Long-Term Clinical Outcome after Treatment for High-Grade Cervical Lesions: A Retrospective Monoinstitutional Cohort Study

The Role of Medical Therapies in the Management of Cervical Intraepithelial Neoplasia: A Narrative Review

Cervical cancer and its precursors (cervical intraepithelial neoplasia (CIN)) represent a current major public health concern. Currently, the treatment of choice for patients with HSILs (high-grade intraepithelial lesions) is surgical treatment-LEEP or cold-knife conization-except for in pregnant women, where it may have significant future consequences. In this paper, we aim to review the current evidence regarding the efficacy of non-surgical approaches for CINs. Therefore, we searched Google Scholar and PubMed for papers on CIN treatments; 91 studies published in English were included in the analysis. The results of the reviewed studies were variable depending on the agent and methodology used. Overall, the remission rates of CIN II ranged from 43 to 93%. However, for some agents, the results were contradictory. Once topical agents have been proven to be effective, they could be used as an alternative to surgical methods in treating HPV-associated CIN, with fewer adverse effects. The use of local agents could allow for more personalized treatments for patients with CINs. Future directions were also sought.

Treatment characteristics, HPV genotype distribution and risk of subsequent disease among women with high-grade cervical intraepithelial neoplasia in Europe: A systematic literature review

INTRODUCTION

High-grade cervical intraepithelial neoplasia (CIN), a premalignant lesion of the uterine cervix, is caused by persistent Human Papillomavirus (HPV) infection. CIN can be identified through screening programs and high-grade CIN is usually treated by ablation or excision. This study aimed to summarize the clinical management and outcomes among women with high-grade CIN in Europe.

METHODS

A systematic literature review was conducted to identify treatment methods and their frequency of use, report HPV genotype prevalence and distribution and summarize patterns for subsequent lesions after primary treatment, among women with high-grade CIN in Europe. Embase®, MEDLINE® and Cochrane databases were searched (1st January 2012 to 30th August 2022), along with relevant conference proceedings (2018-2022), inclusive. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) compliant methodology was adopted. Eligibility criteria included non-immunosuppressed female patients with CIN2+ from Europe (published in English).

RESULTS

In total, n = 55 studies were included. CIN excisional therapy was the most received treatment approach (15.8-100 %, loop electrosurgical excision procedure/large loop excision of the transformation zone most common), followed by ablative therapies (1-43.3 %, cold coagulation most common). Other approaches included 'wait and watch' (4.8-52.6 %) and hysterectomy (4.8-16.2 %). HPV positivity rates ranged from 67.8-100 % pre-conization and 4.7-32.8 % post-conization. The most prevalent HPV genotypes reported (both pre- and post-treatment) were HPV16 and HPV18. In patients who received excisional or ablative procedures subsequent CIN was most frequently diagnosed ≤6 months after treatment. The overall rate of subsequent CIN reported was 0.5-20.9 %.

CONCLUSION

Conization and ablation were the most common techniques, however, these procedures were associated with sub-optimal outcomes. Close clinical follow-up is important due to the risk of subsequent CIN or invasive cancer. This review serves as a reference point for the comparison of future treatment patterns as they evolve across Europe, following improved implementation of prophylactic HPV vaccination and screening.

Factors associated with adherence to post-treatment follow-up among a cohort of women with acetic acid/Lugol's iodine positive lesions of the cervix in Cameroon: A retrospective cohort study

Background

Women treated for cervical precancerous lesions have up to a 30 % increased risk of developing cervical cancer compared to women in the general population. The aim of this study was to identify predictors for adherence to follow-up among women treated for precancerous lesions of the cervix in Cameroon.

Materials and Methods

The study design was a retrospective cohort analysis of a five-year follow-up for women in Cameroon who were initially treated for cervical precancer lesions in 2013. Logistic regression models were used to determine factors associated with adherence to post-treatment follow-up. Statistical significance was set at p < 0.05.

