Cervical cancer screening in developing countries at a crossroad: Emerging technologies and policy choices

Poor Performance of Applicator Tampon-Based Self-Collection for Liquid-Based Cytology Among Women Attending a Tertiary Hospital in South Africa

BACKGROUND

The South African Cervical Cancer Prevention and Control Policy was updated in June 2017, recommending liquid-based cytology (LBC) as the preferred screening method and the investigation of self-sampling for cervical cancer screening.

AIM

To compare the performance of the Self Collection Cervical Health Screening Kit [SelfCerv (applicator tampon)] to the Cervex-Brush Combi for cytology screening. The study further aimed to compare high-risk (hr-) human papillomavirus (HPV) and LBC test results from both methods.

METHODS

The study included 446 paired samples, comprising self-collected (SelfCerv) and healthcare provider-collected (Cervex-Brush Combi) samples from women aged ≥ 18 years attending gynaecology outpatient clinics at a tertiary hospital in Pretoria, South Africa. LBC slides were prepared using the ThinPrep 5000 processor and manually stained with Hematoxylin and Eosin (H&E). Detection of 14 hr-HPV types was performed using the Abbott RealTime HR-HPV assay. Statistical analyses were performed using STATA version 17.0 (Stata Corp., College Station, Texas, USA).

RESULTS

A statistically significant difference in cervical cytology detection between the two methods was observed (p = 0.0025). The Cervex-Brush Combi was more effective in collecting endocervical cells (73.4%; 95% CI: 69.0-77.9) compared to the SelfCerv applicator tampon (7.3%; 95% CI: 4.7-9.9); (p < 0.001). Cytological abnormalities were detected in 65.4% (136/208) of participants who tested positive for hr-HPV by healthcare provider sampling compared to 40.8% (84/206) by self-sampling. A fair agreement (κ: 0.35) with a concordance rate of 96.2% (95% CI: 94.4-98.0) was observed for specimen adequacy and diagnosis parameters [κ: 0.34, with a concordance rate of 67.7% (95% CI: 63.2-72.1)] between the two methods.

CONCLUSION

The findings of this study do not support the implementation of applicator tampon-based self-collection as a method for cytology-based cervical cancer screening.

Addressing Global Disparities in Cervical Cancer Burden: A Narrative Review of Emerging Strategies

PURPOSE OF REVIEW

Cervical cancer burden is disproportionately higher in low to middle income countries, especially in countries with a high human immunodeficiency virus (HIV) burden. This review investigates barriers to implementation and assesses current progress in cervical cancer screening in lower resource settings by reviewing technologies and strategies that have already been implemented in low to middle income countries.

RECENT FINDINGS

Several novel innovations embrace the recent World Health Organization (WHO) update to screening guidelines that recommends a "screen and treat" approach rather than a "screen, triage and treat" approach. Innovations include human papillomavirus (HPV) self-sampling, portable cervical visualization devices, and creative large-scale approaches to increase screening accessibility. Overall, a low-cost, accurate, point-of-care screening test could alleviate most of the barriers associated with cervical cancer screening in lower resource settings. Further research into the development of a low-cost HPV test in conjunction with the HPV vaccine and other screening tools could expedite progress.

Identification of differentially expressed MiRNA clusters in cervical cancer

BACKGROUND

Aberrant miRNA expression has been associated with cervical cancer (CC) progression. The present study aimed to identify the miRNA clusters (MCs) altered in CC, identify their clinical utility, and understand their biological functions via computational analysis.

METHODS

We used small RNA sequencing and qRT‒PCR to identify and validate abnormally expressed MCs in cervical squamous cell carcinoma (CSCC) samples. We compared our data with publicly available CC datasets to identify the differentially expressed MCs in CC. The potential targets, pathways, biological functions, and clinical utility of abnormally expressed MCs were predicted via several computational tools.

RESULTS

Small RNA sequencing revealed that 229 miRNAs belonging to 48 MCs were significantly differentially expressed in CSCC (p-value ≤ 0.05). Validation by qRT‒PCR confirmed the downregulation of members of the miR-379/656, namely, hsa-miR-376c-3p (2.8-fold; p-value 0.03), hsa-miR-494-3p (3.4-fold; p-value 0.02), hsa-miR-495-3p (eightfold; p-value 0.01), and hsa-miR-409-3p (fivefold; p-value 0.03), in CSCC samples compared with normal samples. The prognostic model generated via miRNA expression and random forest analysis showed robust sensitivity and specificity (0.88 to 0.92) in predicting overall survival. In addition, we report 22 prognostically important miRNAs in CC. Pathway analysis revealed the enrichment of several cancer-related pathways, notably p53, the cell cycle, viral infection and MAPK signalling. CDC25A, CCNE1, E2F1, CCNE2, RBL1, E2F3, CDK2, RBL2, E2F2 and CCND2 were identified as the top ten gene targets of MC. Drug‒gene interaction analysis revealed enrichment of 548 approved drugs and 62 unique genes.

CONCLUSION

Our study identified MCs, their target genes, their prognostic utility, and their potential functions in CC and recommended their usefulness in CC management.

A Systematic Review of Interventions to Promote Cervical Cancer Screening among Immigrant Vietnamese Women

Vietnamese women have a higher incidence rate of cervical cancer and are less likely to have ever been screened for cervical cancer than their White counterparts in the US. This review synthesizes findings from published interventions to promote cervical cancer screening in this vulnerable population. Articles were identified through a systematic search of PsycInfo, Embase, Pubmed, Web of Science, and the Cochrane Register of Controlled Trials in October 2022. Articles were included if they were published in a peer-reviewed journal, written in English, included one or more interventions promoting cervical cancer screening, assessed at least one outcome relevant to screening, and included a sample of ≥ 70% Vietnamese participants. Quality assessment scores were computed using the Downs and Black Checklist. Fifteen articles met review inclusion criteria. Studies were, on average, of good quality. Most studies were conducted in the US (n = 12), used a quasi-experimental design (n = 9), and employed multiple intervention strategies (n = 12). Intervention strategies included educational sessions, lay health worker (LHW) outreach, small media, mass media, patient navigation, and community or healthcare-based strategies. The most common study outcomes were screening intention and receipt. All but two studies reported improved cervical cancer screening outcomes following intervention. Findings support the effectiveness of multicomponent culturally tailored interventions to improve cervical cancer screening outcomes in immigrant Vietnamese women. Further research is needed to determine whether these interventions will be as successful in non-US countries and to address broader community- and healthcare-based factors in screening.

Cervical cancer screening by cotesting method for Vietnamese women 25-55 years old: a cost-effectiveness analysis

BACKGROUND

Cervical cancer (CC) is preventable through regular screening and vaccination against human papillomavirus (HPV). However, CC remains a significant public health issue in low-income and middle-income countries (LMICs) like Vietnam, where financial constraints hinder the widespread implementation of HPV vaccination and screening programmes. Currently, Vietnam lacks both a national CC screening intervention and an HPV vaccination programme for women and girls. To date, cost-effectiveness studies evaluating CC screening methods in Vietnam remain limited.

OBJECTIVES

To evaluate the cost-effectiveness of two CC screening strategies for Vietnamese women aged 25-55 years: (1) cotesting combining cytology and HPV testing conducted three times at 5 year intervals (intervention) and (2) cytology-based screening conducted five times at 2 year intervals (comparator). The objective is to provide evidence to inform policy and clinical practice in Vietnam.

DESIGN

Cost-effectiveness analysis using a Markov model with 1 year cycles to simulate the natural progression of CC.

SETTING

The Vietnamese healthcare system, modelled from the provider's perspective, with parameters adapted to the local context through expert consultations.

PARTICIPANTS

A simulated cohort of Vietnamese women aged 25-55 years.

INTERVENTIONS

The intervention involved cotesting (cytology and HPV testing) three times at 5 year intervals. The comparator was cytology-based screening conducted five times at 2 year intervals.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was quality-adjusted life years (QALYs). Costs and cost-effectiveness ratios were assessed using Vietnam's gross domestic product (GDP) per capita as the cost-effectiveness threshold (1-3 times GDP per capita). Sensitivity analyses (one-way deterministic and probabilistic) were conducted to account for uncertainties.

RESULTS

The cotesting strategy was less effective and more costly than cytology-based screening across all age groups. Cotesting resulted in higher costs and fewer QALYs than the comparator. Probabilistic sensitivity analyses confirmed that cotesting was not cost-effective under current conditions in Vietnam.

CONCLUSIONS

Cytology-based screening conducted five times at 2 year intervals is a more cost-effective option for CC screening in Vietnamese women aged 25-55 years. The cotesting strategy cannot be recommended due to its higher cost and lower effectiveness.

