American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer

The Impact of Surgical Conization of the Cervix and Loop Electrosurgical Excision Procedure on Female Sexual Function

Objectives: The aim of the study was to analyze and compare the possible effect of cervical conization and the loop electrosurgical excision procedure (LEEP) on female sexual function up to one year after intervention, as existing studies provide incoherent results. Methods: This prospective cohort study enrolled patients who underwent either LEEP (n = 35) or surgical conization of the cervix (n = 44). Patients completed the questionnaire before the intervention and at three, six, and twelve months after the end of the postoperative period. The questionnaire included the Polish version of the Female Sexual Function Index (FSFI) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire of Cancer Patients with the module Cervix-24. Results: In the LEEP group, significant deterioration was observed in the FSFI orgasm subscale after three and six months in comparison to the baseline (3.98 ± 2.08 vs. 3.19 ± 2.29 vs. 3.09 ± 2.24; p < 0.02). The difference in the orgasm subscale compared to the baseline score was not reported after twelve months of follow-up. In the surgical conization group, significant deterioration was observed in the general FSFI score between the baseline and three months after (22.37 ± 12.38 vs. 20.82 ± 12.02; p < 0.003) and in the arousal subscale between the baseline and three months after (3.69 ± 2.14 vs. 3.01 ± 2.02; p < 0.001). In the orgasm subscale, there was a significant improvement between three and twelve months of observation (3.05 ± 2.22 vs. 3.63 ± 2.29; p < 0.003). A significant deterioration was observed in the sexual activity subscale of the EORTC QLQ-C30 + CX24 between baseline and after three months (49.42 ± 36.12 vs. 39.09 ± 36.81; p < 0.03). All reported deteriorations had a tendency to resolve within twelve months of observation. Conclusions: Both LEEP and surgical conization of the cervix seem to have a mild, transient negative impact on female sexual function, which normalizes one year after the procedure. Long-term consequences of both procedures are similar. Further research with larger sample sizes is necessary to confirm these findings.

Diagnosis to Excision: Estimates for Guideline-Concordant Treatment of High-Grade Cervical Intraepithelial Neoplasia

OBJECTIVE

To estimate the proportion of participants with high-grade cervical intraepithelial neoplasia (CIN 2/3) who completed indicated therapeutic procedures.

METHODS

This was a retrospective observational cohort study of the National Institutes of Health's All of Us database enriched for racial and ethnic minorities historically underrepresented in biomedical research. We included female participants aged 25 and older with a diagnosis of CIN 2/3 only, excluding invasive malignancy. We conducted both univariate and multivariate logistic regression to identify background characteristics associated with guideline-concordant ablative and excisional procedures.

RESULTS

Of 1,764 participants with CIN 2/3, only 27.7% of participants underwent a therapeutic procedure in the 12 months following a diagnosis of CIN 2/3. We found that Hispanic participants had a 1.48 increased odds ratio (OR) (95% CI = 1.18-1.85) of undergoing therapeutic procedures (compared to non-Hispanic). Participants residing in the Midwest had a 2.04 OR (95% CI = 1.6-2.6) of undergoing a therapeutic procedure compared to the Northeast. After adjusting for race, ethnicity, region, and smoking status, Hispanic ethnicity remained associated with therapeutic excision (OR = 2.37, 1.13-4.78). Geography was significant with 2.37 (95% CI = 1.17-3.29) increased odds of therapy completions for Midwest residents but 0.52 (95% CI = 0.27-0.96) decreased odds for Western residents.

CONCLUSION

In this large US national database enriched for racial and ethnic minorities, we found that 3 of 4 participants with cervical precancer did not undergo a therapeutic procedure in the 12 months following their first diagnosis. Increased efforts to promote access to and completion of treatment of CIN 2/3 are needed to prevent cancer.

A multimodal deep learning model for cervical pre-cancers and cancers prediction: Development and internal validation study

BACKGROUND

The current cervical cancer screening and diagnosis have limitations due to their subjectivity and lack of reproducibility. We describe the development of a deep learning (DL)-based diagnostic risk prediction model and evaluate its potential for clinical impact.

METHOD

We developed and internally validated a DL model which accommodates both clinical data and colposcopy images in predicting the patients CIN2+ status using a retrospective cohort of 6356 cases of LEEP-conization/cone-biopsy (gold-standard diagnosis) following an abnormal screening result. The overall performance, discrimination, and calibration of the model were compared to expert clinician's colposcopic impression. The potential for clinical impact was assessed with rate of unnecessary conizations that could be avoided by using our model.

RESULTS

The model combining clinical history and colposcopy images demonstrated superior performance prediction of CIN2+(AUC-ROC = 95.3 %, accuracy = 90.8 %, PPV = 94.1 %, NPV = 87.9 %) and better calibration compared to models that used image or clinical history data alone and outperformed clinician's colposcopic impressions. Moreover, if a decision threshold of 10 % is applied to the predicted probability from this model to recommend conization, up to 35 % of conizations could be avoided without missing any true CIN2+ cases.

CONCLUSION

We present a novel DL model to predict cervical neoplasia with potential for reducing unnecessary conization. External validation studies are warranted for assessing generalizability.

Drugs and drug targets for the treatment of HPV-positive cervical cancer

Cervical cancer is primarily driven by persistent infection with high-risk human papillomavirus (HPV) strains and remains a significant global health challenge, particularly in low- and middle-income countries where late-stage diagnoses is common. While vaccination and screening programs have reduced incidence rates, the need for novel and more effacacious and cost-effective therapeutic options is therefore critical especially for advanced cervical cancer. This review highlights several key advances in the understanding of HPV-induced carcinogenesis and the development of therapeutic strategies over the past five years. Important areas of focus include the role of HPV oncoproteins E5, E6 and E7 in modulating signalling pathways, treatment strategies for precancerous lesions, the potential of natural compounds to target cervical cancer cells, and the emergence of immunotherapies, checkpoint inhibitors, antibody-drug conjugates, and novel drug combinations to treat cervical cancer. Additionally, lifestyle recommendations and the integration of natural supplements are discussed for their potential to enhance treatment efficacy and improve patient outcomes. The developments reported in this review underscore the evolving landscape of cervical cancer treatment and the need for continued research to validate and integrate these emerging therapies into clinical practice.

Epidemiological study of human papillomavirus infection in 105,679 women in Wuhan, China

BACKGROUND

Quality assessment of the prevalence and distribution of human papillomavirus (HPV) genotypes could support additional targeted HPV vaccinations. However, the characteristics of HPV infection in Wuhan city are limited in the past decade. We aimed to assess the epidemiology of HPV infection among women and provide a reference for the prevention and treatment of cervical cancer in this region.

METHODS

A retrospective study employing 105,679 women attending Wuhan Medical and Health Center for Women and Children for cervical cancer screening from January 2015 to December 2022 was conducted. The HPV genotype was detected by polymerase chain reaction (PCR) and diversion hybridization. The overall incidence and age-specific type distribution of HPV infection and the relationship between HPV infection and cervical cytology were analyzed.

RESULTS

The overall HPV infection rate was 16.87% in Wuhan city, and the prevalence rates of high-risk, low-risk and mixed high- and low-risk HPV infections were 13.64%, 1.77% and 1.46%, respectively. The five most prevalent genotypes were HPV52 (4.24%), HPV58 (2.42%), HPV16 (2.34%), HPV53 (1.87%), and HPV39 (1.66%). The prevalence of HPV in women exhibited a "two-peak" pattern, the peaks of which were observed in the < 21 years group (37.4%) and the 61-65 years group (41.72%). Logistic regression analysis revealed no significant difference in the rate of high-grade lesion positivity between single and multiple high-risk HPV infections. Among patients with a high-grade squamous intraepithelial lesion+ (HSIL+) ThinPrep cytologic test (TCT) diagnosis, HPV58 was the most common type, followed by HPV52, HPV16, HPV39 and HPV53.

CONCLUSIONS

HPV types 52, 58, 16, 53, and 39 were the most common types in the general female population in Wuhan, and the prevalence of HPV infection varied among different age groups. This study provides a comprehensive overview of the epidemiological characteristics of HPV infection in women, which could support the development of targeted prevention and control strategies for cervical cancer in the region.

Dr. George Papanicolaou: The Visionary Who Revolutionized Women's Health

Dr. George Papanicolaou, a distinguished Greek physician, biologist, and researcher, made monumental contributions to medical science, particularly in the field of cytopathology. His groundbreaking work in the early detection of cervical cancer through the development of the Pap smear has had an enduring global impact, transforming women's healthcare and significantly reducing mortality rates associated with cervical cancer. Papanicolaou's journey from his early education in Greece to his pioneering research in the United States exemplifies a relentless pursuit of scientific discovery and innovation. Papanicolaou's life and achievements continue to serve as a beacon of innovation in medical research, illustrating the profound impact that one individual's dedication can have on public health and the ongoing fight against cancer.

Is there a need for screening of cervical HPV infections and carcinoma?

Antenatal cervical screening aims to detect cervical intraepithelial neoplasms as precancerous lesions and invasive cervical cancer. Whether this screening is performed routinely during pregnancy varies depending on each country's screening participation rates, guidelines, and the risks to the pregnant woman. In some countries with the high rate of routinely implemented cervical screening among the target women, women are recommended to defer cervical screening intentionally to post-delivery, though having screening in consultation with physicians may be possible if routine screening overlaps. However, when cervical screening rate in fertile women is low and the incidence of cervical cancer is high, cervical screening during pregnancy may play an important role in the early detection of cervical cancer. Cervical screening using high-risk human papillomavirus (HPV) testing is accepted worldwide as a highly sensitive and objective test method, and it should replace traditional primary cervical cytology in the future. However, the benefits and disadvantages of using HPV testing in pregnant women is unclear because a false positive rate may be increased due to pregnant women being generally under an immunosuppressed condition.

