Cervical Cancer and Its Precursors: A Preventative Approach to Screening, Diagnosis, and Management

LncRNA-miRNA-mRNA regulatory axes as potential biomarkers in cervical cancer: a comprehensive overview

Despite the recent advances in vaccination and treatment strategies, cervical cancer continues to claim numerous lives every year. Owing to the fact that non-coding RNAs (ncRNAs) such as long non-coding RNAs (lncRNAs) and microRNAs (miRNAs) interact with coding transcripts, and effectuate key roles in the tumorigenesis and metastasis of cervical cancer, there has been extensive research in recent years to explore their potential as biomarkers for early detection, or as therapeutic targets. Through this review, we aim to provide a comprehensive overview of the recent advancements in discoveries about cervical cancer-associated lncRNA-miRNA-mRNA axes, their dysregulation, and their roles in various signaling pathways associated with the growth, survival, invasion, and metastasis of cervical cancer cells. We further discuss the potential therapeutic strategies to utilize the dysregulated lncRNAs as diagnostic and prognostic biomarkers, and as therapeutic targets to ameliorate the prognosis of cervical cancer.

The relationship between long non-coding gene CASC21 polymorphisms and cervical cancer

BACKGROUND

CASC21 was reported to be a hotspot gene in cervical cancer. The relationship between CASC21 genetic polymorphisms and cervical cancer has not been reported. Genetic factors influence the occurrence of cervical cancer. Thus, we explored the correlation between CASC21 polymorphisms and cervical cancer.

METHODS

A total of 973 participants within 494 cervical cancer cases and 479 healthy controls were recruited. Five single nucleotide polymorphisms (SNPs) in the CASC21 gene were genotyped using the Agena MassARRAY platform. Chi-squared test, logistic regression analysis, odds ratio (OR), multifactor dimensionality reduction (MDR), and 95% confidence interval (95%CI) were used for data analysis.

RESULTS

In the overall analysis, rs16902094 (p = .014, OR = 1.86, 95% CI = 1.12-3.08) and rs16902104 (p = .014, OR = 1.86, 95% CI = 1.12-3.09) had the risk-increasing correlation with the occurrence of cervical cancer. Stratification analysis showed that rs16902094 and rs16902104 were still associated with cervical cancer risk in the subgroups with age > 51, BMI < 24 kg/m2, smokers, and patients with cervical squamous cell carcinoma. MDR analysis displayed that rs16902094 (.49%) and rs16902104 (.52%) were the main influential attribution factor for cervical cancer risk.

CONCLUSION

Our finding firstly determined that two CASC21 SNPs (rs16902094, rs16902104) were associated with an increased risk of cervical cancer, which adds to our knowledge regarding the effect of CASC21 on cervical carcinogenesis.

The performance of JAM3/PAX1 methylation in the diagnosis of high-grade squamous intraepithelial lesions for women with high-risk HPV infection

OBJECTIVE

To assess the clinical value of DNA methylation measurement in exfoliated cervical cells for distinguishing high-grade squamous intraepithelial lesions (HSIL) from other cervical abnormalities.

METHODS

A total of 276 patients were enrolled, and general clinical information was collected. Exfoliated cervical cells were obtained to assess human papillomavirus (HPV) infection, conduct ThinPrep cytology tests (TCT), and measure methylation levels of JAM3 (△CtJ) and PAX1 (△CtP). Logistic regression was performed to identify factors significantly associated with HSIL diagnosis. A conditional inference tree model and the area under the curve (AUC) were employed to evaluate the efficacy of JAM3 and PAX1 methylation in detecting HSIL.

RESULTS

Independent risk factors for HSIL diagnosis included △CtJ, △CtP, atypical squamous cells of undetermined significance (ASCUS), and HPV16 infection. The conditional inference tree indicated that 96.4% of patients were non-HSIL when △CtJ > 11.66, and 99.1% were non-HSIL when △CtP > 10.97. The diagnostic performance of △CtJ/△CtP surpassed that of TCT/HPV alone. Among six methods, the combination of △CtP, TCT, and high-risk HPV (hr-HPV) testing achieved the highest sensitivity (91.2%), positive predictive value (50.0%), negative predictive value (98.6%), and AUC (0.932).

CONCLUSION

In women with hr-HPV infection, DNA methylation analysis of cervical cytology outperformed traditional TCT or HPV testing. The combination of △CtP with TCT and HPV may offer the most accurate screening approach for HSIL.

Effectiveness of continuity of care in postoperative patients with cervical cancer: a systematic evaluation and meta-analysis of a randomized controlled trial

Objective

To analyze the effect of implementing continuity of care for postoperative patients with cervical cancer, to improve the continuity of care model in China, and to provide comprehensive, continuous, and personalized care services for patients.

Methods

PubMed, Web of Science, Science Direct, China Knowledge Network, Wanfang database, China Biomedical sources Service System, Wipro, Cochrane Library, Embase, and other databases were searched for relevant sources on the effect of continuity of care on postoperative cervical cancer patients. The Cochrane Handbook of Systematic Evaluation and Revman 5.3 software was used to evaluate the quality of the retrieved sources and perform meta-analysis.

Results

Compared with the control group, extended care could improve patients' quality of life [SMD=1.35,95%CI(1.05,1.64), P<0.05], alleviate patients' postoperative anxiety [SMD=-0.92,95%CI(-1.85,0.00), P<0.05] and postoperative depression [SMD=-1.15,95% CI(-1.35,-0.95), P<0.05].

Conclusion

The use of continuity of care form has an important role in improving the quality of life of cervical cancer patients and improving negative emotions.

Discussion on cervical cytology in postmenopausal women

BACKGROUND

Considering the cervix at the climacteric period, important changes take place in the morphology of the epithelium and stroma due to hypoestrogenism. Therefore, the aim of the present study was to compare the presence of transformation zone cells in the cervix of premenopausal and postmenopausal women.

METHODS

In a private laboratory in São Paulo (Brazil) a retrospective analysis of cervical cytology results was performed. A total of 1,026,671 satisfactory cytology tests were evaluated between January 2010 and December 2015.

RESULTS

A marked decline in transformation zone cells with age was evident, with a greater decrease in the ≥50 years age groups. Only 35% of women ≥50 years of age had transformation zone cells in cytology, while in those <50 years, the figure was 67.5% (P<0.001). The prevalence of negative cytological results in these two age groups was respectively 89.9% and 95.3%; however, it was observed that the most serious cytological results occurred in the group after menopause.

CONCLUSIONS

Although cytology is the recommended screening method for cervical cancer in Brazil, the low number of transformation zone cells in cytology in menopausal patients could be less sensitive for screening of dysplasia and cancer. So, we suggest routine high-risk HPV DNA testing, when possible, given that this test is considered more sensitive for detecting cervical lesions in this group of patients. When HPV DNA testing is not possible, cytology should be collected, and for cytology sampling we suggest regular topical estrogenization and use of appropriate technique.

Cervical Cancer Screening and Prevention Uptake in Females with Autism Spectrum Disorder

This study reports on uptake rates of cervical cancer prevention and screening in a clinically-referred cohort of adolescent and adult females with autism spectrum disorder (ASD). Females with ASD (11-65 years) were invited to participate in an online survey to report on uptake of the human papillomavirus (HPV) vaccination and cervical cancer screening. Participants also provided demographic and clinical information. Chi-square statistical analysis was utilized to examine the relationship between categorical variables and receipt of cervical cancer prevention and screening. Forty-one out of 73 (56%) of adolescent (11-17 years) and 51/108 (47%) of adult (≥ 18 years) females with ASD reported having received at least one dose of the HPV vaccine. Only 30/73 (41%) and 37/108 (34%) of adolescents and adults respectively, were fully vaccinated (≥ 2 doses). Language impairment was the only clinical factor found to be associated with non-receipt of the HPV vaccine. Thirty-one out of 82 (38%) adult females (≥ 21 years) with ASD had received at least one pap smear. Language impairment, intellectual disability, non-independent living, and lower level of education were all associated with not receiving a pap smear. Females with ASD are vulnerable to invasive cervical cancer disease due to low uptake rates of the HPV vaccine and routine pap smear screening.