Are we ready for self-sampling for cervical cancer screening? Insights from service providers and policy makers in Nepal

Cervical cancer is the leading cancer among women in Nepal, but the country has very low screening rate, with only 8.2% of women being screened. In recent years, a self-sampling kit for testing for the human papillomavirus (HPV) has been developed to allow self-sampling and enable early detection of cervical abnormalities. This kit enables women to collect cervical samples without the need for trained healthcare providers or healthcare facilities. Nevertheless, there has been a notable absence of scientific studies to analyse the feasibility and acceptability of self-sampling for cervical cancer screening in Nepal, particularly from the perspective of various service providers. The qualitative research method used semi-structured in-depth interviews and key informant interviews with healthcare providers, online service providers, and policymakers. These interviews were conducted in person with 20 participants until data saturation was achieved. Thematic analysis was performed where the translated data was coded inductively using NVivo 12. The majority of the participants identified the self-sampling method as an alternative sampling option for detection of cervical abnormalities/cancer in Nepal. Barriers to self-sampling included a low level of knowledge and information, the cost of the self-sampling kit, unclear information regarding self-sampling process and concerns about inaccurate results among women and girls, who are the end users. Similarly, factors such as knowledge and information regarding the self-sampling technique, accessibility of available services and information, and national self-care guidelines and policies for cervical cancer screening were identified as facilitators for self-sampling. It is crucial to have evidence-based discussions, especially regarding the effectiveness of a self-care approach in cervical cancer screening and help create a supportive policy environment for implementing self-care strategies in Nepal. Furthermore, disseminating education and information nationwide through campaigns to raise awareness about self-sampling is essential among beneficiaries for the scaling up of self-sampling for cervical cancer in Nepal.

Biological functions of extracellular vesicle double C2-like domain beta in cervical cancer

Double C-2 Like Domain Beta (DOC2B) located at 17q13.3 prevents metastasis by senescence induction and epithelial to mesenchymal transition inhibition in cervical cancer (CC). The extracellular vesicle (EV) mediated trafficking of DOC2B and its impact on tumor suppressive activity are not investigated in CC. Using a retroviral method, we first ectopically expressed DOC2B in SiHa, which do not normally express DOC2B. DOC2B-SiHa and vector-SiHa EVs were co-incubated separately with recipient cell and subjected to various cellular and biochemical experiments. For the first time, we demonstrated that DOC2B localizes to EVs, and its transfer to EV may require intracellular calcium. Co-culture of SiHa and HeLa cells with DOC2B-SiHa derived EVs induced morphological changes and suppressed their growth and migration, possibly by induction of G0/G1 to S phase arrest and anoikis. DOC2B-SiHa EVs elevated intracellular reactive oxygen species (ROS) and calcium levels and promoted lipid droplet accumulation and lipid peroxidation rate in recipient cells. DOC2B-SiHa EVs reduced active AKT1 and ERK1/2 levels and EMT marker expression and enhanced cellular senescence and cytotoxic effects of cisplatin. Re-expression of DOC2B significantly altered the global metabolite profile of EVs.  Finally, we demonstrated that intracellular calcium chelation significantly reduces DOC2B localization to EVs and impacts its tumor-suppressive properties. Altogether, EV-mediated DOC2B transfer may reduce the aggressive behavior of CC cells.

Integration and acceptability of cervical cancer screening as part of postnatal care among women attending postnatal clinics in the Accra Metropolis, Greater Accra Region, Ghana

Cervical cancer is a recognized preventable disease yet the fourth most common cancer among women globally. This study assessed the integration and acceptability of cervical cancer screening as part of routine sixth-week postnatal care among women attending a postnatal clinic. This was a cross-sectional descriptive study among 347 postpartum women who were attending their 6th-week postnatal visit. A Pap smear test was performed on each consenting study participant. Only conventional cervical smears were performed. The Pap smear samples were taken using a special kit (PAP-PAK Cytology brush kit) for a 3-smear sampling of the ectocervix (emphasis on the squamo-columnar junction), endocervix (endocervical canal past squamo-columnar junction) and the posterior fornix via a cervical-vaginal scraper and a CytoSoft cytology brush respectively. All smears were fixed with 95% ethyl alcohol and allowed to dry in cool air. The samples were sent to the cytology laboratory and stained with the Pap staining technique. All the smears were examined and reported by the cytology department of Korle-Bu Teaching Hospital. Descriptive statistics such as frequency tables were drawn and proportions were estimated. Bivariable analysis between categorical variables and outcome variables was done. A p-value ≤ 0.05 was considered statistically significant. Most (90.5%) of the study participants were satisfied with the Pap test procedure and about 52.7% indicated that paying Gh₵60.00 ($12.50) for screening test was affordable. The outcome of Pap smear tests revealed that most (90.8%) of the participants had normal Pap test results. In the univariable analysis, participants' educational level (p = 0.006); occupation (p < 0.001), and contraceptive use (p = 0.019) were significantly associated with the acceptability of the Pap test procedure. The multivariable analysis revealed that educational level (aOR = 3.27; 95% CI = 1.05-10.21; p = 0.041) and occupation (aOR = 6.49; 95% CI = 1.67-25.29; p = 0.007) were significantly associated with the acceptability of the Pap test procedure and showed higher odds of acceptability. Integration of cervical cancer screening into the routine sixth-week postnatal clinic has the potential to be feasible with anticipated high uptake. We therefore recommend a pilot study be initiated to integrate cervical cancer screening into the routine maternal health services as part of postnatal care. Also, the Ministry of Health/Ghana Health Service should initiate discussion with the National Health Insurance Authority for possible inclusion as part of the national health insurance scheme's benefit package in the nearby future.

High-risk human papillomavirus testing for cervical cancer screening in Uganda: Considering potential harms and benefits in a low-resource setting

OBJECTIVES

The World Health Organization supports both the screen-and-treat (ST) approach and the screen, triage and treat (STT) approach to cervical cancer screening using high-risk human papillomavirus (hrHPV) testing. For Uganda, the sequence of hrHPV-ST and hrHPV-STT could be similar, with visual inspection with acetic acid (VIA) after positive hrHPV tests in both. To consider potential tradeoffs (overtreatment in ST versus missed cancer cases in STT), we compared hrHPV-STT with VIA triage (STT-VIA), and STT with HPV 16/18 genotyping risk stratification, to hrHPV-ST for Uganda, in terms of overtreatment, cervical cancer incidence, and life years, for the general female population of Uganda.

METHODS

A microsimulation model of cervical cancer was adapted. Incremental benefit-harm ratios of STT were calculated as ratios of prevented overtreatment to reduced life years, and to increased cancer cases. Additional scenarios with 20% difference in intra- and inter-screening follow-up between ST and STT were modeled.

RESULTS

Both STT strategies resulted in life year losses on average compared to ST. STT-VIA prevented more overtreatment but led to increased cervical cancer incidence and life year losses. STT-G-VIA resulted in better harm-benefit ratios and additional costs. With better follow-up, STT prevented overtreatment and improved outcomes.

DISCUSSION

For Uganda, the STT approach appears preferrable, if the screening sequences of hrHPV-based ST and STT are similar in practice. While VIA triage alone would reduce overtreatment the most, it could also result in more cancer cases. Risk stratification via genotyping could improve STT. Potential follow-up differences and resource availability should be considered by decision-makers when planning Uganda's hrHPV-based screening strategy.

Early adoption of innovation in HPV prevention strategies: closing the gap in cervical cancer

Cervical cancer (CC) is one of the highest prevailing causes of female cancer-related mortality globally. A significant discrepancy in incidence has been noted between high and low-middle-income countries. The origins of CC have been accredited to the human papillomavirus (HPV) with serotypes 16 and 18 being the most prevalent. HPV vaccines, with 90%-97% efficacy, have proven safe and currently function as the primary prevention method. In addition, secondary prevention by timely screening can potentially increase the 5-year survival rate by >90%. High-precision HPV DNA testing has proven to be both highly sensitive and specific for early detection and is advocated by the WHO. Lack of public awareness, poor screening infrastructure and access to vaccines, socio-cultural concerns, along with economic, workforce-associated barriers and the presence of marginalised communities unable to access services have contributed to a continued high incidence. This article comprehensively analyses the efficacy, coverage, benefits and cost-effectiveness of CC vaccines and screening strategies including the transition from cytological screening to HPV self-sampling, while simultaneously exploring the real-world disparities in their feasibility. Furthermore, it calls for the implementation of population-based approaches that address the obstacles faced in approaching the WHO 2030 targets for CC elimination.

Usability of a smartphone-compatible, confocal micro-endoscope for cervical cancer screening in resource-limited settings

BACKGROUND

More efficient methods to detect and treat precancerous lesions of the cervix at a single visit, such as low-cost confocal microscopy, could improve early diagnosis and hence outcomes. We piloted a prototype smartphone-compatible confocal micro-endoscope (SCME) among women presenting to a public cervical cancer screening clinic in Kampala, Uganda. We describe the piloting of the SCME device at an urban clinic used by lower cadre staff.

METHODS

We screened women aged 18 and 60 years, who presented for cervical cancer screening at the Kawempe National Referral Hospital Kampala, and evaluated the experience of their providers (nurses). Nurses received a 2-day training by the study doctors on how to use the SCME, which was added to the standard Visual Inspection with Acetic acid (VIA)-based cervical cancer screening. The SCME was used to take colposcopy images before and after VIA at positions 12 and 6 O'clock if VIA negative, and on precancer-suspicious lesions if VIA positive. We used questionnaires to assess the women's experiences after screening, and the experience of the nurses who operated the SCME.

