Projections up to 2100 and a budget optimisation strategy towards cervical cancer elimination in China: a modelling study

Projected Time for the Elimination of Cervical Cancer Under Various Intervention Scenarios: Age-Period-Cohort Macrosimulation Study

BACKGROUND

The World Health Organization aims for the global elimination of cervical cancer, necessitating modeling studies to forecast long-term outcomes.

OBJECTIVE

This paper introduces a macrosimulation framework using age-period-cohort modeling and population attributable fractions to predict the timeline for eliminating cervical cancer in Taiwan.

METHODS

Data for cervical cancer cases from 1997 to 2016 were obtained from the Taiwan Cancer Registry. Future incidence rates under the current approach and various intervention strategies, such as scaled-up screening (cytology based or human papillomavirus [HPV] based) and HPV vaccination, were projected.

RESULTS

Our projections indicate that Taiwan could eliminate cervical cancer by 2050 with either 70% compliance in cytology-based or HPV-based screening or 90% HPV vaccination coverage. The years projected for elimination are 2047 and 2035 for cytology-based and HPV-based screening, respectively; 2050 for vaccination alone; and 2038 and 2033 for combined screening and vaccination approaches.

CONCLUSIONS

The age-period-cohort macrosimulation framework offers a valuable policy analysis tool for cervical cancer control. Our findings can inform strategies in other high-incidence countries, serving as a benchmark for global efforts to eliminate the disease.

Incidence and Mortality of Cancers in Female Genital Organs - China, 2022

Introduction

This study presented the incidence and mortality rates of cancers affecting the female genital organs in China, along with their trends spanning from 2010 to 2018.

Methods

700 population-based cancer registries provided relevant cancer incidence and mortality data for the year 2018. Among these, 106 registries had continuous monitoring data suitable for trend analysis from 2010 to 2018. We focused specifically on cancers affecting female genital organs (ICD10=C51-C54, C56) and projected their incidences and mortalities in China for 2022 based on data from 2018 and the trends observed from 2010 to 2018. Age-standardized incidence rate (ASIR) and mortality rate (ASMR) were calculated using Segi's world standard population.

Results

In 2022, there were an estimated 296,300 new cases and 104,900 deaths from female cancers in China. ASIRs for vulva (C51), vagina (C52), cervix uteri (C53), corpus uteri (C54), and ovary (C56) were 0.32, 0.23, 13.83, 6.84, and 5.68 per 100,000 population. ASIRs for corpus uteri and ovary cancers were higher in urban areas. ASMRs for vulva, vagina, cervix, corpus uteri, and ovary cancers were 0.14, 0.08, 4.54, 1.05, and 2.64 per 100,000 population, respectively. ASMR for ovarian cancer was higher in urban areas. ASIRs and ASMRs for most female genital organ cancers increased from 2010 to 2018, although the rate of increase for vulvar and cervical cancers in rural areas has slowed recently.

Conclusions

Tailored cancer prevention and control programs specific to each region are necessary to address the growing disease burden.

Modeling the Health Impact and Cost-Effectiveness of a Combined Schoolgirl HPV Vaccination and Cervical Cancer Screening Program in Guangdong Province, China

Low human papillomavirus (HPV) vaccine uptake is a key barrier to cervical cancer elimination. We aimed to evaluate the health impact and cost-effectiveness of introducing different HPV vaccines into immunization programs and scaling up the screening program in Guangdong. We used a dynamic compartmental model to estimate the impact of intervention strategies during 2023-2100. We implemented the incremental cost-effectiveness ratio (ICER) in costs per averted disability-adjusted life year (DALY) as an indicator to assess the effectiveness of the intervention. We used an age-standardized incidence of 4 cases per 100,000 women as the threshold for the elimination of cervical cancer. Compared with the status quo, scaling up cervical cancer screening coverage alone would prevent 215,000 (95% CI: 205,000 to 227,000) cervical cancer cases and 49,000 (95% CI: 48,000 to 52,000) deaths during 2023-2100. If the coverage of vaccination reached 90%, domestic two-dose 2vHPV vaccination would be more cost-effective than single-dose and two-dose 9vHPV vaccination. If Guangdong introduced domestic two-dose 2vHPV vaccination at 90% coverage for schoolgirls from 2023 and increased the screening coverage, cervical cancer would be eliminated by 2049 (95% CI 2047 to 2051). Introducing two doses of domestic 2vHPV vaccination for schoolgirls and expanding cervical cancer screening is estimated to be highly cost-effective to accelerate the elimination of cervical cancer in Guangdong.

Health and economic impact of delaying large-scale HPV vaccination and screening implementation on cervical cancer in China: a modelling study

Background

Current uptake of HPV vaccination and screening in China is far below World Health Organization 2030 targets for cervical cancer elimination. We quantified health and economic losses of delaying large-scale HPV vaccination and screening implementation in China.

Methods

We used a previously validated transmission model to project lifetime health benefits, costs, effectiveness, and timeline for cervical cancer elimination of alternative scenarios, including combining HPV vaccination initiated from 2022 to 2030 with screening in different modalities and coverage increase rates, as well as screening alone. All women living or projected to be born in China during 2022-2100 were considered. We employed a societal perspective.

Findings

Regardless of vaccine type, immediate large-scale vaccination initiated in 2022 and achieving 70% coverage of HPV-based screening in 2030 (no-delay scenario) would be the least costly and most effective. Compared with the no-delay scenario, delaying vaccination by eight years would result in 434,000-543,000 additional cervical cancer cases, 138,000-178,000 deaths, and $2863-4437 million costs, and delay elimination by 9-10 years. Even with immediate vaccination, the gradual scale-up of LBC-based screening to 70% coverage in 2070 would result in 2,530,000-3,060,000 additional cases, 909,000-1,040,000 deaths, and $5098-5714 million costs compared with no-delay scenario, and could not achieve elimination if domestic 2vHPV or 4vHPV vaccines are used (4.09-4.21 cases per 100,000 woman in 2100).

Interpretation

Delaying large-scale HPV vaccination and/or high-performance screening implementation has detrimental consequences for cervical cancer morbidity, mortality, and expenditure. These findings should spur health authorities to expedite large-scale vaccine rollout and improve screening.

Funding

Bill & Melinda Gates Foundation (INV-031449 and INV-003174) and CAMS Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1-004).

Strategies to eliminate cervical cancer in China

Cervical cancer is a widely distributed disease that is preventable and controllable through early intervention. The World Health Organization has identified three key measures, coverage populations and coverage targets to eliminate cervical cancer. The WHO and several countries have conducted model predictions to determine the optimal strategy and timing of cervical cancer elimination. However, specific implementation strategies need to be developed in the context of local conditions. China has a relatively high disease burden of cervical cancer but a low human papillomavirus vaccination rate and cervical cancer screening population coverage. The purpose of this paper is to review interventions and prediction studies for the elimination of cervical cancer and to analyze the problems, challenges and strategies for the elimination of cervical cancer in China.

Cost-effectiveness of the screen-and-treat strategies using HPV test linked to thermal ablation for cervical cancer prevention in China: a modeling study

BACKGROUND

Self-sampling HPV test and thermal ablation are effective tools to increase screening coverage and treatment compliance for accelerating cervical cancer elimination. We assessed the cost-effectiveness of their combined strategies to inform accessible, affordable, and acceptable cervical cancer prevention strategies.

METHODS

We developed a hybrid model to evaluate costs, health outcomes, and incremental cost-effectiveness ratios (ICER) of six screen-and-treat strategies combining HPV testing (self-sampling or physician-sampling), triage modalities (HPV genotyping, colposcopy or none) and thermal ablation, from a societal perspective. A designated initial cohort of 100,000 females born in 2015 was considered. Strategies with an ICER less than the Chinese gross domestic product (GDP) per capita ($10,350) were considered highly cost-effective.