Validation and usability of SeDAR e-health video for enhancing cervical cancer screening

BACKGROUND

The cervical cancer (CC) incidence rate is increasing among young women aged <50 years despite early screening is proven effective. Electronic health (e-health) has great potential for disseminating health education.

METHODS

This study validated a newly developed e-health tool "SeDAR®" and assessed its usability via evaluations by health experts (HE), media experts (ME), and women. The SeDAR® content was developed based on protection motivation theory (PMT) using the nominal group technique and in-depth interviews that involved HE and women, respectively. Content validation was performed among the HE (n = 12) and ME (n = 5) using the content validation index (CVI) to identify their agreement. Subsequently, the Video Engagement Scale (VES®) was used to validate SeDAR® among women of different ethnicities (n = 11) to achieve ecological validity. The experts and women also commented on the presentation of the video.

RESULTS

The validation yielded a good CVI among the HE (scale-level CVI-average [SCVI/Ave] = 0.986; scale-level CVI-universal agreement [SCVI/UA] = 0.900) and ME (SCVI/Ave = 0.979, SCVI/UA = 0.897). The highest VES® score [mean (±SD) = 92.90(±3.46)] proved the ecological validity of SeDAR®. The experts' feedback established that SeDAR® conveyed a clear message about awareness of performing CC screening and was suitable for public viewing. The women considered SeDAR® easy to understand, and it advised early exposure for early CC screening.

CONCLUSIONS

SeDAR® was valid and could constitute an important e-health tool to improve motivation and uptake of CC screening.

A Multimodality Treatment Approach for the Management of Recurrent Cervical Cancer in an Elderly Female Patient: A Case Report

Squamous cells in the cervix can develop into a type of cervical cancer. Cervical squamous cells are the cells that line the outside of the cervix. These thin, flat cells have a striking resemblance to fish scales under a microscope. Squamous cell carcinomas (SCCs) are the most common type of cervical cancer. We report the case of a 60-year-old woman with SCC devoid of a family history of cancer or related diseases. Following a biopsy confirming SCC, the patient's contrast-enhanced computed tomography scan revealed a somewhat enlarged cervix along with a white discharge per vagina. The patient underwent a Wertheim hysterectomy and was diagnosed with microinvasive SCC, adenomyosis, and negative lymph nodes. Two years after being free from disease, the issue reappeared even with routine follow-ups. The patient underwent six rounds of chemotherapy, followed by chemoradiation and interstitial brachytherapy. The multimodality therapy method applied to an aged female patient experiencing recurrent SCC of the cervix is demonstrated in this case study. It underlines how crucial regular follow-ups and multimodal therapy are to control recurrent cervical cancer.

Transient receptor potential channels' genes forecast cervical cancer outcomes and illuminate its impact on tumor cells

Introduction: In recent years, there has been a strong association between transient receptor potential (TRP) channels and the development of various malignancies, drug resistance, and resistance to radiotherapy. Consequently, we have investigated the relationship between transient receptor potential channels and cervical cancer from multiple angles. Methods: Patients' mRNA expression profiles and gene variants were obtained from the TCGA database. Key genes in transient receptor potential channel prognosis-related genes (TRGs) were screened using the least absolute shrinkage and selection operator (LASSO) regression method, and a risk signature was constructed based on the expression of key genes. Various analyses were performed to evaluate the prognostic significance, biological functions, immune infiltration, and response to immunotherapy based on the risk signature. Results: Our research reveals substantial differences between high and low-risk groups in prognosis, tumor microenvironment, tumor mutational load, immune infiltration, and response to immunotherapy. Patients in the high-risk group exhibited poorer prognosis, lower tumor microenvironment scores and reduced response to immunotherapy while showing increased sensitivity to specific targeted drugs. In vitro experiments further illustrated that inhibiting transient receptor potential channels effectively decreased the proliferation, invasion, and migration of cervical cancer cells. Discussion: This study highlights the significant potential of transient receptor potential channels in cervical cancer, emphasizing their crucial role in prognostic prediction and personalized treatment strategies. The combination of TRP inhibitors with immunotherapy and targeted drugs may offer promise for individuals affected by cervical cancer.

Effect of HPV Vaccination on Virus Disappearance in Cervical Samples of a Cohort of HPV-Positive Polish Patients

The introduction of human papillomavirus vaccines revolutionized cervical cancer prevention. Our research hypothesis is that HPV vaccination affects the remission of HPV in cervical swabs. We provide a prospective, ongoing, 24-month, non-randomized study in HPV-positive women. We enrolled 60 patients with positive HPV swabs from the cervix (fifty-one vaccinated with the nine-valent vaccine against HPV and nine unvaccinated). Using an enzyme-linked immunosorbent assay, we determined IgG class antibodies of HPV in the patients' serums. Persistent HPV infection after vaccination was significantly less frequent in the nine-valent vaccinated group (23.5%) compared to the control group (88.9%; p < 0.001). Antibody level after vaccination was significantly higher in the vaccinated patients compared to the control group. The reactive antibody level was seen in the case of all patients in the vaccinated group and one-third of the unvaccinated group (33.3%, n = 3). The vaccination of HPV-positive patients may increase the chance of HPV remission in cervical swabs and may be a worthwhile element of secondary prevention in HPV-positive patients.

Cervical cancer screening programs for female sex workers: a scoping review

Background

Cervical cancer (CC) is the fourth most common neoplasia affecting women worldwide. Female sex workers (FSWs) are among those at highest risk of developing and succumbing to CC. Yet, they are often overlooked in CC screening programs and have limited access to CC healthcare globally. The development of CC screening programs for this high-risk target population is necessary to reduce the global burden of this disease and to reach the World Health Organization's objective of accelerating the elimination of CC.

Objective

This review summarizes findings on CC screening programs for FSWs that have been implemented worldwide, and assesses their effectiveness and sustainability.

Methods

A scoping review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A literature search was performed on PubMed, Swisscovery, and Google Scholar for studies describing and assessing CC screening programs for FSWs. In addition, targeted searching online Non-Governmental and International Organizations websites identified grey literature. A single reviewer screened titles and abstracts, and extracted data from the research findings.

Results

The search identified 13 articles published from 1989 to 2021. All implemented programs successfully reached FSWs and provided them with CC screening during the study period. The most effective and sustainable strategies were the Screen and Treat approach, introducing CC screening into existing STI services in drop-in or outreach clinics, HPV-DNA self-sampling, and integrating sex-workers-specific services in public health facilities. Follow-up was deemed the main challenge in providing and enhancing CC healthcare to FSWs with rates of loss to follow-up ranging from 35 to 60%.

Conclusion

FSWs are often omitted in national CC screening programs. The further development and improvement of CC healthcare, including follow-up systems, for this high-priority target population are imperative.

