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de Waard J, Bhattacharya A, de Boer MT, van Hemel BM, Esajas MD, Vermeulen KM, de Bock GH, Schuuring E, Wisman GBA. Methylation analysis to detect CIN3+ in hrHPV-positive self-samples from the population-based cervical cancer screening program. Mod Pathol 2024:100528. [PMID: 38810730 DOI: 10.1016/j.modpat.2024.100528] [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: 10/23/2023] [Revised: 05/09/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
Since 2017, a self-sampling device has been introduced to the Dutch population-based screening program (PBS) to enable higher participation rates. However, routine triage cytology cannot be performed on self-sampling material. Methylation is an alternative triage method that can be performed directly on DNA extracted from self-samples. Recently, we tested a set of 15 published cervical intraepithelial neoplasia grade 3 or worse (CIN3+)-specific methylation markers and found a panel of three markers with a sensitivity of 82% and a specificity of 74%. In this study, we determined the sensitivity and specificity of two commercial assays using quantitative methylation-specific PCR (QMSP). DNA from the same cohort of high-risk human papillomavirus (hrHPV)-positive self-sampled material obtained through the PBS in the North of the Netherlands from women with CIN2 or less (
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Affiliation(s)
- J de Waard
- Department of Gynecologic Oncology, Cancer Research Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - A Bhattacharya
- Department of Medical Oncology, Cancer Research Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - M T de Boer
- Department of Gynecologic Oncology, Cancer Research Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - B M van Hemel
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - M D Esajas
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - K M Vermeulen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - G H de Bock
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - E Schuuring
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - G B A Wisman
- Department of Gynecologic Oncology, Cancer Research Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
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2
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Malagón T, Franco EL, Tejada R, Vaccarella S. Epidemiology of HPV-associated cancers past, present and future: towards prevention and elimination. Nat Rev Clin Oncol 2024:10.1038/s41571-024-00904-z. [PMID: 38760499 DOI: 10.1038/s41571-024-00904-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
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.
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Affiliation(s)
- Talía Malagón
- Department of Oncology, McGill University, Montréal, Quebec, Canada.
- St Mary's Research Centre, Montréal West Island CIUSSS, Montréal, Quebec, Canada.
- Department of Epidemiology Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada.
| | - Eduardo L Franco
- Department of Oncology, McGill University, Montréal, Quebec, Canada
- Department of Epidemiology Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada
| | - Romina Tejada
- Department of Oncology, McGill University, Montréal, Quebec, Canada
- Department of Epidemiology Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada
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3
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Geron Y, From A, Peled Y, Zeevi G, Matot R, Nachshon S, Krissi H. Abnormal Pathology Following Vaginal Hysterectomy for Pelvic Organ Prolapse Repair. J Womens Health (Larchmt) 2024. [PMID: 38700374 DOI: 10.1089/jwh.2023.1019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
Objective: Uterine-sparing surgery for pelvic organ prolapse (POP) repair has shown good results, but the potential negative implications of leaving the uterus in place are yet to be fully defined. We aimed to assess the risk of unanticipated abnormal gynecological pathology at the time of reconstructive pelvic surgery. Methods: A retrospective consecutive case series including women who underwent vaginal hysterectomy for POP repair at a tertiary medical center in 2006-2020. All patients were offered a free Pap smear test at the age of 65 years as part of a national screening program. Transvaginal ultrasound was routinely performed preoperatively. Standard 3 pedicle hysterectomy was performed with/without bilateral salpingo-oophorectomy (BSO). Results: The study comprised 462 women of mean age 63 ± 9.3 years without previous known malignant or premalignant pathology. Benign pathology was observed in 286 patients (61.9%). Endometrial malignancy was found in three patients (0.7%) and significant premalignant pathology in 15 patients (3.2%), including cervical intraepithelial neoplasia stage 2-3 in seven patients (1.5%) and complex hyperplasia with atypia in eight patients (1.7%). All these pathologies were found in postmenopausal women. None had preoperative clinical symptoms or endometrial thickness of ≥5 mm on preoperative ultrasound. In the 35 patients after BSO, adnexal findings were normal (77.2%) or benign (22.8%). Conclusions: Premenopausal women with uterovaginal prolapse and normal preoperative evaluation have a minimal risk of significant abnormal uterine pathology. In postmenopausal women, the risk of unanticipated malignant uterine pathology is 0.7% and 3.2% for significant premalignancy.
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Affiliation(s)
- Yossi Geron
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Anat From
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Peled
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Gil Zeevi
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ran Matot
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Sapir Nachshon
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Haim Krissi
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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4
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Rebolj M, Brentnall AR, Cuschieri K. Predictable changes in the accuracy of human papillomavirus tests after vaccination: review with implications for performance monitoring in cervical screening. Br J Cancer 2024; 130:1733-1743. [PMID: 38615108 PMCID: PMC11130303 DOI: 10.1038/s41416-024-02681-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/15/2024] Open
Abstract
Vaccination against human papillomavirus (HPV) is changing the performance of cytology as a cervical screening test, but its effect on HPV testing is unclear. We review the effect of HPV16/18 vaccination on the epidemiology and the detection of HPV infections and high-grade cervical lesions (CIN2+) to evaluate the likely direction of changes in HPV test accuracy. The reduction in HPV16/18 infections and cross-protection against certain non-16/18 high-risk genotypes, most notably 31, 33, and/or 45, will likely increase the test's specificity but decrease its positive predictive value (PPV) for CIN2+. Post-vaccination viral unmasking of non-16/18 genotypes due to fewer HPV16 co-infections might reduce the specificity and the PPV for CIN2+. Post-vaccination clinical unmasking exposing a higher frequency of CIN2+ related to non-16/18 high-risk genotypes is likely to increase the specificity and the PPV of HPV tests. The effect of HPV16/18 vaccination on HPV test sensitivity is difficult to predict based on these changes alone. Programmes relying on HPV detection for primary screening should monitor the frequency of false-positive and false-negative tests in vaccinated (younger) vs. unvaccinated (older) cohorts, to assess the outcomes and performance of their service.
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Affiliation(s)
- Matejka Rebolj
- Centre for Cancer Screening, Prevention, and Early Detection, Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
| | - Adam R Brentnall
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Kate Cuschieri
- Scottish HPV Reference Laboratory, Royal Infirmary of Edinburgh, NHS Lothian Scotland, Edinburgh, UK
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5
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Costanzi JM, Stosic MS, Løvestad AH, Ambur OH, Rounge TB, Christiansen IK. Changes in intrahost genetic diversity according to lesion severity in longitudinal HPV16 samples. J Med Virol 2024; 96:e29641. [PMID: 38708811 DOI: 10.1002/jmv.29641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/07/2024]
Abstract
Human papillomavirus type 16 (HPV16) is the most common cause of cervical cancer, but most infections are transient with lesions not progressing to cancer. There is a lack of specific biomarkers for early cancer risk stratification. This study aimed to explore the intrahost HPV16 genomic variation in longitudinal samples from HPV16-infected women with different cervical lesion severity (normal, low-grade, and high-grade). The TaME-seq deep sequencing protocol was used to generate whole genome HPV16 sequences of 102 samples collected over time from 40 individuals. Single nucleotide variants (SNVs) and intrahost SNVs (iSNVs) were identified in the viral genomes. A majority of individuals had a unique set of SNVs and these SNVs were stable over time. Overall, the number of iSNVs and APOBEC3-induced iSNVs were significantly lower in high-grade relative to normal and low-grade samples. A significant increase in the number of APOBEC3-induced iSNVs over time was observed for normal samples when compared to high-grade. Our results indicates that the lower incidence of iSNVs and APOBEC3-induced iSNVs in high-grade lesions may have implications for novel biomarkers discoveries, potentially aiding early stratification of HPV-induced cervical precancerous lesions.