RESULTS

Compared with current strategies in China (physician-HPV with genotype or cytology triage), all screen-and-treat strategies are cost-effective and self-HPV without triage is optimal with the most incremental quality-adjusted life-years (QALYs) gained (220 to 440) in rural and urban China. Each screen-and-treat strategy based on self-collected samples is cost-saving compared with current strategies (-$818,430 to -$3540) whereas more costs are incurred using physician-collected samples compared with current physician-HPV with genotype triage (+$20,840 to +$182,840). For screen-and-treat strategies without triage, more costs (+$9404 to +$380,217) would be invested in the screening and treatment of precancerous lesions rather than the cancer treatment compared with the current screening strategies. Notably, however, more than 81.6% of HPV-positive women would be overtreated. If triaged with HPV 7 types or HPV16/18 genotypes, 79.1% or 67.2% (respectively) of HPV-positive women would be overtreated with fewer cancer cases avoided (19 cases or 69 cases).

CONCLUSIONS

Screen-and-treat strategy using self-sampling HPV test linked to thermal ablation could be the most cost-effective for cervical cancer prevention in China. Additional triage with quality-assured performance could reduce overtreatment and remains highly cost-effective compared with current strategies.

A population-based cross-sectional study on the situation of cervical cancer screening in Liaoning, China

Background

Cervical cancer (CC) screening is currently recognized as an effective intervention for CC. Previous studies found that the proportion of screening was low in China, especially in Liaoning. Therefore, we performed a population-based cross-sectional survey to investigate the situation of cervical cancer screening and analyze their related factors for providing a decision-making basis for sustainable and effective development of cervical cancer screening.

Methods

This population-based cross-sectional study involved aged 30 to 69 years in nine counties/districts in Liaoning from 2018 to 2019. Data were collected using the quantitative data collection methods, and analyzed in SPSS version 22.0.

Results

Overall, only 22.37% of 5334 respondents reported having ever been screened for cervical cancer in past 3 years, and 38.41% of respondents reported having the willingness for cervical cancer screening in next 3 years. In the rate of CC screening, multilevel analysis indicated that age, marital status, education level, type of occupation, medical insurance, family income, place of residence and regional economic level had a significant impact on proportion of screening. In the rate of CC screening willingness, multilevel analysis indicated that age, family income, health status, place of residence, regional economic level and CC screening still had a significant impact, but marital status, education level and medical insurance type had no significant impact. There was no significant difference in marital status, education level and medical insurance type after the factors of CC screening were added in the model.

Conclusion

Our study found both proportion of screening and willingness were at a low level, and age, economic and regional factors were the main factors for implementation of CC screening in China. In the future, targeted policies should be formulated according to the characteristics of different groups of people, and reduce the gap in the current health service capacity between different regions.

Prevention Strategies and Early Diagnosis of Cervical Cancer: Current State and Prospects

Cervical cancer ranks third among all new cancer cases and causes of cancer deaths in females. The paper provides an overview of cervical cancer prevention strategies employed in different regions, with incidence and mortality rates ranging from high to low. It assesses the effectiveness of approaches proposed by national healthcare systems by analysing data published in the National Library of Medicine (Pubmed) since 2018 featuring the following keywords: "cervical cancer prevention", "cervical cancer screening", "barriers to cervical cancer prevention", "premalignant cervical lesions" and "current strategies". WHO's 90-70-90 global strategy for cervical cancer prevention and early screening has proven effective in different countries in both mathematical models and clinical practice. The data analysis carried out within this study identified promising approaches to cervical cancer screening and prevention, which can further enhance the effectiveness of the existing WHO strategy and national healthcare systems. One such approach is the application of AI technologies for detecting precancerous cervical lesions and choosing treatment strategies. As such studies show, the use of AI can not only increase detection accuracy but also ease the burden on primary care.

Optimal allocation strategies for HPV vaccination introduction and expansion in China accommodated to different supply and dose schedule scenarios: A modelling study

BACKGROUND

A key barrier to cervical cancer elimination in China is low human papillomavirus (HPV) vaccine uptake, which is limited by supply constraints, high prices, and restriction to two/three-dose schedule. We explored optimal vaccination strategies for maximizing health and economic benefits accommodated to different supply and dose schedules.

METHODS

We evaluated different HPV vaccine strategies under 4 scenarios with different assumptions about vaccine availability and dose schedules. Each strategy involved different vaccine types, target ages, and modes of delivery. We used a previously validated transmission model to assess the health impact (cervical cancer cases averted), efficiency (number of doses needed to be given to prevent one case of cervical cancer [NND]), and value for money (incremental cost-effectiveness ratio [ICER] and return on investment [ROI]) of different strategies in Chinese females over a 100-year time horizon. All costs are expressed in 2021 dollars. We adopted a societal perspective and discounted quality-adjusted life-years (QALYs), costs and benefits by 3% annually for cost-effectiveness analysis and ROI calculation.

FINDINGS

In a supply-constrained and on-label use scenario, compared with no vaccination, two-dose routine vaccination of 14-year-olds would be the optimal, cost-saving strategy for a future national program (NNDs: 150-220, net cost saving: $15 164 million-$22 034 million, ROIs: 7-14, depending on vaccine type). If the one-dose schedule recommended by WHO is permitted in China, then reallocating the second dose from the routine cohorts to add a catch-up vaccination at 20-year-olds would be the most efficient strategy (NNDs: 73-107), and would be cost-saving compared with routine one-dose vaccination only (net cost saving: $4127 million-$6035 million, ROIs: 19-37). When supply constraints are lifted, scaling up vaccination in older females to 26 years could further expand the health benefits and still be cost-saving compared to maintaining the optimal vaccination strategy in the supply-constrained context.

INTERPRETATION

Our study provides timely evidence for the current and future HPV vaccination strategy planning in China, and may also be of value to other countries with supply and dose restrictions.

FUNDING

Bill & Melinda Gates Foundation; CAMS Innovation Fund for Medical Sciences (CIFMS).

Knowledge, attitude, and perception regarding HPV-related diseases and vaccination among the general public in Guizhou Province of China

BACKGROUND

The rising prevalence of high-risk human papillomavirus (HR-HPV) type-related diseases pose an ongoing health challenge in China. In this study, we assessed the current views of the general public of the Guizhou Province on HPV and HPV vaccinations to provide recommendations for future directions regarding the rollout of HPV vaccination in the area.

METHODS

An online questionnaire survey was conducted that included 3412 (2532 females and 880 males) native adult residents of the Guizhou Province. Data on the socio-demographic characteristics, knowledge of HPV, and perceptions of HPV vaccinations were collected. Data comparisons were made between students and non-students and between participants with and without medical backgrounds. All statistical analyses were performed using SPSS 26.0.

RESULTS

The self-reported HPV infection rates were 5.85% in women and 0.86% in men. A total of 46.29% of women and 34.43% of men achieved acceptable knowledge levels of HPV and 47.54% of women possessed an acceptable knowledge level of HPV vaccines. Non-students and medical participants performed significantly better in the knowledge tests than their respective opposing groups. Online media was the most popular HPV information source for all the participants. A total of 93.58% of women and 87.88% of men expressed willingness toward HPV vaccination. The major facilitators of vaccination acceptance were females (OR = 1.932, 95% CI: 1.390-2.685, p < 0.001) or students (OR = 2.276, 95% CI: 1.207-4.291, p = 0.011), and participants with higher HPV knowledge level (OR = 1.796, 95% CI: 1.300-2.481, p < 0.001). Ages 41-50 (OR = 0.255, 95% CI: 0.121-0.538, p = 0.001) or > 50 (OR = 0.141, 95% CI: 0.059-0.337, p < 0.001) were significant predictors of a negative attitude towards HPV vaccination.

CONCLUSION

Guizhou residents had poor knowledge of HPV-related issues. The percentage of healthcare workers who achieved acceptable knowledge levels was one-half or less. The increasing HPV prevalence and cervical cancer incidence can be contained if more affordable vaccines are developed and the low knowledge levels pervading young adults and medical staff is eliminated.

Trends in Incidence Rates, Mortality Rates, and Age-Period-Cohort Effects of Cervical Cancer - China, 2003-2017

Introduction

This study reported the trends and analyzed the age-period-cohort effects on the incidence and mortality rates of cervical cancer in China.

Methods

The age-standardized incidence rate (ASIR) and mortality rate (ASMR) by Segi's world standard population were calculated using qualified consecutive data from 22 cancer registries from 2003 to 2017 in China. We performed joinpoint analysis to describe the trends and age-period-cohort analysis to estimate the independent effects of age, period and cohort on trends in incidence and mortality rates of cervical cancer.