Privacy Preserved Cervical Cancer Detection Using Convolutional Neural Networks Applied to Pap Smear Images

Image processing has enabled faster and more accurate image classification. It has been of great benefit to the health industry. Manually examining medical images like MRI and X-rays can be very time-consuming, more prone to human error, and way more costly. One such examination is the Pap smear exam, where the cervical cells are examined in laboratory settings to distinguish healthy cervical cells from abnormal cells, thus indicating early signs of cervical cancer. In this paper, we propose a convolutional neural network- (CNN-) based cervical cell classification using the publicly available SIPaKMeD dataset having five cell categories: superficial-intermediate, parabasal, koilocytotic, metaplastic, and dyskeratotic. CNN distinguishes between healthy cervical cells, cells with precancerous abnormalities, and benign cells. Pap smear images were segmented, and a deep CNN using four convolutional layers was applied to the augmented images of cervical cells obtained from Pap smear slides. A simple yet efficient CNN is proposed that yields an accuracy of 0.9113% and can be successfully used to classify cervical cells. A simple architecture that yields a reasonably good accuracy can increase the speed of diagnosis and decrease the response time, reducing the computation cost. Future researchers can build upon this model to improve the model's accuracy to get a faster and more accurate prediction.

Adjuvant Human Papillomavirus Vaccination After Excisional Procedure for Cervical Intraepithelial Neoplasia: A Cost-Effectiveness Analysis

OBJECTIVE

To examine the cost effectiveness of human papillomavirus (HPV) vaccination after excisional procedure compared with no vaccination.

METHODS

We constructed a decision-analytic model (TreeAge Pro 2021) to compare outcomes between patients who underwent an excisional procedure followed by nonavalent HPV vaccination to those who underwent an excisional procedure without vaccination. Our theoretical cohort contained 250,000 patients, the approximate number undergoing excisional procedures annually in the United States. Our outcomes were costs, quality-adjusted life-years (QALYs), recurrence events, number of surveillance Pap tests with co-testing, number of colposcopies, and second excisional procedures. Probabilities of recurrence were based on a recently published meta-analysis. All values were derived from the literature, and QALYs were discounted at a rate of 3%. Outcomes were applied for 4 years after the initial excisional procedure. Our cost-effectiveness threshold was $100,000 per QALY. Sensitivity analyses were performed to evaluate the robustness of the model.

RESULTS

In our theoretical cohort of patients who underwent an excisional procedure, the HPV vaccination strategy was associated with 17,281 fewer recurrences of cervical intraepithelial neoplasia (CIN) (8,360 fewer cases of CIN 1 and 8,921 fewer cases of CIN 2 or 3), 26,203 fewer Pap tests (1,025,368 vs 1,051,570), 17,281 fewer colposcopies (20,588 vs 37,869), and 8,921 fewer second excisional procedures (4,779 vs 13,701). The vaccination strategy was associated with a higher cost of $135 million. Vaccination was a cost-effective strategy, with an incremental cost-effectiveness ratio of $29,181 per QALY, compared with no vaccination. In our sensitivity analyses, the HPV vaccination strategy remained cost effective until the cost of the three-dose HPV vaccine series reached $1,899 or the baseline (nonvaccinated) probability of recurrence was less than 4.8%.

CONCLUSION

In our model, HPV vaccination for patients with a prior excisional procedure led to improved outcomes and was cost effective. Our study suggests that clinicians should consider offering the three-dose HPV vaccine series to patients who have undergone an excisional procedure to decrease the risk of CIN recurrence and its sequelae.

Impact of malnutrition as defined by the GLIM criteria on treatment outcomes in patients with cancer: A systematic review and meta-analysis

BACKGROUND & AIMS

Malnutrition has been reported to lead to poor postoperative outcomes. The Global Leadership Initiative on Malnutrition (GLIM) criteria were published in 2019 as a global consensus on the criteria for diagnosing malnutrition. However, the relationship between GLIM-defined malnutrition and treatment outcomes in patients with cancer has not been fully investigated. Therefore, this study aimed to clarify the impact of GLIM-defined malnutrition on the treatment outcomes of patients with cancer.

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception to January 17, 2022. We conducted a systematic review and random-effects meta-analysis studies that included patients with cancer aged >18 years who received any kind of treatment and whose nutritional status was assessed using GLIM criteria. We independently assessed the risk of bias and quality of evidence using Quality In Prognosis Studies and Grading of Recommendations, Assessment, Development, and Evaluation approach. The primary outcomes were overall survival (OS) and postoperative complications. Hazard ratios and 95% confidence intervals (CIs) for OS and relative risk ratios and 95% CIs for postoperative complications were pooled. The protocol was published by PROSPERO (CRD42022304004).

RESULTS

Of 67 studies after screening, ten studies (n = 11,700) reported the impact of GLIM-defined malnutrition on postoperative outcomes. Compared with no malnutrition, GLIM-defined malnutrition may worsen OS (hazard ratio, 1.56; 95% CI, 1.38-1.75; I² = 37%) and increase postoperative complications (relative risk ratio, 1.82; 95% CI, 1.28-2.60; I² = 87%). The risk of bias in each study was either moderate or high. The certainty of the evidence was low because of publication bias and a moderate or high risk of bias.

CONCLUSIONS

GLIM-defined malnutrition may worsen OS and increase the risk of postoperative complications in patients with cancer undergoing treatment. Further studies are needed to confirm these findings and mitigate this risk.

Identification and Validation of the Anoikis-Related Gene Signature as a Novel Prognostic Model for Cervical Squamous Cell Carcinoma, Endocervical Adenocarcinoma, and Revelation Immune Infiltration

Background and Objectives: Cervical squamous cell carcinoma and endocervical adenocarcinoma (CESC) are malignant disorders with adverse prognoses for advanced patients. Anoikis, which is involved in tumor metastasis, facilitates the survival and separation of tumor cells from their initial site. Unfortunately, it is rarely studied, and in the literature, studies have only addressed the prognosis character of anoikis for patients with CESC. Materials and Methods: We utilized anoikis-related genes (ANRGs) to construct a prognostic signature in CESC patients that were selected from the Genecards and Harmonizome portals. Furthermore, we revealed the underlying clinical value of this signature for clinical maneuvers by providing clinical specialists with an innovative nomogram on the basis of ANRGs. Finally, we investigated the immune microenvironment and drug sensitivity in different risk groups. Results: We screened six genes from fifty-eight anoikis-related differentially expressed genes in the TCGA-CESC cohort, and we constructed a prognostic signature. Then, we built a nomogram combined with CESC clinicopathological traits and risk scores, which demonstrated that this model may improve the prognosis of CESC patients in clinical therapy. Next, the prognostic risk scores were confirmed to be an independent prognostic indicator. Additionally, we programmed a series of analyses, which included immune infiltration analysis, therapy-related analysis, and GSVA enrichment analysis, to identify the functions and mechanisms of the prognostic models during the progression of cancer in CESC patients. Finally, we performed quantitative reverse transcription polymerase chain reaction (qRT-PCR) to verify the six ANRGs. Conclusions: The present discovery verified that the predictive 6-anoikis-related gene (6-ANRG) signature and nomogram serve as imperative factors that might notably impact a CESC patient's prognosis, and they may be able to provide new clinical evidence to assume the role of underlying biological biomarkers and thus become indispensable indicators for prospective diagnoses and advancing therapy.

Can Adjuvant HPV Vaccination Be Helpful in the Prevention of Persistent/Recurrent Cervical Dysplasia after Surgical Treatment?—A Literature Review

Simple Summary

Primary prophylactic, early detection and the treatment of precancerous lesions are the main goals of cervical cancer screening. Despite effective surgical treatment methods, using loop electrosurgical excision procedures and conization, the overall risk of the recurrence of HSIL lesions remains at approximately 6.6%. There is increasing evidence of the potential role of HPV vaccines in the adjuvant setting and their impact on the reduction of disease recurrence. This review aims to analyze the up-to-date research concerning the use and efficacy of secondary human papilloma virus (HPV) vaccination as an adjuvant method to surgical treatment in patients diagnosed with cervical HSILs.