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Affiliation(s)
- Jean-Marc Costanzi
- Department of Microbiology and Infection Control, Akershus University Hospital, Lørenskog, Norway
- Centre of Bioinformatics, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Milan S Stosic
- Department of Microbiology and Infection Control, Akershus University Hospital, Lørenskog, Norway
- Department of Life Sciences and Health, Faculty of Health Sciences, OsloMet-Oslo Metropolitan University, Oslo, Norway
| | - Alexander H Løvestad
- Department of Microbiology and Infection Control, Akershus University Hospital, Lørenskog, Norway
- Department of Life Sciences and Health, Faculty of Health Sciences, OsloMet-Oslo Metropolitan University, Oslo, Norway
- Clinical Molecular Biology (EpiGen), Akershus University Hospital Lørenskog, Norway and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ole H Ambur
- Department of Life Sciences and Health, Faculty of Health Sciences, OsloMet-Oslo Metropolitan University, Oslo, Norway
| | - Trine B Rounge
- Centre of Bioinformatics, Department of Pharmacy, University of Oslo, Oslo, Norway
- Department of Research, Cancer Registry of Norway, Norwegian Institute of Public Health, Oslo, Norway
| | - Irene K Christiansen
- Department of Microbiology and Infection Control, Akershus University Hospital, Lørenskog, Norway
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6
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Liu Q, Zhang T, Chen L, Zhou X, Zhang X, Zheng W, Niu S, Zhou F. Correlation of immediate prevalence of cervical precancers and cancers with HPV genotype and age in women with ASC-US/hrHPV+: a retrospective analysis of 2292 cases. J Clin Pathol 2024; 77:338-342. [PMID: 36653168 DOI: 10.1136/jcp-2022-208580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/09/2023] [Indexed: 01/20/2023]
Abstract
AIMS To stratify the risk of cervical precancers (high-grade squamous intraepithelial lesion (HSIL) and adenocarcinoma in situ (AIS)) and cancers (squamous cell carcinoma (SCC) and adenocarcinoma) based on distinct high-risk human papillomavirus (hrHPV) genotypes as well as age groups among women with atypical squamous cells of undetermined significance (ASC-US) and hrHPV+results. METHODS In total, 2292 cases of ASC-US/hrHPV+ with immediate follow-up biopsy results were included in the study for prevalence analysis. RESULTS Overall, 12.2% women with ASC-US /hrHPV+ had HSIL+ while 0.22% had AIS+ lesions. The HPV-16+ group (31.6%) showed significantly higher prevalence of HSIL+ squamous lesions than other genotype groups (p<0.0001). The prevalence of SCC is significantly higher in HPV-16+ (1.8%) or HPV-18/45+ (1.1%) group than women in other genotype groups (0.1%) (p<0.0001). The HPV-18/45+ group (1.7%) showed significantly higher prevalence of AIS+ glandular lesions than other genotype groups (p=0.003). In addition, SCC prevalence was significantly higher in age over 50 group than that in age under 50 group (1.2% vs 0.2%, p=0.012). CONCLUSION Women with ASC-US/hrHPV+ are at significant risk of cervical precancers and cancers; notably, HPV-16+ group has a higher risk of HSIL squamous lesions and SCC while HPV-18/45+ group has a higher risk of AIS+ glandular lesions. In addition, the older patient group (>50 years) has a significantly higher risk of SCC. Therefore, HPV genotyping as well as patient age need to be considered in the clinical management of patient.
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Affiliation(s)
- Qin Liu
- Department of Pathology, Zhejiang University School of Medicine Women'sHospital, Hangzhou, Zhejiang, China
| | - Tao Zhang
- Department of Gynecology, Zhejiang University School of Medicine Women's Hospital, Hangzhou, Zhejiang, China
| | - Liqing Chen
- Department of Gynecology, Zhejiang University School of Medicine Women's Hospital, Hangzhou, Zhejiang, China
| | - Xin Zhou
- Department of Pathology, Zhejiang University School of Medicine Women'sHospital, Hangzhou, Zhejiang, China
| | - Xiaofei Zhang
- Department of Pathology, Zhejiang University School of Medicine Women'sHospital, Hangzhou, Zhejiang, China
| | - Wenxin Zheng
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Parkland Hospital, Dallas, Texas, USA
| | - Shuang Niu
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Parkland Hospital, Dallas, Texas, USA
| | - Feng Zhou
- Department of Pathology, Zhejiang University School of Medicine Women'sHospital, Hangzhou, Zhejiang, China
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7
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Yin J, Zhang S, Li Z, Li Y, Wang H, Zhang X, Pan Q, Chen W, Luo X, Sun X, Zhao F, Qiao Y. Impact of high-performance human papillomavirus testing to improve cervical cancer screening in China: a prospective population-based multicentre cohort study. Clin Microbiol Infect 2024:S1198-743X(24)00166-6. [PMID: 38599463 DOI: 10.1016/j.cmi.2024.03.035] [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: 10/24/2023] [Revised: 03/04/2024] [Accepted: 03/30/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVES The aim of the study was to evaluate the clinical performance of HBRT-H14, a real-time PCR-based assay that separates human papillomavirus (HPV) 16 and HPV18 from 12 other high-risk (HR) HPV types, in population according to Chinese guideline. METHODS A total of 9829 eligible women aged 21-64 years from Henan, Shanxi, and Guangdong provinces were performed by HBRT-H14 testing and liquid-based cytology (LBC) screening at baseline and followed up for 3-year. The sensitivity, specificity, positive predictive value (absolute risk), and negative predictive value of LBC diagnosis and HPV testing were calculated for cervical intraepithelial neoplasia grade 2 or worse (CIN2+) Lesions. RESULTS At baseline, 80 (0.81%) participants were diagnosed with CIN2+. HR-HPV with reflex LBC had a significantly higher sensitivity (78/80, 97.50% [95% CI, 91.34-99.31%] vs. 62/80, 77.50% [67.21-85.27%], McNemar's test p < 0.001), and a slightly lower specificity (8528/9749, 87.48% [86.80-88.12%] vs. 8900/9749, 91.29% [90.72-91.83%], McNemar's test p < 0.001) than LBC with reflex HR-HPV for CIN2+. 7832 (79.6%) participants completed 3-year follow-up and 172 (2.20%) participants were cumulatively diagnosed with CIN2+. Compared with LBC with reflex HR-HPV, HR-HPV with reflex LBC significantly increased the sensitivity (161/172, 93.60% [88.91-96.39%] vs. 87/172, 50.58% [43.18-57.96%], McNemar's test p < 0.001), but marginally decreased the specificity (6776/7660, 88.46% [87.72-89.16%] vs. 6933/7660, 90.51% [89.83-91.15], McNemar's test p < 0.001). In addition, the absolute 3-year risk of CIN2+ in HPV16/18-positive individuals was as high as 33% (80/238), whereas the risk in the HPV-negative population was only 0.16% (11/6787), much lower than those in the negative for intraepithelial lesion or malignancy population (1.21%, 85/7018). Moreover, similar results were found in women ≥30 years old. DISCUSSION The study has indicated that HBRT-14 has a reliable clinical performance for use in cervical screening. The validated HPV test would improve the quality of population screening.