Results

The ASIR and ASMR for cervical cancer in females over 20 years old increased during 2003-2017. For females <50 years, a decreasing trend in ASIR and a stable trend in ASMR were observed in urban areas after 2009. But the ASIR and ASMR kept increasing in rural areas during the whole period. For females >50 years, the ASIR and ASMR increased both in urban and rural areas. Age-period-cohort analysis showed increasing period effects on cervical cancer incidence and mortality during the whole period. The cohort effects exhibited a downward-upward-downward pattern for the incidence (1918-1938, 1938-1963, 1963-1993) and mortality rates (1918-1943, 1943-1963, 1963-1993) in urban areas, a fluctuating pattern for incidence rate and a continuing downward pattern for mortality rate (1918-1993) in rural areas.

Conclusions

The increases in cervical cancer incidence and mortality rates can be mostly explained by period effects. We observed decreases in risk for cervical cancer incidence and mortality in young female generations, which were more obvious in urban areas.

GFPT1 promotes the proliferation of cervical cancer via regulating the ubiquitination and degradation of PTEN

Cervical cancer demonstrates the fourth incidence and death rate in females worldwide. Glutamine--fructose-6-phosphate transaminase 1 (GFPT1), the first rate-limited enzyme of the hexosamine biosynthesis pathway, has been reported to promote the progression of cancers. However, the prognostic value and roles of GFPT1 in cervical cancer are largely unknown. Transcription expression data for cervical cancer were downloaded from public databases. GFPT1 overexpressed and knockdown cell lines were constructed. Colony formation assays, Edu assays and 3-(4,5-dimethylthiazole-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assays were used to measure the proliferation capabilities of cervical cancer cells. Western blot, Immunofluorescence and co-immunoprecipitation assays were performed to verify the interaction between GFPT1and Phosphatase and tensin homolog (PTEN). Animal assays were applied to verify the results in vivo. GFPT1 expression was higher in cervical cancer cell lines. The proliferation capabilities of cervical cancer cells were suppressed in GFPT1 knockdown cells and GFPT1 inhibitor L-DON treated cells. And overexpression of GFPT1 promoted cell proliferation. PTEN was up-regulated in GFPT1 knockdown cells and downregulated in GFPT1 overexpression cells. Immunofluorescence and co-immunoprecipitation results showed that GFPT1 was co-localized and interacted with PTEN. GFPT1 promoted the ubiquitination and degradation of PTEN. Silence of PTEN offsets the growth inhibition of cervical cancer caused by GFPT1 knockdown. Animal assays showed that GFPT1 promoted the proliferation of cervical cancer in vivo. Our study revealed that GFPT1 could promote the progression of cervical cancer by regulating PTEN expression. Our study highlights the GFPT1-PTEN regulation as a potential therapy target for cervical cancer. .

Patient delay and related influencing factors in Chinese women under 35 years diagnosed with cervical cancer: A cross-sectional study

Objective

Patient delay was defined as an interval between the discovery of the initial symptoms and diagnosis, which was longer than 90 days. This study aimed to determine the patient delay rate and related factors in women with cervical cancer in Hunan province, South-Central China.

Methods

A cross-sectional study was conducted among 140 women with cervical cancer aged <35 years from October, 2019 to March, 2021. Assumptions in Andersen Behavioral Model of Health Services Utilization were used to measure the factors influencing patient delay. Logistic regression models were used to identify factors associated with patient delay. A P-value of <5% was considered significant.

Results

A total of 57 (40.71%) young women with cervical cancer had patient delay, with an average delay time of 178.70 (307.90) days. Predisposing factors, such as religion, unemployment, health beliefs related to cancer screening, and a history of cervical cancer screening within 2 years or more (P ​< ​0.05), were associated with patient delay. Enabling factors, such as distance to the nearest medical facility and type of the nearest medical facility, were associated with a reduced likelihood of patient delay. With the need-for-care factor, young women who experienced vaginal pain after or during intercourse had a higher risk (adjusted odds ratio, 33.48; 95% confidence interval, 3.22-348.68, P ​= ​0.003) of patient delay.

Conclusions

These findings reinforce the need for programs to enhance knowledge and awareness about cervical cancer screening and the importance of early diagnosis in women to help eliminate cervical cancer in China by 2050.

Rapid elimination of cervical cancer while maintaining the harms and benefits ratio of cervical cancer screening: a modelling study

BACKGROUND

Human papillomavirus (HPV) vaccination and intensifying screening expedite cervical cancer (CC) elimination, yet also deteriorate the balance between harms and benefits of screening. We aimed to find screening strategies that eliminate CC rapidly but maintain an acceptable harms-benefits ratio of screening.

METHODS

Two microsimulation models (STDSIM and MISCAN) were applied to simulate HPV transmission and CC screening for the Dutch female population between 2022 and 2100. We estimated the CC elimination year and harms-benefits ratios of screening for 228 unique scenarios varying in vaccination (coverage and vaccine type) and screening (coverage and number of lifetime invitations in vaccinated cohorts). The acceptable harms-benefits ratio was defined as the number of women needed to refer (NNR) to prevent one CC death under the current programme for unvaccinated cohorts (82.17).

RESULTS

Under current vaccination conditions (bivalent vaccine, 55% coverage in girls, 27.5% coverage in boys), maintaining current screening conditions is projected to eliminate CC by 2042, but increases the present NNR with 41%. Reducing the number of lifetime screens from presently five to three and increasing screening coverage (61% to 70%) would prevent an increase in harms and only delay elimination by 1 year. Scaling vaccination coverage to 90% in boys and girls with the nonavalent vaccine is estimated to eliminate CC by 2040 under current screening conditions, but exceeds the acceptable NNR with 23%. Here, changing from five to two lifetime screens would keep the NNR acceptable without delaying CC elimination.

CONCLUSIONS

De-intensifying CC screening in vaccinated cohorts leads to little or no delay in CC elimination while it substantially reduces the harms of screening. Therefore, de-intensifying CC screening in vaccinated cohorts should be considered to ensure acceptable harms-benefits ratios on the road to CC elimination.

Absolute Risk and Attributable Fraction of Type-Specific Human Papillomavirus in Cervical Cancer and Precancerous Lesions-A Population-Based Study of 6286 Women in Rural Areas of China

Background: To investigate the human papillomavirus (HPV) genotype distribution among the general population and assess the attribution of HPV genotypes targeted by vaccines to protect against cervical lesions theoretically. Methods: Cervical samples were collected from women aged 21 to 64 years old from Inner Mongolia and Shanxi Province in China who had not been vaccinated against HPV. HPV type-specific absolute risk (AR) to classified cervical lesions was calculated and then the attributable fraction (AF) was estimated, together with the combined contributions of the HPV types, targeted by four available HPV vaccines and five HPV vaccines in clinical trials in China to protect against cervical lesions. Results: A total of 6286 women with an average age of 44.1 years ± 8.41 (range: 21−64) participated in the study. The age distribution of 14 HR-HPV and HPV16/18 all showed a ‘U’ shape, which peaked in the ≤25 year-group and >55 year-group. The five most common genotypes were HPV16 (4.3%), HPV52 (4.1%), HPV58 (2.1%), HPV51 (2.1%), and HPV66 (1.7%). The prevalence of HPV types 6 and 11 infections was 1.1% and observed with n significant differences across age stratifications in China. AF to CIN2+ was predominated by HPV 16 with 56.2%, followed by HPV58 (12.0%), HPV52 (8.5%), HPV18 (4.3%), and HPV51 (2.9%). HPV52 and 58 in the prophylactic HPV vaccine would enhance the protection against CIN2+ by approximately 20%. Conclusions: Regarding multi-valent HPV vaccine development in China, the HPV types 16, 52, 58, and 18 should be given priority for their high prevalence at the population level, high AR, notable AF, and high relative risk to high-grade cervical lesions.

Status quo and problem analysis of cervical cancer screening program in China: Based on RE-AIM framework

Background

An organized cervical cancer screening program is an effective method to prevent and control cervical cancer. This study aims to find barriers and facilitators in the implementation process of National Cervical Cancer Screening Program in Rural Areas (NACCSPRA) in China through program evaluation, and thus propose suggestions for optimization of the program.