Abstract

Cervical cancer formation is preceded by precursor lesions, including low-grade squamous intraepithelial lesions (LSILs) and high-grade squamous intraepithelial lesions (HSILs), which are usually diagnosed in women of reproductive age. Despite the recent advanced diagnostic and treatment methods, including colposcopy, the loop electrosurgical excision procedure (LEEP), and surgical conization, the recurrence or residual disease affects as many as 6.6% of patients. The lesions are often associated with human papilloma virus (HPV) infection. As HPV persistence is the leading and only modifiable factor affecting the risk of progression of CIN lesions into high-grade cervical dysplasia and cancer, it has been proposed to conduct adjuvant vaccination in patients treated for high-grade cervical dysplasia. To date, no vaccine has been approved for therapeutic use in patients diagnosed with HSILs; however, attempts have been made to determine the use of HPV prophylactic vaccination to reduce recurrent HSILs and prevent cervical cancer. The aim of this review was to analyze the up-to-date literature concerning the possible use of secondary human papilloma virus (HPV) vaccination as an adjuvant method to surgical treatment in patients diagnosed with cervical HSILs. Adjuvant HPV vaccination after surgical treatment may reduce the risk of recurrent cervical dysplasia.

Investigation of the Clinical Application Value of HR-HPV DNA Combined with Liquid Based Cytology in Colposcopy of Cervical Cancer

In order to investigate the clinical application value of HR-HPV DNA combined with liquid-based cytology in colposcopy of cervical cancer, a retrospective analysis is performed on 428 patients who underwent a cervical pathological examination in our hospital from May 2020 to December 2021. The pathological biopsy results are used as the gold standard to determine whether cervical lesions occurred in patients, and patients with positive gold standard results are included in the study group. The positive rates of liquid-based cytology and HR-HPV DNA are observed and recorded, and the patients with negative gold standard results are used as the control group. The positive rate of HR-HPV DNA and liquid-based cytology will increase with the aggravation of pathological results. The ROC curve shows that HR-HPV DNA combined with liquid-based cytology has high diagnostic efficiency in colposcopy of cervical lesions. It is clearly evident that both liquid-based cytology and HR-HPV DNA tests have certain advantages in the screening of cervical lesions, and the combined detection can further improve the screening value of cervical lesions.

Role of Self-Sampling for Cervical Cancer Screening: Diagnostic Test Properties of Three Tests for the Diagnosis of HPV in Rural Communities of Cuenca, Ecuador

Background: HPV primary screening has shown effectiveness for cancer prevention; however, gynaecological examination is considered uncomfortable. Self-sampling methods increase the acceptance of screening. The aim of this study is to compare the sensitivity and specificity of clinician sampling versus vaginal and urine self-sampling for HPV diagnosis. Methods: A diagnostic test study was conducted in a rural parish of Cuenca, Ecuador. A total of 120 women participated. Each participant self-collected urine and vaginal samples and underwent clinician sampling for HPV testing. The latter was considered as the golden standard. All three samples were processed with the same amplification and hybridization protocol for HPV detection (Hybribio) following the manufacturer’s instructions. Results: Characteristics of the participants were: median age 35 years; 40.8% married; 46.7% had a primary level of education; and median age of sexual onset, 17.6 years. The prevalence of any type of HPV with clinician sampling was 15.0%, 17.5% with urine sampling and 18.3% with vaginal self-sampling. Self-sampling sensitivity reached 94.4% (IC 74.2–99.9), and specificity 92.1% (IC 85.2–95.9). Urine sampling had a sensitivity of 88.8% (IC 67.2, 96.9), and specificity 94.1% (IC 67.2–96.9). The negative predictive value was 98.9% (IC 94.2–99.8) for vaginal self-sampling and 97.6% (IC 92.6–99.4) for urine sampling. Conclusions: This study shows that vaginal and urine self-sampling methods have similar sensitivity and specificity compared with clinician sampling for the diagnosis of HPV. The correlation between HPV genotypes among the three tests is satisfactory.

Survival of Patients With Cervical Cancer Treated With Definitive Radiotherapy or Concurrent Chemoradiotherapy According to Histological Subtype: A Systematic Review and Meta-Analysis

Background

Cervical cancer is a leading cause of morbidity and mortality for women worldwide. Different histopathological cervical cancer subtypes (i.e., adenocarcinoma/adenosquamous carcinoma, and squamous cell carcinoma) are all treated similarly with definitive radiotherapy or concurrent chemoradiotherapy, but studies have reported differing survival prognoses. In this review and meta-analysis, we compared the disease-free and overall survivals of patients with cervical cancer treated with definitive radiotherapy or concurrent chemoradiotherapy according to the histopathological subtypes.

Objective

To compare the disease-free and overall survivals of patients with adenocarcinoma/adenosquamous carcinoma and squamous cell carcinoma cervical cancer treated with definitive radiotherapy or concurrent chemoradiotherapy.

Methods

We systematically searched the Web of Science, EMBASE, CENTRAL, Scopus, and MEDLINE academic databases following PRISMA guidelines. We identified publications to conduct a random-effects meta-analysis to evaluate the disease-free and overall survivals of patients with cervical adenocarcinoma/adenosquamous carcinoma and squamous cell carcinoma treated with definitive radiotherapy or concurrent chemoradiotherapy.

Results

From 963 studies, we found eight eligible ones with 13,859 patients with cervical cancer (mean age, 52.2 ± 7.9 years). Our meta-analysis revealed a poorer outcome of disease-free (hazard ratio, 1.51; 95% CI, 1.28–1.79) and overall (hazard ratio 1.41; 95% CI, 1.26–1.57) survivals for patients with adenocarcinoma/adenosquamous carcinoma undergoing definitive radiotherapy or concurrent chemoradiotherapy than for those with squamous cell carcinoma undergoing similar treatments. We also observed that larger tumor size and advanced tumor stage are also significant prognostic factors that adversely impact survival outcomes in cervical cancer patients undergoing definitive radiotherapy or concurrent chemoradiotherapy.

Conclusion

Our results show poor disease-free and overall survivals for patients with cervical cancer and adenocarcinoma/adenosquamous carcinoma than for those with squamous cell carcinoma after treatment with definitive radiotherapy or concurrent chemoradiotherapy. Our findings clarify the risks associated with the conventional management of cervical cancer according to the histological type.

Impact of prior underinsurance on cervical cancer screening among Davidson County, Tennessee, women diagnosed with invasive cervical cancer, 2008-2018

INTRODUCTION

We sought to investigate the association between insurance coverage history and cervical cancer screening among Davidson County, Tennessee, women diagnosed with incident cervical cancer.

METHODS

We reviewed medical records of women diagnosed with invasive cervical cancer from 2008 through 2018 identified via the state's cancer registry and by active surveillance of diagnostic pathology reports for the HPV-IMPACT project. Per 2012 United States Preventive Services Task Force recommended cervical cancer screening guidelines, women were characterized into three screening history categories: "no screening", "no follow-up" and "test/screening failure". Multivariable logistic regression measured the association of prior inadequate insurance (underinsurance) and screening history ("no screening/no follow-up" compared to "test/screening failure").