Results

Of the 344 women treated in 2013, 154 (44.77 %) never returned for a single post-treatment follow-up in five years. Marital status was the only variable statistically significantly associated with 5-year post-treatment follow-up adherence. women who had ever been married were 0.36 times (0.14 0.93)); p = 0. 0.035] less likely to adhere to post-treatment follow-up compared to women who have never been married. Although age was not statistically significant, women in the age group 30-49 years had some significance and they were 60 % [aOR, 95 %CI: 0.40 (0.18 0.89); p = 0.024] less likely to adhere to post-treatment follow-up when compared to women who were<30 years.

Conclusion

Only about half of the women treated for cervical precancer in this cohort returned for post-treatment follow-up. Conducting needs assessments among these populations that are less likely to adhere to follow-up will allow us to implement and test strategies to improve adherence to follow-up.

Cost-effectiveness of p16/Ki-67 Dual-Stained Cytology Reflex Following Co-testing with hrHPV Genotyping for Cervical Cancer Screening

The first biomarker-based cervical cancer screening test, p16/Ki-67 dual-stained cytology (DS), has been clinically validated and approved in the United States for triage of women being screened for cervical cancer who test positive for high-risk human papillomavirus (hrHPV). The primary aim of this work is to evaluate the cost-effectiveness of DS triage after co-testing findings of positive non-16/18 HPV types and atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions cytology. A payer-perspective Markov microsimulation model was developed to assess the impact of DS reflex testing. Each comparison simulated 12,250 screening-eligible women through health states defined by hrHPV status and genotype, cervical intraepithelial neoplasia grades 1-3, invasive cervical cancer (ICC) by stage, and cancer-related or non-cancer death. Screening test performance data were from the IMPACT clinical validation trial. Transition probabilities were from population and natural history studies. Costs of baseline medical care, screening visits, tests, procedures, and ICC were included. DS reflex after co-testing was cost-effective with incremental cost-effectiveness ratios per quality-adjusted life-year gained of $15,231 [95% confidence interval (CI), $10,717-$25,400] compared with co-testing with hrHPV pooled primary and genotyped reflex testing, and $23,487 (95% CI, $15,745-$46,175) compared with co-testing with hrHPV genotyping with no reflex test. Screening and medical costs and life-years increased, while ICC costs and risk of ICC death decreased. Incorporating DS reflex into co-testing cervical cancer screening algorithms is projected to be cost-effective.

PREVENTION RELEVANCE

The p16/Ki-67 dual-stained cytology (DS) test was recently approved in the United States as a reflex test for cervical cancer screening following positive high-risk human papillomavirus (hrHPV) test results. Adding DS reflex to hrHPV and cervical cytology co-testing strategies in the United States is expected to be cost-effective per life-year or quality-adjusted life-year gained.

Human Papillomavirus Same Genotype Persistence and Risk of Cervical Intraepithelial Neoplasia2+ Recurrence

Simple Summary

Women diagnosed with cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and treated by excisional procedures remain at high risk for recurrence over time. “Treatment failure” has been reported in up to 23% of women within two years after treatment. The aim of this study was to investigate the impact of HPV same genotype persistence on CIN2+ recurrence. Our findings confirm that HPV same genotype persistence has 30-fold increased odds of developing CIN2+ recurrence (p < 0.001), whereas histological grade, glandular crypt involvement, and margin status are not significantly related with treatment failure. Persistence of multiple genotypes and of HPV 16/18 with or without other HR genotypes show a significant impact on relapse free survival. HPV genotyping as “test-of-cure” enables a personalized risk-based management, by identifying women at higher risk of relapse who need intensive follow-up and avoiding risk of over-treatment in women with new HPV genotype infection after surgery.

Abstract

To evaluate the significance of HPV persistence as a predictor for the development of CIN2+ recurrence and the impact of multiple genotypes and of HPV 16/18 on recurrence risk. A prospective cohort observational study was carried out at the European Institute of Oncology, Milan, Italy, from December 2006 to December 2014. A total of 408 women surgically treated by excisional procedure for pre-neoplastic and neoplastic cervical lesions were enrolled. HPV test was performed at baseline and at first follow-up visit planned at 6 ± 3 months after treatment. Two-year cumulative incidences for relapse were estimated and compared by the Gray’s test. Overall, 96 (23.5%) patients were persistent for at least one genotype at three to nine months from baseline and 21 (5.1%) patients relapsed. The two-year cumulative relapse incidence was higher in HPV persistent patients compared to not-persistent (CIF = 27.6%, 95% CI: 16.2–40.2% versus CIF = 1.7%, 95% CI: 0.3–5.8%, p < 0.001), in women with persistent multiple infections (CIF = 27.2%, 95% CI: 7.3–52.3%, p < 0.001), and with the persistence of at least one genotype between 16 and 18, irrespective of the presence of other HR genotypes (CIF = 32.7%, 95% CI: 17.9–48.3%, p < 0.001), but not significantly different from women positive for single infections or any other HR genotype, but not for 16 and 18. The risk of CIN2+ recurrence should not be underestimated when same HPV genotype infection persists after treatment.