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Affiliation(s)
- Jian Yin
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China; Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shaokai Zhang
- Department of Cancer Prevention and Control, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Zhifang Li
- Department of Preventive Medicine, Changzhi Medical College, Changzhi, China
| | - Yufei Li
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; The State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health, Xiamen University, Xiamen, Fujian, China
| | - Hong Wang
- Department of Cancer Prevention and Control, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Xun Zhang
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qinjing Pan
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen Chen
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiping Luo
- Department of Gynecology, Guangdong Provincial Women and Child Health Hospital, Guangzhou, China
| | - Xibin Sun
- Department of Cancer Prevention and Control, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Fanghui Zhao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Youlin Qiao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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8
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Bellosillo B, Ibáñez R, Roura E, Monfil L, Asensio-Puig L, Álvarez I, Muset M, Florencia Y, Paytubi S, de Andrés-Pablo Á, Calvo S, Serrano-Munné L, Pavón MÁ, Lloveras B. Clinical Validation of the Vitro HPV Screening Assay for Its Use in Primary Cervical Cancer Screening. Cancers (Basel) 2024; 16:1322. [PMID: 38611001 PMCID: PMC11011158 DOI: 10.3390/cancers16071322] [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: 02/28/2024] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Many scientific societies have issued guidelines to introduce population-based cervical cancer screening with HPV testing. The Vitro HPV Screening assay is a fully automatic multiplex real-time PCR test targeting the L1 GP5+/GP6+ region of HPV genome. The assay detects 14 high risk (HR) HPV genotypes, identifying individual HPV16 and HPV18 genotypes, and the HPV-positive samples for the other 12 HR HPV types are subsequently genotyped with the HPV Direct Flow Chip test. Following international guidelines, the aim of this study was to validate the clinical accuracy of the Vitro HPV Screening test on ThinPrep-collected samples for its use as primary cervical cancer screening, using as comparator the validated cobas® 4800 HPV test. The non-inferiority analysis showed that the clinical sensitivity and specificity of the Vitro HPV Screening assay for a diagnosis of cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) were not inferior to those of cobas® 4800 HPV (p = 0.0049 and p < 0.001 respectively). The assay has demonstrated a high intra- and inter-laboratory reproducibility, also among the individual genotypes. The Vitro HPV Screening assay is valid for cervical cancer screening and it provides genotyping information on HPV-positive samples without further sample processing in a fully automated workflow.
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Affiliation(s)
- Beatriz Bellosillo
- Department of Pathology, Hospital del Mar, 08003 Barcelona, Spain; (B.B.); (I.Á.); (M.M.); (S.C.); (L.S.-M.)
- Cancer Research Program, IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), University Pompeu Fabra, Doctor Aiguader 88, 08003 Barcelona, Spain
| | - Raquel Ibáñez
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology—Bellvitge Biomedical Research Institute (IDIBELL), 08908 L’Hospitalet de Llobregat, Spain; (R.I.); (E.R.); (L.M.); (L.A.-P.); (Y.F.); (S.P.); (Á.d.A.-P.); (M.Á.P.)
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública—CIBERESP, 28029 Madrid, Spain
| | - Esther Roura
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology—Bellvitge Biomedical Research Institute (IDIBELL), 08908 L’Hospitalet de Llobregat, Spain; (R.I.); (E.R.); (L.M.); (L.A.-P.); (Y.F.); (S.P.); (Á.d.A.-P.); (M.Á.P.)
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública—CIBERESP, 28029 Madrid, Spain
| | - Laura Monfil
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology—Bellvitge Biomedical Research Institute (IDIBELL), 08908 L’Hospitalet de Llobregat, Spain; (R.I.); (E.R.); (L.M.); (L.A.-P.); (Y.F.); (S.P.); (Á.d.A.-P.); (M.Á.P.)
| | - Laura Asensio-Puig
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology—Bellvitge Biomedical Research Institute (IDIBELL), 08908 L’Hospitalet de Llobregat, Spain; (R.I.); (E.R.); (L.M.); (L.A.-P.); (Y.F.); (S.P.); (Á.d.A.-P.); (M.Á.P.)
| | - Isabel Álvarez
- Department of Pathology, Hospital del Mar, 08003 Barcelona, Spain; (B.B.); (I.Á.); (M.M.); (S.C.); (L.S.-M.)
| | - Mercè Muset
- Department of Pathology, Hospital del Mar, 08003 Barcelona, Spain; (B.B.); (I.Á.); (M.M.); (S.C.); (L.S.-M.)
| | - Yolanda Florencia
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology—Bellvitge Biomedical Research Institute (IDIBELL), 08908 L’Hospitalet de Llobregat, Spain; (R.I.); (E.R.); (L.M.); (L.A.-P.); (Y.F.); (S.P.); (Á.d.A.-P.); (M.Á.P.)
| | - Sonia Paytubi
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology—Bellvitge Biomedical Research Institute (IDIBELL), 08908 L’Hospitalet de Llobregat, Spain; (R.I.); (E.R.); (L.M.); (L.A.-P.); (Y.F.); (S.P.); (Á.d.A.-P.); (M.Á.P.)
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública—CIBERESP, 28029 Madrid, Spain
| | - Álvaro de Andrés-Pablo
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology—Bellvitge Biomedical Research Institute (IDIBELL), 08908 L’Hospitalet de Llobregat, Spain; (R.I.); (E.R.); (L.M.); (L.A.-P.); (Y.F.); (S.P.); (Á.d.A.-P.); (M.Á.P.)
| | - Susana Calvo
- Department of Pathology, Hospital del Mar, 08003 Barcelona, Spain; (B.B.); (I.Á.); (M.M.); (S.C.); (L.S.-M.)
| | - Laia Serrano-Munné
- Department of Pathology, Hospital del Mar, 08003 Barcelona, Spain; (B.B.); (I.Á.); (M.M.); (S.C.); (L.S.-M.)
- Cancer Research Program, IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
| | - Miguel Ángel Pavón
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology—Bellvitge Biomedical Research Institute (IDIBELL), 08908 L’Hospitalet de Llobregat, Spain; (R.I.); (E.R.); (L.M.); (L.A.-P.); (Y.F.); (S.P.); (Á.d.A.-P.); (M.Á.P.)
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública—CIBERESP, 28029 Madrid, Spain
| | - Belen Lloveras
- Department of Pathology, Hospital del Mar, 08003 Barcelona, Spain; (B.B.); (I.Á.); (M.M.); (S.C.); (L.S.-M.)
- Cancer Research Program, IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), University Pompeu Fabra, Doctor Aiguader 88, 08003 Barcelona, Spain
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9
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Ghouneimy A, Ali Z, Aman R, Jiang W, Aouida M, Mahfouz M. CRISPR-Based Multiplex Detection of Human Papillomaviruses for One-Pot Point-of-Care Diagnostics. ACS Synth Biol 2024; 13:837-850. [PMID: 38349963 PMCID: PMC10949237 DOI: 10.1021/acssynbio.3c00655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/20/2023] [Accepted: 01/24/2024] [Indexed: 02/15/2024]
Abstract
The World Health Organization's global initiative toward eliminating high-risk Human Papillomavirus (hrHPV)-related cancers recommends DNA testing over visual inspection in all settings for primary cancer screening and HPV eradication by 2100. However, multiple hrHPV types cause different types of cancers, and there is a pressing need for an easy-to-use, multiplex point-of-care diagnostic platform for detecting different hrHPV types. Recently, CRISPR-Cas systems have been repurposed for point-of-care detection. Here, we established a CRISPR-Cas multiplexed diagnostic assay (CRISPRD) to detect cervical cancer-causing hrHPVs in one reaction (one-pot assay). We harnessed the compatibility of thermostable AapCas12b, TccCas13a, and HheCas13a nucleases with isothermal amplification and successfully detected HPV16 and HPV18, along with an internal control in a single-pot assay with a limit of detection of 10 copies and 100% specificity. This platform offers a rapid and practical solution for the multiplex detection of hrHPVs, which may facilitate large-scale hrHPV point-of-care screening. Furthermore, the CRISPRD platform programmability enables it to be adapted for the multiplex detection of any two nucleic acid biomarkers as well as internal control.