RESULTS

Between November 2021 and July 2022, we screened 291 women with a median age of 36 years and 65.7% were HIV positive. Of the women screened, 146 were eligible for VIA, 123 were screened with the SCME, and we obtained confocal images from 103 women. Of those screened with the SCME, 60% found it comfortable and 81% were willing to screen again with it. Confocal images from 79% of the women showed distinguishable cellular features, while images from the remaining 21% were challenging to analyze. Nurses reported a mean score of 85% regarding the SCME's usefulness to their work, 71% regarding their satisfaction and willingness to use it again, 63% in terms of ease of use, and 57% concerning the ease of learning how to operate the SCME.

CONCLUSION

Our findings demonstrate the feasibility of using the SCME by lower cadre staff in low-resource settings to aid diagnosis of precancerous lesions. However, more work is needed to make it easier for providers to learn how to operate the SCME and capture high-quality confocal images.

Enhancing outcome prediction of concurrent chemoradiation treatment in patients with locally advanced cervical cancer through plasma extracellular vesicle proteomics

Most patients with locally advanced cervical cancer (LACC) are primarily treated using concurrent chemoradiation (CCRT); however, LACC lacks reliable predictive biomarkers. Extracellular vesicles (EVs) could define the dynamic biological response to CCRT. However, the relationship between EVs and the therapeutic response to LACC is unestablished. Thus, we aimed to determine the relationship of plasma EVs pre- and post-CCRT in 62 patients with LACC. For proteomic analyses, EVs were isolated using ultracentrifugation (UC) with size exclusion chromatography or UC alone. We found that plasma particle concentration was significantly increased post-treatment in non-responders. After CCRT, there was a decrease in proteins related to serine protease and fibrinogen, which contribute to tumor microenvironment alteration. This reduction also extended to proteins involved in innate immune and viral immune responses, correlating with reduced tumor burden. Sparse partial least squares discriminant analysis revealed 8, 13, and 19 proteins at diagnosis, one month, and three months, respectively, influencing the CCRT response. Among these, FIBG, TFR1, HBA, and FINC are prognostic markers according to The Cancer Genome Atlas tissue gene expression database. Our discriminant model demonstrated excellent specificity and negative predictive value, underscoring the model's reliability in determining responsiveness to CCRT and highlighting the potential clinical applicability of EVs in improving outcomes in LACC.

Drivers of breast cancer and cervical cancer screening among women of reproductive age: insights from the Ghana Demographic and Health Survey

BACKGROUND

The two major causes of cancer-related deaths among women in Ghana are breast cancer (BC) and cervical cancer (CC). These types of cancers typically do not show any symptoms until they have progressed. Therefore, it is important to screen for early detection. This research aimed to investigate the rate of breast cancer and cervical cancer screening, as well as the factors associated with it, among women of reproductive age in Ghana.

METHODS

This study analysed data from the 2022 Ghana Demographic and Health Survey. A total of 15,014 women aged 15 to 49 years were included in the analysis. Descriptive statistics and binary logistic regression were employed to analyse the data with the aid of STATA/SE, version 17.

RESULTS

It was found that 18.4% and 5.0% of the women had screened for BC and CC, respectively. Women aged 45-49 years were about three times more likely (aOR = 2.83, 95% CI: 1.88-4.24) to screen for BC compared to those aged 15-19 years. Women who had tested for HIV had increased odds (aOR = 1.88, 95% CI: 1.56-2.25) of screening for BC compared to their counterparts. Women within the richest wealth index (aOR = 1.95, 95% CI: 1.40-2.72) had increased odds of screening for BC compared to those in the poorest wealth index. Regarding CC screening, women with higher education (aOR = 2.56, 95% CI: 1.53-4.29) were two times more likely to screen for CC compared to those with no formal education. Women who did not use tobacco (aOR = 0.45, 95% CI: 0.21-0.96) had decreased odds of CC screening compared to their counterparts.

CONCLUSIONS

This study showed that the uptake of BC and CC screening services among women in Ghana was very low. The drivers of BC and CC screening included enabling, predisposing, and need factors. Stakeholders can leverage the mass media to raise awareness and educate women in reproductive age about the importance of BC and CC screening. This study provides relevant information that can inform BC and CC policies and programmes in Ghana.

Knowledge, Attitude and Practice Concerning Cervical Cancer Screening Among Reproductive Age Group Women in Low-Resource Settings Yenagoa Bayelsa State

Background

Nigeria has one of the highest rates of cervical cancer morbidity and mortality in Sub-Saharan Africa. Both the human papillomavirus vaccine (HPV) and cervical screening are effective prevention strategies against both HPV infection and cervical cancer. Lack of awareness, limited knowledge, limited decision-making agency, lack of spousal support and stigma are barriers to uptake of these preventive measures. Cervical cancer is the second most diagnosed cancer and the third leading cause of cancer death in women worldwide. Eighty three percent (83%) of the world's new cases and 85% of all cervical cancer-related deaths occur in developing countries. It is primarily caused by human papilloma virus (HPV); a sexually transmitted pathogen that could be prevented with safe sexual practice and using vaccines, among others. The aim of the study was to assess the knowledge and attitude of reproductive age group women in low resource setting in towards cervical cancer and its prevention in Yenagoa, Bayelsa State Nigeria.

Methodology

This study employed the use of a descriptive study design to examine the knowledge and assessment of cervical cancer among women of reproductive age (19-54), about cervical cancer, its prevention, and their utilization of Pap smear screening; using a convenience sample of 406 women in two communities (Okaka and Agudama) in Yenagoa Local Government Area of Bayelsa State, Nigeria. Women voluntarily completed a structured questionnaire.

Result

Results showed that women who participated in the study were aware of cervical cancer (78.3%; n=318) but many (70.4%; n= 286) were unaware of Pap smears as the screening tests for cervical cancer. Although few of them (45.6%; n =185) knew about a screening center, out of which 17.6% (n= 32) reported that the screening center was less than 2km away from their residences.

Conclusion

There is need for health care professionals, to intensify efforts to increase awareness about cervical cancer screening and encourage women through the different clinics to use these services. The benefits of screening and early diagnosis of cervical cancer should be emphasized to enhance the utilization of cervical cancer screening services.

Epidemiology of HPV-associated cancers past, present and future: towards prevention and elimination

Cervical cancer is the first cancer deemed amenable to elimination through prevention, and thus lessons from the epidemiology and prevention of this cancer type can provide information on strategies to manage other cancers. Infection with the human papillomavirus (HPV) causes virtually all cervical cancers, and an important proportion of oropharyngeal, anal and genital cancers. Whereas 20th century prevention efforts were dominated by cytology-based screening, the present and future of HPV-associated cancer prevention relies mostly on HPV vaccination and molecular screening tests. In this Review, we provide an overview of the epidemiology of HPV-associated cancers, their disease burden, how past and contemporary preventive interventions have shaped their incidence and mortality, and the potential for elimination. We particularly focus on the cofactors that could have the greatest effect on prevention efforts, such as parity and human immunodeficiency virus infection, as well as on social determinants of health. Given that the incidence of and mortality from HPV-associated cancers remain strongly associated with the socioeconomic status of individuals and the human development index of countries, elimination efforts are unlikely to succeed unless prevention efforts focus on health equity, with a commitment to both primary and secondary prevention.

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

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

Discovery and technical validation of high-performance methylated DNA markers for the detection of cervical lesions at risk of malignant progression in low- and middle-income countries

BACKGROUND

Cervical cancer remains a leading cause of death, particularly in developing countries. WHO screening guidelines recommend human papilloma virus (HPV) detection as a means to identify women at risk of developing cervical cancer. While HPV testing identifies those at risk, it does not specifically distinguish individuals with neoplasia. We investigated whether a quantitative molecular test that measures methylated DNA markers could identify high-risk lesions in the cervix with accuracy.

RESULTS

Marker discovery was performed in TCGA-CESC Infinium Methylation 450 K Array database and verified in three other public datasets. The panel was technically validated using Quantitative Multiplex-Methylation-Specific PCR in tissue sections (N = 252) and cervical smears (N = 244) from the USA, South Africa, and Vietnam. The gene panel consisted of FMN2, EDNRB, ZNF671, TBXT, and MOS. Cervical tissue samples from all three countries showed highly significant differential methylation in squamous cell carcinoma (SCC) with a sensitivity of 100% [95% CI 74.12-100.00], and specificity of 91% [95% CI 62.26-99.53] to 96% [95% CI 79.01-99.78], and receiver operating characteristic area under the curve (ROC AUC) = 1.000 [95% CI 1.00-1.00] compared to benign cervical tissue, and cervical intraepithelial neoplasia 2/3 with sensitivity of 55% [95% CI 37.77-70.84] to 89% [95% CI 67.20-98.03], specificity of 93% [95% CI 84.07-97.38] to 96% [95% CI 79.01-99.78], and a ROC AUC ranging from 0.793 [95% CI 0.68-0.89] to 0.99 [95% CI 0.97-1.00] compared to CIN1. In cervical smears, the marker panel detected SCC with a sensitivity of 87% [95% CI 77.45-92.69], specificity 95% [95% CI 88.64-98.18], and ROC AUC = 0.925 [95% CI 0.878-0.974] compared to normal, and high-grade squamous intraepithelial lesion (HSIL) at a sensitivity of 70% (95% CI 58.11-80.44), specificity of 94% (95% CI 88.30-97.40), and ROC AUC = 0.884 (95% CI 0.822-0.945) compared to low-grade intraepithelial lesion (LSIL)/normal in an analysis of pooled data from the three countries. Similar to HPV-positive, HPV-negative cervical carcinomas were frequently hypermethylated for these markers.