Immediate risk of cervical intraepithelial neoplasia and diagnostic value of colposcopy among cytology-negative women with oncogenic HPV: a retrospective study

BACKGROUND

Cervical cancer screening results that are negative for cytology but positive for high-risk human papillomavirus (HR-HPV) are not uncommon. One-year follow-up is suggested for patients with no history of HPV positivity under the most recent American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines (2019). The aim of this study was to evaluate the immediate risk of cervical intraepithelial neoplasia (CIN) among cytology-negative patients positive for HR-HPV. The diagnostic accuracy of colposcopy in these patients was investigated.

METHODS

A retrospective study was conducted in patients who were cytology negative but HR-HPV positive and referred for colposcopy from January 2022 to August 2023. Patients were compared in terms of the immediate rate of CIN lesions among the HPV16-positive group, the HPV18-positive group and the non-16/18 HR-HPV-positive group. The distribution of CIN2 + lesions according to age was evaluated. The factors associated with the accuracy of colposcopy were evaluated using univariate and multivariate logistic regression.

RESULTS

Among the 372 patients, 195 had chronic cervicitis, 131 had CIN1, 37 had CIN2/3, and nine had carcinoma. The immediate rates of CIN2 + lesions and CIN3 + lesions in patients who were not HR-HPV16/18-positive were comparable to those in patients who were HPV16/18-positive (P = 0.699). In addition, among patients diagnosed with CIN2 + lesions, 8 (17.39%) patients were women aged < 30 years. When pathological results were used as a reference, the consistency rate of colposcopy was 61.0% (227/372). Multivariate analyses revealed that age and the type of cervical transformation zone were independent factors affecting the accuracy of colposcopy (P < 0.001).

CONCLUSIONS

In countries with limited resources, immediate colposcopy referral should be recommended for patients who are cytology negative but HR-HPV-positive (including non-16/18 HR-HPV-positive), and cervical cancer screening via cotesting should be suggested for women aged < 30 years. Colposcopy has moderate diagnostic value and can be affected by age and the type of cervical transformation zone.

High-Risk Genotypes of Human Papillomavirus at Diverse Anogenital Sites among Chinese Women: Infection Features and Potential Correlation with Cervical Intraepithelial Neoplasia

BACKGROUND

Both cervical cancer and cervical intraepithelial neoplasia (CIN) are associated with human papillomavirus (HPV) infection at different anogenital sites, but the infection features of high-risk (HR) HPVs at these sites and their association with cervical lesions have not been well characterized. Given the limitation of cervical HPV 16/18 test in screening patients with high-grade CIN (CIN 2+), studies on whether non-16/18 HR-HPV subtype(s) have potential as additional indicator(s) to improve CIN 2+ screening are needed.

METHODS

The infection of 15 HR-HPVs in vulva, anus, vagina, and cervix of 499 Chinese women was analyzed, and CIN lesion-associated HR-HPV subtypes were revealed.

RESULTS

In addition to the well-known cervical-cancer-associated HPV 16, 52, and 58, HPV 51, 53, and 56 were also identified as high-frequency detected subtypes prevalently and consistently present at the anogenital sites studied, preferentially in multi-infection patterns. HPV 16, 52, 58, 56, and 53 were the top five prevalent subtypes in patients with CIN 2+. In addition, we found that cervical HPV 33/35/52/53/56/58 co-testing with HPV 16/18 might improve CIN 2+ screening performance.

CONCLUSION

This study provided a new insight into HR-HPV screening strategy based on different subtype combinations, which might be used in risk stratification clinically.

Assessing Disparities in Cervical Cancer Screening with Pap Test by Disability Types

Prior research has found that women with disabilities have often experienced disparities in receipt of cervical cancer screening. However, there is a research gap regarding receipt of cervical cancer screening by types of disability. This study examined the differences in receiving cervical cancer screening through self-reported Pap testing among women by disability type. This cross-sectional study analyzed data from the 2016, 2018, and 2020 Behavioral Risk Factor and Surveillance System (BRFSS). The relative risk of cervical cancer screening through self-reported Pap tests received within the past three years among women aged 21-65 by disability type was compared using modified Poisson regression with robust error variance. A total of 307,142 women from across the USA were sampled. In every disability group, older women were significantly less likely to receive Pap tests than their counterparts without disabilities. Women with multiple disabilities (aRR=0.91; 95% CI, 0.89-0.94) and those with ambulatory disabilities (aRR=0.93; 95% CI, 0.91-0.97) reported being less likely to receive Pap tests than women with no disability. Ambulatory disability and multiple disabilities are associated with a lower likelihood of cervical cancer screening with Pap test, increasing the need to eliminate disability-specific disparities in Pap testing. Future efforts should focus on improving cancer education programs tailored to the needs of women with disabilities, addressing barriers related to mobility and access to healthcare services, and ensuring equitable access to preventive screenings.

Persistent cervical cancer disparities among American Indian/Alaska Native women: a systematic scoping review exploring the state of the science in this population

PURPOSE

American Indian/Alaska Native (AI/AN) populations experience significantly higher incidence and mortality rates of cervical cancer. The objective of this systematic scoping review is to characterize the volume and nature of research being conducted specific to the AI/AN population regarding cervical cancer and related clinical themes.

METHODS

This scoping review was conducted in collaboration with the Pacific Northwest Evidence-based Practice Center. Search strategies identified eligible publications from 1990 through 4 February 2022. Two reviewers independently abstracted study data, including clinical area, number of participants and percent inclusion of AI/AN, intervention or risk factor, outcomes reported, Indian Health Service (IHS) Region, and funding source. We used published algorithms to assess study design.

RESULTS

Database searches identified 300 unique citations. After full-text evaluation of 129 articles, 78 studies and 9 secondary publications were included (total of 87). Approximately 74% of studies were observational in design, with cross-sectional methodology accounting for 42.7% of all included studies. The most common clinical theme was cervical cancer screening. The most common intervention/exposure was risk factor, typically race (AI/AN compared with other groups) (69%). For studies with documented funding sources, 67% were funded by the US Government.

CONCLUSION

Of the small number of publications identified, the majority are funded through government agencies, are descriptive and/or cross-sectional studies that are hypothesis generating in nature, and fail to represent the diversity of the AI/AN populations in the US. This systematic scoping review highlights the paucity of rigorous research being conducted in a population suffering from a greater burden of disease.

Chatbot-interfaced and cognitive-affective barrier-driven messages to improve colposcopy adherence after abnormal Pap test results in underserved urban women: A feasibility pilot study

Challenges in ensuring adherence to colposcopy and follow-up recommendations, particularly within underserved communities, hinder the delivery of appropriate care. Informed by our established evidence-based program, we sought to assess the feasibility and acceptability of a novel cognitive-affective intervention delivered through a Chatbot interface, aimed to enhance colposcopy adherence within an urban inner-city population. We developed the evidence-based intervention, CervixChat, to address comprehension of colposcopy's purpose, human papillomavirus (HPV) understanding, cancer-related fatalistic beliefs, procedural concerns, and disease progression, offered in both English and Spanish. Females aged 21-65, with colposcopy appointments at an urban OBGYN clinic, were invited to participate. Enrolled patients experienced real-time counseling messages tailored via a Chatbot-driven barriers assessment, dispatched via text one week before their scheduled colposcopy. Cognitive-affective measures were assessed at baseline and through a 1-month follow-up. Participants also engaged in a brief post-intervention satisfaction survey and interview to capture their acceptance and feedback on the intervention. The primary endpoints encompassed study adherence (CervixChat response rate and follow-up survey rate) and self-evaluated intervention acceptability, with predefined feasibility benchmarks of at least 70% adherence and 80% satisfaction. Among 48 eligible women scheduled for colposcopies, 27 (56.3%) agreed, consented, and completed baseline assessments. Participants had an average age of 34 years, with 14 (52%) identifying as non-Hispanic White. Of these, 21 (77.8%) engaged with the CervixChat intervention via mobile phones. Impressively, 26 participants (96.3%) attended their diagnostic colposcopy within the specified timeframe. Moreover, 22 (81.5%) completed the follow-up survey and a brief interview. Barriers assessment revealed notable encodings in the Affect and Values/Goals domains, highlighting concerns and understanding around HPV, as well as its impact on body image and sexual matters. Persistent and relatively high intrusive thoughts and lowered risk perceptions regarding cervical cancer were reported over time, unaffected by the intervention. Post-intervention evaluations documented high satisfaction and perceived usefulness, with recommendations for incorporating additional practical and educational content. Our findings underscore the robust satisfaction and practicality of the CervixChat intervention among a diverse underserved population. Moving forward, our next step involves evaluating the intervention's efficacy through a Sequential Multiple Assignment Randomized Trial (SMART) design. Enhanced by personalized health coaching, we aim to further bolster women's risk perception, address intrusive thoughts, and streamline resources to effectively improve colposcopy screening attendance.

Feasibility of 5-fluorouracil and imiquimod for the topical treatment of cervical intraepithelial neoplasias (CIN) 2/3

OBJECTIVES

To determine the feasibility (as measured by tolerability and safety) and efficacy of topical 5-fluorouracil (5-FU) and imiquimod for the treatment of cervical intraepithelial neoplasia (CIN) 2/3.

METHODS

This pilot prospective study was conducted in women aged 18-45 years with p16+ CIN 2/3. Participants underwent an 8-week alternating regimen of self-applied 5% 5-FU on weeks 1, 3, 5, and 7 and physician-applied imiquimod on weeks 2, 4, 6, and 8. Adverse events (AEs) were collected by symptom diary and clinical exam. Feasibility was measured by tolerability and safety (AEs) of the study intervention. Tolerability was assessed as the number of participants able to apply 50% or more of the treatment doses. The safety outcome was calculated as the number of participants who experienced "specified AEs" defined as possibly, probably, or definitely related grade 2 or worse AE or grade 1 genital AEs (blisters, ulcerations, or pustules) lasting more than 5 days. The efficacy of the intervention was determined by histology and high-risk human papillomavirus (hrHPV) testing was done after treatment.