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Affiliation(s)
- Ahmed Ghouneimy
- Laboratory
for Genome Engineering and Synthetic Biology, Division of Biological
Sciences, 4700 King Abdullah University
of Science and Technology, Thuwal 23955-6900, Saudi Arabia
| | - Zahir Ali
- Laboratory
for Genome Engineering and Synthetic Biology, Division of Biological
Sciences, 4700 King Abdullah University
of Science and Technology, Thuwal 23955-6900, Saudi Arabia
| | - Rashid Aman
- Laboratory
for Genome Engineering and Synthetic Biology, Division of Biological
Sciences, 4700 King Abdullah University
of Science and Technology, Thuwal 23955-6900, Saudi Arabia
| | - Wenjun Jiang
- Laboratory
for Genome Engineering and Synthetic Biology, Division of Biological
Sciences, 4700 King Abdullah University
of Science and Technology, Thuwal 23955-6900, Saudi Arabia
| | - Mustapha Aouida
- Division
of Biological and Biomedical Sciences, College of Health and Life
Sciences, Hamad Bin Khalifa University, Education City, Qatar Foundation, P.O. Box: 34110 Doha, Qatar
| | - Magdy Mahfouz
- Laboratory
for Genome Engineering and Synthetic Biology, Division of Biological
Sciences, 4700 King Abdullah University
of Science and Technology, Thuwal 23955-6900, Saudi Arabia
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10
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Mazurec K, Trzeszcz M, Mazurec M, Streb J, Halon A, Jach R. Should we use risk selection tests for HPV 16 and/or 18 positive cases: Comparison of p16/Ki67 and cytology. J Med Virol 2024; 96:e29500. [PMID: 38440951 DOI: 10.1002/jmv.29500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/06/2024]
Abstract
Major screening abnormalities in precolposcopic stage are tests results that imply direct referral to colposcopy (and/or expedited treatment) without performing additional high-grade squamous intraepithelial lesions or worse (HSIL+) risk selection testing. Currently, both clinically validated HSIL+ risk selection tests, reflex cytology and reflex p16/Ki67 dual staining (DS), are being compared for use in primary human papillomavirus (HPV)-based screening to avoid possible overtreatment, but there is still no sufficient data available for their performance. Among 30 066 liquid-based cervical cancer screening tests results, a group of 332 women was selected with available high-risk types of HPV tests results with 16/18 limited genotyping, liquid-based cytology, DS, and histology results from standardized colposcopy with biopsy. In HPV 16/18+ cases, three triage approaches were retrospectively analyzed. Predictive values for detection of HSIL+ were calculated and number of colposcopies required in each strategy. Both triage models with DS used (reflex cytology followed by DS, and reflex DS alone in all cases) had significantly higher positive predictive value for HSIL+ than strategy with reflex cytology alone (44.2%/45.7% vs. 28.3%; p < 0.0001). In models with DS, less colposcopies were required (95/92 vs. 152) and less colposcopies were needed per HSIL+ detection (2.26/2.19 vs. 3.54). Only one HSIL+ case was missed in both triage models with DS incorporation. p16/Ki67 dual-stain may be an effective, alone or combined with cytology, triage test to detect HSIL+ in patients with major screening abnormalities in primary HPV-based cervical cancer screening. Performing cytology as the first triage test improves the strategy by enabling referrals to expedited treatment in selected cases.
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Affiliation(s)
| | - Martyna Trzeszcz
- Corfamed Woman's Health Center, Wroclaw, Poland
- Division of Pathology and Clinical Cytology, University Hospital in Wroclaw, Wroclaw, Poland
| | | | - Joanna Streb
- Department of Oncology, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Halon
- Department of Clinical and Experimental Pathology, Division of Clinical Pathology, Wroclaw Medical University, Wroclaw, Poland
| | - Robert Jach
- Division of Gynecologic Endocrinology, Jagiellonian University Medical College, Krakow, Poland
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11
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Mitra A, Gultekin M, Burney Ellis L, Bizzarri N, Bowden S, Taumberger N, Bracic T, Vieira-Baptista P, Sehouli J, Kyrgiou M. Genital tract microbiota composition profiles and use of prebiotics and probiotics in gynaecological cancer prevention: review of the current evidence, the European Society of Gynaecological Oncology prevention committee statement. THE LANCET. MICROBE 2024; 5:e291-e300. [PMID: 38141634 DOI: 10.1016/s2666-5247(23)00257-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 12/25/2023]
Abstract
Female genital tract (FGT) microbiota has been associated with the development of gynaecological cancers. Thus, the possibility of whether manipulation of the FGT microbiota can help in the prevention of disease should be investigated. Various prebiotics, probiotics, and other non-clinician prescribed agents have been reported to have therapeutic effects in cervical disease. Numerous studies have reported an association between human papillomavirus infection and subsequent cervical dysplasia and a decrease in the abundance of Lactobacillus species. A continuum of microbiota composition is observed from the vagina to the upper parts of the FGT, but no evidence suggests that manipulation of the vaginal microbiota can help to modify the composition of other FGT compartments. Although prebiotics and probiotics have been reported to be beneficial, the studies are small and of varying design, and high-quality evidence to support their use is lacking. Currently, no studies have examined these therapeutics in other gynaecological malignancies. Thus, recommendation of probiotics, prebiotics, or other over-the-counter supplements for the prevention of gynaecological cancers warrants larger, well designed studies.
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Affiliation(s)
- Anita Mitra
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Laura Burney Ellis
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Sarah Bowden
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Nadja Taumberger
- Department of Obstetrics & Gynecology, Medical University of Graz, Graz, Austria; Hospital Spittal a d Drau, Carinthia, Austria
| | - Taja Bracic
- Department of Obstetrics & Gynecology, Medical University of Graz, Graz, Austria
| | - Pedro Vieira-Baptista
- Department of Gynecology-Obstetrics and Pediatrics, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal
| | - Jalid Sehouli
- Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin, Germany
| | - Maria Kyrgiou
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
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12
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Cao D, Yang Z, Dong S, Li Y, Mao Z, Lu Q, Xu P, Shao M, Pan L, Han X, Yuan J, Fan Q, Chen L, Wang Y, Zhu W, Yu W, Wang Y. PCDHGB7 hypermethylation-based Cervical cancer Methylation (CerMe) detection for the triage of high-risk human papillomavirus-positive women: a prospective cohort study. BMC Med 2024; 22:55. [PMID: 38317152 PMCID: PMC10845746 DOI: 10.1186/s12916-024-03267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/22/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Implementation of high-risk human papillomavirus (hrHPV) screening has greatly reduced the incidence and mortality of cervical cancer. However, a triage strategy that is effective, noninvasive, and independent from the subjective interpretation of pathologists is urgently required to decrease unnecessary colposcopy referrals in hrHPV-positive women. METHODS A total of 3251 hrHPV-positive women aged 30-82 years (median = 41 years) from International Peace Maternity and Child Health Hospital were included in the training set (n = 2116) and the validation set (n = 1135) to establish Cervical cancer Methylation (CerMe) detection. The performance of CerMe as a triage for hrHPV-positive women was evaluated. RESULTS CerMe detection efficiently distinguished cervical intraepithelial neoplasia grade 2 or worse (CIN2 +) from cervical intraepithelial neoplasia grade 1 or normal (CIN1 -) women with excellent sensitivity of 82.4% (95% CI = 72.6 ~ 89.8%) and specificity of 91.1% (95% CI = 89.2 ~ 92.7%). Importantly, CerMe showed improved specificity (92.1% vs. 74.9%) in other 12 hrHPV type-positive women as well as superior sensitivity (80.8% vs. 61.5%) and specificity (88.9% vs. 75.3%) in HPV16/18 type-positive women compared with cytology testing. CerMe performed well in the triage of hrHPV-positive women with ASC-US (sensitivity = 74.4%, specificity = 87.5%) or LSIL cytology (sensitivity = 84.4%, specificity = 83.9%). CONCLUSIONS PCDHGB7 hypermethylation-based CerMe detection can be used as a triage strategy for hrHPV-positive women to reduce unnecessary over-referrals. TRIAL REGISTRATION ChiCTR2100048972. Registered on 19 July 2021.