CONCLUSIONS

This 5-marker panel detected SCC and HSIL in cervical smears with a high level of sensitivity and specificity. Molecular tests with the ability to rapidly detect high-risk HSIL will lead to timely treatment for those in need and prevent unnecessary procedures in women with low-risk lesions throughout the world. Validation of these markers in prospectively collected cervical smear cells followed by the development of a hypermethylated marker-based cervical cancer detection test is warranted.

Vaginal Microbiota and HPV in Latin America: A Narrative Review

With the expansion of human microbiome studies in the last 15 years, we have realized the immense implications of microbes in human health. The human holobiont is now accepted, given the commensal relationships with bacteria, fungi, parasites, viruses, and human cells. The cervicovaginal microbiota is a specific case within the human microbiome where diversity is lower to maintain a chemical barrier of protection against infections. This narrative review focuses on the vaginal microbiome. It summarizes key findings on how native bacteria protect women from disease or predispose them to damaging inflammatory processes with an emphasis on the role of HPV infections in Latin America, one of the world's regions with the highest cervical cancer prevalence.

Comparison of Colposcopy and Histopathology in Abnormal Cervix

Cervicovaginal cancer (CVC) is the most common malignancy of the genital tract. Colposcopy is a diagnostic procedure that is used to examine the cervix and tissue samples of the urethra and vulva in a magnified view. The colposcopy and histological findings of unhealthy cervixes in a tertiary care hospital were compared. This comparative cross-sectional study was conducted from November 2022 to March 2023 among women with a variety of gynecological complaints who visited the Department of Obstetricians and Gynecologists in a tertiary care facility. One hundred participants were included in this study. The data collected were analyzed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, United States). Participants had an average age of 35.22 ± 7.18 years, and white discharge was the most reported ailment (73%). Comparing the results of the colposcopy with the histological findings revealed a sensitivity of 91.5% and a specificity of 72.2%. The high sensitivity of colposcopy highlights the need to combine it with histological techniques to obtain better results.

Precision Population Cancer Medicine in Cancer of the Uterine Cervix: A Potential Roadmap to Eradicate Cervical Cancer

With the success of the Human Genome Project, the era of genomic medicine (GM) was born. Later on, as GM made progress, there was a feeling of exhilaration that GM could help resolve many disease processes. It also led to the conviction that personalized medicine was possible, and a relatively synonymous word, precision medicine (PM), was coined. However, the influence of environmental factors and social determinants of diseases was only partially given their due importance in the definition of PM, although more recently, this has been recognized. With the rapid advances in GM, big data, data mining, wearable devices for health monitoring, telemedicine, etc., PM can be more easily extended to population-level health care in disease management, prevention, early screening, and so on.and the term precision population medicine (PPM) more aptly describes it. PPM's potential in cancer care was posited earlier,and the current authors planned a series of cancer disease-specific follow-up articles. These papers are mainly aimed at helping emerging students in health sciences (medicine, pharmacy, nursing, dentistry, public health, population health), healthcare management (health-focused business administration, nonprofit administration, public institutional administration, etc.), and policy-making (e.g., political science), although not exclusively. This first disease-specific report focuses on the cancer of the uterine cervix (CC). It describes how recent breakthroughs can be leveraged as force multipliers to improve outcomes in CC - by improving early detection, better screening for CC, potential GM-based interventions during the stage of persistent Human papillomavirus (HPV) infection and treatment interventions - especially among the disadvantaged and resource-scarce populations. This work is a tiny step in our attempts to improve outcomes in CC and ultimately eradicate CC from the face of the earth.

Validation in Zambia of a cervical screening strategy including HPV genotyping and artificial intelligence (AI)-based automated visual evaluation

BACKGROUND

WHO has recommended HPV testing for cervical screening where it is practical and affordable. If used, it is important to both clarify and implement the clinical management of positive results. We estimated the performance in Lusaka, Zambia of a novel screening/triage approach combining HPV typing with visual assessment assisted by a deep-learning approach called automated visual evaluation (AVE).

METHODS

In this well-established cervical cancer screening program nested inside public sector primary care health facilities, experienced nurses examined women with high-quality digital cameras; the magnified illuminated images permit inspection of the surface morphology of the cervix and expert telemedicine quality assurance. Emphasizing sensitive criteria to avoid missing precancer/cancer, ~ 25% of women screen positive, reflecting partly the high HIV prevalence. Visual screen-positive women are treated in the same visit by trained nurses using either ablation (~ 60%) or LLETZ excision, or referred for LLETZ or more extensive surgery as needed. We added research elements (which did not influence clinical care) including collection of HPV specimens for testing and typing with BD Onclarity™ with a five channel output (HPV16, HPV18/45, HPV31/33/52/58, HPV35/39/51/56/59/66/68, human DNA control), and collection of triplicate cervical images with a Samsung Galaxy J8 smartphone camera™ that were analyzed using AVE, an AI-based algorithm pre-trained on a large NCI cervical image archive. The four HPV groups and three AVE classes were crossed to create a 12-level risk scale, ranking participants in order of predicted risk of precancer. We evaluated the risk scale and assessed how well it predicted the observed diagnosis of precancer/cancer.

RESULTS

HPV type, AVE classification, and the 12-level risk scale all were strongly associated with degree of histologic outcome. The AVE classification showed good reproducibility between replicates, and added finer predictive accuracy to each HPV type group. Women living with HIV had higher prevalence of precancer/cancer; the HPV-AVE risk categories strongly predicted diagnostic findings in these women as well.

CONCLUSIONS

These results support the theoretical efficacy of HPV-AVE-based risk estimation for cervical screening. If HPV testing can be made affordable, cost-effective and point of care, this risk-based approach could be one management option for HPV-positive women.

Use of grape-based stain (Vinatela) on cervical cytology: A Peruvian validation study

Objectives

The Papanicolaou's (Pap's) stain is used for cervical cancer screening. It employs toxic-carcinogenic expensive reagents, which may not be easily accessible to many communities worldwide. The objective of this study was to validate the grape-based alcohol-extracted dye (Vinatela) on normal cervical samples for the Pap test.

Material and Methods

Samples of the two grape species were collected from two vineyards through the Agroindustrial Research Institute of Universidad Privada San Juan Bautista. The dye extraction from the grape species and the dye performance to stain cells were conducted in three phases: (a) direct staining with pre-fermentation wine products, (b) direct fragmentation of grapes and direct staining with shells of the grapes, and (c) alcoholic extraction of the dye. Vinatela obtained from two species (Vitis vinifera "Tempranillo" and "Malbec") and posterior staining of cervical samples. We conducted a double-blind validation on 30 cervical samples.

Results

The basophilic components of the cervical cells were stained. Alcoholic extraction staining protocol had a low yield. The nuclear and cytoplasmic borders, the nuclear details, and the polymorphonuclear nuclei were stained with Vinatela and could be differentiated during nuclear coloration. The initial staining protocol was 10- 20 min × (mean ~12 min) staining time. We noted a slightly better staining with V. v. Tempranillo as compared to V. v. Malbec (P = 0.045).

Conclusion

Cervical cells stained with Vinatela stain from two grape species cultivated in the Southern of Peru, showed basophilic nuclear details.

Development of Enzymatic Recombinase Amplification Assays for the Rapid Visual Detection of HPV16/18

Human papillomavirus (HPV) types 16 and 18 are the major causes of cervical lesions and are associated with 71% of cervical cancer cases globally. However, public health infrastructures to support cervical cancer screening may be unavailable to women in low-resource areas. Therefore, sensitive, convenient, and cost-efficient diagnostic methods are required for the detection of HPV16/18. Here, we designed two novel methods, real-time ERA and ERA-LFD, based on enzymatic recombinase amplification (ERA) for quick point-of-care identification of the HPV E6/E7 genes. The entire detection process could be completed within 25 min at a constant low temperature (35-43°C), and the results of the combined methods could be present as the amplification curves or the bands presented on dipsticks and directly interpreted with the naked eye. The ERA assays evaluated using standard plasmids carrying the E6/E7 genes and clinical samples exhibited excellent specificity, as no cross-reaction with other common HPV types was observed. The detection limits of our ERA assays were 100 and 101 copies/μl for HPV16 and 18 respectively, which were comparable to those of the real-time PCR assay. Assessment of the clinical performance of the ERA assays using 114 cervical tissue samples demonstrated that they are highly consistent with real-time PCR, the gold standard for HPV detection. This study demonstrated that ERA-based assays possess excellent sensitivity, specificity, and repeatability for HPV16 and HPV18 detection with great potential to become robust diagnostic tools in local hospitals and field studies.