RESULTS

Of 212 women, most (77%) had not undergone recommended cervical cancer screening or follow-up prior to cancer diagnosis. Overall, 28% of women had history of underinsurance in 5 years prior to diagnosis. In adjusted analyses, underinsured women were more likely to have a "no screening/no follow-up" prior to cancer diagnosis (aOR 4.26; 95% CI 1.15-15.80) compared to "test/screening failure" history. Non-white race (aOR 2.73; 95% CI 0.98-7.61), older age (aOR 1.03 per year; 95% CI 1.00-1.07), and history of smoking (aOR 4.07; 95% CI 1.54-10.74) were also associated with increased likelihood of "no screening/no follow-up".

CONCLUSIONS

Previous underinsurance was independently associated with non-adherence to cervical cancer screening and follow-up guidelines among women with incident cervical cancer. Further study of factors contributing to inadequate cervical cancer screening and interventions to increase cervical cancer screening in high-risk populations is needed.

Atuação de profissionais de saúde e qualidade das ações no controle de câncer cervicouterino: um estudo transversal

Resumo Objetivo avaliar o tempo de atuação de médicos e enfermeiros na Atenção Primária à Saúde (APS) e qualidade das ações desenvolvidas para controle do câncer cervicouterino (CC). Métodos estudo transversal, conduzido de janeiro a março de 2019 em região de saúde compreendida em 19 municípios localizada no estado da Bahia, Brasil. A amostra foi de 241 médicos e enfermeiros da APS. Utilizou-se a linha de cuidado do CC como condição traçadora. Elegeram-se o desfecho tempo de atuação na APS no mesmo município, categorizado em < 2 anos e ≥ 2 anos, e indicadores representativos da qualidade da APS. Os testes χ2 de Pearson e exato de Fisher foram empregados. Resultados a prevalência de tempo de atuação na APS foi 43,57% (IC95%: 37,40%; 49,94%) para < 2 anos e 56,43% (IC95%: 50,06%; 62,60%) para ≥ 2 anos. Observaram-se maiores prevalências, com diferença estatística significativa, dos indicadores de qualidade para o maior tempo de atuação. Conclusões e implicações para a prática a rotatividade profissional parece afetar o cuidado longitudinal de mulheres na linha de cuidado eleita. Sugere-se a ampliação do número e do papel dos enfermeiros, especialmente nos serviços de APS, para maior resolutividade e eficiência do sistema de saúde.

Infection by High-Risk Human Papillomaviruses, Epithelial-to-Mesenchymal Transition and Squamous Pre-Malignant or Malignant Lesions of the Uterine Cervix: A Series of Chained Events?

Wound healing requires static epithelial cells to gradually assume a mobile phenotype through a multi-step process termed epithelial-to-mesenchymal transition (EMT). Although it is inherently transient and reversible, EMT perdures and is abnormally activated when the epithelium is chronically exposed to pathogens: this event deeply alters the tissue and eventually contributes to the development of diseases. Among the many of them is uterine cervical squamous cell carcinoma (SCC), the most frequent malignancy of the female genital system. SCC, whose onset is associated with the persistent infection of the uterine cervix by high-risk human papillomaviruses (HR-HPVs), often relapses and/or metastasizes, being resistant to conventional chemo- or radiotherapy. Given that these fearsome clinical features may stem, at least in part, from the exacerbated and long-lasting EMT occurring in the HPV-infected cervix; here we have reviewed published studies concerning the impact that HPV oncoproteins, cellular tumor suppressors, regulators of gene expression, inflammatory cytokines or growth factors, and the interactions among these effectors have on EMT induction and cervical carcinogenesis. It is predictable and desirable that a broader comprehension of the role that EMT inducers play in SCC pathogenesis will provide indications to flourish new strategies directed against this aggressive tumor.

Antibody-Antineoplastic Conjugates in Gynecological Malignancies: Current Status and Future Perspectives

In the last decade, antibody-drug conjugates (ADCs), normally formed by a humanized antibody and a small drug via a chemical cleavable or non-cleavable linker, have emerged as a potential treatment strategy in cancer disease. They allow to get a selective delivery of the chemotherapeutic agents at the tumor level, and, consequently, to improve the antitumor efficacy and, especially to decrease chemotherapy-related toxicity. Currently, nine antibody-drug conjugate-based formulations have been already approved and more than 80 are under clinical trials for the treatment of several tumors, especially breast cancer, lymphomas, and multiple myeloma. To date, no ADCs have been approved for the treatment of gynecological formulations, but many formulations have been developed and have reached the clinical stage, especially for the treatment of ovarian cancer, an aggressive disease with a low five-year survival rate. This manuscript analyzes the ADCs formulations that are under clinical research in the treatment of gynecological carcinomas, specifically ovarian, endometrial, and cervical tumors.

Cervical Cancer Screening Among Marginalized Women: A Cross-Sectional Intervention Study

Background

Many countries organize population-based cervical cancer screening programs (CSP). In the Netherlands, eligible women are invited by mail. Marginalized women living in unstable conditions and homeless women often fail to receive the invitation letter. These women also experience access barriers to regular healthcare. Consequently, despite presumably being at higher risk of developing cervical cancer due to prevalent risk factors, marginalized women are rarely screened for cervical cancer. The aim of the study was to identify the prevalence of (pre)cancerous abnormalities among marginalized women, and subsequently explore invitation approaches to enhance their screening participation.

Methods

A cross-sectional intervention study was conducted in Rotterdam, the Netherlands. Between February and May 2019, marginalized women aged 20–60 years were invited to participate in cervical screening. A participant was considered screen-positive when they tested positive for high-risk human papilloma virus (HR-HPV) and showed cytological abnormalities. Data of the study population were compared with regional data of the Dutch CSP. Various invitation approaches were used to recruit women.

Results

Out of 74 included women, 12 participants (16%) were found screen-positive, against 3.4% in women screened by the Dutch CSP. The prevalence ratio for the study population was 4.4 (95% CI 1.9–8.6) compared with women screened by the Dutch CSP. Using a direct, pro-active approach resulted in participation of 92% of the included women.

Conclusion

Marginalized women have an increased risk of (pre)cancerous cervical abnormalities in screening, compared with women screened by the Dutch CSP. A direct pro-active approach was the most effective to stimulate screening participation. Enhancement of screening uptake for this population needs special effort.

Integrated Analysis of ceRNA Regulatory Network Associated With Tumor Stage in Cervical Cancer

Objective

To analyze the abnormally expressed genes involved in cervical cancer occurrence and development.

Materials and Methods

Integrated bioinformatics methods were used to analyze differentially expressed (DE) RNAs, including mRNAs, microRNAs (miRNAs), and long non-coding RNAs (lncRNAs), in stage I, II, III, and IV cervical cancer patients from the TCGA database to fully reveal the dynamic changes caused by cervical cancer.

Results

First, DE RNAs in cervical cancer tissues from stage I, II, III, and IV patients and normal cervical tissues were identified and divided into different profiles. Several DE RNA profiles were down-regulated or up-regulated in stage I, III, and IV patients. GO and KEGG analysis of DE mRNA profile 1, 2, 4, 5, 6 and 22 which were significantly down-regulated or up-regulated showed that DE mRNAs are involved in cell division, DNA replication, cell adhesion, the positive and negative regulation of RNA polymerase ll promoter transcription. Besides, DE RNA profiles with significant differences in patient stages were analyzed to perform a competing endogenous RNA (ceRNA) regulatory network of lncRNA, miRNA, and mRNA. The protein-protein interaction (PPI) network of DE mRNAs in the ceRNA regulatory network was also constructed. The network had nine central genes (up-regulated genes: CDKN2A, GSK3B, BIRC5, CYCS, MAD2L1; down-regulated genes: PTEN, FOXO3, CCND2, TGFBR2). Survival analysis found that 5 lncRNAs, 9 mRNAs, and 4 miRNAs can be used as prognostic indicators of cervical cancer. Finally, combined with cluster analysis results, we further screened 2 DE RNAs (AMZ2P1 and HDAC5) using clinical samples, suggesting that AMZ2P1, and HDAC5 may act as diagnostic biomarkers for the development of cervical cancer.