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Affiliation(s)
- Dan Cao
- Department of Gynecology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Zhicong Yang
- Shanghai Public Health Clinical Center and Department of General Surgery, Huashan Hospital, Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shihua Dong
- Shanghai Public Health Clinical Center and Department of General Surgery, Huashan Hospital, Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuhong Li
- Department of Gynecology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Zhanrui Mao
- Shanghai Public Health Clinical Center and Department of General Surgery, Huashan Hospital, Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qi Lu
- Department of Obstetrics and Gynecology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Peng Xu
- Shanghai Public Health Clinical Center and Department of General Surgery, Huashan Hospital, Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai, China
| | - Minfang Shao
- Department of Obstetrics and Gynecology, 2nd Affiliated Hospital of Soochow University, Suzhou, China
| | - Lei Pan
- Department of Gynecology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Xu Han
- Department of Gynecology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Jiangjing Yuan
- Department of Gynecology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Qiong Fan
- Department of Gynecology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Lei Chen
- Department of Gynecology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Yanzhong Wang
- Department of Population Health Sciences, School of Life Course and Population Sciences, King's College London, London, UK.
| | - Weipei Zhu
- Department of Obstetrics and Gynecology, 2nd Affiliated Hospital of Soochow University, Suzhou, China.
| | - Wenqiang Yu
- Shanghai Public Health Clinical Center and Department of General Surgery, Huashan Hospital, Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Yudong Wang
- Department of Gynecology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.
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13
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Luckett R, Ramogola-Masire D, Harris DA, Gompers A, Gaborone K, Mochoba L, Ntshese L, Mathoma A, Kula M, Shapiro R, Larson E. Feasibility and acceptability of an HPV self-testing strategy: lessons from a research context to assess for ability to implement into primary care at a national level in Botswana. Front Glob Womens Health 2024; 4:1300788. [PMID: 38259634 PMCID: PMC10800890 DOI: 10.3389/fgwh.2023.1300788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/08/2023] [Indexed: 01/24/2024] Open
Abstract
Background The WHO strategy for cervical cancer elimination strives to achieve 70% coverage with high-performance cervical screening. While few low- and middle-income countries have achieved this, high-risk human papillomavirus (hrHPV) self-testing creates the possibility to rapidly upscale access to high-performance cervical screening across resource settings. However, effective hrHPV screening requires linkage to follow-up, which has been variable in prior studies. This study developed and tested an implementation strategy aimed at improving screening and linkage to follow-up care in South East District in Botswana. Methods This study performed primary hrHPV self-testing; those with positive results were referred for a triage visit. Withdrawals for any reason, loss-to follow-up between hrHPV test and triage visit, and number of call attempts to give hrHPV results were also documented. Acceptability of the program to patients was measured as the proportion of patients who completed a triage visit when indicated, meeting the a priori threshold of 80%. Feasibility was defined as the proportion of participants receiving the results and attending follow-up. To assess the associations between participant characteristics and loss-to-follow-up we used log-binomial regressions to estimate risk ratios and 95% confidence intervals (CI). Results Enrollment of 3,000 women occurred from February 2021 to August 2022. In total, 10 participants withdrew and an additional 33 were determined ineligible after consent, leaving a final cohort of 2,957 participants who underwent self-swab hrHPV testing. Half (50%) of participants tested positive for hrHPV and nearly all (98%) of participants received their hrHPV results, primarily via telephone. Few calls to participants were required to communicate results: 2,397 (82%) required one call, 386 (13%) required 2 calls, and only 151 (5%) required 3-5 calls. The median time from specimen collection to participant receiving results was 44 days (IQR, 27-65). Of all hrHPV positive participants, 1,328 (90%) attended a triage visit. Discussion In a large cohort we had low loss-to-follow-up of 10%, indicating that the strategy is acceptable. Telephonic results reporting was associated with high screening completion, required few calls to participants, and supports the feasibility of hrHPV self-testing in primary care followed by interval triage.
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Affiliation(s)
- Rebecca Luckett
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa
| | - Devon A. Harris
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
| | - Annika Gompers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | | | | | - Lapelo Ntshese
- Department of Obstetrics and Gynaecology, Bamalete Lutheran Hospital, Ramotswa, Botswana
| | - Anikie Mathoma
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - Maduke Kula
- National Cervical Cancer Prevention Program, Ministry of Health and Wellness Botswana, Gaborone, Botswana
| | - Roger Shapiro
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Elysia Larson
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
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14
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Aljrees T. Improving prediction of cervical cancer using KNN imputer and multi-model ensemble learning. PLoS One 2024; 19:e0295632. [PMID: 38170713 PMCID: PMC10763959 DOI: 10.1371/journal.pone.0295632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/23/2023] [Indexed: 01/05/2024] Open
Abstract
Cervical cancer is a leading cause of women's mortality, emphasizing the need for early diagnosis and effective treatment. In line with the imperative of early intervention, the automated identification of cervical cancer has emerged as a promising avenue, leveraging machine learning techniques to enhance both the speed and accuracy of diagnosis. However, an inherent challenge in the development of these automated systems is the presence of missing values in the datasets commonly used for cervical cancer detection. Missing data can significantly impact the performance of machine learning models, potentially leading to inaccurate or unreliable results. This study addresses a critical challenge in automated cervical cancer identification-handling missing data in datasets. The study present a novel approach that combines three machine learning models into a stacked ensemble voting classifier, complemented by the use of a KNN Imputer to manage missing values. The proposed model achieves remarkable results with an accuracy of 0.9941, precision of 0.98, recall of 0.96, and an F1 score of 0.97. This study examines three distinct scenarios: one involving the deletion of missing values, another utilizing KNN imputation, and a third employing PCA for imputing missing values. This research has significant implications for the medical field, offering medical experts a powerful tool for more accurate cervical cancer therapy and enhancing the overall effectiveness of testing procedures. By addressing missing data challenges and achieving high accuracy, this work represents a valuable contribution to cervical cancer detection, ultimately aiming to reduce the impact of this disease on women's health and healthcare systems.
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Affiliation(s)
- Turki Aljrees
- College of Computer Science and Engineering, University of Hafr Al-Batin, Hafar Al-Batin, Saudi Arabia
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15
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Swanson AA, Pantanowitz L. The evolution of cervical cancer screening. J Am Soc Cytopathol 2024; 13:10-15. [PMID: 37865567 DOI: 10.1016/j.jasc.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/23/2023]
Abstract
There are few medical success stories in history as significant as the reduction in cervical cancer incidence. Through the collaborative efforts of dedicated scientific pioneers, the past century has witnessed remarkable advancement that began with the detection of exfoliated cancer cells through cytologic examination to widespread implementation of cervical cancer screening programs to the discovery of the link between cervical cancer and human papillomavirus (HPV). Current screening methods apply HPV-based testing, and artificial intelligence-based screening systems utilizing digitalized cytology images are being used in a continuous effort to optimize the accuracy and efficiency of the Papanicolaou test. This review summarizes the major milestones in cervical cancer screening history to emphasize its evolution as the World Health Organization aims for the global elimination of cervical cancer.
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Affiliation(s)
- Amy A Swanson
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota.
| | - Liron Pantanowitz
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
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16
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Chang MM, Ma A, Novak EN, Barra M, Kundrod KA, Montealegre JR, Scheurer ME, Castle PE, Schmeler K, Richards-Kortum R. A novel tailed primer nucleic acid test for detection of HPV 16, 18 and 45 DNA at the point of care. Sci Rep 2023; 13:20397. [PMID: 37989845 PMCID: PMC10663460 DOI: 10.1038/s41598-023-47582-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
Cervical cancer is a leading cause of death for women in low-resource settings despite being preventable through human papillomavirus (HPV) vaccination, early detection, and treatment of precancerous lesions. The World Health Organization recommends high-risk HPV (hrHPV) as the preferred cervical cancer screening strategy, which is difficult to implement in low-resource settings due to high costs, reliance on centralized laboratory infrastructure, and long sample-to-answer times. To help meet the need for rapid, low-cost, and decentralized cervical cancer screening, we developed tailed primer isothermal amplification and lateral flow detection assays for HPV16, HPV18, and HPV45 DNA. We translated these assays into a self-contained cartridge to achieve multiplexed detection of three hrHPV genotypes in a disposable cartridge. The developed test achieves clinically relevant limits of detection of 50-500 copies per reaction with extracted genomic DNA from HPV-positive cells. Finally, we performed sample-to-answer testing with direct lysates of HPV-negative and HPV-positive cell lines and demonstrated consistent detection of HPV16, HPV18, and HPV45 with 5000-50,000 cells/mL in < 35 min. With additional optimization to improve cartridge reliability, incorporation of additional hrHPV types, and validation with clinical samples, the assay could serve as a point-of-care HPV DNA test that improves access to cervical cancer screening in low-resource settings.