MALDI-TOF MS Analysis of Serum Peptidome Patterns in Cervical Cancer

BACKGROUND

Cervical cancer is the fourth most common cancer among females worldwide. Identifying peptide patterns discriminating healthy individuals from those with diseases has gained interest in the early detection of cancers. Our study aimed to determine signature peptide patterns for cervical cancer screening.

METHODS

Our study focused on the serum peptidome analysis of 83 healthy women and 139 patients with cervical cancer. All spectra derived from matrix-assisted laser desorption/ionization time-of-flight mass spectrometry were analyzed using FlexAnalysis 3.0 and ClinProTools 2.2 software.

RESULTS

In the mass range of 1000-10,000 Da, the total average spectra were represented as the signature pattern. Principal component analysis showed that all the groups were separately distributed. Furthermore, the peaks at m/z 1466.91, 1898.01, 3159.09, and 4299.40 significantly differed among the investigated groups (Wilcoxon/Kruskal-Wallis test and ANOVA, p < 0.001).

CONCLUSIONS

Laboratory-based rapid mass spectrometry showed that serum peptidome patterns could serve as diagnostic tools for diagnosing cervical cancer; however, verification through larger cohorts and association with clinical data are required, and the use of externally validated samples, such as patients with other types of cancers, should be investigated to validate the specific peptide patterns.

Cervical Cancer Screening Recommendations: Now and for the Future

Cervical cancer is the fourth most common cancer worldwide, with over 600,000 new cases annually and approximately 350,000 cancer-related deaths per year. The disease burden is disproportionately distributed, with cancer-related mortality ranging from 5.2 deaths per 100,000 individuals in highly-developed countries, to 12.4 deaths per 100,000 in less-developed countries. This article is a review of the current screening recommendations and potential future recommendations.

Task-shifting for point-of-care cervical cancer prevention in low- and middle-income countries: a case study from Uganda

Cervical cancer remains the leading cause of female cancer deaths in sub-Saharan Africa. This is despite cervical cancer being both preventable and curable if detected early and treated adequately. This paper reports on a series of action-research 'cycles' designed to progressively integrate a comprehensive, task-shifted, point-of-care, prevention program in a community-based public health facility in Uganda. The work has been undertaken through a UK-Ugandan Health Partnership coordinated by Knowledge for Change, a UK-registered Charity. The intervention demonstrates the effectiveness of task-shifting responsibility to Community Health Workers combined with the use of Geographic Information Systems to strategically guide health awareness-raising and the deployment of medical devices supporting respectful and sustainable point-of-care screen-and-treat services. The integration of this with public human immunodeficiency virus services demonstrates the ability to engage hard-to-reach 'key populations' at greatest risk of cervical cancer. The findings also demonstrate the impact of external influences including the Results Based Financing approach, adopted by many foreign Non-Governmental Organizations. The model presents opportunities for policy transfer to other areas of health promotion and prevention with important lessons for international Health partnership engagement. The paper concludes by outlining plans for a subsequent action-research cycle embracing and evaluating the potential of Artificial Intelligence to enhance service efficacy.

HPV self-sampling versus healthcare provider collection on the effect of cervical cancer screening uptake and costs in LMIC: a systematic review and meta-analysis

BACKGROUND

Cervical cancer is a major global health issue, with 89% of cases occurring in low- and middle-income countries (LMICs). Human papillomavirus (HPV) self-sampling tests have been suggested as an innovative way to improve cervical cancer screening uptake and reduce the burden of disease. The objective of this review was to examine the effect of HPV self-sampling on screening uptake compared to any healthcare provider sampling in LMICs. The secondary objective was to estimate the associated costs of the various screening methods.

METHOD

Studies were retrieved from PubMed, Embase, CINAHL, CENTRAL (by Cochrane), Web of Science, and ClinicalTrials.gov up until April 14, 2022, and a total of six trials were included in the review. Meta-analyses were performed mainly using the inverse variance method, by pooling effect estimates of the proportion of women who accepted the screening method offered. Subgroup analyses were done comparing low- and middle-income countries, as well as low- and high-risk bias studies. Heterogeneity of the data was assessed using I2. Cost data was collected for analysis from articles and correspondence with authors.

RESULTS

We found a small but significant difference in screening uptake in our primary analysis: RR 1.11 (95% CI: 1.10-1.11; I2 = 97%; 6 trials; 29,018 participants). Our sensitivity analysis, which excluded one trial that measured screening uptake differently than the other trials, resulted in a clearer effect in screening uptake: RR: 1.82 (95% CI: 1.67-1.99; I2 = 42%; 5 trials; 9590 participants). Two trials reported costs; thus, it was not possible to make a direct comparison of costs. One found self-sampling more cost-effective than the provider-required visual inspection with acetic acid method, despite the test and running costs being higher for HPV self-sampling.

CONCLUSION

Our review indicates that self-sampling improves screening uptake, particularly in low-income countries; however, to this date, there remain few trials and associated cost data. We recommend further studies with proper cost data be conducted to guide the incorporation of HPV self-sampling into national cervical cancer screening guidelines in low- and middle-income countries.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020218504.

Development and validation of radiomic signature for predicting overall survival in advanced-stage cervical cancer

Background

The role of artificial intelligence and radiomics in prediction model development in cancer has been increasing every passing day. Cervical cancer is the 4th most common cancer in women worldwide, contributing to 6.5% of all cancer types. The treatment outcome of cervical cancer patients varies and individualized prediction of disease outcome is of paramount importance.

Purpose

The purpose of this study is to develop and validate the digital signature for 5-year overall survival prediction in cervical cancer using robust CT radiomic and clinical features.

Materials and Methods

Pretreatment clinical features and CT radiomic features of 68 patients, who were treated with chemoradiation therapy in our hospital, were used in this study. Radiomic features were extracted using an in-house developed python script and pyradiomic package. Clinical features were selected by the recursive feature elimination technique. Whereas radiomic feature selection was performed using a multi-step process i.e., step-1: only robust radiomic features were selected based on our previous study, step-2: a hierarchical clustering was performed to eliminate feature redundancy, and step-3: recursive feature elimination was performed to select the best features for prediction model development. Four machine algorithms i.e., Logistic regression (LR), Random Forest (RF), Support vector classifier (SVC), and Gradient boosting classifier (GBC), were used to develop 24 models (six models using each algorithm) using clinical, radiomic and combined features. Models were compared based on the prediction score in the internal validation.

Results

The average prediction accuracy was found to be 0.65 (95% CI: 0.60-0.70), 0.72 (95% CI: 0.63-0.81), and 0.77 (95% CI: 0.72-0.82) for clinical, radiomic, and combined models developed using four prediction algorithms respectively. The average prediction accuracy was found to be 0.69 (95% CI: 0.62-0.76), 0.79 (95% CI: 0.72-0.86), 0.71 (95% CI: 0.62-0.80), and 0.72 (95% CI: 0.66-0.78) for LR, RF, SVC and GBC models developed on three datasets respectively.

Conclusion

Our study shows the promising predictive performance of a robust radiomic signature to predict 5-year overall survival in cervical cancer patients.

Comparison of the AmpFire® Multiplex HPV Assay to the Xpert® HPV Assay for detection of human papillomavirus and cervical disease in women with human immunodeficiency virus: a pragmatic performance evaluation

BACKGROUND

Low- and middle-income countries (LMICs) account for nearly 85% of the global cervical cancer burden, yet have the least access to high-performance screening. International guidelines recommend human papillomavirus testing (HPV) as primary screening, yet implementation is inhibited by the cost of HPV testing. Atila AmpFire® HPV Assay (AmpFire) is both affordable and easy to use, and offers individual genotyping. The objective of this study was to compare the performance of the AmpFire HPV assay to the Xpert® HPV assay in detection of both HPV and clinically significant cervical disease.

METHODS

We utilized stored cervical specimens from a prospective cohort study of women living with human immunodeficiency virus (HIV) in Botswana conducted from May to July 2018. Positive and negative percent agreement was calculated for the AmpFire and Xpert assays, as was detection of high-grade cervical dysplasia.

RESULTS

63 stored cervical specimens had detectable DNA after thawing and were included in the analysis. The positive percent agreement was 91.2% (95%CI 76.3-98.1) and negative percent agreement was 79.3% (95% CI 60.3-92.0). Six cases positive by AmpFire but negative by Xpert were HPV genotypes 35, 52 (n = 2), 58, 68, and co-infection with HPV 45 and 68. Both Xpert and AmpFire assays detected HPV in all 10 samples of women who had high-grade cervical dysplasia.

CONCLUSIONS

The AmpFire HPV assay demonstrated excellent analytic performance in both detection of HPV and clinically significant cervical disease. AmpFire HPV is a promising option to increase access to affordable, type-specific HPV screening for cervical cancer in LMICs.

Prevalence of high-risk human papillomavirus infections and associated factors among women living with HIV in Shashemene town public health facilities, Southern Ethiopia

BACKGROUND

Every year, large number of women are suffering from cervical cancer. Particularly women living with HIV are at high-risk of being suffered with it. Early testing of high-risk human papillomavirus infection can significantly reduce the incidence of cervical cancer. However, lack of early and regular testing has been identified as one of the major problems among risky populations.

