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Mungo C, Adewumi K, Adoyo E, Zulu G, Goraya SK, Ogollah C, Omoto J, Ferrari RM, Rahangdale L. "There is nothing that can prevent me from supporting her:" men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya. Front Oncol 2024; 14:1360337. [PMID: 38532929 PMCID: PMC10964769 DOI: 10.3389/fonc.2024.1360337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/16/2024] [Indexed: 03/28/2024] Open
Abstract
Purpose Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies. Methods Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description. Results Thirty-nine male participants meeting the eligibility criteria participated in five FGDs. The mean age of participants was 42.5 years. Most participants, 79.5%, had a female partner with a history of cervical precancer treatment, 5.1% did not, and 15.4% were unsure of their female partner's prior precancer treatment history. The study aimed to assess men's support of their female partners' use of topical therapies for treating cervical precancer. We find that male participants strongly express acceptance and willingness to support their wives or partners in using such therapies, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support. Conclusion The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.
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Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Konyin Adewumi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Graham Zulu
- University of Denver, Denver, CO, United States
| | - Supreet Kaur Goraya
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | - Renée M. Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Mwalwanda A, Chavura E, Chisale MR, Mbakaya BC. Cervical cancer screening among female health workers: Evidence from a secondary health facility in Northern Malawi. Prev Med Rep 2024; 37:102581. [PMID: 38268615 PMCID: PMC10805659 DOI: 10.1016/j.pmedr.2023.102581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 12/24/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024] Open
Abstract
Cervical cancer is preventable and curable if identified early. Although health workers have a critical role in influencing beliefs and practices of the entire population, some studies have shown paradoxical efforts among female health workers themselves-a threat towards attainment of the triple-intervention strategy as propagated by the World Health Organization (WHO). The study aimed to assess knowledge, attitudes and practices of cervical cancer screening among female health workers. The study used a descriptive cross-sectional design. Data entry and analysis were carried out using IBM Statistical Package for Social Scientists (SPSS) version 20.0 (SPSS, Michigan Avenue, Chicago, IL, USA). The response rate was 65.4 % and mean age of 32 years with standard deviation=±8.397. The majority of participants were nurses n = 31 (43.3). There was poor knowledge on signs/symptoms and risk factors as only 15.7 % were aware of multiple sexual partners, 7.1 % for each early sexual encounter and uncircumcised men as risk factors. Regarding willingness, 77.1 % were willing to have the screening test. Their practices were rated poor as only 35.7 % (n = 25) had ever undergone screening within the past 6 years. There was poor knowledge, fair attitudes and poor practices of cervical cancer screening among female health workers. As part of the efforts to achieve sustainable development goal (SDG) target 3.4 and the attainment of WHO 90-70-90 target by 2030; this study recommends scaling up health education, social mobilization and Human Papillomavirus (HPV) vaccinations to support awareness, detection and treatment of cervical cancer. Acceptability of the current screening methods must be further explored.
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Affiliation(s)
- Atusaye Mwalwanda
- University of Livingstonia, Department of Public Health, Malawi
- Luke International Malawi, Malawi
| | - Elton Chavura
- Mzuzu University, Faculty of Environmental Science, Mzuzu, Malawi
| | - Master R.O. Chisale
- Mzuzu University, Faculty of Science Technology and Innovations, Biological Sciences, Mzuzu, Malawi
| | - Balwani Chingatichifwe Mbakaya
- University of Livingstonia, Department of Public Health, Malawi
- Mzuzu University, Faculty of Science Technology and Innovations, Biological Sciences, Mzuzu, Malawi
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Guthrie L, Mkandawire J, Stevenson E, Bonya S, Sherwin B, Kasumba M, Hong L, Ioffe Y, Lum S. Lessons in Cultural Adaptations: Translation of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Cervical Cancer Module From English to Chichewa in Malawi. J Surg Res 2023; 292:150-157. [PMID: 37619500 DOI: 10.1016/j.jss.2023.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 07/02/2023] [Accepted: 07/23/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION To complete a culturally appropriate translation of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Cervical Cancer module (QLQ-CX24) from English to Chichewa (one of the official languages of Malawi) in preparation for postsurgical outcomes research in rural Malawian cervical cancer patients. METHODS Following the EORTC translation procedure manual, two distinct forward translations from English were reconciled into a preliminary Chichewa translation, followed by two distinct back-translations to English. The English back-translation was reconciled and the translation report sent for discussion and proofreading by EORTC; this was followed by pilot testing. All translators were physicians fluent in English and Chichewa. RESULTS Of 24 questions in QLQ-CX24, three had prior translations available; all three required revision to clarify tense or wording. Three discussion exchanges with EORTC refined the translation and ensured faithfulness to the original English meaning; proofreaders contributed minor changes. Pilot testing was completed on 10 female patients (three with cervical cancer, four suspicious cervical lesions, and three screening only). Three patients were illiterate. During pilot testing, translation of question 46 (Q46) was misunderstood as referring to vaginal discharge instead of feeling "feminine". The remaining questions were understood, with minor feedback for six questions. Final revision of Q46 yielded a phrase describing "feminine" as "appearance or activities as a woman". Concepts comparable to "feminine" were absent in the Chichewa language/regional Malawian culture. The final revision of Q46 was pilot-tested on five patients (three illiterate) and found acceptable. CONCLUSIONS Translation of the QLQ-CX24 module was completed successfully and revealed absence of the modern concept of femininity in Chichewa language and regional Malawian culture. Care should be taken when creating and translating healthcare-related documents for surgical research to ensure broad applicability across cultures.