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Affiliation(s)
- Megan M Chang
- Department of Bioengineering, Rice University, Houston, TX, USA
| | - Ariel Ma
- Department of Bioengineering, Rice University, Houston, TX, USA
| | | | - Maria Barra
- Department of Bioengineering, Rice University, Houston, TX, USA
| | - Kathryn A Kundrod
- Department of Bioengineering, Rice University, Houston, TX, USA
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Jane Richards Montealegre
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Pediatrics Hematology/Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Michael E Scheurer
- Department of Pediatrics Hematology/Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Philip E Castle
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
- Division of Cancer Prevention, National Cancer Institute, Rockville, MD, USA
| | - Kathleen Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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17
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Kabue M, Gauvreau CL, Daceney N, Bertram MM, Shissler T, Reis V, Dodo M, Garces A, Llave C, Dao B, Mohan D, Huang L. Understanding integrated HPV testing and treatment of pre-cancerous cervical cancer in Burkina Faso, Cote d'Ivoire, Guatemala and Philippines: study protocol. Reprod Health 2023; 20:167. [PMID: 37957689 PMCID: PMC10644460 DOI: 10.1186/s12978-023-01696-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 10/09/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Many low- and-middle-income countries are disproportionately burdened by cervical cancer, resulting in high morbidity and mortality. HPV-DNA testing coupled with treatment with thermal ablation is a recommended screening and precancer treatment strategy, but not enough is known about how this can be effectively implemented in the context of integrated services. The (Scale Up Cervical Cancer Elimination by Secondary prevention Strategy, (SUCCESS) project is conducting a study to understand this approach, integrated into existing women's health services in Burkina Faso, Cote d'Ivoire, Guatemala, and the Philippines (2020-2024). METHODS A hybrid effectiveness-implementation type III mixed-methods observational study design is used to assess feasibility, acceptability, and costs of integrated service delivery in 10 sites per country, selected considering urban/rural location, facility level, onsite/offsite laboratories, and health services type. In each country, a sample size of 2227 women aged 25-49 years will be enrolled with about 20% being women living with HIV. The primary outcome is proportion of HPV positive women completing precancer treatment, if eligible, within three months of screening. Data collection and analysis includes; facility and client exit surveys, key informant and client interviews, registries and project records extractions, and costing data analysis. Analysis includes descriptive statistics, context description, thematic analysis, and document analysis. Quantitative analyses will be stratified by participant's HIV status. DISCUSSION Recruitment of study participants started in April 2022 (Burkina Faso and Côte d'Ivoire) and August 2022 (Guatemala and the Philippines). Enrolment targets for women screened, client exit, in-depth and key informant interviews conducted were reached in Burkina Faso and Cote d'Ivoire in November 2022. Guatemala and Philippines are expected to complete enrolment by June 2023. Follow-up of study Participants 12-months post-treatment is ongoing and is expected to be completed for all countries by August 2024. In LMICs, integrating cervical cancer secondary prevention services into other health services will likely require specific rather than incidental recruitment of women for screening. Reconfiguration of laboratory infrastructure and planning for sample management must be made well in advance to meet induced demand for screening. Trail Registration ClinicalTrials.Gov ID: NCT05133661 (24/11/2021).
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Affiliation(s)
| | - Cindy L Gauvreau
- The Hospital for Sick Children, Research Institute, Toronto, Canada
| | | | | | | | | | | | | | | | | | - Diwakar Mohan
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa Huang
- Expertise France, Abidjan, Côte d'Ivoire
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18
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Lv N, Zhao Y, Song Y, Ji M, Zhou Y. Development of a sensitive droplet digital PCR according to the HPV infection specificity in Chinese population. BMC Cancer 2023; 23:1022. [PMID: 37872500 PMCID: PMC10594741 DOI: 10.1186/s12885-023-11529-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/15/2023] [Indexed: 10/25/2023] Open
Abstract
HPV16 and 18 are positively correlated with cervical carcinogenesis. However, HPV prevalence tends to vary according to region, nationality, and environment. The most prevalent high-risk (HR) HPV genotypes are HPV16, 52, 58, 56, 18, 33, and 45), while the low-risk (LR) genotypes are HPV6 and 11 in the Chinese population. Importantly, undetectable low-copy HPV DNA could be an important indicator of integration into the human genome and may be a precursor to cancer progression. The HPV viral load changes dramatically, either increasing or decreasing rapidly during carcinogenesis, and traditional quantitative real-time PCR (qPCR) cannot accurately capture this subtle change. Therefore, in this study, a reliable droplet digital PCR (ddPCR) method was developed to simultaneously detect and quantify HPV genotypes. The ddPCR quantitative results showed high accuracy, sensitivity, and specificity compared to qPCR results employing the same clinical specimens and supplemented the ddPCR assay for HPV52/56/58/6 genotypes according to the infection specificity of the Chinese population. In summary, this procedure is valuable for quantifying HPV DNA, especially under conditions of low template copy number in cervical intraepithelial neoplasia (CIN) and/or cervical cancer. Additionally, this method can dynamically observe the prognosis and outcome of HPV infection and thus be used as an effective means for real-time monitoring of tumor load.
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Affiliation(s)
- Nan Lv
- Department of Clinical Laboratory Diagnosis, Jinan Central Hospital, Shandong University, Jinan, 250013, People's Republic of China
| | - Yue Zhao
- Department of Clinical Laboratory Diagnosis, Jinan Central Hospital, Shandong University, Jinan, 250013, People's Republic of China
| | - Yiying Song
- Department of Clinical Laboratory Diagnosis, Jinan Central Hospital, Shandong University, Jinan, 250013, People's Republic of China
| | - Mingyu Ji
- Medical Research & Laboratory Diagnostic Center, Central Hospital Affiliated to Shandong First Medical University, No.105, Jiefang Road, Lixia Area, Jinan, 250013, People's Republic of China
| | - Yunying Zhou
- Department of Clinical Laboratory Diagnosis, Jinan Central Hospital, Shandong University, Jinan, 250013, People's Republic of China.
- Medical Research & Laboratory Diagnostic Center, Central Hospital Affiliated to Shandong First Medical University, No.105, Jiefang Road, Lixia Area, Jinan, 250013, People's Republic of China.
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19
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Ramírez AT, Valls J, Baena A, Rojas FD, Ramírez K, Álvarez R, Cristaldo C, Henríquez O, Moreno A, Reynaga DC, Palma HG, Robinson I, Hernández DC, Bardales R, Cardinal L, Salgado Y, Martínez S, González E, Guillén D, Fleider L, Tatti S, Villagra V, Venegas G, Cruz-Valdez A, Valencia M, Rodríguez G, Terán C, Picconi MA, Ferrera A, Kasamatsu E, Mendoza L, Calderon A, Luciani S, Broutet N, Darragh T, Almonte M, Herrero R. Performance of cervical cytology and HPV testing for primary cervical cancer screening in Latin America: an analysis within the ESTAMPA study. LANCET REGIONAL HEALTH. AMERICAS 2023; 26:100593. [PMID: 37766799 PMCID: PMC10520426 DOI: 10.1016/j.lana.2023.100593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/28/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
Background Cervical cytology remains widely used as the initial tool in cervical cancer screening worldwide. WHO guidelines recommend replacing cytology with primary HPV testing to reach cervical cancer elimination goals. We assessed the performance of cytology and high-risk HPV testing to detect cervical precancer, cervical intraepithelial neoplasia (CIN) grade 3 or worse (CIN3+) among women aged 30-64 years participating in the ESTAMPA study. Methods Women were screened with cytology and HPV across ESTAMPA study centres in Latin America. Screen-positives were referred to colposcopy with biopsy collection and treatment as needed. Those with no evident precancer were recalled at 18-months for a second HPV test to complete disease ascertainment. Performance indicators for cytology and HPV to detect CIN3+ were estimated. Findings 30,606 participants with available cytology and HPV results were included in the analysis. A total of 440 histologically confirmed CIN3s and 30 cancers were diagnosed. Cytology sensitivity for CIN3+ was 48.5% (95% CI: 44.0-53.0), whereas HPV testing had a sensitivity of 98.1% (95% CI: 96.3-96.7). Specificity was 96.5% (95% CI: 96.3-96.7) using cytology and 88.7% (95% CI: 88.3-89.0) with HPV. Performance estimates varied substantially by study centre for cytology (ranging from 32.1% to 87.5% for sensitivity and from 89.2% to 99.5% for specificity) while for HPV results were more consistent across sites (96.7%-100% and 83.6-90.8%, respectively). Interpretation The limited and highly variable sensitivity of cytology strongly supports transition to the more robust and reproducible HPV-based cervical screening to ensure progress towards global cervical cancer elimination targets in Latin America. Funding IARC/WHO, UNDP, HRP/WHO, NCI and local funders.