Conclusion

This research provides new effective targets and reliable biological markers for the diagnosis and prognosis of cervical cancer.

Agreement between careHPV and hybrid capture 2 in detecting high-risk HPV in women in Tanzania

INTRODUCTION

Visual inspection of the cervix with acetic acid is used to control the burden of cervical cancer in low- and middle-income countries. This method has some limitations and HPV DNA testing may be an alternative, but it is expensive and requires a laboratory setup. Cheaper and faster HPV tests have been developed. This study describe the agreement between a fast HPV test (careHPV) and hybrid capture 2 (HC2) in detection of high-risk HPV among Tanzanian women.

MATERIAL AND METHODS

The study involved women attending routine cervical cancer screening at the Ocean Road Cancer Institute and Kilimanjaro Christian Medical Centre in Tanzania. The women were offered HIV testing. Two cervical samples were subsequently obtained; the first sample was processed at the clinics using careHPV and the second sample was transported to Denmark and Germany for cytology and HC2 analysis. Kappa statistic was calculated to assess the agreement between careHPV and HC2. The sensitivity, specificity and predictive values of careHPV were calculated using HC2 as reference. The analyses were done for the overall study population and stratified by testing site and HIV status.

RESULTS

A total of 4080 women were enrolled, with 437 being excluded due to invalid information, lack of careHPV or HC2 results. Overall agreement between the tests was substantial with a kappa value of 0.69 (95% confidence interval [CI] 0.66-0.72). The sensitivity and specificity of careHPV was 90.7% (95% CI 89.6-91.8) and 84.2% (95% CI 81.2-86.8), respectively. The agreement was similar in the stratified analyses where the kappa values were 0.75 (95% CI 0.70-0.79) in women aged 25-34, 0.66 (95% CI 0.62-0.70) in women aged 35-60, 0.73 (95% CI 0.70-0.77) at the Ocean Road Cancer Institute, 0.64 (95% CI 0.60-0.69) at the Kilimanjaro Christian Medical Center, 0.73 (95% CI 0.68-0.79) in HIV-positive and 0.66 (95% CI 0.63-0.70) in HIV-negative women. The kappa value of 0.64 (95% CI 0.39-0.88) for cervical high-grade lesions indicates a substantial agreement between careHPV and HC2 in detecting HPV among women with cervical high-grade lesions.

CONCLUSIONS

A substantial agreement was found between careHPV and HC2 in detecting HPV overall as well as detecting HPV among women with cervical high-grade lesions. However, given the limited resources available in low and middle-income countries, the HPV testing assay should be weighed against the cost-effectiveness of the test.

Intravaginal Application of Topical Black Salve for High-Grade Cervical Intraepithelial Neoplasia

Background: Black salve, or sanguinarine, is a topical escharotic agent that has been used by patients for homeopathic ablation of epithelial dysplasia, including cervical intraepithelial neoplasia. Case Report: A 33-year-old female presented to the obstetric and gynecologic clinic for management of a missed abortion. At the time of presentation, she admitted to the use of topical black salve for treatment of cervical intraepithelial neoplasia 2 years prior. Speculum examination revealed a stenotic cervix that appeared flush against the vaginal cuff. Hysteroscopy performed 4 months later after the patient developed new oligomenorrhea revealed significant vaginal scarring with formation of a blind pouch that concealed the true cervix. Conclusion: Health care providers should be aware of homeopathic remedies trialed by patients on their own or as an alternative to recommended treatment. Such self-treatment may cause significant patient harm, such as scarring or deformity.

Screening for the prevention and early detection of cervical cancer: protocol for systematic reviews to inform Canadian recommendations

PURPOSE

To inform recommendations by the Canadian Task Force on Preventive Health Care on screening in primary care for the prevention and early detection of cervical cancer by systematically reviewing evidence of (a) effectiveness; (b) test accuracy; (c) individuals' values and preferences; and (d) strategies aimed at improving screening rates.

METHODS

De novo reviews will be conducted to evaluate effectiveness and to assess values and preferences. For test accuracy and strategies to improve screening rates, we will integrate studies from existing systematic reviews with search updates to the present. Two Cochrane reviews will provide evidence of adverse pregnancy outcomes from the conservative management of cervical intraepithelial neoplasia. We will search Medline, Embase, and Cochrane Central (except for individuals' values and preferences, where Medline, Scopus, and EconLit will be searched) via peer-reviewed search strategies and the reference lists of included studies and reviews. We will search ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. Two reviewers will screen potentially eligible studies and agree on those to include. Data will be extracted by one reviewer with verification by another. Two reviewers will independently assess risk of bias and reach consensus. Where possible and suitable, we will pool studies via meta-analysis. We will compare accuracy data per outcome and per comparison using the Rutter and Gatsonis hierarchical summary receiver operating characteristic model and report relative sensitivities and specificities. Findings on values and preferences will be synthesized using a narrative synthesis approach and thematic analysis, depending on study designs. Two reviewers will appraise the certainty of evidence for all outcomes using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and come to consensus.

DISCUSSION

The publication of guidance on screening in primary care for the prevention and early detection of cervical cancer by the Task Force in 2013 focused on cytology. Since 2013, new studies using human papillomavirus tests for cervical screening have been published that will improve our understanding of screening in primary care settings. This review will inform updated recommendations based on currently available studies and address key evidence gaps noted in our previous review.

Current Status and Future Perspectives of Molecular Prevention Strategies for Cervical Cancers

Cervical cancer continues to be a global health problem; despite the potential for prevention through organised screening programmes that can detect and treat pre-cancerous lesions and also more recently, the availability of HPV (Human Papilloma Virus) vaccines. While routine screening with Pap smear testing has reduced the burden of cervical cancer in the high-income countries, the implementation of organised Pap-based screening programmes has not been found feasible in low-resource settings due to a lack of health care delivery infrastructure and limited health budgets. The well-established causal relationship between cervical cancer development and high-risk-HPV (HR-HPV) infection and the subsequent appreciation of the greater sensitivity of HPV testing over Pap smear cytology eventually lead to HPV testing being incorporated in the primary cervical cancer prevention programmes. An organised cervical cancer screening programme incorporating HR-HPV testing and HPV vaccine administration are currently considered to be the two major interventions for a comprehensive cervical cancer control programme worldwide. However, there are concerns that the requirement of a sophisticated infrastructure with its associated costs may make cervical cancer screening using molecular prevention by HPV testing impracticable to be implemented, especially in resource-poor, low-income countries. Visual Inspection with Acetic acid (VIA) represents one of the alternative methods for cervical cancer screening proposed for the countries with low- to middle-income resources and has gained popularity in India following the successful completion of two randomised controlled trials, but this method but has low sensitivity to detect cervical pre-cancers. More recently, the cost-effectiveness analysis of many studies including randomised controlled trials, even from the low-resource settings, has found that HPV testing is followed by treatment for HPV-positive women to be an effective and cost-effective screening strategy as compared to other screening methods including VIA. The incorporation of self-sampling and HPV testing by partial genotyping has the potential to significantly add to the effectiveness and the cost-effectiveness. The current status and future perspectives of molecular prevention strategies for cervical cancer prevention is further discussed.

A systematic review and meta-analysis of diagnostic accuracy of HPV tests for the screening of cervical cancer in low-resource settings

BACKGROUND

HPV tests for the screening of cervical cancer in low-income countries (LICs) might improve early detection and preventive efforts.