RESULTS

The median age of the 13 participants was 27 ± 2.9 years. Eleven (84.61%) participants applied 50% or more of the treatment. All participants reported grade 1 AEs; 6 (46.15%) reported grade 2 AEs; and 0 reported grade 3/4 AEs. Three (23.08%) participants had specified AEs. Histologic regression to normal or CIN 1 among those completing 50% or more of the treatment doses was observed in 10 (90.91%) participants, and 7 (63.63%) tested negative for hr-HPV at the end of the study.

CONCLUSIONS

Topical treatment for CIN 2/3 with 5-FU/imiquimod is feasible, with preliminary evidence of efficacy. Topical therapies need further investigation as adjuncts or alternatives to surgical therapy for CIN 2/3.

A qualitative study of primary care clinician's approach to ending cervical cancer screening in older women in the United States

The United States Preventive Services Task Force (USPSTF) recommends that cervical cancer screening end in average-risk patients with a cervix at 65 years of age if adequate screening measures have been met, defined as having 1) at least three normal consecutive cytology (Pap) tests, or 2) two normal cytology tests and/or two negative high-risk human papillomavirus tests between ages 55-65; the last test should be performed within the prior 5 years. Up to 60 % of all women aged 65 years and older who are ending screening do not meet the criteria for adequate screening. The objective of this study was to understand the process and approach that healthcare clinicians use to determine eligibility to end cervical cancer screening. In 2021 we conducted semi-structured interviews in San Francisco, CA with twelve healthcare clinicians: two family medicine physicians, three general internal medicine physicians, two obstetrician/gynecologists and five nurse practitioners. Thematic analysis, using inductive and deductive coding, was utilized. Three major themes emerged: following guidelines, relying on self-reported data regarding prior screening, and considering sexual activity as a factor in the decision to end screening. All interviewees endorsed following the USPSTF guidelines and they utilized self-report to determine eligibility to end screening. Clinicians' approach was dependent in part on their judgement about the reliability of the patient to convey their screening history. Sexual activity of the patient was considered when making clinical recommendations. Shared decision-making was often utilized. Clinicians voiced a strong reliance on self-reported screening history to end cervical cancer screening.

Validation of an on-chip p16ink4a/Ki-67 dual immunostaining cervical cytology system using microfluidic device technology

More specific screening systems for cervical cancer may become necessary as the human papillomavirus (HPV) vaccine becomes more widespread. Although p16/Ki-67 dual-staining cytology has several advantages, it requires advanced diagnostic skills. Here, we developed an automated on-chip immunostaining method using a microfluidic device. An electroactive microwell array (EMA) microfluidic device with patterned thin-film electrodes at the bottom of each microwell was used for single-cell capture by dielectrophoresis. Immunostaining and dual staining for p16/Ki-67 were performed on diagnosed liquid cytology samples using the EMA device. The numbers of p16/Ki-67 dual-stained cells captured by the EMA device were determined and compared among the cervical intraepithelial neoplasia (CIN) lesion samples. Seven normal, fifteen CIN grade 3, and seven CIN grade 2 samples were examined. The percentage of dual-positive cells was 18.6% in the CIN grade 2 samples and 23.6% in the CIN grade 3 samples. The percentages of dual-positive staining increased significantly as the severity of the cervical lesions increased. p16/Ki67 dual immunostaining using the EMA device is as sensitive as the conventional method of confirming the histopathological diagnosis of cervical samples. This system enables a quantified parallel analysis at the individual cell level.

A cross-sectional survey examining clinician characteristics, practices, and attitudes associated with adoption of the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines

BACKGROUND

The 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) risk-based management consensus guidelines are the most recent national guidelines for the management of abnormal cervical cancer screening tests. These guidelines benefit patients by concentrating testing and treatment in those at highest cervical cancer risk. Adoption of guidelines often occurs slowly, with few studies examining the factors associated with guideline-adherent management of abnormal results.

METHODS

To elucidate the factors associated with the use of the 2019 ASCCP guidelines among clinicians who perform cervical cancer screening, physicians and advanced practice professionals who perform cervical cancer screening were cross-sectionally surveyed. Clinicians responded to screening vignettes with differing recommendations for management between the 2019 and prior management guidelines. Screening vignette 1 involved reduction of invasive testing on a low-risk patient; screening vignette 2 involved increased surveillance testing on a high-risk patient. Binomial logistic regression models determined the factors associated with the use of the 2019 guidelines.

RESULTS

A total of 1251 clinicians participated from across the United States. For screening vignettes 1 and 2, guideline-adherent responses were given by 28% and 36% of participants, respectively. Management recommendations differed by specialty and were incorrect in different situations: there was inappropriate invasive testing by obstetrics and gynecology physicians (vignette 1) and inappropriate discontinuation of screening by family and internal medicine physicians (vignette 2). Regardless of their chosen response, over half erroneously believed they were guideline adherent.

CONCLUSIONS

Many clinicians who believe they are following appropriate guidelines may not realize their management strategy is inconsistent with the 2019 guidelines. Education initiatives tailored to clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.

PLAIN LANGUAGE SUMMARY

The 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines are the most recent national guidelines for abnormal cervical cancer screening test management. We surveyed over 1200 obstetrics and gynecology (OB/GYN), family medicine, and internal medicine physicians and advanced practice providers about their screening and abnormal results follow-up practices in relation to guidelines. Few clinicians are following the 2019 guidelines. Management recommendations differed by clinician specialty and were incorrect in different situations: there was inappropriate invasive testing by OB/GYN physicians and inappropriate screening discontinuation by family and internal medicine physicians. Education tailored by clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.

Reproductive late effects after hematopoietic stem cell transplant in pediatric, adolescent, and young adult cancer survivors

Reproductive late effects after hematopoietic stem cell transplant can have a significant impact on cancer survivors' quality of life. Potential late effects include gonadal insufficiency, genital graft-versus-host disease, uterine injury, psychosexual dysfunction, and an increased risk of breast and cervical cancer in patients treated with total body irradiation. Despite guidelines, screening and treatment are not standardized among at-risk patients. Provider barriers include lack of knowledge of at-risk therapies and evidenced-based guidelines. Patient barriers include a reluctance to report symptoms and lack of awareness of treatment options. System barriers include inefficient implementation of screening tools and poor dissemination of guidelines to providers who serve as the medical home for survivors. This review guides the clinician in identifying and managing reproductive late effects after hematopoietic stem cell transplant to improve outcomes.

Cervical Cancer Screening: Evolution of National Guidelines and Current Recommendations

Cancer of the cervix is preventable through vaccination against human papillomavirus and by screening and treatment of cervical precancers. Cervical cancer screening has evolved since the Pap smear was first discovered in the 1920s. Current guidelines from the US Preventive Services Task Force and the American Cancer Society incorporate the use of cervical cytology and high-risk human papillomavirus tests performed every 3 to 5 years for screening in average-risk asymptomatic patients. Testing should begin at age 21 to 25 years old and stop at 65 years old if sufficient cessation criteria has been met.

Efficiency of CIN2+ Detection by Thyrotropin-Releasing Hormone (TRH) Site-Specific Methylation

Cervical cancer screening typically involves a Pap smear combined with high-risk human papillomavirus (hr-HPV) detection. Women with hr-HPV positivity but normal cytology, as well as those with precancerous abnormal cytology, such as low-grade squamous intraepithelial lesions (LSIL) and high-grade SIL (HSIL), are referred for colposcopy and histology examination to identify abnormal lesions, such as cervical intraepithelial neoplasia (CIN) and cervical cancer. However, in order to enhance the accuracy of detection, bioinformatics analysis of a microarray database was performed, which identified cg01009664, a methylation marker of the thyrotropin-releasing hormone (TRH). Consequently, a real-time PCR assay was developed to distinguish CIN2+ (CIN2, CIN3, and cervical cancer) from CIN2- (CIN1 and normal cervical epithelia). The real-time PCR assay utilized specific primers targeting methylated cg01009664 sites, whereas an unmethylated reaction was used to check the DNA quality. A cut-off value for the methylated reaction of Ct < 33 was established, resulting in improved precision in identifying CIN2+. In the first cohort group, the assay demonstrated a sensitivity of 93.7% and a specificity of 98.6%. In the cytology samples identified as atypical squamous cells of undetermined significance (ASC-US) and LSIL, the sensitivity and specificity for detecting CIN2+ were 95.0% and 98.9%, respectively. However, when self-collected samples from women with confirmed histology were tested, the sensitivity for CIN2+ detection dropped to 49.15%, while maintaining a specificity of 100%. Notably, the use of clinician-collected samples increased the sensitivity of TRH methylation testing. TRH methylation analysis can effectively identify women who require referral for colposcopy examinations, aiding in the detection of CIN2+.

Cytological DNA methylation for cervical cancer screening: a validation set

Background

In a previous training set with a case-controlled design, cutoff values for host EPB41L3 and JAM3 gene methylation were obtained for the detection of cervical intraepithelial neoplasia (CIN) 2 or more severe lesions (CIN2+). This validation trial was conducted to evaluate the role of DNA methylation in screening for CIN2+ by cervical cytology among unselected participants.

Methods

From June 1, 2019, to September 1, 2019, in our study center, we collected liquid-based samples from cervical swabs for methylation assays and hrHPV testing in eligible patients. The primary endpoint was the diagnostic accuracy of DNA methylation and hrHPV genotyping for CIN2+ according to confirmed histology results.

Results

Among 307 participants, compared with hrHPV testing, the methylation assay for CIN2+ had lower sensitivity (68.7% versus 86.1%, p=0.002) but higher specificity (96.7% versus 0.696, p<0.001). The methylation assay also had favorable sensitivity and specificity in patients with negative hrHPV testing (56.3% and 96.9%) and in patients with cervical adenocarcinoma (73.7% and 92.7%). DNA methylation had higher specificity than the hrHPV assay (100.0% versus 44.4%, p<0.001) for identifying residual CIN2+ in patients without residual lesions. Positive cervical DNA methylation was associated with a diagnostic probability of endometrial carcinoma (odds ratio 15.5 [95% confidence interval 4.1-58.6]) but not of ovarian epithelial carcinoma (1.4 [0.3-6.5]).