METHODS

Institutional-based cross-sectional study design was conducted among women living with HIV in Shashemene town public health facilities with a total sample size of 406 from February 1-March 30, 2022. Systematic random sampling technique was employed to select the study subjects. A structured questionnaire and checklist was used to collect data. The collected data were cleaned, coded, and entered into Epi-info version 7.2.5 and exported to statistical package for social science version 24 for analysis. Finally, bi-variable and multivariable logistic regression analyses were performed to identify determinants of high-risk human papillomavirus. Odds ratio with 95% confidence interval was used to test association between exposure and outcome under study and p-value < 0.05 was considered significant.

RESULTS

The prevalence of high-risk HPV infections among study participant was 173(35.2%) with 95% CI (30.5%-40.1%). Prevalence of high-risk HPV type 16, 18 and other high-risk HPV types were 62(15.3%), 23(5.7%) and 58(14.3%), respectively. Having history of sexually transmitted infections [AOR = 3.120; 95% CI (1.977-4.923)], Endline CD4 count < 200 cells/mm3 [AOR = 3.072; 95% CI(1.009-9.350)], Endline HIV viral-load ≥ 50 copies/ml [AOR = 3.446; 95% CI(1.368-8.683)] and more than one-lifetime sexual partner [AOR = 2.112; 95% CI(1.297-3.441)] were significantly associated with high-risk HPV infections.

CONCLUSION

More than one third of women living with HIV had high-risk HPV. Having history of STI, low CD4 count, high viral load and multiple sexual partners were associated with high risk HPV. HIV positive women with these risk factors should be given special consideration in clinical and public health intervention.

Female adolescents' knowledge and acceptability of human papillomavirus vaccine in Debre Tabor Town, Ethiopia: a cross-sectional study

OBJECTIVE

This study aimed to assess the knowledge and acceptability of the human papillomavirus (HPV) vaccine and associated factors among female adolescent students in Debre Tabor Town, Ethiopia, 2021.

DESIGN

Cross-sectional study was done from 9 December 2020 to 28 February 2021.

ANALYSIS

The data were entered into EpiData V.4.2 and analysed with SPSS V.23 software. The OR, 95% CI and p<0.05 were used to determine the bivariable and multivariable statistical association.

SETTING

Three high schools (grades 9 and 10) and six primary schools (grades 7 and 8) were included in the study.

PARTICIPANTS

Adolescent female students in Debre Tabor Town.

RESULTS

The overall knowledge score in the questionnaire was six, and it was divided into two groups based on scoring level: poor (score <3) and good (score ≥3). More than half respondents (59.2%) scored good knowledge. The proportion of acceptability of the HPV vaccine was 61.9%. Age (adjusted OR, AOR 1.70, 95% CI 1.17 to 3.88), and having a source of information (AOR 1.94, 95% CI 1.06 to 3.22) were significantly associated with the knowledge of the HPV vaccine. Place of birth (AOR 1.55, 95% CI 1.15 to 1.95), fathers' educational status (AOR 2.80, 95% CI 1.18 to 5.65), having a source of information (AOR 2.14, 95% CI 1.05 to 4.32) and knowledge about the HPV vaccine (AOR 6.41, 95% CI 3.45 to 11.90) were significantly associated with the acceptance of the female adolescent HPV vaccine.

CONCLUSION

In this study, the knowledge and acceptability of students of the HPV vaccine were low. Health authorities, through the mass media, should strengthen HPV vaccine promotion in schools, religious institutions and health facilities.

Comparison of the AmpFire Multiplex HPV Assay to the Xpert HPV Assay for detection of human papillomavirus and cervical disease in women with human immunodeficiency virus: A pragmatic performance evaluation

Background: Low- and middle-income countries (LMICs) account for nearly 85% of the global cervical cancer burden, yet have the least access to high-performance screening. International guidelines recommend human papillomavirus testing (HPV) as primary screening, yet implementation is inhibited by the cost of HPV testing.Atila AmpFire HPV Assay (AmpFire) is both affordable and easy to use, and offers individual genotyping. The objective of this study was to compare the performance of the AmpFire HPV assay to the Xpert HPV assay in detection of both HPV and clinically significant cervical disease. Methods: We utilized stored cervical specimens from a prospective cohortstudy of women living with human immunodeficiency virus (HIV) in Botswana conducted from May to July 2018. Positive and negative percent agreement was calculated for the AmpFire and Xpert assays, as was detection of high-grade cervical dysplasia. Results : 63 stored cervical specimens haddetectable DNA after thawing and were included in the analysis. The positive percent agreement was 91.2% (95%CI: 76.3-98.1) and negative percent agreement was 79.3% (95% CI: 60.3-92.0). Six cases positive by AmpFire but negative by Xpert were HPV genotypes 35, 52 (n=2), 58, 68, and co-infection with HPV 45 and 68. Both Xpert and AmpFire assays detected HPV in all 10 samples of women who had high-grade cervical dysplasia. Conclusions : The AmpFire HPV assay demonstrated excellent analytic performance in both detection of HPV and clinically significant cervical disease. AmpFire HPV is a promising option to increase access to affordable, type-specific HPV screening for cervical cancer in LMICs.

Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening

BACKGROUND

Human papillomavirus (HPV) testing on self-samples represents a great opportunity to increase cervical cancer screening uptake among under-screened women.

METHODS

A systematic review and meta-analysis on randomised controlled trials (RCTs) were performed to update the evidence on the efficacy of strategies for offering self-sampling kits for HPV testing compared to conventional invitations and to compare different self-sampling invitation scenarios. Four experimental invitational scenarios were considered. Women in the control group were invited for screening according to existing practice: collection of a cervical specimen by a healthcare professional. Random-effects models were used to pool proportions, relative participation rates and absolute participation differences.

RESULTS

Thirty-three trials were included. In the intention-to-treat analysis, all self-sampling invitation scenarios were more effective in reaching under-screened women compared to controls. Pooled participation difference (PD) and 95% confidence interval (CI) for experimental vs. control was 13.2% (95% CI = 11.0-15.3%) for mail-to-all, 4.4% (95% CI = 1.2-7.6%) for opt-in, 39.1% (95% CI = 8.4-69.9%) for community mobilisation & outreach and 28.1% (23.5-32.7%) for offer at healthcare service. PD for the comparison opt-in vs. mail-to-all, assessed in nine trials, was -8.2% (95% CI = -10.8 to -5.7%).

DISCUSSION

Overall, screening participation was higher among women invited for self-sampling compared to control, regardless of the invitation strategy used. Opt-in strategies were less effective than send-to-all strategies.

Audio-Visual Training Improves Awareness and Willingness of Cervical Cancer Screening among Healthy Indian Women: Findings from a Survey

Priya GaneshkumarObjectives  We evaluated the impact of a standardized, simple audio-visual (AV) training video developed in regional languages on cervical cancer awareness among apparently healthy women and their willingness to undergo regular cervical cancer screening. Materials and Methods  This cross-sectional noninterventional multicentric survey was conducted in 69 centers across 14 states in India and one center in UAE among women aged between 18 and 88 years attending clinics for a variety of indications. Using a short questionnaire, cervical cancer awareness and willingness to undergo cervical cancer screening were assessed before and after the AV training. Statistical Analysis  In addition to descriptive analysis, improvement in awareness after the AV training was assessed using McNemar's test, and comparison of responses between subgroups was performed using Pearson chi-squared test. Results  The survey was completed by 3,188 apparently healthy women (mean age: 36.8 ± 11.3 years). Before AV training, correct answers were given to only 4/6 questions by majority of the participants; most participants were unaware about the main cause of cervical cancer (1,637/3,188, 51.4%), availability of cervical cancer screening tests (1,601/3,188, 50.2%), and cervical cancer vaccines (1,742/3,188, 54.6%). Only 576 women (18.1%) had undergone cervical cancer screening in the past. After the AV training, the proportion of women correctly responding to all six questions improved significantly (p < 0.05), and 84.4% (2691/3188) women showed willingness to undergo periodic cervical cancer screening. Compared to unmarried and professional women, although married women and home-makers had lower awareness scores, the latter subgroups had more often undergone previous cervical cancer screening. Conclusion  It is possible to improve cervical cancer awareness among healthy women, and to enhance their willingness to undergo regular cervical cancer screening tests using a simple, six minute-long, standardized AV training material.

Enhancing the Effect of Nucleic Acid Vaccines in the Treatment of HPV-Related Cancers: An Overview of Delivery Systems

Prophylactic vaccines against human papillomavirus (HPV) have proven efficacy in those who have not been infected by the virus. However, they do not benefit patients with established tumors. Therefore, the development of therapeutic options for HPV-related malignancies is critical. Third-generation vaccines based on nucleic acids are fast and simple approaches to eliciting adaptive immune responses. However, techniques to boost immunogenicity, reduce degradation, and facilitate their capture by immune cells are frequently required. One option to overcome this constraint is to employ delivery systems that allow selective antigen absorption and help modulate the immune response. This review aimed to discuss the influence of these different systems on the response generated by nucleic acid vaccines. The results indicate that delivery systems based on lipids, polymers, and microorganisms such as yeasts can be used to ensure the stability and transport of nucleic acid vaccines to their respective protein synthesis compartments. Thus, in view of the limitations of nucleic acid-based vaccines, it is important to consider the type of delivery system to be used-due to its impact on the immune response and desired final effect.