OBJECTIVES

To determine the diagnostic accuracy of HPV tests for detecting cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) in LICs.

SEARCH STRATEGY

The Cochrane Library, MEDLINE, and CINAHL databases were searched on June 1, 2020. References of relevant studies were hand-searched.

SELECTION CRITERIA

Diagnostic test accuracy studies were included if women had an HPV test for cervical cancer screening, followed by verification with colposcopy and colposcopy-directed biopsy. The primary target was CIN2+.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies, extracted data, and assessed methodological quality. Bivariate diagnostic random-effects meta-analysis was used.

MAIN RESULTS

Eleven studies including 82 556 women were eligible, most of which were at low risk of bias. The pooled diagnostic odds ratio of hybrid capture test of samples collected from the cervix by healthcare providers for detecting CIN2+ and CIN3+ was 42.0 (95% confidence interval [CI] 20.7-76.3) and 97.1 (95% CI 35.3-215.0), respectively.

CONCLUSIONS

Evidence indicates that hybrid capture tests can be used for screening of cervical cancer in LICs. Future studies are warranted for self-sampling and for low-cost HPV tests.

Identification of circ_0085616 as an Upregulated and Oncogenic Circular RNA in Cervical Cancer Via the miR-503-5p-Mediated ATXN7L3 Activation

Background: Increasing evidence enhanced the recognition of circular RNAs (circRNAs) implicated in cancer progression. CircRNA_0085616 (circ_0085616) is a novel circRNA with high expression in cervical cancer (CC); its function and action mechanism are explored during this study. Methods: The measurement of circ_0085616, microRNA-503-5p (miR-503-5p), and Ataxin-7L3 (ATXN7L3) was performed via quantitative real-time polymerase chain reaction. Next, 3-(4,5-dimethylthiazol-2-y1)-2, 5-diphenyl tetrazolium bromide (MTT) and colony formation assays were implemented to analyze the proliferative ability. Cell metastasis was evaluated by using transwell migration and invasion assays. Glycolysis was analyzed by using glucose consumption, lactate and adenosine triphosphate production. Western blot was employed for protein analysis. The target binding was performed by dual-luciferase reporter assay and RNA immunoprecipitation assay. An animal experiment in vivo was conducted by xenografts. Results: Circ_0085616 was heightened and its downregulation blocked cellular proliferation, metastasis, and glycolysis in CC. Then, we found that circ_0085616 had a sponge effect on miR-503-5p and the miR-503-5p inhibitor could ameliorate the effects of circ_0085616 knockdown on CC cells. In addition, miR-503-5p directly targeted ATXN7L3 to obstruct CC cell proliferation, metastasis, and glycolytic process. Further, circ_0085616 could enhance ATXN7L3 by sequestering miR-503-5p, and the miR-503-5p/ATXN7L3 axis was also responsible for circ_0085616 on promoting CC tumorigenesis in vivo. Conclusion: It was obvious that circ_0085616 facilitated the carcinogenic effect on CC via the activation of ATXN7L3 by sponging miR-503-5p. Our study may be likely to provide a novel molecular target for CC therapy.

Adjuvant Human Papillomavirus Vaccine to Reduce Recurrent Cervical Dysplasia in Unvaccinated Women: A Systematic Review and Meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis evaluating the efficacy of adjuvant human papillomavirus (HPV) vaccination in preventing recurrent cervical intraepithelial neoplasia (CIN) 2 or greater after surgical excision.

DATA SOURCES

Electronic databases (Cochrane, PubMed, EMBASE, MEDLINE, Scopus, and ClinicalTrials.gov) were searched for studies comparing surgical excision alone to surgical excision with adjuvant HPV vaccination for CIN 2 or greater. Studies published from January 1990 to January 2019 were included.

METHODS

A total of 5,901 studies were reviewed. The primary outcomes evaluated included: recurrence of CIN 2 or greater, CIN 1 or greater, and HPV 16,18 associated CIN within 6-48 months. We used Covidence software to assist with screening, and meta-analysis was performed using Review Manager.

TABULATION, INTEGRATION, AND RESULTS

Six studies met inclusion criteria and were included in the final analysis. In total 2,984 women were included; 1,360 (45.6%) received adjuvant HPV vaccination after surgical excision, and 1,624 (54.4%) received either placebo or surgical management alone for CIN 2 or greater. Recurrence of CIN 2 or greater occurred within 6-48 months in 115 women (3.9%) overall; however, recurrence was significantly lower for vaccinated women: 26 of 1,360 women (1.9%) vs 89 of 1,624 unvaccinated women (5.9%) (relative risk [RR] 0.36 95% CI 0.23-0.55). The risk of CIN 1 or greater was also significantly lower with adjuvant HPV vaccination, occurring in 86 of 1,360 vaccinated women (6.3%) vs 157 of 1,624 unvaccinated women (9.7%) (RR 0.67 95% CI 0.52-0.85). Thirty-five women developed recurrent CIN 2 or greater lesions specific to HPV 16,18; nine received adjuvant vaccination (0.9%) vs 26 who were unvaccinated (2.0%) (RR 0.41 95% CI 0.20-0.85).

CONCLUSION

Adjuvant HPV vaccination in the setting of surgical excision for CIN 2 or greater is associated with a reduced risk of recurrent cervical dysplasia overall and a reduction in the risk of recurrent lesions caused by the most oncogenic strains (HPV 16,18). Human papillomavirus vaccination should therefore be considered for adjuvant treatment in patients undergoing surgical excision for CIN 2 or greater.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019123786.

A prognostic signature based on immune-related genes for cervical squamous cell carcinoma and endocervical adenocarcinoma

Cervical squamous cell carcinoma and endocervical adenocarcinoma (CESC) is the fourth commonest female malignancy worldwide. CESC progresses in immune-microenvironment mainly composed of infiltrating immune and stromal cells. Here, we performed an integrated analysis incorporating the expression profiles from the Cancer Genome Atlas (TCGA) database and scores of immune and stromal cells calculated by Estimation of Stromal and Immune cells in Malignant Tumours using Expression data (ESTIMATE) algorithm. A two-gene signature (CD1C and CD6 genes) was established to predict the prognosis of CESC. Based on this signature, patients were divided into the high- and low-risk groups, and this signature showed good prognostic performance according to the results of Kaplan-Meier analysis and receiver operating characteristic (ROC) analysis in train set and two validation sets. A nomogram was built for evaluating the clinical applicability of this signature. In addition, based on Tumor Immune Estimation Resource (TIMER) database, 2 hub genes showed negative correlations with tumor purity and positive correlations with infiltrating levels of immune filtrating cells. What's more, we propose new treatment strategies for the two prognostic subtypes. Low- risk patients were found presenting with a higher level of immune checkpoint molecules and showing higher immunogenicity in immunophenoscore (IPS) analysis, which indicated a better response for immunotherapy. Meanwhile, estimated by Genomics of Drug Sensitivity in Cancer (GDSC) database, the high-risk patients showed sensitive responses to five chemotherapy drugs. Finally, 10 candidate small-molecule drugs for CESC were defined. In summary, the CD1C-CD6 signature can accurately predict the prognosis of CESC.