Conclusions

The host EPB41L3 and JAM3 gene methylation assay in cervical cytology had favorable diagnostic accuracy for CIN2+ and was highly specific for residual CIN2+ lesions The methylation assay is a promising triage tool in hrHPV+ women, or even an independent tool for cervical cancer screening. The methylation status in cervical cytology could also serve as a prognostic biomarker. Its role in detecting endometrial carcinomas is worthy of further exploration.

Impact of HPV testing in opportunistic cervical screening: Support for primary HPV screening in the United States

Human papillomavirus (HPV) testing for cervical screening increases diagnosis of precancer and reduces the incidence of cervical cancer more than cytology alone. However, real-world evidence from diverse practice settings is lacking for the United States (U.S.) to support clinician adoption of primary HPV screening. Using a population-based registry, which captures all cervical cytology (with or without HPV testing) and all cervical biopsies, we conducted a real-world evidence study of screening in women aged 30 to 64 years across the entire state of New Mexico. Negative cytology was used to distinguish cotests from reflex HPV tests. A total of 264 198 cervical screening tests (with exclusions based on clinical history) were recorded as the first screening test between 2014 and 2017. Diagnoses of cervical intraepithelial neoplasia grades 2 or 3 or greater (CIN2+, CIN3+) from 2014 to 2019 were the main outcomes. Of cytology-negative screens, 165 595 (67.1%) were cotests and 4.8% of these led to biopsy within 2 years vs 3.2% in the cytology-only group. Among cytology-negative, HPV tested women, 347 of 398 (87.2%) CIN2+ cases were diagnosed in HPV-positive women, as were 147 of 164 (89.6%) CIN3+ cases. Only 29/921 (3.2%) CIN3+ and 67/1964 (3.4%) CIN2+ cases were diagnosed in HPV-negative, cytology-positive women with biopsies. Under U.S. opportunistic screening, across a diversity of health care delivery practices, and in a population suffering multiple disparities, we show adding HPV testing to cytology substantially increased the yield of CIN2+ and CIN3+. CIN3+ was rarely diagnosed in HPV-negative women with abnormal cytology, supporting U.S. primary HPV-only screening.

Performance of p16/Ki67 Immunostaining for Triage of Elderly Women with Atypical Squamous Cells of Undetermined Significance

BACKGROUND

The p16/Ki67 technique has been poorly studied in postmenopausal women with ASC-US cytology. The objective of this study was to compare the accuracy of p16/Ki67 staining, HPV testing and HPV 16 genotyping for the identification of CIN2 + lesions in postmenopausal women with ASC-US cytology.

METHOD

A total of 324 postmenopausal women with positive ASC-US were included. The women underwent HPV test, colposcopy, and biopsy. The slides were discolored and then stained with the CINtec Plus Kit for p16/Ki67. The HPV test results were classified as HPV16 +, hrHPV+ (other hrHPV genotypes), or HPV negative.

RESULTS

The p16/Ki67 sensitivity for CIN2+ was 94.5%, the specificity 86.6%, PPV of 59% and NPV of 95.9%. The HPV test showed a sensitivity of 96.4% for CIN2+, a specificity of 62.8%, a PPV of 35% and a NPV of 98.8%. In postmenopausal women, the prevalence of genotype 16 decreases in favor of the other high-risk genotypes.

CONCLUSION

Given the low sensitivity of cytology and the low percentage of HPV16-positive cancers among elderly women, triage via cytology and genotyping is not the best strategy; double staining cytology shows high profiles of sensibility and specificity for CIN2+ in ASCUS postmenopausal women.

Provider- and Facility-Level Variation in Precancerous Cervical Biopsy Diagnoses

OBJECTIVES

Reproducibility of cervical biopsy diagnoses is low and may vary based on where the diagnostic test is performed and by whom. Our objective was to measure multilevel variation in diagnoses across colposcopists, pathologists, and laboratory facilities.

METHODS

We cross-sectionally examined variation in cervical biopsy diagnoses within the 5 sites of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR I) consortium within levels defined by colposcopists, pathologists, and laboratory facilities. Patients aged 18 to 65 years with a colposcopy with biopsy performed were included, with diagnoses categorized as normal, cervical intraepithelial neoplasia grade 1 (CIN1), grade 2 (CIN2), and grade 3 (CIN3). Using Markov Chain Monte-Carlo methods, we fit mixed-effects logistic regression models for biopsy diagnoses and presented median odds ratios (MORs), which reflect the variability within each level. Median odds ratios can be interpreted as the average increased odds a patient would have for a given outcome (e.g., CIN2 or CIN3 vs normal or CIN1) when switching to a provider with higher odds of diagnosing that outcome. The MOR is always 1 or greater, and a value of 1 indicates no variation in outcome for that level, with higher values indicating greater variation.

RESULTS

A total of 130,110 patients were included who received care across 82 laboratory facilities, 2,620 colposcopists, and 489 pathologists. Substantial variation in biopsy diagnoses was found at each level, with the most occurring between laboratory facilities, followed by pathologists and colposcopists. Substantial variation in biopsy diagnoses of CIN2 or CIN3 (vs normal or CIN1) was present between laboratory facilities (MOR: 1.26; 95% credible interval = 1.19-1.36).

CONCLUSIONS

Improving consistency in cervical biopsy diagnoses is needed to reduce underdiagnosis, overdiagnosis, and unnecessary treatment resulting from variation in cervical biopsy diagnoses.

Cervical Cancer Screening

Cervical cancer screening is an essential component of preventative health care. Although rates of cervical cancer have decreased over the last 50 years, survival has not changed dramatically, and there are significant discrepancies in disease detection by race. Multiple national organizations contribute to the recommendations for cervical cancer screening timing, testing modalities, and management. This article aims to summarize the current understanding of cervical cancer pathogenesis, options for cervical cancer screening, and the shift in guidelines toward risk-based clinical management.

Tse KY, Ushijima K, Tan AL, Intasorn P, Pariyar J, Chang CL, Domingo EJ, Konar H, Kumarasamy S, Tjokroprawiro BA, Wilailak S. A questionnaire study on disparity of cervical cancer prevention programs in Asia-Oceania

BACKGROUND

Despite the introduction of cervical cancer screening and human papillomavirus (HPV) vaccines, the utilization pattern was not standardized. The aim of this study was to elicit the current prevention care in Asia-Oceania.

METHODS

An online questionnaire was circulated to different countries/cities in Asia-Oceania. The primary objective was to evaluate the coverage of HPV vaccination and cervical screening programs. The secondary objectives were to study the structures of these programs. Five case scenarios were set to understand how the respondents manage the abnormal screening results.

RESULTS

Fourteen respondents from 10 countries/cities had participated. Cervical cancer ranked the first in Myanmar and Nepal. About 10%-15% did not have national vaccination or screening program. The estimated coverage rate for vaccination and screening varied from less than 1% to 70%, which the coverage ran in parallel with the incidence and mortality rates of cervical cancer. All regions approved HPV vaccines, although only four provided free or subsidized programs for nonavalent vaccine. Cervical cytology remained the most common screening tool, and 20%-30% relied heavily on visual inspection using acetic acid. The screening age groups varied in different regions. From the case scenarios, it was noted that some respondents tended to offer more frequent screening tests or colposcopy than recommended by international guidelines.

CONCLUSION

This study revealed discrepancy in the practice of cervical cancer prevention in Asia-Oceania especially access to HPV vaccines. There is an urgent need for a global collaboration to eliminate cervical cancer by public education, reforming services, and medical training.

Positive pathological margins after loop electrosurgical excision procedure - Management and outcome

OBJECTIVE

Pathological involvement of cervical conization margins is a risk factor for recurrence, although management of these patients is controversial. We aimed to define risk factors for positive margins and compare recurrence following additional surgical intervention compared to conservative management.

METHODS

A retrospective study of all conizations at our center between 2010 and 2019. Univariate analysis identified characteristics associated with positive margins. Women were stratified by mode of management comparing three groups (surveillance, repeat conization or hysterectomy) then two groups (surveillance vs. additional surgery). Kaplan Meyer survival curves compared cumulative recurrence stratified by mode of management. Pathological results of subsequent surgical procedures were examined for residual disease.

RESULTS

Of 448 conizations performed, 131 (29.2%) had positive margins which were associated with menopause, high-grade cytology and endocervical gland involvement. Women who underwent surveillance (n = 45) were more likely to be nulliparous, with low-grade histology and less endocervical gland involvement. Women who underwent hysterectomy (n = 61) were more likely to be postmenopausal and parous. Recurrence did not differ significantly in the three-group (p = 0.073) or two-group model (6.4% vs. 7.1% p = 0.869). Kaplan Meyer survival curves depicting cumulative recurrence did not differ significantly in either model (log rank test p = 0.642 for the three-group model, and p = 0.868 for the two-group model). Residual disease was found in 51.6% of hysterectomy specimens and 52.6% of repeat conizations.

CONCLUSION

Surveillance is non-inferior to additional surgery in cases with positive conization margins and constitutes a valid option specifically for younger women at risk of future obstetric complications and those susceptible post-hysterectomy complications.

Significant outcomes associated with high-risk human papillomavirus negative Papanicolaou tests

INTRODUCTION

The 2020 American Cancer Society guidelines preferred primary human papillomavirus (HPV) screening for cervical cancer prevention. Studies investigating the role of cytology in detection of cervical precancer/cancer have focused on high-grade squamous intraepithelial lesion (HSIL) or worse interpretations. Here, we have examined the significance of all those cytology results that require histologic follow-up as per the current management guidelines, regardless of the HPV test result.

MATERIALS AND METHODS

A database search (September 2010 to December 2019) retrieved cervical Papanicolaou tests with any of the following interpretations: ≥ atypical squamous cells - cannot exclude HSIL or low-grade squamous intraepithelial lesion, HSIL cannot be excluded, and ≥ atypical glandular cells, not otherwise specified and its subcategories. Of these, those with concurrent negative HPV test result were included for further analysis. For this cohort, relevant clinical history and histologic follow-up (within 1 year) were recorded.