Methods

Through stratified sampling, 8 provinces (autonomous cities/districts) in eastern, southern, western, northern, and central China were selected for evaluation of NACCSPRA based on the RE-AIM framework. We obtained 15 program providers' experience and perspectives through semi-structured interviews. The data was analyzed using a combination of deductive and inductive analysis methods.

Results

The study found that NACCSPRA mainly serves women with rural household registration or urban minimum living guarantee. Population mobility and certain demographic characteristics such as low education and poor health awareness are common participation barriers, while program publicity acts as a facilitator. A screening program's direct benefit is to promote early detection and treatment of cervical cancer, and its perceived indirect effect is to raise people's health awareness. The proportion of regions adopting the project is relatively high, and factors affecting employees' participation are screening workload, working environment, welfare benefits, degree of preference for grassroots work, and whether the project is included in the performance appraisal; In terms of implementation, there are disparities in screening methods, network informatization levels, and capital investment in various regions. Poor development of screening information system and insufficient screening funds are significant barriers to improvement of project implementation. In contrast, the overall implementation of follow-up is better; related policies issued by the local government and financial subsidies for poor women ensure the maintenance of the project.

Conclusion

Shortage of funds is an important problem faced by current screening project, which negatively influences upgrade of cervical cancer prevention strategy, implementors' working environment, and impedes improvement of information network. In addition, defects in population coverage, especially in mobile population also deserves attention. The study found barriers and facilitators of NACCSPRA perceived by project providers and provided a theoretical foundation for project optimization.

Epidemiological trends of female breast and gynecologic cancers in adolescents and young adults in China from 1990 to 2019: Results from the Global Burden of Disease Study 2019

Background

Research on the incidence, mortality, and disability-adjusted life years (DALYs) of female breast and gynecologic cancers (FeBGCs) and the relevant risk factors for adolescents and young adults (AYAs) are valuable for policy-making in China. We aimed to estimate the incidence, deaths, and DALYs and predict epidemiological trends of FeBGCs among AYAs in China between 1990 and 2019.

Methods

Data from the 2019 Global Burden of Disease (GBD) study between 1990 and 2019 in 195 countries and territories were retrieved. Data about the number of FeBGC incident cases, deaths, DALYs, age-standardized rates (ASRs), and estimated annual percentage changes (EAPCs) were extracted. A comparative risk assessment framework was performed to estimate the risk factors attributable to breast cancer deaths and DALYs, and autoregressive integrated moving average (ARIMA) models were fitted for time-series analysis to predict female cancer morbidity and mortality among Chinese AYAs until 2030.

Results

In 2019, there are 61,038 incidence cases, 8,944 deaths, and 529,380 DALYs of FeBGCs among the AYAs in China, respectively. The estimated annual percentage change (EAPC) values were positive scores (>0) in ASIRs and negative scores (<0) in ASMR and ASDR. Furthermore, in 2030, the incidence rate of FeBGCs would grow to 30.49 per 100,000 in China, while the mortality rate would maintain a steady state. Of the deaths and DALYs, diet high in red meat was the greatest contributor to breast cancer, while a high body mass index (BMI) was the greatest contributor to cervical, ovarian, and uterine cancers.

Conclusion

The increasing Chinese FeBGC burden is mainly observed in AYAs and non-red meat diet, and the control of body weight could reduce FeBGC burden in China.

α-Pinene inhibits the growth of cervical cancer cells through its proapoptotic activity by regulating the miR-34a-5p/Bcl-2 signaling axis

Among gynecological tumors, cervical cancer (CC) has the second-highest prevalence and mortality rate. α-Pinene is a bicyclic monoterpenoid compound extracted from pine needles that carried promising anticancer properties. Nevertheless, its effect on CC and the underlying mechanism has not yet been elucidated. Therefore, we investigated the effect of α-Pinene on apoptosis in CC via in vitro assays of flow cytometry (FCW), terminal deoxynucleotidyl transferase-mediated nick end labeling (TUNEL) assay, quantitative real-time polymerase chain reaction (qRT-PCR), and Western blot. Following that, we detected the proapoptotic function of α-Pinene on HeLa cells in vivo by TUNEL assay and immunofluorescence staining. Our results displayed that the α-Pinene inhibited the growth of HeLa cells and stalled the cells in the G0/G1 phase. Interestingly, we also detected that α-Pinene induced HeLa cells to apoptosis. The results investigated that α-Pinene induced HeLa cells apoptosis along with up-regulating the expression of Bax, Bid, caspase-9, caspase-3, miR-34a-5p, and down-regulating the expression of Bcl-2 in vitro. At the same time, the expression levels of target genes in vivo were consistent with those in vitro. Our experiment proved that α-Pinene promoted apoptosis, which will be used to hopefully maximize the therapeutic strategies in clinical studies in CC.

Global trends and age-specific incidence and mortality of cervical cancer from 1990 to 2019: an international comparative study based on the Global Burden of Disease

OBJECTIVE

To describe the trends of incidence and mortality of cervical cancer in different age groups and regions from 1990 to 2019.

DESIGN

An international comparative study based on the Global Burden of Disease (GBD) study estimates.

PARTICIPANTS

Data were publicly available and individuals were not involved.

METHODS

We collected detailed information on cervical cancer from the GBD study between 1990 and 2019. Average annual percentage changes (AAPCs) of age-standardised incidence and mortality rate (ASIR and ASMR) in cervical cancer, by age group and region, were calculated to quantify the temporal trends.

RESULTS

Globally, the absolute numbers of incident cases and deaths were increasing, with the most cervical cancer cases and deaths being reported in China, India and Brazil. Although the ASIR and ASMR have declined overall from 1990 to 2019, an increasing or stable trend was also observed in East Asia and Southern sub-Saharan Africa. Particularly, we found that the age-specific AAPC of incidence showed an increasing trend in the age group of 15-49 years globally, and the high Sociodemographic Index region increased the most.

CONCLUSIONS

Cervical cancer remains a concerning disease that affects women all over the world, although the ASIR and ASMR are decreasing. Efforts to control the younger trend and to reduce the disparity between regions are imminent.

Tumoral Morphologic Features From Cervical Biopsies That Are Predictive of a Negligible Risk for Nodal Metastasis and Tumor Recurrence in Usual-type Cervical Adenocarcinomas: A Multi-institutional Study

The metastatic or recurrent potential of localized human papillomavirus-associated endocervical adenocarcinoma (HPVA EAC) is difficult to predict, especially based upon biopsy alone. Recent analyses of small cohorts indicate that high tumor nuclear grade (TNG) and the presence of necrotic tumor debris (NTD) from HPVA EACs in cervical biopsy specimens are highly predictive of nodal metastasis (NM). In the present study, we aimed to investigate how reliably tumoral morphologic features from cervical biopsy specimens predict NM or tumor recurrence (TR) and patient outcomes in a large cohort of endocervical adenocarcinoma patients. A cohort comprised of 397 patients with HPVA EAC treated at 18 institutions was identified, and cervical biopsies were paired with their associated complete tumor resections for a total of 794 specimens. A variety of tumoral histologic features were examined for each paired specimen, including TNG (assessed on a 3-tiered scale of increasing abnormalities-TNG1, TNG2, TNG3) and NTD (defined by the presence of necrotic and apoptotic tumor cells within tumor glandular lumens admixed with granular and eosinophilic amorphous material and inflammatory cells), which were correlated with outcomes. The distribution of TNG in biopsies was as follows: 86 (21.7%) TNG1, 223 (56.2%) TNG2, and 88 (22.2%) TNG3. NTD was identified in 176 (44%) of the biopsy specimens. The sensitivity, specificity, positive predictive value, and negative predictive value of a TNG1 assignment in the biopsy being predictive of the same assignment in the full resection were 0.82 (95% confidence interval [CI]: 0.7-0.9), 0.895 (0.86-0.93), 0.593 (0.48-0.696), and 0.96 (0.94-0.98), respectively. Respective values for an NTD-negative status were 0.89 (95% CI: 0.83-0.92), 0.715 (0.64-0.77), 0.72 (0.65-0.77), and 0.89 (0.83-0.93), respectively. Compared with the other cases in each category, both TNG1 and an NTD-negative status were each significantly associated with lower rates of NM (odds ratio for TNG1=0.245, 95% CI: 0.070-0.857, P=0.0277; for NTD=0.199, 95% CI: 0.094-0.421, P<0.0001) and TR (odds ratio for TNG1=0.225, 95% CI: 0.051-0.987, P=0.0479; for NTD=0.367, 95% CI: 0.171-0.786, P=0.0099) independent of depth of stromal invasion, lymphovascular invasion, tumor size, FIGO stage, and Silva pattern. Overall, 73/379 (19%) cases were both TNG1 and NTD-negative on the biopsy, and none of these 73 cases showed NM (0%), but a single case (1.4%) showed TR. In contrast, among the 324 biopsies with TNG2/3 and/or presence of NTD, 62 (19.1%) had NM, and 41 (12.9%) had TR. In summary, 2 variables in combination (ie, TNG1 and NTD-negative) identified a subset of HPVA EAC patients-∼19%-with a 0% frequency of nodal metastases and only 1.4% frequency of recurrence. Biopsies highly but imperfectly predicted these features. Nonetheless, these findings may potentially be of clinical utility in the risk stratification of patients with HPVA EACs. This may allow some patients with a minimal risk of nodal metastases and TR to be identified at the biopsy phase, thereby facilitating more personalized, possibly less aggressive treatment.