Improving the repeatability of deep learning models with Monte Carlo dropout

The integration of artificial intelligence into clinical workflows requires reliable and robust models. Repeatability is a key attribute of model robustness. Ideal repeatable models output predictions without variation during independent tests carried out under similar conditions. However, slight variations, though not ideal, may be unavoidable and acceptable in practice. During model development and evaluation, much attention is given to classification performance while model repeatability is rarely assessed, leading to the development of models that are unusable in clinical practice. In this work, we evaluate the repeatability of four model types (binary classification, multi-class classification, ordinal classification, and regression) on images that were acquired from the same patient during the same visit. We study the each model's performance on four medical image classification tasks from public and private datasets: knee osteoarthritis, cervical cancer screening, breast density estimation, and retinopathy of prematurity. Repeatability is measured and compared on ResNet and DenseNet architectures. Moreover, we assess the impact of sampling Monte Carlo dropout predictions at test time on classification performance and repeatability. Leveraging Monte Carlo predictions significantly increases repeatability, in particular at the class boundaries, for all tasks on the binary, multi-class, and ordinal models leading to an average reduction of the 95% limits of agreement by 16% points and of the class disagreement rate by 7% points. The classification accuracy improves in most settings along with the repeatability. Our results suggest that beyond about 20 Monte Carlo iterations, there is no further gain in repeatability. In addition to the higher test-retest agreement, Monte Carlo predictions are better calibrated which leads to output probabilities reflecting more accurately the true likelihood of being correctly classified.

Cervical cancer in Nepal: Current screening strategies and challenges

Nepal has a high burden of cervical cancer primarily due to a limited screening program. Most present with advanced cervical disease. Despite no national cervical cancer control program, Nepal's Ministry of Health and Population has taken many initiatives with various international collaborations in screening, vaccination, and treating pre-invasive and invasive cancer. However, the existing prevention and treatment modalities are dismally inadequate to meet the targets of WHO's cervical cancer eliminative initiative by 2030. We provide an overview of the Ministry of Health and Population, Nepal's efforts to tackle the growing cervical cancer burden in the country. We discuss the challenges and potential solutions that could be practical and augment screening uptakes, such as single-dose vaccination and HPV DNA tests. The screen-and-treat approach on the same day could potentially address treatment delays and follow-up loss after testing positive. Our narrative summary highlights existing and innovative strategies, unmet needs, and collaborations required to achieve elimination across implementation contexts.

Barriers and recommendations for a cervical cancer screening program among women in low-resource settings in Lagos Nigeria: a qualitative study

Background

Cervical cancer is the fourth most common cancer in women globally despite being a largely treatable and preventable malignancy. Developing countries account for over 80% of all new cases. Women residing in low-resource settings such as those residing in slums have a higher risk of cervical cancer, and lower uptake of cervical cancer screening. Diverse barriers influence the uptake of cervical cancer screening among women in low-resource settings.

Objectives

This qualitative study was done prior to the introduction of a cervical cancer screening program in two slum areas in Lagos Nigeria and explored women’s knowledge about cervical cancer, and their perceived barriers and recommendations for the program.

Method

Four focus group discussions(FGD) were conducted among 35 women between the ages of 21–65 years residing in two urban slums in Lagos, Nigeria from February to April 2019. Each FGD was limited to 8–10 participants of women of similar ages. Voice recordings were transcribed verbatim and thematic analysis was done.

Results

Most of the women were not aware of cervical cancer and none knew the symptoms or risk factors of cervical cancer. The participants felt that the cervical cancer screening program would be well accepted in the community, however, expressed concerns about the cost of the screening test and the sex of the person performing the test. The recommendations proffered for a successful cervical cancer screening program include; reducing the cost of the test or providing the test free of charge, having people that speak the local language as part of the team, using female health care providers, using a private location within the community or nearby primary health center, and publicizing the program with the use of SMS, phone calls, town crier, and health talks. It was recommended that organizing health education sessions would help improve women’s poorly perceived susceptibility to cervical cancer.

Conclusion

Interventions to increase uptake of cervical cancer screening among women in low resource settings need to improve knowledge of cervical cancer and address barriers to cervical cancer screening such as cost, distance, and as much as possible, sex of the healthcare provider should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14314-2.

Modelling cervical cancer elimination using single-visit screening and treatment strategies in the context of high HIV prevalence: estimates for KwaZulu-Natal, South Africa

INTRODUCTION

In settings with high HIV prevalence, cervical cancer incidence rates are up to six-fold higher than the global average of 13.1 cases per 100,000 women-years. To inform strategies for global cervical cancer elimination, we used a dynamic transmission model to evaluate scalable screening and treatment strategies, accounting for HIV-associated cancer risks and weighing prevention gains against overtreatment.

METHODS

We developed a dynamic model of HIV-HPV co-infection and disease progression, which we calibrated to KwaZulu-Natal, South Africa. Our baseline scenario reflects the current practice of HPV vaccination with a multi-visit screening and treatment strategy involving cytology and colposcopy triage. We evaluated 13 comparator scenarios with increased vaccination coverage and one-time, two-time or repeat HIV-targeted cervical cancer screening with the following single-visit strategies: HPV DNA testing, HPV genotyping, automated visual evaluation (AVE) and HPV DNA with AVE triage. In all scenarios, HIV antiretroviral therapy, condom use and voluntary male medical circumcision continue at baseline levels. We simulated cancer incidence under each scenario from 2020 to 2120 using the 25 best-fitting parameter sets. We present the median and range of model output from these simulations to account for parameter uncertainty.

RESULTS

We estimate that cervical cancer incidence will decrease by 87% with the continuation of current cervical cancer and HIV prevention strategies, from an age-standardized rate per 100,000 women of 80.4 (range 58.2, 112.1) in 2020 to 10.7 (4.2, 29.9) in 2120. Scenarios scaling up vaccination and single-visit strategies resulted in near- and long-term gains. With repeat HIV-targeted screening, incidence rates were projected to be 29-34% lower in 2030 relative to the baseline scenario, and elimination (incidence <4/100,000) was achieved with HPV DNA testing in 2095 and with AVE in 2114. A strategy of HPV DNA with AVE triage optimized the tradeoff between cancer cases averted and overtreatment.

CONCLUSIONS

Single-visit screening strategies could avert a substantial burden of cervical cancer and accelerate progress towards elimination in settings with a high burden of HIV. Increasing the screening frequency among women with HIV and reducing loss-to-follow-up for treatment will be key components of a successful elimination strategy.

An Overview of HPV Screening Tests to Improve Access to Cervical Cancer Screening Amongst Underserved Populations: From Development to Implementation

Cervical cancer is the most common human papillomavirus (HPV)-related disease. Knowledge of the natural history and aetiology of cervical cancer offers unique opportunities for its prevention, and the development of HPV screening tests is one of the most effective strategies. The current HPV diagnostics detect HPV DNA or E6/E7 mRNA in cervical/vaginal samples using molecular-based technologies. HPV screening tests are more sensitive than cytology or visual inspection with acetic acid (VIA) as a primary screening method and are even more clinically valuable in triaging mild cytological abnormalities as a hybrid test. As technical and laboratory resources are grossly limited in marginalized or underserved settings which thus require that women travel long distances for screening and treatment. The practical implementation of an HPV-based screening programme may face many challenges and measures should be instituted to overcome these challenges without compromising disease detection. These measures may include a reduction in screening frequency using the WHO global strategy of offering HPV screening tests at 35 and 45 years of age, adoption of a high throughput testing technology, and improved access to vaginal HPV self-sampling screening tests to women in remote settings or those who are reluctant to undergo gynecologic examination. Another important strategy is the implementation of a "see-and-treat" approach using a point-of-care platform that requires limited skills of laboratory technicians. In addition, the development and large-scale incorporation of more specific HPV testing technologies that are much cheaper and easier to use in non-laboratory settings than the currently available options should be prioritized for underserved settings. At the same time, there is a need to develop and commence the implementation of an affordable and readily available intermediate or secondary test with optimal specificity for triaging or segregating clinically unimportant HPV infections that do not require colposcopy.

Investigating feasibility of 2021 WHO protocol for cervical cancer screening in underscreened populations: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC)

Background

High-risk human papillomavirus (hrHPV) testing has been recommended by the World Health Organization as the primary screening test in cervical screening programs. The option of self-sampling for this screening method can potentially increase women’s participation. Designing screening programs to implement this method among underscreened populations will require contextualized evidence.

Methods

PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC) will use a multi-method approach to investigate the feasibility of implementing a cervical cancer screening strategy with hrHPV self-testing as the primary screening test in Bangladesh, India, Slovak Republic and Uganda. The primary outcomes of study include uptake and coverage of the screening program and adherence to follow-up. These outcomes will be evaluated through a pre-post quasi-experimental study design. Secondary objectives of the study include the analysis of client-related factors and health system factors related to cervical cancer screening, a validation study of an artificial intelligence decision support system and an economic evaluation of the screening strategy.