RESULTS

The study cohort comprised 763 patients. Of them, 586 (76.8%) patients had histologic follow-up: 53 (9.0%) had ≥ HSIL/adenocarcinoma in situ; of which, 43 (81.1%) had prior abnormal cytology/histology/not otherwise specified history and/or HPV positivity, and 66 (11.3%) had HPV-unassociated neoplasia; of which, 60 (90.9%) had a known diagnosis or clinical signs/symptoms of the disease.

CONCLUSION

With widespread adoption of risk-based approach to management, the role of cytology, by itself, will likely diminish in the detection of HPV-associated lesions. Additional data regarding the role of cytology in the screening of patients with no/unknown/limited history and in the detection/management of HPV-independent lesions may be helpful for designing future screening guidelines.

Evaluation of CD4+ cells infiltration as a prognostic factor in cervical intraepithelial neoplasia 2

OBJECTIVE

To identify candidate predictors for the prognosis of cervical intraepithelial neoplasia 2 (CIN2) lesions and evaluate the prognostic value of the local immune response.

METHODS

One hundred fifteen CIN2 patients were enrolled. The percentage of p16-, minichromosome maintenance complex component 2- or apolipoprotein B mRNA editing enzyme catalytic subunit 3G (APOBEC3G)-positive cells was determined immunohistochemically. Tumor-infiltrating lymphocytes (TILs) in intertumoral lesions were scored using an automated system. CIN3 disease progression and regression rates were estimated by the Kaplan-Meier method. A case-control study was conducted to screen CIN2 prognostic factors in 10 regression and 10 progression patients. Selected factors were examined in a cohort study to determine their prognostic value for CIN2.

RESULTS

Among all participants, the cumulative progression and regression rates at 60 months were 0.477 and 0.510, respectively. In the case-control study, p16- and APOBEC3G-positive cells were higher in the progression group (p=0.043, p=0.023). Additionally, CD4⁺ cell infiltration was enhanced in the regression group (p=0.023). The cohort study revealed a significantly increased progression rate in patients with elevated p16-positive cells (p<0.001), and increased CD4⁺ TIL infiltration was associated with better regression (p=0.011). Kaplan-Meier analysis according to human papillomavirus (HPV) positivity revealed a greater CIN3 development risk in HPV16-positive patients than in HPV16-negative cases. Finally, multivariate analysis identified HPV16 infection and CD4⁺ TIL infiltration as independent prognostic factors in CIN2 regression.

CONCLUSION

CD4⁺ TIL infiltration in intertumoral lesions was related with CIN2 regression. Our findings suggest CD4⁺ TIL infiltration may be useful for the triage of CIN2 patients.

Use Trends and Recent Expenditures for Cervical Cancer Screening-Associated Services in Medicare Fee-for-Service Beneficiaries Older Than 65 Years

Importance

Since 1996, the US Preventive Services Task Force has recommended against cervical cancer screening in average-risk women 65 years or older with adequate prior screening. Little is known about the use of cervical cancer screening-associated services in this age group.

Objective

To examine annual use trends in cervical cancer screening-associated services, specifically cytology and human papillomavirus (HPV) tests, colposcopy, and cervical procedures (loop electrosurgical excision procedure, cone biopsy, and ablation) in Medicare fee-for-service beneficiaries during January 1, 1999, to December 31, 2019, and estimate expenditures for services performed in 2019.

Design, Setting, and Participants

This population-based, cross-sectional analysis included health service use data across 21 years for women aged 65 to 114 years with Medicare fee-for-service coverage (15-16 million women per year). Data analysis was conducted between July 2021 and April 2022.

Main Outcomes and Measures

Proportion of testing modalities (cytology alone, cytology plus HPV testing [cotesting], HPV testing alone); annual use rate per 100 000 women of cytology and HPV testing, colposcopy, and cervical procedures from 1999 to 2019; Medicare expenditure for these services in 2019.

Results

There were 15 323 635 women 65 years and older with Medicare fee-for-service coverage in 1999 and 15 298 656 in 2019. In 2019, the mean (SD) age of study population was 76.2 (8.1) years, 5.1% were Hispanic, 0.5% were non-Hispanic American Indian/Alaska Native, 3.0% were non-Hispanic Asian/Pacific Islander, 7.4% were non-Hispanic Black, and 82.0% were non-Hispanic White. From 1999 to 2019, the percentage of women who received at least 1 cytology or HPV test decreased from 18.9% (2.9 million women) in 1999 to 8.5% (1.3 million women) in 2019, a reduction of 55.3%; use rates of colposcopy and cervical procedures decreased 43.2% and 64.4%, respectively. Trend analyses showed a 4.6% average annual reduction in use of cytology or HPV testing during 1999 to 2019 (P < .001). Use rates of colposcopy and cervical procedures decreased before 2015 then plateaued during 2015 to 2019. The total Medicare expenditure for all services rendered in 2019 was about $83.5 million. About 3% of women older than 80 years received at least 1 service at a cost of $7.4 million in 2019.

Conclusions and Relevance

The results of this cross-sectional study suggest that while annual use of cervical cancer screening-associated services in the Medicare fee-for-service population older than 65 years has decreased during the last 2 decades, more than 1.3 million women received these services in 2019 at substantial costs.

Prevention of Cervical Cancer in Low-Resource African Settings

Cervical cancer is a leading cause of cancer among women. Approximately 350,000 women die from cervical needlessly from cancer each year, and 85% of the global burden occurs in low- and middle-income countries (LMICs). Disparities in the incidence and mortality between LMICs and industrialized countries can be attributed to differences in access to human papillomavirus (HPV) vaccination and cervical cancer screening and treatment. The World Health Organization (WHO) is leading a renewed international effort to reduce the global burden of cervical cancer. In this article, we discuss recommendations for HPV vaccination, primary HPV screening, and treatment of precancerous lesions.

Association of Swede Score and 2011 IFCPC Nomenclature in Women with Abnormal Cytology

OBJECTIVE

 To assess the association between two colposcopic indices, the Swede score and the 2011 International Federation of Cervical Pathology and Colposcopy (IFCPC) Nomenclature as well as to determine the efficacy of the Swede score with cutoffs of 7 and 8.

METHODS

 In the present cross-sectional pilot study, 34 women who had at least 1 colposcopy-directed biopsy due to abnormal cytology were enrolled. The colposcopic findings were scored by both the Swede score and the 2011 IFCPC Nomenclature and were compared with each other. The Kappa coefficient and the McNemar test were used. Accuracy, sensitivity, specificity, and positive and negative predictive values (NPV and PPV, respectively) were calculated, as well as the effectiveness with cutoffs of 7 and 8 in identifying cervical intraepithelial neoplasm (CIN) 2+ when using the Swede score.

RESULTS

 The correlation between the 2 colposcopic indices was 79.41%. The Kappa coefficient and the McNemar p-value were 0.55 and 0.37, respectively. The IFCPC Nomenclature had sensitivity, specificity, accuracy, PPV, and NPV of 85.71, 55.00, 67.64, 57.14, and 84.61%, respectively. The Swede score had sensitivity, specificity, accuracy, PPV, and NPV of 100, 63.15, 79.41, 68.18, and 100%, respectively. A Swede score cutoff of 7 for CIN 2+ detection had a specificity of 94.73%, while with a cutoff of 8 it increased to 100%. The sensitivity for both values was 60%. The PPV and NPV for cutoffs of 7 and 8 were 90 and 75 and 100 and 76%, respectively.

CONCLUSION

 Although both colposcopic indices have good reproducibility, the Swede score showed greater accuracy, sensitivity, and specificity in identifying CIN 2 + , especially when using a cutoff of 8.

Which is the best management for women with normal cervical cytologic findings despite positivity for non-16/18 high risk human papillomaviruses?

Women who test positive for the human papillomavirus (HPV) but have normal cytology constitute the predominant subgroup of patients in the screening population in the post-vaccination era. The distribution of HPV genotypes changed dramatically, which was attributable to an increase in HPV vaccination coverage. These changes have created uncertainty about how to properly manage women with normal cytology, non-HPV16/18 infections, or persistent infections. Current recommendations include retesting and continued surveillance in the absence of HPV16/18 infection. However, these are not always applicable. The ability to implement genotyping or incorporate HPV16/18 with some additional high-risk HPV (HR-HPV) types for triage and management with the aim of identifying type-specific risks in this population could be acceptable. When the next set of guidelines is updated, generating potential triage strategies for detecting high-grade cervical lesions, such as the p16/Ki67 cytology assay and other alternatives that incorporate genotyping with newer tests, should be considered. Current clinical management is shifting to risk-based strategies; however, no specific risk threshold has been established in this population. Importantly, innovative triage testing should be evaluated in combination with primary screening and management. Furthermore, there is an untapped opportunity to coordinate HPV genotyping in combination with colposcopic characteristics to modify risk in this group. Hence, providing a more personalized schedule through the efficient application of risk stratification and improving the detection of pre-cancer and cancer is an option worth exploring.

Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Guideline Update

PURPOSE

To update resource-stratified, evidence-based recommendations on secondary prevention of cervical cancer globally.

METHODS

American Society of Clinical Oncology convened a multidisciplinary, multinational Expert Panel to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, formal consensus-based process, and modified ADAPTE process to adapt existing guidelines was conducted. Other experts participated in formal consensus.

RESULTS

This guideline update reflects changes in evidence since the previous update. Five existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement.

RECOMMENDATIONS

Human papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies vary by the following setting: maximal: age 25-65 years, every 5 years; enhanced: age 30-65 years, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: age 30-49 years, every 10 years; basic: age 30-49 years, one to three times per lifetime. For basic settings, visual assessment is used to determine treatment eligibility; in other settings, genotyping with cytology or cytology alone is used to determine treatment. For basic settings, treatment is recommended if abnormal triage results are obtained; in other settings, abnormal triage results followed by colposcopy is recommended. For basic settings, treatment options are thermal ablation or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure or ablation is recommended; with a 12-month follow-up in all settings. Women who are HIV-positive should be screened with HPV testing after diagnosis, twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in basic settings; in other settings, screening is recommended at 6 months. In basic settings without mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.Additional information is available at www.asco.org/resource-stratified-guidelines.