The Impact of Early Neighborhood Cohesion, and Its Mechanism, on Cognitive Function in Later Life

Objectives

This study aimed to explore the impact of early neighborhood cohesion, and its mechanism, on cognitive function in later life.

Methods

In total, 10,727 Chinese elderly, aged 60-90, forming two datasets (2014 and 2018) from the China Health and Retirement Longitudinal Study (CHARLS) were used as a sample. Childhood neighborhood cohesion was measured by the extent of how much neighbors were willing to help and how close-knit neighbors were. Mini-Mental State Examination (MMSE) and Center for Epidemiologic Studies Depression Scale (CESD-10) were used to assess the cognitive functions and depression of the elderly. We used a structural equation model to examine the relationship between early neighborhood cohesion and late-life cognitive function and conducted bootstrapping analyses to assess the mechanism.

Results

Cognitive function was positively predicted by childhood neighborhood cohesion (β = 0.06, p < 0.001), and cognitive function of the elderly were also positively predicted through the mediating effects of childhood friendships, which included depression and social activity participation as two chain paths.

Conclusion

The findings suggest that childhood neighborhood cohesion positively predicts cognitive function among elderly people through the mediating roles of childhood friendship, depression, and social activity engagement. Childhood neighborhood cohesion is correlated with better childhood friendships, then to fewer depression symptoms and greater elderly social activity participation, and finally to better cognitive functions in the elderly.

Microsimulation Model for Prevention and Intervention of Coloretal Cancer in China (MIMIC-CRC): Development, Calibration, Validation, and Application

Introduction

A microsimulation model provides important references for decision-making regarding colorectal cancer (CRC) prevention strategies, yet such a well-validated model is scarce in China.

Methods

We comprehensively introduce the development of MIcrosimulation Model for the prevention and Intervention of Colorectal Cancer in China (MIMIC-CRC). The MIMIC-CRC was first constructed to simulate the natural history of CRC based on the adenoma-carcinoma pathway. The parameters were calibrated and validated using data from population-based cancer registry data and CRC screening programs. Furthermore, to assess the model’s external validity, we compared the model-derived results to outcome patterns of a sigmoidoscopy screening trial in the UK [UK Flexible Sigmoidoscopy Screening (UKFSS) trial]. Finally, we evaluated the application potential of the MIMIC-CRC model in CRC screening by comparing the 8 different strategies.

Results

We found that most of the model-predicted colorectal lesion prevalence was within the 95% CIs of observed prevalence in a large population-based CRC screening program in China. In addition, model-predicted sex- and age-specific CRC incidence and mortality were equivalent to the registry-based data. The hazard ratios of model-estimated CRC-related incidence and mortality for sigmoidoscopy screening compared to no screening were 0.60 and 0.51, respectively, which were comparable to the reported results of the UKFSS trial. Moreover, we found that all 8 strategies could reduce CRC incidence and mortality compared to no screening.

Conclusions

The well-calibrated and validated MIMIC-CRC model may represent a valid tool to assess the comparative effectiveness of CRC screening strategies and will be useful for further decision-making to CRC prevention.

The role of nurses as human papillomavirus vaccination advocates in China: perception from nursing students

This study aimed to investigate nursing students' perspectives regarding the role of nurses as HPV vaccine advocates and their perception of barriers to advocacy. A cross-sectional study using a Web-based survey was sent out to all undergraduate nursing students enrolled at the Fujian Medical University, Fuzhou, China. A total of 1,041 students responded to the survey. In total, 58.0% of students expressed an intent to advocate HPV vaccines as a counselor and 56.4% as an HPV information provider in their future practice. However, 33.4% stated that they do not intend to be HPV vaccine advocates. Grade 1 students, students from homes with higher annual household incomes and those with a higher level of knowledge about HPV and HPV vaccination expressed higher intentions to advocate for HPV vaccines as a counselor. Students who have a higher level of knowledge about HPV and HPV vaccination and have received HPV vaccines reported a higher advocacy intent in the provision of HPV information. The main perceived barriers in HPV vaccine advocacy include inadequate training (87.1%) and insufficient HPV-related knowledge (84.8%); also, anxious patients may not feel comfortable with nurses discussing HPV vaccination (52.8%). Nurses are uniquely positioned to nurture patient HPV vaccine acceptance and maybe the key strategy to increase HPV vaccination coverage in China. Institutional support is needed to train nurses as HPV vaccine advocates and should focus on enhancing HPV-related knowledge while destigmatising the embarrassment around discussing HPV-related issues with patients.

Functional New Transcription Factors (TFs) Associated with Cervical Cancer

The goal of this research was to find noval transcription factors (TFs) that are involved in cervical carcinogenesis. The Gene Expression Omnibus (GEO) database was utilized to analyze ten cervical cancer datasets using the Robust Rank Aggregation (RRA) technique. Survival and differential expression were validated using GEPIA (Gene Expression Profiling Interactive Analysis). The transcriptional regulatory network and putative targets were built using Cytoscape. A real-time PCR (quantitative real-time polymerase chain reaction) experiment was used to confirm the mRNA expression. Using public cervical cancer single-cell RNA-sequencing (scRNA-seq), bulk TCGA-CESC RNA-seq, and microarray datasets, coexpression correlations between putative targets and TFs were confirmed. After combining the results of 10 datasets, 8 TFs, including EMX2 (Empty Spiracles Homeobox 2), were chosen among 385 robust DEGs. In the normal female reproductive tract, EMX2 is extensively expressed, but it is reduced in cervical cancer. Overexpression EMX2 suppresses the proliferation of HeLa cells. 12 potential targets of EMX2 were selected. Our research has revealed evidence that EMX2 acted as a tumor suppressor in cervical cancer and PDZRN3 might be possible target of EMX2 in cervical cancer. It might be a therapeutic target in the future.

Genetic characteristics of human papillomavirus type 16, 18, 52 and 58 in southern China

Persistent infections of high-risk human papillomaviruses (HPVs) are the leading cause of cervical cancers. We collected cervical exfoliated cell samples from females in Changsha city, Hunan Province and obtained 338 viral genomes of four major HPV types, including HPV 16 (n = 82), 18 (n = 35), 52 (n = 121) and 58 (n = 100). The lineage/sublineage distribution of the four HPVs confirmed previous epidemiological reports, with the predominant prevailing sublineage as A4 (50%), A1 (37%) and A3 (13%) for HPV16, A1 (83%) for HPV18, B2 (86%) for HPV52 and A1 (65%), A3 (19%) and A2 (12%) for HPV58. We also identified two potentially novel HPV18 sublineages, i.e. A6 and A7. Virus mutation analysis further revealed the presence of HPV16 and HPV58 sublineages associated with potentially high oncogenicity. These findings expanded our knowledge of the HPV genetic diversity in China, providing valuable evidence to facilitate HPV DNA screening, vaccine effectiveness evaluation and control strategy development.