Evaluation of the Factors Affecting the Cure Rate of Cervical Intra-Epithelial Neoplasia Recurrence Using Defective Models

BACKGROUND

Treatment of cervical intraepithelial neoplasia is very important since if it remains untreated, it may progress to cervical cancer. It is usually treated with excisional surgery. This study aimed to find the factors affecting the cure rate of cervical intraepithelial neoplasia recurrence after surgery using defective models.

STUDY DESIGN

A retrospective cohort study.

METHODS

Excisional surgery was performed on 307 patients with high-grade cervical intraepithelial neoplasia, from 2009 to 2017. The patients were followed up until recurrence based on histopathology report. Hematologic factors were measured before surgery. The cure rates were estimated using defective models with a Gamma frailty term and the results were compared.

RESULTS

Neutrophil-to-lymphocyte ratio (NLR) (P<0.001) and excised mass size (P<0.001) had significant impacts on cure rates, and their cut-off values were 1.9 (P<0.001) and 15 mm2 (P<0.001), respectively. Patients with lower neutrophil-to-lymphocyte ratios and larger excised tissues had higher cure rates. Defective 3-parameter Gompertz distribution with gamma frailty term had the best fit to the data, and its estimated cure rates were 98% among patients with an excised mass size of > 15 mm2 and NLR of <1.9, 84% among patients with an excised mass size of >15 mm2 and NLR of >1.9, 79% among patients with an excised mass size of <15 mm2 and NLR of <1.9, and 30% among patients with an excised mass size of <15 mm2 and NLR of >1.9.

CONCLUSION

Cervical intraepithelial neoplasia must be identified and treated before its progress. Excision of more tissues during excisional surgery, especially when the NLR of the patient is high, can help to prevent cervical intraepithelial neoplasia recurrence.

T Cell Receptor Repertoires Acquired via Routine Pap Testing May Help Refine Cervical Cancer and Precancer Risk Estimates

Cervical cancer is the fourth most common cancer and fourth leading cause of cancer death among women worldwide. In low Human Development Index settings, it ranks second. Screening and surveillance involve the cytology-based Papanicolaou (Pap) test and testing for high-risk human papillomavirus (hrHPV). The Pap test has low sensitivity to detect precursor lesions, while a single hrHPV test cannot distinguish a persistent infection from one that the immune system will naturally clear. Furthermore, among women who are hrHPV-positive and progress to high-grade cervical lesions, testing cannot identify the ~20% who would progress to cancer if not treated. Thus, reliable detection and treatment of cancers and precancers requires routine screening followed by frequent surveillance among those with past abnormal or positive results. The consequence is overtreatment, with its associated risks and complications, in screened populations and an increased risk of cancer in under-screened populations. Methods to improve cervical cancer risk assessment, particularly assays to predict regression of precursor lesions or clearance of hrHPV infection, would benefit both populations. Here we show that women who have lower risk results on follow-up testing relative to index testing have evidence of enhanced T cell clonal expansion in the index cervical cytology sample compared to women who persist with higher risk results from index to follow-up. We further show that a machine learning classifier based on the index sample T cells predicts this transition to lower risk with 95% accuracy (19/20) by leave-one-out cross-validation. Using T cell receptor deep sequencing and machine learning, we identified a biophysicochemical motif in the complementarity-determining region 3 of T cell receptor β chains whose presence predicts this transition. While these results must still be tested on an independent cohort in a prospective study, they suggest that this approach could improve cervical cancer screening by helping distinguish women likely to spontaneously regress from those at elevated risk of progression to cancer. The advancement of such a strategy could reduce surveillance frequency and overtreatment in screened populations and improve the delivery of screening to under-screened populations.