Impact of an educational tool on young women's knowledge of cervical cancer screening recommendations

PURPOSE

Current cervical cancer screening guidelines recommend 3-year screening intervals, in contrast to the previous recommendation of annual screening, to prevent over screening and overtreatment. We evaluated the impact of viewing a tablet-based educational tool prior to seeing a clinician on young women's knowledge and understanding of cervical cancer screening, HPV vaccination follow-up of abnormal pap smears, and comfort in communicating with their providers.

METHODS

This cross-sectional study was part of a cluster-randomized study of fourteen primary care clinics from January 2015 to December 2016. We developed the cervical cancer education tool in English and Spanish using a community-based approach that included formative work and cognitive interviewing. Clinics were randomized to use the intervention (tablet-based patient education tool) or to participate as a control group. We administered surveys to a convenience sample of 229 English- or Spanish-speaking women aged 19 to 35 years in these clinics. We used descriptive analyses and logistic regression models with cluster-robust standard errors to compare differences among the two groups.

RESULTS

Compared to women seen in control clinics, women seen in intervention clinics demonstrated greater knowledge regarding human papilloma virus (HPV (p = 0.004) and understanding (p < 0.001) of cervical cancer screening. Comfort in communicating with providers was not statistically different (p = 0.053). Women in the intervention group felt that the tool helped them understand that an abnormal Pap smear does not require immediate treatment (61.5%).

CONCLUSION

Innovative online patient education that is offered prior to patients' interaction with their clinicians can improve their knowledge about cervical cancer prevention and treatment.

The concordance between colposcopic biopsy and loop electrosurgical excision procedures in patients with known smear cytology and human papillomavirus results

Objective:

The objective of the study was to evaluate the concordance between colposcopic biopsy and loop electrosurgical excision procedure (LEEP) methods to diagnose cervical pre-invasive lesions and cervical cancer, and to calculate the low and high prediction rates of lesions for both methods.

Methods:

A total of 241 patients who underwent LEEP after colposcopic biopsy for different indications and also known cervical cytology and human papillomavirus test results were included in the study. Clinical variables such as age, gravida, parity, menopausal status, smoking, endocervical curettage results, and surgical margins were recorded.

Results:

The total concordance between colposcopic biopsy and LEEP was 41.9%. The rates of finding a more serious lesion than in colposcopic biopsy with LEEP (underestimation) for negative, Cervical Intraepithelial Neoplasia (CIN) 1, CIN 2, and CIN 3 were calculated as 100%, 12.8%, 14.8%, and 3.9%, respectively. Rates of finding a less serious lesion than detected in colposcopic biopsy with LEEP (overestimation) for CIN 1, CIN 2, and CIN 3, cervical carcinoma were calculated as 56.4%, 33.3%, 3.9%, and 0%, respectively. Underestimation was seen in a total of 28 patients, and overestimation was present in 113 patients. Parity was found to be the only associated factor that affected the final diagnosis for high-grade lesions in univariate logistic regression analysis (odds ratio=1.234, 95% confidence interval: 1.005–1.514).

Conclusion:

Discrepancies between colposcopically directed punch biopsy and subsequent histopathologic LEEP findings are common. New methods to reduce the inconsistency between colposcopic biopsy and LEEP are necessary to prevent patients from being under or over treated.

The Potential Impact of High-Risk Human Papillomavirus-Negative Cervical Intraepithelial Neoplasia 2+ on Primary Human Papillomavirus Screening

OBJECTIVES

To investigate the prevalence of high-risk human papillomavirus (HPV)-negative cervical intraepithelial neoplasia (CIN) and invasive cervical carcinoma (ICC) and to analyze the distribution of other genotypes in this subset.

METHODS

In total, 431 women who underwent excisional surgical treatment for CIN or ICC at the European Institute of Oncology, Milan, Italy, from January 2016 to December 2017 were retrospectively analyzed. The Linear Array HPV genotyping test (Roche Diagnostics) was performed on a postaliquot from high-risk-HPV-negative liquid-based cervical specimens, when available. Patient characteristics and the prevalence of high-risk-HPV-negative CIN grade 2 or worse (CIN2+) were tabulated. We used t tests to compare age between high-risk-HPV-positive and high-risk-HPV-negative patients.

RESULTS

Overall, 8.9% of CIN2+ and 7.5% of ICC cases were high-risk HPV negative. There was no age difference between high-risk-HPV-negative CIN2+ women (mean [SD], 41.3 [8.7] years) and high-risk-HPV-positive women (mean [SD], 39.5 [9.0] years) (P = .28). The Linear Array result was available in 22 cases. Most high-risk-HPV-negative patients were positive for a single other genotype infection (32.6%). HPV 73 was the most prevalent genotype, followed by HPV 53 and HPV 84. HPV 26 was detected in 1 case of ICC.

CONCLUSIONS

Our results showed a not-negligible proportion of high-risk-HPV-negative CIN2+, suggesting that cotesting would not miss these cases.

Does mailing unsolicited HPV self-sampling kits to women overdue for cervical cancer screening impact uptake of other preventive health services in a United States integrated delivery system?

Women overdue for cervical cancer screening often have other preventive care gaps. We examined whether mailing unsolicited human papillomavirus (HPV) self-sampling kits to increase cervical cancer screening impacted receipt of other preventive services women were due for: mammography, colorectal cancer (CRC) screening, influenza vaccination, depression screening, and diabetic HbA1c monitoring. From 2014 to 2016, 16,590 underscreened women were randomized to receive a mailed kit or usual care Pap reminders within Kaiser Permanente Washington. We used logistic regression to estimate odds ratios (ORs) of preventive services receipt within 12-months between the intervention vs. control arms, and within the intervention arm (comparing those returning a kit vs. attending Pap vs. nothing), adjusting models for demographic variables. There were no significant between-arm differences in uptake of any of the preventive services: intervention vs. control: mammography OR = 1.01 (95% confidence interval:0.88-1.17), CRC screening OR = 0.98 (0.86-1.13), influenza vaccination OR = 0.99 (0.92-1.06), depression screening OR = 1.07 (0.99-1.16), HbA1c OR = 0.84 (0.62-1.13). Within the intervention arm, preventive services uptake was higher in women who completed cervical cancer screening vs. did not, with stronger effects for women who attended Pap: Pap vs. nothing: mammography OR = 11.81 (8.11-17.19), CRC screening OR = 7.31 (5.57-9.58), influenza vaccination OR = 2.06 (1.82-2.32), depression screening OR = 1.79 (1.57-2.05), HbA1c OR = 3.35 (1.49-7.52); kit vs. nothing: mammography OR = 2.26 (1.56-3.26), CRC screening OR = 5.05 (3.57-7.14), influenza vaccination OR = 1.67 (1.41-1.98), depression screening OR = 1.09 (0.89-1.33), HbA1c OR = 1.23 (0.57-2.65). Mailing HPV self-sampling kits to underscreened women did not negatively impact uptake of other preventive services. However, overall preventive service uptake was the highest among women who attended in-clinic cervical cancer screening.

Unindicated cervical cancer screening in adolescent females within a large healthcare system in the United States

BACKGROUND

Current consensus recommendations are to not initiate cervical cancer screening for immunocompetent adolescent females before 21 years of age. This is in part because of the very low rate of 0.8 per 100,000 new cervical cancer cases diagnosed among women aged between 20 to 24 years. Timely human papillomavirus vaccination further decreases the incidence of cervical cancer to 4 cases per 100,000 persons by the age of 28 years. Screening before 21 years of age has demonstrated no clear benefit in cancer risk reduction or outcomes. In addition, unindicated screening among adolescents can lead to patient harm and increasing costs to the healthcare system.

OBJECTIVE

It is important to assess the rates of overutilization of cervical cancer screening and to identify areas where improvements have occurred and where further opportunities exist. This study aimed to assess the trends over time and the practice and provider factors associated with unindicated cervical cancer screening tests in adolescent females within the largest healthcare system in the state.

STUDY DESIGN

Cross-sectional data from patients aged 13 to 20 years who underwent cervical cancer screening between January 1, 2012, and December 31, 2018, across a large multihospital health system were reviewed. All cervical cancer screening results were included. The incidence rate of unindicated screening was analyzed over 6-month intervals using the Poisson regression analysis.

RESULTS

The study included data from 118 providers and 794 women. Among the 900 screening results, most (90%) were unindicated: 87% with unindicated cytology testing alone and 14% with unindicated human papillomavirus testing. Screening tests were collected from patients aged 13 to 20 years, many of whom had multiple unindicated cytology tests, with 25 patients having ≥3 tests before the age of 21 years. Most results of cytology testing were negative for intraepithelial lesion or malignancy (77%). Moreover, 52 invasive diagnostic or therapeutic procedures (49 colposcopies and 3 conizations) were performed, of which 45 (87%) followed an unindicated screening test. Between 2012 and 2018, the incidence rate of unindicated cytology decreased by 33% (12.6 to 8.5 unindicated cytology per 1000 encounters). The incidence rate of unindicated screening was lower in the academic setting than in the community setting (incidence rate ratio, 0.43; P<.01). Even with decreases in the overall rates of unindicated screening throughout the study period, there were still 58 unindicated screening tests performed in the final year of this study.

CONCLUSION

Despite substantial reductions in unindicated screening for women aged <21 years, there remained areas for improvement. Our data reflected practices of guideline nonadherence up to 7 years after the 2012 guideline. Now, with a new series of changes to the guidelines, which may be even more challenging for patients and providers, it is more important than ever to utilize evidence-based strategies to improve guideline dissemination and adherence.