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Affiliation(s)
- Arianis Tatiana Ramírez
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Joan Valls
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Armando Baena
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Freddy David Rojas
- Caja Costarricense de Seguro Social (CCSS), Región Pacífico Central, San Jose, Costa Rica
| | - Katherine Ramírez
- Caja Costarricense de Seguro Social (CCSS), Región Pacífico Central, San Jose, Costa Rica
| | - Rodrigo Álvarez
- Caja Costarricense de Seguro Social (CCSS), Región Pacífico Central, San Jose, Costa Rica
| | - Carmen Cristaldo
- Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | | | - Adrián Moreno
- Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Daysi Colque Reynaga
- Facultad de Medicina, Universidad Mayor, Real y Pontificia de San Francisco Xavier de Chuquisaca, Sucre, Bolivia
| | - Hans González Palma
- Facultad de Medicina, Universidad Mayor, Real y Pontificia de San Francisco Xavier de Chuquisaca, Sucre, Bolivia
| | | | - Diana Carolina Hernández
- Laboratorio de citología, IPS Universitaria, Escuela de Microbiología, Universidad de Antioquia, Medellín, Colombia
| | - Rosa Bardales
- Departamento Laboratorio Clínico y Anatomía Patológica, Hospital Nacional Dos de Mayo, Lima, Perú
| | - Lucia Cardinal
- Hospital de Clínicas, Jose de San Martín, Buenos Aires, Argentina
| | - Yuly Salgado
- Instituto Nacional de Cancerología, Bogotá, Colombia
| | | | - Emmanuel González
- Caja Costarricense de Seguro Social, Departamento de Patología, Hospital Dr. Enrique Baltodano Briceño, Guanacaste, Costa Rica
- Agencia Costarricense de Investigaciones Biomédicas (ACIB), Fundación Inciensa, Guanacaste, Costa Rica
| | - Diego Guillén
- Agencia Costarricense de Investigaciones Biomédicas (ACIB), Fundación Inciensa, Guanacaste, Costa Rica
- Caja Costarricense de Seguro Social, Departamento de Patología, Hospital Max Peralta, Cartago, Costa Rica
| | - Laura Fleider
- Hospital de Clínicas, Jose de San Martín, Buenos Aires, Argentina
| | - Silvio Tatti
- Hospital de Clínicas, Jose de San Martín, Buenos Aires, Argentina
| | | | - Gino Venegas
- Clínica Angloamericana, Lima, Perú
- Escuela de Medicina Humana, Universidad de Piura, Lima, Perú
| | | | - Marleny Valencia
- Laboratorio de citología, IPS Universitaria, Escuela de Microbiología, Universidad de Antioquia, Medellín, Colombia
| | | | - Carolina Terán
- Facultad de Medicina, Universidad Mayor, Real y Pontificia de San Francisco Xavier de Chuquisaca, Sucre, Bolivia
| | | | - Annabelle Ferrera
- Instituto de Infecciones en Microbiología, Universidad Nacional Autónoma de Honduras (UNAH), Tegucigalpa, Honduras
| | - Elena Kasamatsu
- Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Laura Mendoza
- Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Alejandro Calderon
- Caja Costarricense de Seguro Social (CCSS), Región Pacífico Central, San Jose, Costa Rica
| | - Silvana Luciani
- Pan American Health Organization (PAHO), Washington, DC, USA
| | - Nathalie Broutet
- Department of Sexual and Reproductive Health and Research (SRH), World Health Organization, Geneva, Switzerland
| | - Teresa Darragh
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Maribel Almonte
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
- Department of Sexual and Reproductive Health and Research (SRH), World Health Organization, Geneva, Switzerland
| | - Rolando Herrero
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
- Agencia Costarricense de Investigaciones Biomédicas (ACIB), Fundación Inciensa, Guanacaste, Costa Rica
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20
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Gottschlich A, Gondara L, Smith LW, Anderson JJ, Cook D, Krajden M, Lee M, Martin RE, Melnikow J, Peacock S, Proctor L, Stuart G, Franco EL, van Niekerk D, Ogilvie GS. Colposcopy referral rates post-introduction of primary screening with human papillomavirus testing: evidence from a large British Columbia cohort study. LANCET REGIONAL HEALTH. AMERICAS 2023; 26:100598. [PMID: 37786399 PMCID: PMC10542010 DOI: 10.1016/j.lana.2023.100598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/01/2023] [Accepted: 09/08/2023] [Indexed: 10/04/2023]
Abstract
Background Shifting from cytology to human papillomavirus (HPV)-based cervical cancer screening will initially increase colposcopy referrals. The anticipated impact on health systems has been raised as a concern for implementation. It is unclear if the higher rate of colposcopy referrals is sustained after initial HPV-based screens or reverts to new lower baselines due to earlier detection and treatment of precancer. This study aimed to investigate long-term rates of colposcopy referrals after participation in HPV-based screening. Methods Participants of HPV for Cervical Cancer Screening trial (HPV FOCAL) received one (HPV1, N = 6204) or two (HPV2, N = 9540) HPV-based screens. After exit, they returned to British Columbia's (BC) cytology screening program. A comparison cohort from the BC screening population (BCS, N = 1,140,745) was identified, mirroring trial inclusion criteria. All participants were followed for 10-14 years through the provincial screening registry. Colposcopy referral rates per 1000 screens were calculated for each group. Trial colposcopy referrals for HPV1 and HPV2 were calculated under two referral scenarios: (1) all HPV positive referred to colposcopy; (2) cytology triage with ASCUS or greater referred to colposcopy. Colposcopy referrals from post-trial screens in HPV1 an HPV2 and all screens in BCS were based on actual recommendations from the screening program. A multivariable flexible survival regression model compared hazard ratios (HR) throughout follow-up. Findings Scenario 2 referral rates were higher during initial HPV screen(s) vs cytology screen (HPV1: 28 per 1000 screens (95% CI: 24, 33), HPV2: 32 per 1000 screens (95% CI: 29, 36), BCS: 8 per 1000 screens (95% CI: 8.9)). However, post-trial rates in HPV1 and HPV2 were significantly lower than in BCS. Cumulative rates in HPV1 and HPV2 approached the cumulative rate in BCS 11-12 years after HPV-based screening (HPV1: 11 per 1000 screens (95% CI: 10, 12), HPV2: 16 per 1000 screens (95% CI: 15-17), BCS: 11 per 1000 screens (95% CI: 10, 11)). Adjusted models demonstrated reductions in referral rates in HPV1 (HR = 0.6, 95% CI: 0.5, 0.7) and HPV2 (HR = 0.7, 95% CI: 0.6, 0.8) relative to BCS by 54 and 72 months post-final HPV screen respectively. Interpretation Reduced colposcopy referral rates were observed after initial rounds of HPV-based screening. After initial HPV screening, referral rates to colposcopy after cytology triage were below the current rates seen in a centralized cytology program after approximately four years. Any expected increase in referrals at initiation of HPV-based screening could be countered by staged program implementation. Funding This work was supported by the National Institutes of Health (R01 CA221918), Michael Smith Health Research BC (RT-2021-1595), and the Canadian Institutes of Health Research (MCT82072).