Discussion

PRESCRIP-TEC aims to provide evidence regarding hrHPV self-testing and the World Health Organization’s recommendations for cervical cancer screening in a variety of settings, targeting vulnerable groups. The main quantitative findings of the project related to the impact on uptake and coverage of screening will be complemented by qualitative analyses of various determinants of successful implementation of screening. The study will also provide decision-makers with insights into economic aspects of implementing hrHPV self-testing, as well as evaluate the feasibility of using artificial intelligence for task-shifting in visual inspection with acetic acid.

Trial registration

ClinicalTrials.gov, NCT05234112. Registered 10 February 2022

Supplementary Information

The online version contains supplementary material available at (10.1186/s12889-022-13488-z).

The prevalence and distribution of human papillomavirus in 4267 Turkish women with or without cervical lesions: A hospital-based study

In the present study, it was aimed to screen the genotypes of human papillomavirus (HPV) retrospectively in women with gynecological symptoms who were admitted to a tertiary care university hospital in Ankara, Turkey. A total of 4267 cervical swab samples of women aged 18-79 years were sent to Medical Virology Laboratory from January 2017 to November 2020. Nucleic acid extraction and amplification of samples were done by an automated system. The test can detect 14 high-risk HPV (HR-HPV) types in a single analysis that performs a real-time polymerase chain reaction, by providing individual results on the highest-risk genotypes HPV 16 and HPV 18 and pooled results on other high-risk genotypes (OHR-HPV) (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68). HPV DNA positivity was detected in 14.2% (605/4267) of the samples. HPV type 16 and type 18 were detected in 2.4% and 0.7% of the samples, respectively. OHR-HPV types were found in 8.8% of the samples. Of the 1.9% and 0.4% samples had mixed types with type 16+ OHR-HPV and type 18+ OHR-HPV, respectively. The results of this study presented the rates of HR-HPV genotypes of a university hospital in Ankara, over a 4-year period. It was observed that the positivity rate of type 18 is decreasing and some OHR-HPV types are increasing. HPV vaccination is not in the national immunization program in Turkey yet, however, HPV vaccines are available and the vaccination rates for women are increasing.

Factors influencing cervical cancer screening practice among female health workers in Nigeria: A systematic review

BACKGROUND

Cervical cancer is the most prevalent gynaecologic cancer in Nigeria. Despite being largely preventable through screening, cervical cancer is the second leading cause of cancer morbidity and mortality in Nigeria. To reduce the burden of cervical cancer in Nigeria, female health workers (FHWs) are expected to play an influential role in leading screening uptake and promoting access to cervical cancer education and screening.

AIM

The aim of this systematic review is to assess the factors influencing cervical cancer screening (CCS) practice among FHWs in Nigeria.

METHODS

We conducted a systematic literature search across six (6) electronic databases namely MEDLINE, Embase, Scopus, African Index Medicus, CINAHL, and Web of Science between May 2020 and October 2020. Reference list and grey literature search were conducted to complement database search. Four reviewers screened 3171 citations against the inclusion criteria and critically appraised the quality of eligible studies. Narrative synthesis was used in summarising data from included studies.

RESULTS

Overall, 15 studies met the inclusion criteria and were all quantitative cross-sectional studies. Included studies sampled a total of 3392 FHWs in Nigeria. FHWs had a high level of knowledge and positive attitude towards CCS. However, CCS uptake was poor. Predominant barriers to CCS uptake were the cost of screening, fear of positive results, lack of test awareness, reluctance to screen, low-risk perception, and lack of time. In contrast, being married, increasing age, awareness of screening methods, and physician recommendation were the most documented facilitators.

CONCLUSION

This study revealed that a complex interplay of socioeconomic, structural, and individual factors influences CCS among FHWs in Nigeria. Therefore, implementing holistic interventions targeting both health system factors such as cost of screening and infrastructure and individual factors such as low-risk perception and fear of positive result affecting FHWs in Nigeria is critical to reducing the burden of cervical cancer.

The Diagnosis of Cervical Dysplasia in a University Hospital Using Pap Smear and Colposcopy in the Western Region of Saudi Arabia: A Correlational Study

Objectives

To assess the diagnostic performance of Pap smear screening with or without human papillomavirus (HPV) testing and colposcopy in detecting preinvasive lesions of the cervix among women with reference to histopathological findings.

Materials and methods

We performed a retrospective study in a tertiary care center of the clinical and pathological records of women with evocative symptomatology. The diagnostic performance of Pap smear screening and colposcopy was analyzed. The sensitivity and specificity of Pap smear screening and colposcopy in detecting preinvasive lesions of the cervix were calculated in 388 patients.

Results

The mean age was 45.12 years, and the most frequent gynecological symptoms included abnormal bleeding (17.2%) and postcoital bleeding (10.9%). Histopathology showed abnormal results in 26.5% of the 388 patients, including cervical intraepithelial neoplasia 1 (CIN 1; 20.4%), CIN 2 (2.8%), CIN 3 (1.3%), and SCC (1.3%). Both Pap smear screening and colposcopy were highly sensitive in detecting CIN 1+ (94.2%vs.93.2%, respectively) and CIN 2+ (100.0% vs.95.8%, respectively) intraepithelial lesions; however, Pap smears had very low specificity in detecting both CIN 1+ (8.1% vs.73.7%, respectively) and CIN 2+ (8.0% vs. 59.3%, respectively) compared with colposcopy. When combined with HPV status, the specificity of Pap smear increased considerably.

Conclusion

It has become a high priority to improve the efficiency of cervical cancer (CC) screening programs by optimizing the practice of Pap smear screening, increasing the test specificity, and implementing systematic cytology-HPV co-testing.

Developing a framework to describe stigma related to cervical cancer and HPV in western Kenya

BACKGROUND

Despite a high prevalence of human papillomavirus (HPV) and cervical cancer in low and middle-income countries, stigma remains an issue. Addressing HPV and cervical cancer stigma could significantly improve health outcomes for these conditions. The objective of this study was to identify the manifestations of stigma and their potential impacts on health-seeking behavior.

METHODS

Twenty-six in-depth interviews were conducted with women living with HIV, HIV-negative women, community health volunteers, and health care providers in Kisumu, Kenya in 2019. The interviews were designed to draw out existing attitudes or experiences related to stigma within the community. We conducted a thematic analysis of the interviews to identify internalized, anticipated, and discriminatory attitudes.

RESULTS

Within internalized attitudes, a prominent observed theme was a fear of death associated with a positive HPV test. This stemmed from a lack of understanding of differences between HPV and cervical cancer and posed a significant barrier for women deciding to seek screening or to continue with treatment. Discriminatory attitudes of community members, including assumptions of promiscuity, infidelity, or HIV status, were perceived to prevent women from accessing screening and treatment opportunities. The interviews also exhibited a limited awareness of HPV in this region, which may have contributed to a lack of enacted stigma towards people living with HPV or cervical cancer.

CONCLUSION

Stigma has the potential to lead to decreased screening and treatment uptake through its drivers. This includes a decreased perception of personal risk due to a lack of knowledge, which results in increased HPV-risk behaviors. Future research must focus on creating and integrating stigma-reducing interventions, primarily to encourage women to seek out primary and secondary preventative measures.

Effectiveness of Visual Inspection with Acetic Acid (VIA) Screening on Cervical Cancer Mortality and Incidence - A Systematic Review and Meta-Analysis

OBJECTIVES

Despite being a cheap, easy, and commonly used technique for screening early development of cervical cancer, collective evidence on the effect of visual inspection with acetic acid (VIA) for reducing cervical cancer mortality and incidence are conflicting. We conducted a systematic review and meta-analysis to determine the effectiveness of VIA screening on cervical cancer mortality and incidence.

METHODS

We searched PubMed, Embase, Cochrane library (Cochrane Database of Systematic Reviews & Cochrane Central Register of Controlled Trials), World Health Organization's (WHO) International Clinical Trials Registry Platform, and Google Scholar to identify studies conducted among women with no history of cervical cancer that assessed effectiveness of VIA on the cervical cancer mortality and incidence. Random effects model was used to estimate incident rate ratio and sensitivity analysis was conducted using Bayesian methods.

RESULTS

Of the included 4 studies, three were cluster randomized trials from India and one was quasi-experimental study done in Thailand. Duration of follow-up ranged from 7 to 12 years. Based on 3 trials, pooled rate-ratio for cervical cancer mortality and all-cause mortality was 0.68 (95% CI: 0.56-0.81, I2=0%) and 0.91 (0.85-0.97, I2=57%), respectively. Pooled rate-ratio of invasive cervical cancer was 0.94 (95% CI: 0.67 - 1.30, I2=84%). Likewise, there was non-significant reduction in incidence of stage IB, >=stage II, and unknown stage cervical cancer.

CONCLUSIONS

VIA screening may lead to reduction in cervical cancer and all-cause mortality in long run. However, the effectiveness of VIA in preventing invasive cervical cancer is inconclusive.