Silencing of KCNA1 suppresses the cervical cancer development via mitochondria damage

Voltage-gated potassium channel subfamily A member 1 (KCNA1/Kv1.1) is an important component of type A potassium channels, which has been found to be involved in various tumors. This study aimed to identify the role of KCNA1 in cervical cancer and explore the related mechanism. The levels of KCNA1 in cervical cancer tissues and cell lines were examined by Western blot and qPCR. Cell proliferation and invasion were assessed by CCK-8 and transwell assays, respectively. Protein levels of Hedgehog (Hhg), Wnt and Notch were detected by Western blot. The mitochondrial capacity was examined by immunostaining with MitoTracker Red CMXRos. KCNA1 was highly expressed in cervical cancer tissues and cell lines, and correlated with poor prognosis. In addition, depletion of KCNA1 suppressed growth, proliferation, migration and invasion of HeLa cells. Moreover, KCNA1 could regulate the Hhg, Wnt and Notch signaling pathways and cause mitochondrial dysfunction. The present study has demonstrated that KCNA1 is an oncogene excessively expressed in cervical cancer, and promotes tumor progression by regulating the Hhg, Wnt and Notch signaling pathways and the mitochondrial capacity. Therefore, our results provide a theoretical basis for the discovery of novel clinical treatment against cervical cancer.

Downregulation of IL-2 and IL-23 in Cervical Biopsies of Cervical Intraepithelial Lesions: A Cross-Sectional Study

INTRODUCTION

Persistent infection with high-risk human papillomavirus (HPV) types is associated with high-grade intraepithelial lesions (HSILs) and invasive cervical cancer. The host immune response plays a key role in whether HPV clears or persists. Most studies on local immune response to HPV collect cervical mucus in order to quantify secreted cytokines; however, cells located inside the tissue can release different cytokines associated with HPV infection.

OBJECTIVE

This study compared the cytokine levels in cervical biopsy specimens of women with abnormal colposcopic findings according to the histopathological results: low-grade intraepithelial lesion (LSIL), HSIL, and no intraepithelial lesion (NSIL).

METHODS

A cross-sectional study enrolling 141 cervical biopsy specimens examined the cytokine profile for interleukin (IL-) 2, IL-4, IL-10, IL-12, IL-17, and IL-23 and interferon-γ, using the Luminex assay/ELISA. Differences in cytokine levels among the cervical lesion groups were assessed using the Kruskal-Wallis test.

RESULTS

The 141 specimens included 90 HSILs, 22 LSILs, and 29 NSILs. IL-2 levels were significantly higher in NSIL samples than in LSIL or in HSIL samples (p = 0.0001) and IL-23 levels were significantly higher in NSIL than in HSIL samples (p = 0.003).

CONCLUSIONS

Our study shows that in samples from the lesion site point, 2 important pro-inflammatory cytokines, IL-2 and IL-23, are downregulated in HPV lesions.

Acceptability of vaccination against human papillomavirus among women aged 20 to 45 in rural Hunan Province, China: A cross-sectional study

OBJECTIVE

This study aimed to examine the intentions of and barriers to vaccination against human papillomavirus (HPV) among women aged 20 to 45 in rural areas, and to determine the popular sources to getting information about HPV vaccine and vaccination.

METHODS

This cross-sectional study was conducted in 2018 with a sample of women aged 20 to 45 from rural areas of Hunan Province in China. Anonymous self-administered questionnaires were used to collect sociodemographic information and characteristics related to reproductive health of participants, and intentions of and barriers to HPV vaccination. All statistical analysis methods were performed with SPSS 18.0.

RESULTS

A total of 2101 women participated in the study, with 58.55% intended to vaccinate against HPV. Increased intention of HPV vaccination was associated with higher age (adjusted odds ratio [AOR] = 1.35 and 1.50, respectively) and education level (AOR = 1.13 and 1.47, respectively). Women who have heard of HPV vaccine (AOR = 2.67, 95% confidence interval [CI]: 1.20-5.98) and have been aware of that cervical cancer could be prevented (AOR = 2.01, 95%CI: 1.44-2.82) were more willing to vaccinate. Having never heard of HPV vaccine and worry about efficacy and safety of vaccines were the most commonly cited reasons to refuse vaccination. The preferred source to get the knowledge was medical personnel (58.45%), followed by WeChat or Microblog, TV programs, and Internet.

CONCLUSION

We found the intention of HPV vaccination among women aged 20 to 45 in rural China is low. Findings highlighted the importance of knowledge and trust in HPV vaccine, and suggested strengthening educational interventions on HPV vaccine and vaccination through multiple sources, including HPV vaccine coverage in health insurance to increase access.

Self-Sampling as a Plausible Alternative to Screen Cervical Cancer Precursor Lesions in a Population with Low Adherence to Screening: A Systematic Review

BACKGROUND

Cervical cancer is the fourth most common cancer in the world. A raised incidence and mortality parallel a low participation rate in screening, namely screening in poor countries and among specific populations of developed countries. Cervical or vaginal self-sampling may increase adherence to screening due to its low costs and elevated sensibility and specificity. Our main goal was to compare self-sampling with physician sampling and to evaluate the participation rate of women formerly non-adherent to cervical cancer screening.

STUDY DESIGN

We identified relevant studies from PubMed. Studies were eligible for inclusion if they fulfilled the following criteria: women aged between 16 and 80 years, poor and developed countries that use self-sampling, women with a low participation rate in screening and studies published since 2013. After fully reading the articles, data were extracted to an Excel sheet to -display all relevant information in an organized manner. -Results: We identified 18 studies, which altogether enrolled 22,118 women. Self-sampling and physician sampling are quite similar regarding the HPV detection rate. Women have a low participation rate mainly because of limited access to health services, religious and culture beliefs, and lack of time due to several demanding tasks in daily life. Self-sampling shows a significant increase in acceptability and preference compared to physician sampling.

CONCLUSION

Self-sampling is a reliable method to involve women in opportunistic or organized screening programs for cervical cancer prevention.

Inherited alterations of TGF beta signaling components in Appalachian cervical cancers

PURPOSE

This study examined targeted genomic variants of transforming growth factor beta (TGFB) signaling in Appalachian women. Appalachian women with cervical cancer were compared to healthy Appalachian counterparts to determine whether these polymorphic alleles were over-represented within this high-risk cancer population, and whether lifestyle or environmental factors modified the aggregate genetic risk in these Appalachian women.

METHODS

Appalachian women's survey data and blood samples from the Community Awareness, Resources, and Education (CARE) CARE I and CARE II studies (n = 163 invasive cervical cancer cases, 842 controls) were used to assess gene-environment interactions and cancer risk. Polymorphic allele frequencies and socio-behavioral demographic measurements were compared using t tests and χ2 tests. Multivariable logistic regression was used to evaluate interaction effects between genomic variance and demographic, behavioral, and environmental characteristics.

RESULTS

Several alleles demonstrated significant interaction with smoking (TP53 rs1042522, TGFB1 rs1800469), alcohol consumption (NQO1 rs1800566), and sexual intercourse before the age of 18 (TGFBR1 rs11466445, TGFBR1 rs7034462, TGFBR1 rs11568785). Interestingly, we noted a significant interaction between "Appalachian self-identity" variables and NQO1 rs1800566. Multivariable logistic regression of cancer status in an over-dominant TGFB1 rs1800469/TGFBR1 rs11568785 model demonstrated a 3.03-fold reduction in cervical cancer odds. Similar decreased odds (2.78-fold) were observed in an over-dominant TGFB1 rs1800469/TGFBR1 rs7034462 model in subjects who had no sexual intercourse before age 18.

CONCLUSIONS

This study reports novel associations between common low-penetrance alleles in the TGFB signaling cascade and modified risk of cervical cancer in Appalachian women. Furthermore, our unexpected findings associating Appalachian identity and NQO1 rs1800566 suggests that the complex environmental exposures that contribute to Appalachian self-identity in Appalachian cervical cancer patients represent an emerging avenue of scientific exploration.