal inflammation and immune deviation in the tumor microenvironment. Viral evasion from immunosurveillance also supports viral persistence, and virus-like particle-based prophylactic vaccines have been licensed, which are effective against high-risk HPV types. In addition, vaccination awareness programs and preventive strategies could help reduce the rate and incidence of HPV infection. In this review, we emphasize HPV infection and its role in cancer progression, molecular and immunopathogenesis, host immune response, immune evasion by HPV, vaccination, and preventive schemes battling HPV infection and HPV-related cancers.

The Effect of Multimodal Interventions Regarding Early Cervical Cancer Diagnosis on the Women's Knowledge, Attitude and Participation in Cervical Screening Program

OBJECTIVE

The objective of the present study was to assess the effect of multimodal interventions on women's knowledge, attitude, and behavior towards the participation in the cervical screening test.

METHODS

A quasi-experimental design is executed with a multi-stage sampling of 300 women residing in rural India.  Various multimodal interventions, including a documentary film, face-to-face meetings, written booklets, reminder letters, SMS, and telephone calls, are used to motivate the women for cervical cancer screening.

RESULTS

Following the interventions, 99% of the participants became aware of cervical cancer and increased their participation in screening from 3.0 % (Pretest) to 79.9% (Posttest). Three reminders have been sent to the participants, throughout the intervention period which has led to a considerable rise in the participants' willingness to participate in screening, hiking from 58% to 79.9%. The Pap smear test results have shown that: among 288 women, 21 have Typical Malignant cells on their cervix, and two women have been diagnosed with cervical cancer (Stage 1a and Stage 1b).

CONCLUSION

The findings of the study indicate that utilizing diverse interventions in health education alters women's behavior, enhances the compliance of cervical cancer screening, and ultimately helps to prevent life-threatening risks.

CESCProg: a compact prognostic model and nomogram for cervical cancer based on miRNA biomarkers

Cervical squamous cell carcinoma, more commonly cervical cancer, is the fourth common cancer among women worldwide with substantial burden of disease, and less-invasive, reliable and effective methods for its prognosis are necessary today. Micro-RNAs are increasingly recognized as viable alternative biomarkers for direct diagnosis and prognosis of disease conditions, including various cancers. In this work, we addressed the problem of systematically developing an miRNA-based nomogram for the reliable prognosis of cervical cancer. Towards this, we preprocessed public-domain miRNA -omics data from cervical cancer patients, and applied a cascade of filters in the following sequence: (i) differential expression criteria with respect to controls; (ii) significance with univariate survival analysis; (iii) passage through dimensionality reduction algorithms; and (iv) stepwise backward selection with multivariate Cox modeling. This workflow yielded a compact prognostic DEmiR signature of three miRNAs, namely hsa-miR-625-5p, hs-miR-95-3p, and hsa-miR-330-3p, which were used to construct a risk-score model for the classification of cervical cancer patients into high-risk and low-risk groups. The risk-score model was subjected to evaluation on an unseen test dataset, yielding a one-year AUROC of 0.84 and five-year AUROC of 0.71. The model was validated on an out-of-domain, external dataset yielding significantly worse prognosis for high-risk patients. The risk-score was combined with significant features of the clinical profile to establish a predictive prognostic nomogram. Both the miRNA-based risk score model and the integrated nomogram are freely available for academic and not-for-profit use at CESCProg, a web-app (https://apalania.shinyapps.io/cescprog).

Knowledge, Perception, and Acceptance of HPV Vaccination and Screening for Cervical Cancer among Saudi Females: A Cross-Sectional Study

Cervical cancer (CC) ranks as the eighth most prevalent malignancy in Saudi Arabian women of all ages. This cross-sectional study intends to assess women's knowledge, perceptions, and acceptance concerning HPV vaccination and CC screening in Saudi Arabia as well as the contributing variables to women's screening and vaccine acceptability. Data were collected between 1 April 2023 and 30 May 2023 through online questionnaires. Out of 421 responses, 70% of the studied sample had fair knowledge, and 30% had good knowledge related to cervical cancer screening and vaccine. Only 1.9% of the participants had a positive perception, while 41% of the participants had a negative perception toward cervical cancer screening and vaccine. A total of 38% of the participants were fearful of the side effects of the vaccine, while 22.2% doubted the effectiveness of the vaccine. Acceptance was much better correlated with perception (Rho = 0.47) than with knowledge (Rho = 0.177). However, this correlation remains weak. We conclude that Saudi women still have a poor understanding or impression of cervical cancer and prevention methods. Fear of the vaccination's negative effects and skepticism about the effectiveness of the vaccine/screening have recently been the most often-mentioned hurdles to vaccine uptake.

Carcinoma cervix: A single institute experience from Kashmir, Northern India

Background

Carcinoma cervix is the fourth most commonly diagnosed cancer worldwide, with an estimated 604,000 new cases and 342,000 deaths worldwide in 2020. Carcinoma cervix is an uncommon malignancy in Kashmir. In this retrospective study, we have tried to find clinicopathological characteristics of carcinoma cervix along with the survival rates at our tertiary care hospital.