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Affiliation(s)
- Laurel Guthrie
- Department of Surgery, Loma Linda University Health, Loma Linda, California.
| | | | - Emily Stevenson
- Department of Surgery, Loma Linda University Health, Loma Linda, California
| | - Sharon Bonya
- Department of Surgery, Malamulo Adventist Hospital, Malawi, Africa
| | - Brent Sherwin
- Department of Surgery, Malamulo Adventist Hospital, Malawi, Africa
| | - Moses Kasumba
- Department of Surgery, Malamulo Adventist Hospital, Malawi, Africa
| | - Linda Hong
- Department of Obstetrics and Gynecology, Loma Linda University Health, Loma Linda, California
| | - Yevgeniya Ioffe
- Department of Obstetrics and Gynecology, Loma Linda University Health, Loma Linda, California
| | - Sharon Lum
- Department of Surgery, Loma Linda University Health, Loma Linda, California
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Bwanali AN, Lubanga AF, Mphepo M, Munthali L, Chumbi GD, Kangoma M. Vaccine hesitancy in Malawi: a threat to already-made health gains. Ann Med Surg (Lond) 2023; 85:5291-5293. [PMID: 37811119 PMCID: PMC10552950 DOI: 10.1097/ms9.0000000000001198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/05/2023] [Indexed: 10/10/2023] Open
Abstract
Malawi faces a growing concern about vaccine hesitancy. This threatens to undermine significant strides in the fight against infectious diseases in the country. Vaccine hesitancy in Malawi is driven by multiple factors. This short communication discusses the extent of vaccine hesitancy in Malawi and its main drivers according to SAGE's (Strategic Advisory Group of Expert) 3Cs (confidence, complacency and convenience) model of vaccine hesitancy. As an escalating health concern, it is imperative to address it urgently. It is imperative to address it urgently through comprehensive and sustainable awareness campaigns that should aim to increase acceptance and demand for vaccines.
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Affiliation(s)
- Akim N. Bwanali
- Clinical Research Education and Management Services Limited (CREAMS)
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Oli Health Magazine Organization, Research and Education, Kigali, Rwanda
| | - Adriano F. Lubanga
- Clinical Research Education and Management Services Limited (CREAMS)
- Oli Health Magazine Organization, Research and Education, Kigali, Rwanda
| | - Mzati Mphepo
- Clinical Research Education and Management Services Limited (CREAMS)
| | | | | | - Melina Kangoma
- Kamuzu Central Hospital, Ministry of Health (MoH), Lilongwe
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Draganchuk J, Patel T, Chipungu E, Nampandeni P, Wilkinson J. Urinary tract reconstruction for iatrogenic fistula secondary to radical hysterectomy: Cases from Malawi's Fistula Care Center. Gynecol Oncol Rep 2023; 48:101223. [PMID: 37576354 PMCID: PMC10422099 DOI: 10.1016/j.gore.2023.101223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 08/15/2023] Open
Abstract
Complications from radical hysterectomy in low-income countries (LICs) are largely unreported in the medical literature. We report on three cases of urinary tract reconstruction performed at the Fistula Care Center (FCC) in Lilongwe, Malawi for iatrogenic fistula following radical hysterectomy. These cases demonstrate the diversity and complexity of reconstruction techniques required and emphasize the need for careful tracking of surgical outcomes of radical hysterectomy.