<p>Risk Factors for Residual Disease in Hysterectomy Specimens After Conization in Post-Menopausal Patients with Cervical Intraepithelial Neoplasia Grade 3</p>

Background

Post-menopausal patients with cervical intraepithelial neoplasia (CIN) have a high rate of residual or recurrent lesions after treatment, and their risk for cervical cancer later in life is higher than the general population. Hence, management for this specific group of post-menopausal patients needs more attention.

Objective

The study aimed to identify risk factors associated with the presence of residual disease in hysterectomy specimens in post-menopausal patients with cervical intraepithelial neoplasia grade 3 (CIN 3).

Methods

This study was a retrospective analysis of data from post-menopausal women who had undergone hysterectomy following conization for CIN 3 from 2012 to 2018 at Fujian Maternity and Child Health Hospital. Factors extracted from the database included age, parity, Thinprep cytology results, human papillomavirus (HPV) genotype, biopsy results, pre-cone endocervical curettage (ECC) results, conization method, operating surgeon, cone dimension, margin status and glandular involvement. Univariate and multivariate analyses were performed to identify risk factors associated with residual disease in hysterectomy specimens.

Results

Analysis of data from 129 women was performed. The proportion of residual disease was 43.41% overall. A higher grade according to colposcopy biopsy, abnormal pre-cone ECC results, the cone method (LEEP vs CKC), a cone volume >1.57 cm³, and positive margins in conization specimens were found to be significantly associated with residual lesions on univariable analysis. After multivariate analysis, only an abnormal pre-cone ECC result (odds ratio 3.99; 95% confidence interval (CI) 1.41–11.33; p = 0.009) remained significant.

Conclusion

The rate of residual lesions in uterine specimens was high regardless of the cone margin status in post-menopausal women with CIN 3. Risk-based strategies are needed to identify patients who have abnormal pre-cone ECC results, and definitive treatment with hysterectomy should be considered in post-menopausal patients with an elevated risk for residual lesions.

Risk of Cervical Dysplasia After Colposcopy Care and Risk-Informed Return to Population-Based Screening: A Systematic Review

This systematic review examined the risk of cervical dysplasia among women who have undergone a colposcopy episode of care to inform their return to population-based cervical screening. PubMed, Embase, and grey literature were searched between January 2000 and 2018. One reviewer screened citations against pre-defined eligibility criteria. A second reviewer verified 10% and 100% of exclusions at title and abstract and at full-text screening, respectively. One reviewer extracted data and assessed methodological quality of included articles; a second reviewer verified these in full. The primary outcome was incidence of cervical intraepithelial neoplasia grade 2 or greater (CIN2+) subsequent to initial colposcopy evaluation. Secondary outcomes included incidence of CIN2+ after negative follow-up test results and performance of follow-up strategies. Results were synthesized narratively. A total of 48 studies were included. The 1- to 5-year CIN2+ risks after colposcopy evaluation ranged from 2.4% to 16.5% among women treated for CIN2+ and from 0.7% to 16.8% among women untreated for CIN grade 1 or less (≤CIN1). Follow-up strategies included single or repeat cytology, human papillomavirus (HPV) testing, or combined HPV/cytology co-testing at various intervals. After negative follow-up test results, risk varied by follow-up strategy for both groups and by referral cytology severity for untreated women. Performance of follow-up strategies varied among treated women. Among untreated women, co-testing demonstrated greater sensitivity than cytology alone. In conclusion, women treated during colposcopy for CIN2+ and women with ≤CIN1 who were referred to colposcopy for low-grade cytology and who did not receive treatment may be able to return to population-based screening after negative co-testing results. Current evidence does not suggest that women untreated for ≤CIN1 who are referred for high-grade cytology be returned to screening at an average risk interval. The optimal strategy for colposcopy discharge needs ongoing evaluation as implementation of HPV testing evolves.

Cost-Effectiveness and Cost-Benefit of Cervical Cancer Screening with Liquid Based Cytology Compared with Conventional Cytology in Germany

Objective

To assess the health economic impact of cervical screening with liquid based cytology (LBC) compared with conventional cytology (CC) in Germany.