Materials and Methods

Case records of cervical cancer patients registered from January 1, 2015, to January 1, 2019, were retrieved. A total of 138 patients was registered. 22 had undergone surgery, and out of these 17 had received postoperative radiotherapy. 109 patients were treated with definitive chemoradiation and 13 with palliative radiotherapy. Descriptive statistics were used to summarize patient and treatment-related variables, and Kaplan-Meier analysis was performed for survival analysis.

Results

A total of 138 cases that were registered from 2015 to 2019 were included in this study. The median age at the presentation was 56 years. Most of the patients had a performance status of 1 (98 patients (71.01)). Most of the patients 110 (79.71%) were married before 20 years of age, only 1 patient was unmarried, and 85 (61.59) patients were multiparous in our study group. Only 14 (10.14%) patients in our study group had a history of oral contraceptive use and most of them were non-smokers [124 (89.80%)]. Multiple marriages were present in 8 (5.79%) patients only. The most common presenting symptom was bleeding per vagina (78.26%), and the maximum number of patients fall in the post-menopausal group (67.39%). 116 patients had squamous cell carcinoma histology while 10 patients had adenocarcinoma histology. Most of the patients had stage II and stage III disease (85 patients). At last, follow up out of 138 patients 75 (54.35) were alive. 3 year disease-free survival was 54.34% and 3-year overall survival was 72.46%.

Conclusion

Carcinoma cervix is an uncommon malignancy in Kashmir because of different socio-cultural and religious practices but the response to treatment, toxicity profile, and survival are similar to the rest of the world.

Screening Guidelines and Programs for Cervical Cancer Control in Countries of Different Economic Groups: A Narrative Review

Screening guidelines and practices differ according to resource availability and continually update as scientific developments take place. In this article, we have reviewed screening guidelines and programs for cervical cancer prevention in selected countries belonging to different economic groups viz high income, middle income, and low income. We have selected six countries - the United States of America (USA), the United Kingdom (UK), India, South Africa, Bangladesh, and Malawi. Considerable differences are observed across the health systems. Countries with established screening guidelines complemented by organised nationwide programs or insurance practices have much better screening rates. Human Papilloma Virus (HPV) DNA testing is currently the test of choice in the majority of settings for cervical cancer screening due to its higher sensitivity (up to 90-100%) and longer screening intervals (three to five years). It is also cost-effective, less dependent on operator expertise, and suitable for all settings as compared to a Pap smear test or visual inspection with acetic acid (VIA). Self-sampling of HPV can further help to improve screening coverage by increasing opportunities of reaching to women who would otherwise not participate in screening programs. Resource-constrained countries recommend VIA-based screening in their national programs due to its low cost. The share of cervical cancer is higher in middle and low-income countries as they have lower screening coverage, compared to high-income countries. The main barriers faced in the implementation of the program in low-income countries (LICs) are pertaining to the health system, patient-specific challenges, and healthcare provider-specific challenges.

The impact of health education interventions on HPV vaccination uptake, awareness, and acceptance among people under 30 years old in India: a literature review with systematic search

Background

The HPV vaccine is used as one of the main prevention tools for HPV-related cancers globally, yet it is not part of the Indian National Immunization program. In light of the introduction of the indigenous vaccine, we examine the effectiveness of health education about uptake, acceptance, and awareness.

Methods

Research was performed in the following databases: PubMed, CINAHL, Scopus, and Embase to identify studies between 2008 and 2022. Studies were included if: they were conducted in India including primary data research and health education intervention, and participants were between 9 and 29 years old.

Results

Out of the 10.952 results, 7 studies were included. Four studies focused on adolescent girls, aged from 9 to 20 years old, and 3 on university students aged from 17 to 26 years. Five studies were implemented in urban areas and 2 in rural areas. Health education interventions proved to be effective in increasing uptake, awareness, and acceptance of the HPV vaccine. The barriers included among others: cost, lack of awareness, and cultural barriers.

Conclusion

Observations from this study outline immediate action for policymakers to educate and encourage the young population toward HPV vaccination. Future programs should be aimed at different population groups and be adjusted according to their special characteristics and needs. Attention should be given to the male population and marginalized groups. The involvement of various stakeholders proved to be beneficial, and it is highly recommended.