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Affiliation(s)
- Jennifer Draganchuk
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Tulsi Patel
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Ennet Chipungu
- Freedom from Fistula, Fistula Care Center, Lilongwe, Malawi
| | | | - Jeffrey Wilkinson
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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Mendulo R, Chiumia IK. The state of cervical cancer screening in imprisoned women in Malawi: a case of Maula Prison. BMC Womens Health 2023; 23:198. [PMID: 37118738 PMCID: PMC10142221 DOI: 10.1186/s12905-023-02349-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/11/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Malawi is one of the countries with the highest burden of cervical cancer in the world with less than ten percent of women screened for cervical cancer annually. The study aimed to investigate the state of cervical cancer screening among incarcerated women at Maula prison. The study highlights key challenges that women in prison face to access cervical cancer screening to inform policies and strategies to address them. METHODS The study employed a cross-sectional qualitative study design. A total of 31 prisoners aged between 18 to 49 participated in the study. Among these, 15 women participated in in-depth interviews, while 16 women participated in two focus group discussions consisting of 8 women per group. All interviews were recorded and transcribed verbatim. Data was analysed using inductive content analysis. FINDINGS Majority of women at Maula prison demonstrated knowledge of cervical cancer, its associated risk factors and the benefits of cervical cancer screening. Most women also expressed willingness to undergo cervical cancer screening. However, the following were identified as factors that hinder women from accessing cervical cancer screening services at the prison:-limited availability of the services, pain during the screening process, the presence of male practitioners conducting screening, poor treatment by authorities and health workers and favouritism. CONCLUSION To improve cervical cancer screening and its uptake at Maula prison there is a need to ensure unlimited availability of the screening services which should be conducted by female health practitioners. There is also a need to include this service as part of the mandatory health screening exercise that is conducted upon entry into the prison by all prisoners. Conducting in-depth awareness and sensitization with participants before screening would help to eradicate fear, provide assurance and clarification of the screening process. Prison officers and health workers should also be sensitised to improve prisoners' access to healthcare during incarceration.
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Affiliation(s)
- Regina Mendulo
- Department of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi.
| | - Isabel Kazanga Chiumia
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
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Ola IO, Okunowo AA, Habeebu MY, Miao Jonasson J. Clinical and non-clinical determinants of cervical cancer mortality: A retrospective cohort study in Lagos, Nigeria. Front Oncol 2023; 13:1105649. [PMID: 36874121 PMCID: PMC9978796 DOI: 10.3389/fonc.2023.1105649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/01/2023] [Indexed: 02/18/2023] Open
Abstract
Introduction Cervical cancer (CCa) is the fourth most frequent and a common cause of cancer mortality in women, the majority of whom live in low- and middle-income countries. Data on CCa mortality and its determinants have been poorly studied in Nigeria, resulting in a paucity of information that can assist patient management and cancer control policy. Aim The purpose of this study was to assess the mortality rate among CCa patients in Nigeria as well as the major factors influencing CCa mortality. Study design Data from the medical records of 343 CCa patients seen at the Lagos University Teaching Hospital and NSIA-LUTH Cancer Center from 2015 to 2021 were used in a retrospective cohort analysis. The hazard ratios (HR) and confidence intervals (CI) associated with the exposure variables and CCa mortality were calculated using Cox proportional hazard regression. Results The CCa mortality rate was 30.5 per 100 women-years after 2.2 years of median follow-up. Clinical factors such as HIV/AIDS (adjusted HR [aHR]: 11.9; 95% CI: 4.6, 30.4), advanced clinical stage (aHR: 2.7; 95% CI: 1.5, 4.7), and anemia at presentation (aHR: 1.8; 95% CI: 1.1, 3.0) were associated with a higher mortality risk, as were non-clinical factors such as age at diagnosis >50 years (aHR: 1.4; 95% CI: 1.0, 1.9) and family history of CCa (aHR: 3.5; 95%CI: 1.1, 11.1). Conclusion CCa has a high mortality rate in Nigeria. Incorporating these clinical and non-clinical factors into CCa management and control policies may improve women's outcomes.
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Affiliation(s)
- Idris Olasunmbo Ola
- Global Health Program, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Departments of Clinical and Community Service, The Blue-Pink Center for Women's Health, Lagos, Nigeria
| | - Adeyemi Adebola Okunowo
- Department of Obstetrics & Gynaecology, College of Medicine University of Lagos, Lagos, Nigeria
- Department of Obstetrics & Gynaecology, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Muhammad Yaqub Habeebu
- Department of Radiotherapy, College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Radiotherapy, Lagos University Teaching Hospital, Lagos, Nigeria
- Lead Oncologist, NSIA-LUTH Cancer Centre (NLCC), Lagos, Nigeria
| | - Junmei Miao Jonasson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Research and Development, Region Halland, Halmstad, Sweden
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Kakotkin VV, Semina EV, Zadorkina TG, Agapov MA. Prevention Strategies and Early Diagnosis of Cervical Cancer: Current State and Prospects. Diagnostics (Basel) 2023; 13:diagnostics13040610. [PMID: 36832098 PMCID: PMC9955852 DOI: 10.3390/diagnostics13040610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023] Open
Abstract
Cervical cancer ranks third among all new cancer cases and causes of cancer deaths in females. The paper provides an overview of cervical cancer prevention strategies employed in different regions, with incidence and mortality rates ranging from high to low. It assesses the effectiveness of approaches proposed by national healthcare systems by analysing data published in the National Library of Medicine (Pubmed) since 2018 featuring the following keywords: "cervical cancer prevention", "cervical cancer screening", "barriers to cervical cancer prevention", "premalignant cervical lesions" and "current strategies". WHO's 90-70-90 global strategy for cervical cancer prevention and early screening has proven effective in different countries in both mathematical models and clinical practice. The data analysis carried out within this study identified promising approaches to cervical cancer screening and prevention, which can further enhance the effectiveness of the existing WHO strategy and national healthcare systems. One such approach is the application of AI technologies for detecting precancerous cervical lesions and choosing treatment strategies. As such studies show, the use of AI can not only increase detection accuracy but also ease the burden on primary care.