Sustainable Construction Investment, Real Estate Development, and COVID-19: A Review of Literature in the Field

Aspects of sustainable construction investment and real estate development (CIRED) and their interrelations during the period pre-, intra-, and post-COVID-19, are presented in the research. Applications of the topic model, environmental psychology theory, building life cycle method, and certain elements of bibliometrics, webometrics, article level metrics, altmetrics, and scientometrics make it possible to perform a quantitative analysis on CIRED. The CIRED topic model was developed in seven steps. This paper aims to present a literature review on CIRED throughout the pandemic and to look at the responses from the real estate and construction sector. This sector is a field that appears to be rapidly expanding, judging from the volume of current research papers. This review focuses on last year’s leading peer-reviewed journals. A combination of various keywords was applied for the review and the criteria for paper selections included construction investment, real estate development, civil engineering, COVID-19, and sustainability, as well as residential, industrial, commercial, land, and special purpose real estate, along with their risks, strategies, and trends. The articles reviewed for this paper, which analyzes three hypotheses, look at pre-, intra-, and post-pandemic CIRED. The three hypotheses were validated by analyzing scientific publications from around the world. Two innovative elements make this study stand out among the most advanced research on pre-, intra-, and post-pandemic CIRED. The first of the two innovations is the integrated analysis of the COVID-19 pandemic, COVID-19-related national policies, and business investment strategies relevant to CIRED and the interests of investors as well as on the impact a CIRED policy and investors make on the spread of COVID-19. In addition, this research demonstrates a marked increase in the effectiveness of a CIRED analysis, when the life cycle of a CIRED, the involved stakeholders with their own individual interests, the COVID-19 situation, and the external micro-, meso-, and macro-environments are covered comprehensively as a single entity.

Integrated analysis of virus and host transcriptomes in cervical cancer in Asian and Western populations

Race may influence vulnerability to HPV variants in viral infection and perisistence. Integrated analysis of the virus and host transcriptomes from different populations provides an unprecedented opportunity to understand these racial disparities in the prevalence of HPV and cervical cancers. We performed RNA-Seq analysis of 90 tumors and 39 adjacent normal tissues from cervical cancer patients at Zhejiang University (ZJU) in China, and conducted a comparative analysis with RNA-Seq data of 286 cervical cancers from TCGA. We found a modestly higher rate of HPV positives and HPV integrations in TCGA than in ZJU. In addition to LINC00393 and HSPB3 as new common integration hotspots in both cohorts, we found new hotspots such as SH2D3C and CASC8 in TCGA, and SCGB1A1 and ABCA1 in ZJU. We described the first, to our knowledge, virus-transcriptome-based classification of cervical cancer associated with clinical outcome. Particularly, patients with expressed E5 performed better than those without E5 expression. However, the constituents of these virus-transcriptome-based tumor subtypes differ dramatically between the two cohorts. We further characterized the immune infiltration landscapes between different HPV statuses and revealed significantly elevated levels of regulatory T cells and M0 macrophages in HPV positive tumors, which were associated with poor prognosis. These findings increase our understanding of the racial disparities in the prevalence of HPV and its associated cervical cancers between the two cohorts, and also have important implications in the classification of tumor subtypes, prognosis, and anti-cancer immunotherapy in cervical cancer.

Women's cancers in China: a spatio-temporal epidemiology analysis

BACKGROUND

Women's cancers, represented by breast and gynecologic cancers, are emerging as a significant threat to women's health, while previous studies paid little attention to the spatial distribution of women's cancers. This study aims to conduct a spatio-temporal epidemiology analysis on breast, cervical and ovarian cancers in China, thus visualizing and comparing their epidemiologic trends and spatio-temporal changing patterns.

METHODS

Data on the incidence and mortality of women's cancers between January 2010 and December 2015 were obtained from the National Cancer Registry Annual Report. Linear tests and bar charts were used to visualize and compare the epidemiologic trends. Two complementary spatial statistics (Moran's I statistics and Kulldorff's space-time scan statistics) were adopted to identify the spatial-temporal clusters.

RESULTS

The results showed that the incidence and mortality of breast cancer displayed slow upward trends, while that of cervical cancer increase dramatically, and the mortality of ovarian cancer also showed a fast increasing trend. Significant differences were detected in incidence and mortality of breast, cervical and ovarian cancer across east, central and west China. The average incidence of breast cancer displayed a high-high cluster feature in part of north and east China, and the opposite traits occurred in southwest China. In the meantime, the average incidence and mortality of cervical cancer in central China revealed a high-high cluster feature, and that of ovarian cancer in northern China displayed a high-high cluster feature. Besides, the anomalous clusters were also detected based on the space-time scan statistics.

CONCLUSION

Regional differences were detected in the distribution of women's cancers in China. An effective response requires a package of coordinated actions that vary across localities regarding the spatio-temporal epidemics and local conditions.

Effectiveness and cost-effectiveness of eliminating cervical cancer through a tailored optimal pathway: a modeling study

BACKGROUND

The World Health Assembly has adopted a global strategy to eliminate cervical cancer. However, neither the optimal pathway nor the corresponding economic and health benefits have been evaluated. We take China as an example to assess the optimal pathway towards elimination and the cost-effectiveness of tailored actions.

METHODS

A validated hybrid model was used to assess the costs and benefits of alternative strategies combining human papillomavirus vaccination, cervical screening, and treatment of pre-invasive lesions and invasive cancer for females with different immunization history. All Chinese females living or projected to be born during 2015-2100, under projected trends in aging, urbanization, and sexual activity, were considered. Optimal strategies were determined by cost-effectiveness efficiency frontiers. Primary outcomes were cervical cancer cases and deaths averted and incremental cost-effectiveness ratios (ICERs). We employed a lifetime horizon from a societal perspective. One-way and probabilistic sensitivity analyses evaluate model uncertainty.

RESULTS

The optimal pathway represents an integration of multiple tailored strategies from females with different immunization history. If China adopts the optimal pathway, the age-standardized incidence of cervical cancer is predicted to decrease to fewer than four new cases per 100,000 women (i.e., elimination) by 2047 (95% confidence interval 2043 to 2050). Compared to the status quo, the optimal pathway would avert a total of 7,509,192 (6,922,744 to 8,359,074) cervical cancer cases and 2,529,873 (2,366,826 to 2,802,604) cervical cancer deaths in 2021-2100, with the discounted ICER being $- 339 (- 687 to - 79) per quality-adjusted life-year.

CONCLUSIONS

By adopting an optimal pathway from 2021 (namely, the year of the first Chinese Centennial Goals) onwards, cervical cancer could be eliminated by the late 2040s (namely, ahead of the second Chinese Centennial Goals) while saving net economic costs in China.

Achieving cervical cancer elimination among Indigenous women

Achieving the World Health Organisation (WHO) cervical cancer elimination target of fewer than four new cases per 100,000 woman-years requires scaling up HPV vaccination of girls, cervical screening, and pre-cancer and cancer treatment. We reviewed data from four high-income colonised countries (Australia, Canada, Aotearoa New Zealand (NZ), and the United States (US)) to identify how each is currently performing compared to the cervical cancer incidence elimination and triple-intervention targets, nationally and in Indigenous women. We also summarise barriers and enablers to meeting targets for Indigenous women. To achieve elimination, cervical cancer incidence must be reduced by 74% in Indigenous women in Australia, and 63% in Maori women in NZ; data were not published in sufficient detail to compare incidence in Indigenous women in Canada or the US to the WHO target. Only Australia meets the vaccination coverage target, but uptake appears comparatively equitable within Australia, NZ and the US, whereas there appears to be a substantial gap in Canada. Screening coverage is lower for Indigenous women in all four countries though the differential varies by country. Currently, only Australia universally offers HPV-based screening. Data on pre-cancer and cancer treatment were limited in all countries. Large inequities in cervical cancer currently exist for Indigenous peoples in Australia, Canada, New Zealand and the US, and elimination is not on track for all women in these countries. Current data gaps hinder improvements. These countries must urgently address their systemic failure to care and provide health care for Indigenous women.