Sesquiterpenoid-rich Java Ginger rhizome extract prompts autophagic cell death in cervical cancer cell SiHa mainly by modulating cellular redox homeostasis

Java Ginger or Curcuma zanthorrhiza Roxb. has long gained focus among tribal people of Java, for its medicinal properties mainly against gynaecological challenges. The present study aims to identify the most potent phytocompound present in the extract and determine primary mode of action accountable for cytotoxic activity of Curcuma zanthorrhiza rhizome extract against HPV16-positive SiHa cervical cancer cells. The phytochemically-rich extract of rhizome (CZM) was capable to inhibit proliferation of target cells in a dose-dependent manner with an IC50 of 150 μg/ml. Dysregulation of intercellular antioxidant defence system resulted to surges in ROS and RNS level, increased calcium concentration and compromised mitochondrial membrane potential. Nucleus got affected, cell cycle dynamics got impaired while clonogenicity and migration ability diminished. Expression of viral oncogenes E7 and E6 decreased significantly. Accumulation of toxic cell metabolite and decrease in level of essential ones continued. Finally, alteration in PI3K/AKT/mTOR signalling route was followed by onset of autophagic cell death concomitant with the upregulated expression of Beclin1, Atg5-12 and LC3II. Curcumin and a novel crystal as well as few phyto-fractions were isolated by column chromatography. Of these, curcumin was found to be most potent in inducing cytotoxicity in SiHa while two other fractions also showed significant activity. Thus, CZM acted against SiHa cells by inducing autophagy that commences in compliance to the changes in PI3K/AKT/mTOR pathway mainly in response to oxidative stress. To the best of our knowledge this is the first report of Curcuma zanthorrhiza Roxb. inducing autophagy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13205-022-03415-9.

A Review on the Use of the HPV Vaccine in the Prevention of Cervical Cancer

The main risk factor for invasive cervical carcinoma is persistent infection by the high-risk human papillomavirus (HPV). HPV is the most prevalent sexually transmitted infection (STI) and has been linked to 15 different cancers. Cervical cancer is one of the most frequent cancers among women, particularly in resource-limited countries. Cervical cancer is an HPV disease with the highest worldwide burden in resource-limited nations. With improved medical care and nationwide screening programmes, the mortality rate from cervical cancer has decreased in the past 40 years. Many developing nations have been shown to have inadequate knowledge and health-seeking practices, making proper awareness and immunisation programmes necessary. The best strategy to reduce the incidence of cervical cancer is through the administration of HPV vaccines along with routine cervical screening. The HPV vaccine is crucial for public health. Vaccinations against all HPV subtypes, namely, bivalent, quadrivalent, and nonavalent, are available. Financial issues are the main barrier to HPV vaccination. The framework for behavioural and social drivers of vaccination, which includes practical concerns, motivation, social processes, thoughts, and feelings, is widely used to uncover important aspects linked with HPV vaccination. The burden of cervical cancer due to HPV and the advantages of HPV vaccination are summarised in this review article.

Multi-Omics Approaches Identify Necroptosis‑Related Prognostic Signature and Associated Regulatory Axis in Cervical Cancer

Background

Cervical cancer is the fourth most frequent malignancy among women globally, with approximately 604,000 new cases and 341,000 deaths per year. Necroptosis is a newly discovered mechanism of cell death involved in biological behaviors of cancer.

Methods

LASSO Cox regression analysis was conducted to construct a prognostic necroptosis-related signature. lncRNA–miRNA–mRNA regulatory axis was constructed with a ceRNA network. qRT-PCR was performed to verify our result.

Results

A total of 54 necroptosis-related genes were differentially expressed in cervical cancer (all p < 0.05). We also summarized genetic mutation landscape of necroptosis-related genes in cervical cancer. We then developed a necroptosis-related prognostic signature including 13 necroptosis-related genes (ATRX, AXL, DDX58, IDH1, ITPK1, MAP3K7, SLC39A7, TARDBP, TNF, TNFRSF1A, TNFRSF1B, TNFSF10, TRIM11) for cervical cancer. Cervical cancer patients with high riskscore had a poor overall survival (HR = 2.128, p = 0.00194) with an AUC of 0.725, 0.763 and 0.637 in 3-year, 5-year, and 10-year ROC curve. Consensus clustering analysis revealed that all cervical cancer cohort could be divided into three subtypes, which was correlated with different prognosis and immune infiltration (p < 0.05). A PPI network revealed TNF as the hub gene and TNF expression was correlated with immune infiltration (all p < 0.05), microsatellite instability (p < 0.012) and drug sensitivity (p < 0.05). The ceRNA network was performed and identified a lncRNA NUTM2B-AS1/miR-361-5p/TNF regulatory axis for cervical cancer. qRT-PCR result also suggested that TNF was upregulated in cervical cancer (p < 0.001) and associated with a poor overall survival (p = 0.007). Univariate and multivariate analysis demonstrated TNF expression, lymph node metastasis and clinical stage were prognosis factors of cervical cancer patients (p < 0.05).

Conclusion

We developed a necroptosis-related prognostic signature including 13 necroptosis-related genes for cervical cancer. Moreover, we also identified a lncRNA NUTM2B-AS1/miR-361-5p/TNF regulatory axis, which may play a vital role in the progression of cervical cancer. Further studies should be conducted to verify these results.