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Affiliation(s)
- Viktor V. Kakotkin
- Scientific and Educational Cluster MEDBIO, Immanuel Kant Baltic Federal University, A. Nevskogo St., 14, 236041 Kaliningrad, Russia
| | - Ekaterina V. Semina
- Scientific and Educational Cluster MEDBIO, Immanuel Kant Baltic Federal University, A. Nevskogo St., 14, 236041 Kaliningrad, Russia
| | - Tatiana G. Zadorkina
- Kaliningrad Regional Centre for Specialised Medical Care, Barnaulskaia Street, 6, 236006 Kaliningrad, Russia
| | - Mikhail A. Agapov
- Scientific and Educational Cluster MEDBIO, Immanuel Kant Baltic Federal University, A. Nevskogo St., 14, 236041 Kaliningrad, Russia
- Correspondence: ; Tel.: +7-(4012)-59-55-95
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Padavu S, Aichpure P, Krishna Kumar B, Kumar A, Ratho R, Sonkusare S, Karunasagar I, Karunasagar I, Rai P. An insight into clinical and laboratory detections for screening and diagnosis of cervical cancer. Expert Rev Mol Diagn 2023; 23:29-40. [PMID: 36697264 DOI: 10.1080/14737159.2023.2173580] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Cervical cancer is the most frequent malignancy among women caused by an unresolved long-term infection with distinct human papillomavirus (HPV) genotypes. It is the fourth most common form of cancer among women worldwide. The two oncogenic genotypes, HPV 16 and 18, are responsible for >70% of all cervical cancers worldwide. Cervical cancer is one of the most successfully preventable and treatable forms of cancer if detected early. AREAS COVERED In this review article, we have summarizedsummarised the different approaches used in clinical diagnosis and research laboratories to detect HPV-related changes associated with cervical cancer for a better understanding of the advantages and limitations of these tests. EXPERT OPINION Despite the well-known screening strategies for cervical cancer, developing nations lack effective implementation due to various factors. With the current rate of cervical cancer cases, precise and timely identification of HPV can significantly impact the prevention and efficient management of cervical cancer. Cervical cancer is the most common gynecological cancer in developing countries. The primary screening test with cytology and molecular testing of HPV is important for preventing cervical cancer. To address these issues, several point-of-care assays have been developed to facilitate rapid screening of HPV with the least turnaround time.
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Affiliation(s)
- Shruthi Padavu
- Nitte (Deemed to Be University), Nitte University Centre for Science Education and Research (NUCSER), Division of Infectious Diseases, Deralakatte, Mangaluru-575018, Karnataka, India
| | - Pooja Aichpure
- Nitte (Deemed to Be University), Nitte University Centre for Science Education and Research (NUCSER), Division of Infectious Diseases, Deralakatte, Mangaluru-575018, Karnataka, India
| | - Ballamoole Krishna Kumar
- Nitte (Deemed to Be University), Nitte University Centre for Science Education and Research (NUCSER), Division of Infectious Diseases, Deralakatte, Mangaluru-575018, Karnataka, India
| | - Anoop Kumar
- In Vivo Bioassay Laboratory & Animal Facility, National Institute of Biologicals (NIB), Ministry of Health & Family Welfare, Noida, India
| | - RadhaKanta Ratho
- Department of Virology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shipra Sonkusare
- Nitte (Deemed to Be University), Department of Obstetrics & Gynaecology, KS Hegde Medical Academy (KSHEMA), Deralakatte, Mangaluru, India
| | - Indrani Karunasagar
- Nitte (Deemed to Be University), University Enclave, Medical Sciences Complex, Deralakatte, Mangaluru, India
| | - Iddya Karunasagar
- Nitte (Deemed to Be University), University Enclave, Medical Sciences Complex, Deralakatte, Mangaluru, India
| | - Praveen Rai
- Nitte (Deemed to Be University), Nitte University Centre for Science Education and Research (NUCSER), Division of Infectious Diseases, Deralakatte, Mangaluru-575018, Karnataka, India
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