Methods

An economic model was constructed depicting the management of a hypothetical cohort of women aged ≥20 years who undergo cervical screening in Germany. The model estimated the cost-effectiveness and cost-benefit of LBC compared with CC at 2017/18 prices over a time-horizon of 70 years.

Results

Performing cervical screens with LBC instead of CC is expected to increase the probability of detecting a true positive over a subject's lifetime by 73% (0.038 versus 0.022) and of diagnosing a subject with stage 3 cervical intraepithelial neoplasia (CIN3) (0.019 versus 0.011). Women screened with LBC instead of CC are expected to have a 57% reduction in the probability of having undetected CIN3 (0.006 versus 0.014) and to experience a 44% reduction in the probability of transitioning into disease progression (from 0.018 to 0.010). The mean discounted lifetime cost of healthcare resource use associated with performing cervical screens with LBC and CC was estimated at €4852 and €7523 per subject respectively. For every Euro invested in cervical screening with LBC instead of CC, the German healthcare system could potentially save ~€170 over a subject's lifetime.

Conclusion

Within the study's limitations, the analysis showed that LBC affords a cost-effective cervical screening test compared with CC in Germany, since it improves detection rates and has the potential to lead to a reduction in disease progression for less cost.

Human Papillomavirus Genotyping Compared With a Qualitative High-Risk Human Papillomavirus Test After Treatment of High-Grade Cervical Intraepithelial Neoplasia: A Systematic Review

There is moderately high-quality evidence to support the improved clinical utility of human papillomavirus (HPV) genotyping compared with qualitative HPV positivity to follow-up after treatment of high-grade cervical intraepithelial neoplasia.

To systematically examine human papillomavirus (HPV) genotyping compared with qualitative high-risk HPV result during follow-up after treatment of high-grade cervical intraepithelial neoplasia (CIN), for risk estimation of posttreatment high-grade CIN.

Invasive cervical cancer after treatment of CIN

INTRODUCTION

A historical audit of 30 post-treatment cervical cancers (10% of 289 cancers, 1999-2016) compared with a one-year-equivalent control group treated for cervical intraepithelial neoplasia (CIN) grade 3 (n = 164).

MATERIALS AND METHODS

We compared history and follow up of cancer patients and controls and reviewed initial excision biopsies preceding cancer and, in 41% of controls, high-grade recurrence (n = 17) or consistently negative follow-up (n = 51).

RESULTS

Either abnormal post-excision cytology without high-risk human papillomavirus (hrHPV) tests or immediate re-excision was recorded in 70% (19 of 27) of patients with squamous cell carcinoma (SCC). Negative investigations including cytology, colposcopy, re-excision, hysteroscopy, hrHPV, and/or treatment default were recorded in 83% (25 of 30) of all cancers. The mean interval between initial excision and cancer diagnosis was 79.8 ± 30.1 months versus 11.2 ± 30.1 months for CIN3 recurrence. Eight, 13, and 9 patients with cancer had initial excision at age 20-34, 35-49, and 50+ years, respectively, compared with 71%, 23%, and 5% of controls. CIN3 more often preceded SCC than CIN2 (22:1); 5 of 30 initial excisions were originally reported as negative after severe dyskaryosis. No SCC or CIN3 recurrence followed complete excision. Depth of CIN3 2+ mm (20 of 82 reviewed) was strongly associated with cancer/high-grade recurrence or early stromal invasion on review (18 of 20; 90%). Discrepancies were found on review in 10% of biopsies and as occasional abnormal cells in 9 of 34 cytology slides.

CONCLUSIONS

Residual disease may be inconspicuous or absent on cytology, colposcopy, and/or histology. Management taking account of risk of recurrence (age, CIN3 depth, incomplete initial excision) could avoid some post-treatment cancers.