Epidemiology and Burden of Human Papillomavirus and Related Diseases, Molecular Pathogenesis, and Vaccine Evaluation

Diagnosed in more than 90% of cervical cancers, the fourth deadliest cancer in women, human papillomavirus (HPV) is currently the most common pathogen responsible for female cancers. Moreover, HPV infection is associated with many other diseases, including cutaneous and anogenital warts, and genital and upper aerodigestive tract cancers. The incidence and prevalence of these pathologies vary considerably depending on factors including HPV genotype, regional conditions, the study population, and the anatomical site sampled. Recently, features of the cervicovaginal microbiota are found to be associated with the incidence of HPV-related diseases, presenting a novel approach to identify high-risk women through both blood and cervical samples. Overall, the HPV repartition data show that HPV infection and related diseases are more prevalent in developing countries. Moreover, the available (2-, 4-, and 9-valent) vaccines based on virus-like particles, despite their proven effectiveness and safety, present some limitations in terms of system development cost, transport cold chain, and oncogenic HPV variants. In addition, vaccination programs face some challenges, leading to a considerable burden of HPV infection and related diseases. Therefore, even though the new (9-valent) vaccine seems promising, next-generation vaccines as well as awareness programs associated with HPV vaccination and budget reinforcements for immunization are needed.

Inequalities in Cervical Cancer Screening Uptake Between Chinese Migrant Women and Local Women: A Cross-Sectional Study

INTRODUCTION

Uptake of cervical cancer screening services in Chinese migrant workers is unknown and may be lower than non-migrant workers in China.

METHODS

We conducted a cross-sectional study among migrant and non-migrant women aged 21-65 at 7 provinces across China and administered a questionnaire investigating knowledge and attitudes regarding cervical cancer, human papillomavirus (HPV), and HPV vaccine. We used multivariable logistic regression to evaluate odds of previous cervical cancer screening in migrant workers.

RESULTS

737 women participated in the study. Mean age was 41.9 ± 7.2 years. 50.2% of the participants were migrant workers. 27.6% of the migrant workers reported previous cervical cancer screening compared to 33.2% of local participants. 36.6% migrant workers reported awareness of HPV compared to 40.2% of local participants. In adjusted analysis migrant status was not associated with increased odds of previous cervical cancer screening (aOR = 1.11 95%CI: 0.76-1.60). High school or higher education compared to less than high school education and employer-sponsored insurance compared to uninsured were associated with increased odds of previous cervical cancer screening (aOR = 2.15 95%CI: 1.41-3.27 and aOR = 1.67 95% CI: 1.14-2.45, respectively). Having heard of HPV compared to no awareness of HPV was associated with increased odds of cervical cancer screening (aOR = 2.02 95%CI: 1.41-2.91). Awareness of HPV among migrant workers was associated with increased odds of cervical cancer screening compared to migrant and local participants without awareness (aOR = 2.82 95% CI: 1.70-4.69 and 2.97 95%CI: 1.51-5.83, respectively).

CONCLUSIONS

Efforts to increase education opportunities, provide insurance, and promote HPV awareness could increase cervical cancer screening uptake in migrant women in China.

Health economic evaluation of primary human papillomavirus screening in urban populations in China

BACKGROUND

On Nov 17, 2020, WHO launched a global initiative to accelerate the elimination of cervical cancer through the implementation of HPV vaccination, cervical cancer screening and treatment for precancer and cancer. China has the largest burden of cervical cancer in the world, but only has a national cervical cancer screening program in rural areas since 2009. Here, we aimed to evaluate the effectiveness and cost-effectiveness of cervical cancer screening in urban China, using Shenzhen City as an example.

METHODS

We use an extensively validated platform ('Policy1-Cervix'), calibrated to data from Shenzhen city and Guandong Province. We evaluated a range of strategies that have previously been implemented as pilot studies in China, or recommended as guidelines within China and globally, spanning primary HPV, cytology and co-testing strategies. We additionally considered alternate triaging methods, age ranges and screening intervals, resulting in 19 algorithms in total.

RESULTS

Of the 19 strategies considered, the most effective approach involved primary HPV testing. At 3- to 10-yearly intervals, primary HPV testing reduced the age-standardized cancer mortality rate by 37-71 %. The most cost-effective strategy was 5-yearly primary HPV testing with partial genotyping triage for ages 25-65, discharging to 10-yearly screening for low-risk women (ICER = US$7191/QALYS using 2018 costs; willingness-to-pay threshold<1xGDP [US$9771]). This strategy gave an incidence and mortality reduction of 56 % and 63 %, respectively. This remained the most cost-effective strategy under most conditions in sensitivity analysis.

CONCLUSION

Primary HPV testing would be cost-effective in Shenzhen and could more than halve cervical cancer incidence rates to 6 per 100,000 over the long term. In order to achieve rates below 4 per 100,000, the elimination threshold set by the World Health Organization, vaccination will likely also be necessary.

A nationally quasi-experimental study to assess the impact of partial organized breast and cervical cancer screening programme on participation and inequalities

BACKGROUND

Organized breast and cervical cancer screening programme could only provide services at no cost for a fraction of socioeconomic-deprived women in China and other low-resource countries, however, little evidence exists for whether such a programme effectively affect the participation and inequalities at the population level.

METHODS

We used individual-level data from a nationally cross-sectional survey in 2014-2015 for breast and cervical cancer screening participation. Data for intervention and comparison grouping were from 2009 to 2014 national breast and cervical cancer screening programme, and counties covered by the programme were divided into intervention group. We assessed the impact of the intervention on the participation rates and the magnitude of inequalities with two approaches: multivariable multilevel logistic regressions adjusting for individual- and region-level covariates; and a difference analysis combined with propensity score matching that estimated the average intervention effect.

RESULTS

Of 69,875 included women aged 35-64 years, 21,620 were classified into the intervention group and 43,669 into the comparison group for breast cancer screening; and 31,794 into the intervention group, and 33,682 into the comparison group for cervical cancer screening. Participation rate was higher in intervention group than comparison group for breast cancer screening (25.3, 95% confidential interval [CI], 22.8-27.7%, vs 19.1, 17.4-20.7%), and cervical cancer screening (25.7, 23.8-27.7%, vs 21.5, 19.6-23.5%), respectively. Intervention significantly increased the likelihood of participation for both breast cancer and cervical cancer screening in overall women, rural women and urban women, whereas the effect was significantly higher in rural women than urban women. The average intervention effect on the participation rate was an increase of 7.5% (6.7-8.2%) for breast cancer screening, and 6.8% (6.1-7.5%) for cervical cancer screening, respectively. The inequalities were significantly decreased by 37-41% (P < 0.001) between rural and urban, however, were slightly decreased or even increased in terms of age, education status, and household income.

CONCLUSIONS

Organized breast and cervical cancer screening programme targeting for a fraction of women could increase the participation rates at population level, however, it could not significantly affect socioeconomic-introduced inequalities. Further studies are need to conduct time-series analyses and strengthen the causal correlation.

Cancer burden in China: trends, risk factors and prevention

As the most populous country in the world, China has made strides in health promotion in the past few decades. With the aging population, the burden of cancer in China continues to grow. Changes in risk factors for cancer, especially diet, obesity, diabetes, and air pollution, continue to fuel the shift of cancer transition in China. The burden of upper gastrointestinal cancer in China is decreasing, but still heavy. The rising burden of colorectal, prostate, and breast cancers is also significant. Lung cancer became the top cause of cancer-related deaths, together with smoking as the most important contributor to cancer deaths. The Chinese government has taken several approaches to control cancer and cancer-related risk factors. Many achievements have been made, but some challenges remain. Health China 2030 is ambitious and depicts a bright vision of the future for cancer control in China. The decrease in the cancer burden in China will require cross-sector collaboration and coordinated efforts on primary and secondary preventions by governments, public health organizations, and individuals. In this review, we describe the trends of cancer burden and discuss cancer-related risk factors in China, identifying strategies to reduce the burden of cancer in China.

Is it possible to halve the incidence of liver cancer in China by 2050?