Evaluation of Pre-malignant Lesions of the Uterine Cervix by Shear Wave Elastography: A New Diagnostic Tool

The objective of the study was to evaluate the difference in the stiffness between a healthy cervix (no pre-invasive lesions [NPILs]) and a cervix with a pre-invasive lesion (PIL). In the PIL group, we determined whether there was a difference in stiffness between the cervix with persistent low-grade lesions (>2 y, LSIL-persistent) and that with high-grade lesions (HSILs). Evaluation was performed using 2-D shear-wave elastography (SWE) in the midsagittal-plane of the uterine cervix (UC) at 0.5 cm (cervical canal, anterior and posterior cervical lips). In this prospective observational study (consecutive series), we evaluated 96 non-pregnant women: a group with PIL (LSIL-persistent, 22 cases; HSIL, 26 cases) with indications for cervical conization (48 cases) and a group without UC pathology (NPIL, 48 cases). Although we did not observe statistically significant differences (SSDs) in epidemiological characteristics, we did find an SSD in the speed and stiffness between the PIL versus NPIL groups at all evaluated depths (speed: 4.1 m/s vs 3.0 m/s, stiffness: 58.6 and 34.5kPa in the PIL and NPIL groups, respectively, p < 0.001). An SSD in speed and stiffness (speed: 4.9 m/s vs. 3.2 m/s, and stiffness: 76.1 and 38.0 kPa) between the HSIL (26 cases) and LSIL-persistent (22 cases) groups, respectively, was also detected (p < 0.001). The area under the curve of speed differentiation between a cervix with HSILs and without lesions was 73.4% (95% confidence interval [CI]: 63.1-83.7), and the best cutoff of speed was 3.25 m/s (sensitivity = 62.5%, 95% CI: 47.3-76.0), with a specificity of 75.5% (95% CI: 60.4-87.1).

Is cytology/HPV co-testing for cervical cancer screening useful in Japan?

OBJECTIVE

In Japan, no region has introduced primary HPV testing for cervical cancer screening. We assessed the diagnostic value and possible harm of HPV testing in Japan.

METHODS

This cross-sectional study with historical controls used cytology-based screening and co-testing data in Japan. As surrogate indicators of possible harm, colposcopy referral rate and cervical intraepithelial neoplasm (CIN) 1 detection rates were calculated. As surrogate indicators with diagnostic values, the detection rates of CIN2 or greater (CIN2+) and CIN3+ were calculated.

RESULTS

The data of 297 970 women (182 697 for cytology-based, 115 273 for co-testing) were examined. The detection rates of CIN1, CIN2+, and CIN3+ were significantly higher in the co-testing group than in the cytology-based group (P < 0.001, P < 0.0001, P < 0.01, respectively). Between ages 25-49, CIN2+ detection rates were significantly higher in the co-testing group than in the cytology-based group (P < 0.05 for each 5-year age group). Between ages 30-49, CIN3+ detection rates were significantly higher in the co-testing group than in the cytology-based group (P < 0.05 for each 5-year age group).

CONCLUSION

Limiting the target age group may minimize the possible harm of screening. Cytology/HPV co-testing may be useful in Japanese populations if balance is maintained between benefit and harm.

A tumor microenvironment responsive nanosystem for chemodynamic/chemical synergistic theranostics of colorectal cancer

Rationale: The synergism of new modalities alongside chemodynamic therapy into common chemotherapy has shown promising potential in clinical applications. This paper reports a tumor microenvironment-responsive nanosystem for chemodynamic/chemical synergistic therapy and magnetic resonance imaging (MRI). Methods: The biodegradable nanosystem is synthesized using a surface-modified chain transfer agent for surface-initiated living radical polymerization of the chemotherapeutic drug. Results: In this nanosystem, named CAMNSN@PSN38, the cycling time and solubility of the chemotherapeutic drug are improved. The nanoparticles delivered to tumor tissues gradually release the chemotherapeutic drug and Mn2+ through glutathione (GSH)-triggered biodegradation in the tumor microenvironment. SN38, the released chemotherapeutic drug, not only shows excellent chemical therapy effects but also improves the generation of H2O2. Furthermore, with the Fenton-like agent Mn2+, the generation of reactive oxygen species (ROS) is improved markedly. Finally, CAMNSN@PSN38 shows excellent inhibition of tumor growth in three colorectal cancer tumor models, with an improved accumulation of ROS and controlled release of SN38. Conclusions: The CAMNSN@PSN38-mediated chemodynamic/chemical synergistic therapy provides a promising paradigm for the treatment and MRI-guided therapy of colorectal cancer.

Post-Conization FIGO stage IA1 squamous cell cervical carcinoma; is hysterectomy necessary?

OBJECTIVE

To compare and evaluate the results and suitability of two different approaches to the treatment of post-conization International Federation of Gynaecology and Obstetrics (FIGO) stage IA1 cervical carcinoma: a more radical approach, directly scheduling a second surgery versus a more conservative one, which consists of performing a cotest (PAP plus HPV-test) in a follow-up visit and deciding whether to apply a second surgery on the basis of the results.

STUDY DESIGN

Retrospective descriptive study including 144 cases of stage IA1 cervical carcinoma diagnosed after a loop electrosurgical excisional procedure (conization), between 1987 and 2019 in the Mother-and-Child University Hospital of Gran Canaria (Spain). Selected patients were split into two groups for analysis: patients directly undergoing a second surgical intervention (hysterectomy or re-conization) after diagnosis and patients who were followed-up before making a decision whether to schedule a second surgery or continue to follow-up.

RESULTS

75% of women directly receiving a second surgical intervention (no post-conization follow-up) underwent hysterectomy, while 25% underwent re-conization. Histological outcomes from hysterectomized patients showed 65% negative results for intraepithelial lesions, 9% low-grade squamous intraepithelial lesions (LSIL), 16% high-grade squamous intraepithelial lesions (HSIL) and only 10.5% confirmed invasive lesions: hysterectomy complication rate was 7%. Histological studies from women subjected to re-conization showed 32% negative results, 37% LSIL, 5% HSIL and 26% malignancy. In the group of patients who were followed-up after diagnosis, 8.8% needed a second intervention; none of them showed negative histological results, while 100% hysterectomized and 25% patients with re-conization showed HSIL. No unnecessary hysterectomy procedures were conducted in this group. HPV-16 was the most common genotype in both groups.

CONCLUSION

Conization proved to be a suitable alternative to hysterectomy as a treatment for post-conization stage IA1 cervical cancer. Our results showed that 65% hysterectomy procedures conducted without previously monitoring for residual disease corresponded to negative results and were therefore, unnecessary. We conclude that confirmation of the presence of residual disease by using cotest is essential to make a decision on further treatment and that a conservative management is often possible and, in our opinion, preferable.

American Society of Clinical Oncology (ASCO) Cervical Cancer Prevention Program: A Hands-On Training Course in Nepal

Cervical cancer is the leading cause of death among women in Nepal. The American Society of Clinical Oncology (ASCO) and The University of Texas MD Anderson Cancer Center collaborated with international and local experts to hold a cervical cancer prevention course in Nepal in November 2019. The course included didactic lectures and a hands-on workshop. The didactic lectures included the epidemiology of cervical cancer globally and locally, cervical cancer screening guidelines, human papillomavirus vaccination, colposcopy and visual inspection with acetic acid (VIA), cervical dysplasia, and cervical cancer treatment. The hands-on workshop consisted of four stations: (1) VIA; (2) colposcopy, cervical biopsy, and endocervical curettage; (3) thermal ablation; and (4) loop electrosurgical excision procedure (LEEP). A train-the-trainer model short course was held by the international faculty to assist six local faculty to become familiar with the instruments, procedures, and models used in the hands-on training stations. Forty-two people (84% gynecologist, 8% radiation oncologist, and 8% other) attended the course. Following the course, the international faculty visited the regional hospitals for additional educational activities. Increased knowledge in cervical cancer screening guidelines and ability in performing VIA, colposcopy and cervical biopsy, thermal ablation, and LEEP were reported by 89%, 84%, 84%, 87%, and 84% of participants, respectively, from the postcourse on-site evaluations. From the 6-month follow-up survey, all respondents reported that they had made practice changes based on what they learned in the course and had implemented or tried to implement the cervical cancer screening guidelines presented at the course. In conclusion, the course evaluations suggested an improvement in participants' ability to perform cervical cancer screening and diagnostic procedures and reported the changes in practices after training.

Association of cervical carcinogenesis risk with HPV16 E6 and E7 variants in the Taizhou area, China

Background

Human papillomavirus (HPV) type 16 accounts for a larger share of cervical cancer and has been a major health problem worldwide for decades. The progression of initial infection to cervical cancer has been linked to viral sequence properties; however, the role of HPV16 variants in the risk of cervical carcinogenesis, especially with longitudinal follow-up, is not fully understood in China.

Methods

We aimed to investigate the genetic variability of HPV16 E6 and E7 oncogenes in isolates from cervical exfoliated cells. Between December 2012 and December 2014, a total of 310 single HPV16-positive samples were selected from women living in the Taizhou area, China. Sequences of all E6 and E7 oncogenes were analysed by PCR-sequencing assay. Detailed sequence comparison, genetic heterogeneity analyses and maximum-likelihood phylogenetic tree construction were performed with BioEdit Sequence Alignment Editor and MEGA X software. Data for cytology tests and histological diagnoses were obtained from our Taizhou Area Study with longitudinal follow-up for at least 5 years. The relationship between HPV16 variants and cervical carcinogenesis risk was analysed by the chi-square test or Fisher’s exact test.

Results

In this study, we obtained 64 distinct variation patterns with the accession GenBank numbers MT681266-MT681329. Phylogenetic analysis revealed that 98.3% of HPV16 variants belong to lineage A, in which the A4 (Asian) sublineage was dominant (64.8%), followed by A2 (12.1%), A1 (11.4%), and A3 (10.0%). The A4 (Asian) sublineage had a higher risk of CIN2+ than the A1–3 (European) sublineages (OR = 2.69, 95% CI = 1.04–6.97, P < 0.05). Furthermore, nucleotide variation in HPV16 E6 T178G is associated with the development of cervical cancer.

Conclusion

These data could provide novel insights into the role of HPV16 variants in cervical carcinogenesis risk in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08531-y.

Coexisting cancers with atypical glandular abnormalities by liquid-based cytology: A retrospective study in tertiary hospital in a high cervical cancer incident country

OBJECTIVE

To determine the incidence of coexisting cancers in women with glandular cell abnormalities detected from liquid-based cytology and to compare the detection rate of premalignant and malignant lesions among various subtypes of glandular cell abnormalities.