Recurrent disease after treatment for cervical pre-cancer: determining whether prophylactic HPV vaccination could play a role in prevention of secondary lesions

Existing modalities can effectively treat high-grade cervical intraepithelial neoplasia (CIN) but around 7% of treated women will develop recurrence of CIN grade 2 or above within 2 years of treatment. Post-treatment surveillance is therefore required to detect residual or recurrent disease. Since the implementation of human papillomavirus (HPV) vaccination programs in high-income countries, significant reductions in high-grade CIN have been recorded in vaccinated cohorts who were predominantly HPV-naïve at vaccination. There is still debate as to the extent of potential benefit from vaccination for women previously infected with HPV, given that HPV incidence in women falls with age and previously cleared infection provides at least some protection against reinfection. Whilst vaccination-induced antibodies could prevent type-specific new infections, it is unclear whether vaccination could also prevent reactivation of latent, previously acquired infection and subsequent disease. A review of the available evidence suggests a potential reduction in risk of recurrent disease if women diagnosed and treated for CIN are offered prophylactic vaccines. New modeled analyses and, ideally, a prospectively designed randomized controlled trial in women treated and then randomized to vaccination or placebo would provide much-needed additional evidence to support the effectiveness and cost-effectiveness of offering vaccination to women after treatment for CIN.

Barriers and facilitators of follow-up among women with precancerous lesions of the cervix in Cameroon: a qualitative pilot study

Purpose

This pilot study explores the barriers to adherence to follow-up among women with cervical precancer in urban Cameroon. While follow-up of women with a positive screening of cervical precancer is the most important aspect of cervical cancer secondary prevention, women with cervical precancer do not adhere frequently to recommended follow-up schedule in Cameroon. The aim of the study was to explore and describe the barriers and facilitators to follow-up for cervical precancer among women infected and uninfected with HIV in Cameroon.

Participants and methods

A qualitative research design was used to answer the research questions. Participants included eight HIV-infected and -uninfected women diagnosed with cervical precancer and 19 nurses. Data were collected by in-depth individual patient interviews and focus groups with nurses. An interview guide with open-ended questions, using the social ecological model as a framework, included questions that addressed the complexities of the lives of individuals and professionals within a relational context. The interviews were audio-taped and transcribed verbatim in English language. Thematic analysis of data was completed with no epistemological or theoretical perspective underpinning the analyses.

Results

Four major themes emerged from the study. They were clinic, personal, and social barriers, and strategies to improve follow-up.

Conclusion

The use of reminder phone calls and fee reduction, coupled with peer counseling and navigation of women who have been diagnosed with cervical precancer, could be effective ways of improving adherence to follow-up. Further research is needed to explore the same phenomenon among women in rural areas, especially those who were initially attended to in mobile clinics.

Predicting cervical intraepithelial neoplasia recurrence in HIV-infected and -noninfected women by detecting aberrant promoter methylation in the CDH1, TIMP3, and MGMT genes

PURPOSE

Aberrant DNA methylation is present in virtually all types of human cancer. There is no clear evidence that methylation status can predict bad prognosis in patients with CIN recurrence in HIV infected. This study evaluates the relationship between aberrant methylation of CpG islands of CDH1, TIMP3 and MGMT genes and CIN recurrence in HIV-infected and -noninfected women.

METHODS

This is a nested case-control study involving 33 cases with CIN recurrence and 114 controls without recurrence, HIV infected and noninfected, treated with LEEP, between 1999 and 2004. Recurrence diagnosis was established after biopsy. Genes methylation profile was assessed by MSP-PCR technique in formalin-fixed, paraffin-embedded cone specimens. Statistical analysis was performed to compare categorical variables, using χ2 test with Yates correction and Fisher's exact test. Multivariate analysis was carried out using logistic regression.

RESULTS

CIN recurrence was more frequent in women with glandular involvement (OR 11.6; 95% CI 2.93-45.89) and compromised surgical margins (OR 2.5; 95% CI 0.87-7.27) in the cervical cone and in HIV-infected women (OR 2.47; 95% CI 0.87-7.05). One methylated allele of CDH1, TIMP3 and MGMT genes was present in 87.9% women with CIN recurrence. Promoter hypermethylation of TIMP3 and MGMT was detected in women with CIN recurrence and without CIN recurrence independent of HIV infection with significant difference between groups (p = 0.04 and p = 0.02, respectively).

CONCLUSIONS

CIN recurrence was associated with glandular involvement and compromised margins in cone biopsy and HIV infection. The presence of CpG islands hemimethylation in TIMP3 and MGMT genes is a promising triage method in CIN recurrence.