A substantial proportion of liver cancers is attributable to chronic infection with hepatitis B and C (HBV/HCV). Liver cancer could become the second cancer, after cervical, to be effectively controlled globally, if proven interventions such as vaccination can be implemented on a large scale. In 2018, the global mortality rate for liver cancer was estimated to be 8.5 per 100 000 individuals. Given patterns of HBV infection and immigration across countries, liver cancer control requires combined, global action. Liver cancer trends vary between countries, in some Western countries, the incidence rates were relatively low but have increased in recent decades; conversely, in several Asian countries, the incidence rates have decreased over time. China has in the past contributed more than half of the global burden of liver cancer but more recently a national decline in liver cancer incidence has been observed. Here, we review the liver cancer burden and exposure to risk factors in China, compared to other countries. We also review the implementation status for primary and secondary prevention interventions and major outcomes achieved over the past three decades. Using Bayesian age-period-cohort analysis, we examine recent trends and based on these, predict that by 2050, the incidence of liver cancer in China could fall by half. We additionally survey the literature to identify current research needs, and review relevant national policies on liver cancer control in China. A comprehensive set of interventions is proposed to progress toward the long-term goal of liver cancer elimination based on the natural history and evidence-based interventions.

Domestic HPV vaccine price and economic returns for cervical cancer prevention in China: a cost-effectiveness analysis

BACKGROUND

Coinciding with the release of the first Chinese domestic human papillomavirus (HPV) vaccine Cecolin in 2019, and the substantial advancements in cervical cancer screening technology, we aimed to evaluate the cost-effectiveness of the combined strategies of cervical cancer screening programmes and universal vaccination of girls (aged 9-14 years) with Cecolin in China.

METHODS

We did a cost-effectiveness analysis in China, in which we developed a Markov model of cervical cancer to evaluate the incremental cost-effectiveness ratios of 61 intervention strategies, including a combination of various screening methods at different frequencies with and without vaccination, and also vaccination alone, from a health-care system perspective. We did univariate and probabilistic sensitivity analyses to assess the robustness of the model's findings.

FINDINGS

Compared with no intervention, various combined screening and vaccination strategies would incur an additional cost of US$6 157 000-22 146 000 and result in 691-970 quality-adjusted life-years (QALYs) gained in a designated cohort of 100 000 girls aged 9-14 years over a lifetime. With a willingness-to-pay threshold of three times the Chinese per-capita gross domestic product (GDP), careHPV screening (a rapid HPV test) once every 5 years with vaccination would be the most cost-effective strategy with an incremental cost-effectiveness ratio of $21 799 per QALY compared with the lower-cost non-dominated strategy on the cost-effectiveness frontier, and the probability of it being cost-effective (44%) outperformed other strategies. Strategies that combined screening and vaccination would be more cost-effective than screening alone strategies when the vaccination cost was less than $50 for two doses, even with a lower willingness-to-pay of one times the per-capita GDP.

INTERPRETATION

careHPV screening once every 5 years with vaccination is the most cost-effective strategy for cervical cancer prevention in China. A reduction in the domestic HPV vaccine price is necessary to ascertain a good economic return for the future vaccination programme. The findings provide important evidence that informs health policies for cervical cancer prevention in China.

FUNDING

National Natural Science Foundation of China.

E2F1/2/7/8 as independent indicators of survival in patients with cervical squamous cell carcinoma

Background

Cervical cancer is the second leading cause of death in women 20–39 years old. Because coverage for cervical cancer screening is low, and the vaccination rate of human papillomavirus (HPV) is poor in some countries, potential markers to detect the disease at early stages are needed. E2F transcription factors (E2Fs) are a family of transcription factors that function in cell proliferation, differentiation, apoptosis, and tumorigenesis. As abnormal activation and regulation of E2Fs are related to tumor development and poor prognosis, we performed bioinformatic analyses and in vitro assays to evaluate the role of E2Fs in cervical cancer.

Methods

Transcriptional expression of E2Fs was initially evaluated in silico using ONCOMINE and Gene Expression Profiling Interactive Analysis (GEPIA), followed by evaluation of E2F1/2/7/8 protein levels using immunohistochemistry in 88 patient tissues. E2F2 and E2F7 mRNA levels were measured by RT-qPCR. LinkedOmics and Metascape were used to predict functions of E2Fs, and in vitro experiments were performed to assess the tumorigenic role of E2F2 and E2F7.

Results

In silico analysis showed that E2F1/2/7/8 were significantly overexpressed in cervical cancer, findings which were confirmed at the protein level using immunohistochemistry. Further, upregulation of E2F1/2/7/8 was associated with different clinicopathological prognostic factors, including positivity for lymph vessel invasion and deep invasion of cervical stroma. Increased expression of E2F1/2/7/8 was also related to shorter overall survival (OS) and disease-free survival (DFS) in patients with cervical cancer. Using multivariate analysis, we confirmed E2F1/2/7/8 as independent prognostic factors for shorter OS of patients with cervical cancer. Finally, in vitro experiments showed that E2F2 and E2F7 are involved in cell proliferation and migration and cell cycle regulation in both HPV-positive and HPV-negative cervical cancer cells.

Conclusions

E2F1/2/7/8 may be prognostic biomarkers for survival of patients with cervical cancer. E2F2 and E2F7 are involved in cell proliferation, migration, and cell cycle in both HPV-positive and HPV-negative cervical cancer cells.

Cost-effectiveness and accuracy of cervical cancer screening with a high-risk HPV genotyping assay vs a nongenotyping assay in China: an observational cohort study

Background

New screening techniques may affect the optimal approaches for the prevention of cervical cancer. We evaluated the cost-effectiveness and accuracy of alternative screening strategies to provide evidence for cervical cancer screening guidelines in China.

Methods

In total, 32,306 women were enrolled. The current screening with Cervista^® high-risk human papillomavirus (HR-HPV) nongenotyping and cytology cotesting (Cervista^® cotesting) was compared with PCR-reverse dot blot HR-HPV genotyping and cytology cotesting (PCR-RDB cotesting). All eligible participants were divided into Arm 1, in which both HR-HPV assays were performed, and Arms 2 and 3, in which the PCR-RDB HPV or Cervista^® HR-HPV assay, respectively, was performed. Outcome indicators included the cases, sensitivity, negative predictive value (NPV), colposcopy referral rate and cost of identifying cervical intraepithelial neoplasia of grade 2/3 or worse (CIN2+/CIN3+).

Results

Among the eligible participants, 18.4% were PCR-RDB HR-HPV-positive, while 16.9% were Cervista^® HR-HPV-positive, which reflects good agreement (k = 0.73). PCR-RDB cotesting identified more CIN3+ cases than Cervista^® cotesting in the first round of screening in Arm 1 (37 vs 32) and Arms 2/3 (252 vs 165). The sensitivity and NPV of PCR-RDB cotesting for identifying CIN3+ in Arm 1 (sensitivity: 94.9% vs 86.5%; NPV: 99.9% vs 99.7%) and Arms 2/3 (sensitivity: 95.1% vs 80.9%; NPV: 99.9% vs 99.6%) were higher than those of Cervista^® cotesting, but the cost was similar.

Conclusions

The PCR-RDB HR-HPV genotyping and Cervista^® HR-HPV assay results were consistent. PCR-RDB cotesting possesses optimal cost-effectiveness for cervical cancer screening in China, which has the highest number of cases globally but low screening coverage.

HPV Genotype Prevalence and Success of Vaccination to Prevent Cervical Cancer

BACKGROUND

Nearly 500,000 new cases of cervical cancer are estimated annually worldwide. Three vaccines are currently licensed to prevent cervical cancer. The success of vaccination depends mainly on the prevalence of HPV genotypes, and many cases of HPV infection have been diagnosed after vaccination. Our aim was to search for HPV genotyping in cervical samples to verify the proportion of women that remain susceptible to infection even after vaccination.

METHODS

21,017 liquid-based cervical (LBC) specimens were received for cytology and HPV detection from 2015 to 2018. Before slide preparations for cytology, a 1,000-μL aliquot was taken from the LBC fixative and subjected to automated DNA extraction and multiplex PCR followed by capillary electrophoresis to detect and classify HPV.

RESULTS

HPV was detected in 895 (4.3%) specimens. The most prevalent genotype was HPV-16, followed by HPV-58 and HPV-66. A total of 258 (28.8%) cases were positive for high-risk (HR)-HPV types (66, 59, 39, 56, 30, 35, 53, 51, 68, 82, and 70) that are not covered by the HPV vaccines.

CONCLUSION

A significant proportion of HPV types detected in cytological specimens are representative of HR-HPV not covered by the available vaccines. The health system should be aware of the considerable percentage of women who are not being immunized and will continue to need cervical cancer screening.