MATERIALS AND METHODS

From January 2014 to December 2016, liquid-based cytology was performed in 85,517 women. Using the Bethesda system 2001 criteria, abnormal cervical cytology was diagnosed in 3650 women (4.3%). Glandular cell abnormalities were diagnosed in 110 women (0.13%). Ten women with pre-existing genital tract cancers and 13 women who lost to follow up were excluded. Clinical characteristic, colposcopic finding, and histopathological data were reviewed in 87 women.

RESULTS

High-grade premalignant and malignant lesions were diagnosed in 34 patients (39.1%). Co-existing cancer was diagnosed in 31 patients (35.6%); 15 cervical cancers (17.2%) and 16 endometrial cancers (18.4%). The detection rate of significant lesions (CIN2+ or malignant lesions) in patients with AGC-NOS was 14.9%, AGC-FN was 38.9% and AIS/adenocarcinoma was 90.9% (p < 0.001).

CONCLUSION

Glandular cell abnormalities associated with high incidence of coexisting endometrial and cervical cancers. Comprehensive genital tract screening to evaluate gynecologic malignancy is strongly recommended in all women with glandular cell abnormalities.

Navigating the Cancer Screening Decision for Patients with Dementia

PURPOSE OF REVIEW

The risks of developing cancer and dementia both increase with age, giving rise to the complex question of whether continued cancer screening for older dementia patients is appropriate. This paper offers a practice-based clinical approach to determine an answer to this challenging question.

RECENT FINDINGS

There is no consensus on the prevalence of cancer and dementia as co-diagnoses. Persons with dementia are screened less often compared to those without dementia. There is significant literature focusing on screening in the geriatric population, but there is little evidence to support decision-making for screening for older patients with dementia. Given this lack of evidence, individualized decisions should be made in collaboration with patients and family caregivers. Four considerations to help guide this process include prognosis, behavioral constraints, cognitive capacity, and goals for care. Future research will be challenging due to variability of factors that inform screening decisions and the vulnerable nature of this patient population.

Effect of introducing human papillomavirus genotyping into real-world screening on cervical cancer screening in China: a retrospective population-based cohort study

Background:

China’s Fujian Cervical Pilot Project (FCPP) transitioned cervical cancer screening from high-risk human papillomavirus (HR-HPV) nongenotyping to genotyping. We investigated the clinical impact of this introduction, comparing performance indicators between HR-HPV genotyping combined with cytology screening (HR-HPV genotyping period) and the previous HR-HPV nongenotyping combined with cytology screening (HR-HPV nongenotyping period).

Methods:

A retrospective population-based cohort study was performed using data from the FCPP for China. We obtained data for the HR-HPV nongenotyping period from 1 January 2012 to 31 December 2013, and for the HR-HPV genotyping period from 1 January 2014 to 31 December 2016. Propensity score matching was used to match women from the two periods. Multivariable Cox regression was used to assess factors associated with cervical intraepithelial neoplasia of grade 2 or worse (CIN2+). The primary outcome was the incidence of CIN2+ in women aged ⩾25 years. Performance was assessed and included consistency, reach, effectiveness, adoption, implementation and cost.

Results:

Compared with HR-HPV nongenotyping period, in the HR-HPV genotyping period, more CIN2+ cases were identified at the initial screening (3.06% versus 2.32%; p < 0.001); the rate of colposcopy referral was higher (10.87% versus 6.64%; p < 0.001); and the hazard ratio of CIN2+ diagnosis was 1.64 (95% confidence interval, 1.43–1.88; p < 0.001) after controlling for health insurance status and age. The total costs of the first round of screening (US$66,609 versus US$65,226; p = 0.293) were similar during the two periods. Higher screening coverage (25.95% versus 25.19%; p = 0.007), higher compliance with age recommendations (92.70% versus 91.69%; p = 0.001), lower over-screening (4.92% versus 10.15%; p < 0.001), and reduced unqualified samples (cytology: 1.48% versus 1.73%, p = 0.099; HR-HPV: 0.57% versus 1.34%, p < 0.001) were observed in the HR-HPV genotyping period.

Conclusions:

Introduction of an HR-HPV genotyping assay in China could detect more CIN2+ lesions at earlier stages and improve programmatic indicators. Evidence suggests that the introduction of HR-HPV genotyping is likely to accelerate the elimination of cervical cancer in China.

The Mitigation of Racial Disparities in Cervical Cancer Screening Among U.S. Active Duty Service Women

INTRODUCTION

The U.S. Preventive Services Task Force recommends regular cervical cancer screening for women aged 21-65 years. Such screening is key to reducing mortality and morbidity. Despite improvement in the screening rate, cervical cancer still disproportionately affects women of minority groups because of access to quality health care. The Military Health System (MHS) mitigates this barrier through universal healthcare coverage for all active duty service members and their families. However, such racial/ethnic disparities, seen in civilian population, have not been studied in the MHS.

MATERIALS AND METHODS

This is a retrospective cross-sectional study utilizing fiscal years 2011-2016 claims data obtained from the MHS Data Repository for 112,572 active duty service women aged 21-64 years. Study analyses included descriptive statistics on patient demographics, calculations of the proportion of patients who received cervical cancer screenings as well as the proportion of patients in compliance with USPSTF guidelines, and unadjusted odds ratios for the likelihood of compliance by race and military service.

RESULTS

Of the study population, 50.0% of active duty women were screened for cervical cancer. When compared to White women, Black (1.05 OR, 1.03-1.08 CI), Native American/Alaskan Native (1.26 OR, 1.15-1.39 CI), and Other (1.12 OR, 1.06-1.18 CI) women were significantly more likely to receive cervical cancer screenings. The proportions of 3-year compliance were relatively equal within each race category (ranging from 43% to 45%), with no significant findings for the odds of compliance in any race when compared to White active duty women; however, proportions of 3-year compliance by service ranged from 11.7% in the Marines to 84.4% in the Navy, and active duty women in the Navy were six times more likely to be in compliance with guidelines than women in the Army. When looking at 5-year compliance in active duty women aged 30-64 years, women in the Navy were more likely than women in the Army to meet compliance guidelines (1.24 OR, 1.14-1.36 CI), while women in the Air Force were slightly less likely (0.90 OR, 0.82-0.98 CI).

CONCLUSIONS

The women in our population demonstrated similar or lower compliance than other studies conducted in the U.S. general population, and racial disparities for cervical cancer screening were partially mitigated in active duty service women. While our research demonstrates that universal insurance can help provide equal access and care, investigation into the factors that encourage greater usage among members of different military branches may help to understand and develop policies to improve health care systems.

Validation of cobas 4800 HPV assay in SurePath Papanicolaou specimens for cervical cancer screening

INTRODUCTION

The cobas (Roche Diagnostics, Indianapolis, IN) HPV assay was approved by the US Food and Drug Administration for human papillomavirus (HPV) testing in SurePath (Becton Dickinson, Franklin Lakes, NJ) Papanicolaou specimens for cervical cancer prevention. To validate the cobas HPV assay in SurePath specimens in our institution, we compared its accuracy and clinical efficacy to that of the Cervista (Hologic, Marlborough, MA) HPV HR assay.

METHODS

This study used 138 Papanicolaou (Pap) cytology specimens collected in SurePath preservative fluid at our institution in 2018. After Pap cytology testing, the residual specimens were split for testing with the cobas and Cervista assays. Polymerase chain reaction (PCR)-based HPV testing (GP5+/GP6+) was performed on specimens with discrepant results. Clinical follow-up data were reviewed.

RESULTS

The cobas HPV and Cervista HPV HR assays showed good concordance (89.1%), with a kappa value of 0.78 (95% CI: 0.675-0.885). Fifteen specimens showed discrepant results between the 2 assays. Of 7 cases with cobas+/Cervista- results, 5 (71%) were confirmed positive by PCR. Of 8 cases with cobas-/Cervista+ results, 4 (50%) were confirmed positive by PCR. cobas HPV and Cervista HPV HR showed the same HPV-positive rate in cases of pathologically diagnosed ASC-H, LSIL, or HSIL. The sensitivities and specificities for detecting high-risk HPV of cobas HPV (93.7%, 97.3%) and Cervista HPV HR (92.1%, 94.7%) were comparable. The cobas HPV assay had false-negative results in 4 cases (5.2%) including 1 false-negative case that failed to predict CIN3.

CONCLUSIONS

The cobas HPV assay is valid in SurePath Pap cytology specimens for cervical cancer screening but has limitations of false-negative results with clinical implications.

Reliability and diagnostic performance of smartphone colposcopy

OBJECTIVE

To evaluate the interobserver and intraobserver reliability of smartphone colposcopy (SPC) versus conventional colposcopy and to determine diagnostic performance.

METHODS

A smartphone back camera was used to capture cervical images before and after application of acetic acid, and after application of lugol solution. Captured images were reviewed independently by two experienced colposcopists and findings were noted as per colposcopy. Smartphone-based diagnostic performance was calculated, and kappa statistics were used for measurement of agreement between SPC and conventional colposcopy findings.

RESULTS

A total of 114 women were included in the study. The kappa statistic for intraobserver reliability was 0.77 for both normal colposcopic findings and the transformation zone, indicating substantial agreement. Kappa values were 0.54 for acetowhite epithelium, 0.51 for lugol staining, and 0.51-0.60 for atypical vascularization. Kappa values for interobserver reliability were 0.76 for normal colposcopic findings, 0.56 for acetowhite epithelium, and 0.60 for lugol staining. The sensitivity, specificity, PPV, and NPV of SPC for CIN2+ were 88.2 (95% CI, 72.5-96.7), 48.7 (95% CI, 37.4-60.2), 0.42 (95% CI, 0.36-0.48), and 0.91 (95% CI, 0.79-0.96), respectively.

CONCLUSION

SPC showed substantial agreement between the histologic diagnoses based on the captured images and conventional colposcopic findings.