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Affiliation(s)
- Anna Gottschlich
- Women's Health Research Institute, BC Women's Hospital and Health Service, Vancouver, BC, Canada
- Wayne State University, School of Medicine Departments of Oncology, Detroit, MI, USA
- Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA
| | - Lovedeep Gondara
- Cervical Cancer Screening Program, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Laurie W. Smith
- Women's Health Research Institute, BC Women's Hospital and Health Service, Vancouver, BC, Canada
- Cancer Control Research, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Jennifer Joy Anderson
- Women's Health Research Institute, BC Women's Hospital and Health Service, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Darrel Cook
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Mel Krajden
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Lower Mainland Laboratories, Vancouver, BC, Canada
| | - Marette Lee
- Cervical Cancer Screening Program, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Ruth Elwood Martin
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Joy Melnikow
- Center for Healthcare Policy and Research, University of California Davis, Sacramento, CA, USA
| | - Stuart Peacock
- Cancer Control Research, British Columbia Cancer Agency, Vancouver, BC, Canada
- Canadian Centre for Applied Research in Cancer Control (ARCC), Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Lily Proctor
- Women's Health Research Institute, BC Women's Hospital and Health Service, Vancouver, BC, Canada
- Cancer Control Research, British Columbia Cancer Agency, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Gavin Stuart
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Eduardo L. Franco
- Division of Cancer Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Dirk van Niekerk
- Cervical Cancer Screening Program, British Columbia Cancer Agency, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Gina S. Ogilvie
- Women's Health Research Institute, BC Women's Hospital and Health Service, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
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21
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Cannistrà S, Carozzi F, Di Stefano C, Matucci M, Pompeo G, Gorini G, Puliti D, Zappa M, Sani C, Confortini M. Accuracy and Reproducibility of Cytology Triage in a HPV-Based Primary Screening Setting: A Revision of 384 Pap Tests. Acta Cytol 2023; 67:618-628. [PMID: 37751731 DOI: 10.1159/000534282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION After the transition toward the HPV-based screening protocol, which has led to an increase in sensitivity, and in order to bring the specificity back to acceptable values, cytology underwent a change of approach, becoming a triage test. For these reasons, in the Tuscany region (after the recommendations of the GISCi document), it was decided to reduce, as much as possible, the use of ASC-US category in cytology triage, classifying these morphological cases as negative for intraepithelial lesion or malignancies (NILM) or LSIL, basing on the grade of nuclear atypia. So, in Italy, in a cytology triage context (HPV primary screening), a modified Bethesda system (TBS) is currently used. The aim of this study was to evaluate the performance of the review activity of 384 cytology triage cases and of the cervical cancer screening indicators (sensitivity and specificity for CIN2+ lesions) using the TBS 2014 or the modified TBS. MATERIALS AND METHODS 384 HPV positive cases at one-year recall (192 with a cytology result of NILM both at baseline and at one-year recall; 192 with a cytology result of NILM at baseline but abnormal at one-year recall), all with a histologically confirmed result (128 CIN2+, 256 ≤ CIN1), were selected, and their baseline Pap tests were reviewed in blind mode by 5 expert cytologists. RESULTS The cytological results of NILM were confirmed for 92.5% and 83.8% of cases using TBS 2014 or modified TBS, respectively. 20/128 CIN2+ cases could have been reported at the baseline cytology triage, causing an anticipatory effect and an improvement in sensitivity of the screening protocol at baseline (+15.6%). Using TBS 2014, the number of false positives more than tripled with respect to the modified TBS 2014, with a significant increase in unnecessary colposcopies (+11.4%). CONCLUSION This work demonstrated that a greater expertise of cytologists, acquired during the following 3 years of experience with cytological triage, and a strong IQC system could lead to the identification of a significant number of lesions reported to baseline rather than at one-year recall (diagnostic anticipation).
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Affiliation(s)
- Stefania Cannistrà
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
| | - Francesca Carozzi
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
| | - Chiara Di Stefano
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
| | - Marzia Matucci
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
| | - Giampaolo Pompeo
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
| | - Giuseppe Gorini
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
| | - Donella Puliti
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
| | - Marco Zappa
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
| | - Cristina Sani
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
| | - Massimo Confortini
- Institute for Cancer Research, Prevention and Oncological Network (ISPRO), Florence, Italy
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22
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Kultalahti H, Heinävaara S, Sarkeala T, Pankakoski M. Effect of Test History at Ages 50-64 on Later Cervical Cancer Risk: A Population-based Case-control Study. CANCER RESEARCH COMMUNICATIONS 2023; 3:1823-1829. [PMID: 37700796 PMCID: PMC10494786 DOI: 10.1158/2767-9764.crc-23-0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/26/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
As life expectancy increases, the effectiveness of cervical cancer screening programs needs to be reassessed for the older population. We addressed the effect of test history in and outside organized screening at age 50-64 years on later cervical cancer risk. A case-control study was conducted by deriving 229 cases of 65-79 years old women with invasive cervical cancer in 2010-2019 from the Finnish Cancer Registry. Ten controls were matched for each case by birth year and hospital district. The effect of test uptake and abnormal results in 50-64 year olds on cancer risk was investigated using conditional logistic regression and adjusted for self-selection. Test uptake within the 50-64 years age group showed 75% lower odds of cervical cancer [adjusted OR (aOR) = 0.25; 95% confidence interval (95% CI), 0.18-0.35]. Untested women had 4.9 times higher odds than those tested with normal results (aOR = 4.86; 95% CI, 3.42-6.92). Having at least one abnormal test result increased the odds by 2.5 when compared with only normal results but showed lower odds when compared with untested women. The importance of testing is exhibited by the result showing a reduction of odds of cancer to one-fourth for those tested compared with untested. Similarly, receiving abnormal results was protective of cancer compared with having no tests highlighting the importance of proper follow-up. Therefore, screening history should be considered when further developing cervical cancer screening programs with special interest in non-attenders and those receiving abnormal results at older ages. Significance To our knowledge, this is the first study from Finnish data describing the effect of test history on later cervical cancer at older ages. Focusing on the cervical tests taken within the Finnish national screening program and outside it highlights the overall importance of having cervical tests and adds this study into the slowly increasing number of studies considering all cervical testing in Finland.
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Affiliation(s)
- Henric Kultalahti
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Sirpa Heinävaara
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Maiju Pankakoski
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
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23
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Mishra J, Kalantri S, Raphael V, Dey B, Khonglah Y, Das A. Prevalence of human papillomavirus infection in abnormal pap smears. Cytojournal 2023; 20:21. [PMID: 37681080 PMCID: PMC10481853 DOI: 10.25259/cytojournal_8_2021] [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: 01/24/2021] [Accepted: 07/19/2023] [Indexed: 09/09/2023] Open
Abstract
Objectives This study was undertaken to study the prevalence of human papillomavirus (HPV) infection using the polymerase chain reaction (PCR) technique in abnormal cervical pap smears and to correlate the different cytological results with HPV infection. Material and Methods A total of 1788 cervical pap smears of women more than 30 years of age conducted over a period of 1 year 3 months (June 2015-August 2016) were screened by liquid-based cytology. High-risk (HR)-HPV testing was performed by PCR in abnormal lesions. Inflammatory smears and some atypical squamous cells of undetermined significance (ASCUS)-reactive cases were excluded from HPV testing. Histopathological correlation was done wherever possible. Results The overall prevalence of the intraepithelial lesions/malignancy was ASCUS. (ASCUS) - 79 (4.42%), atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H) - 10 (0.56%), low-grade squamous intraepithelial lesion (LSIL) - 26 (1.45%), high-grade squamous intraepithelial lesion (HSIL) - 15 (0.84%), squamous cell carcinoma - 5 (0.28%), and adenocarcinoma - 1 case (0.06%). Overall, 136 (7.60%) samples were classified as abnormal. Seventy-seven samples were included for HR-HPV testing - 20 ASCUS, 10 ASC-H, 26 LSIL, 15 HSIL, and 6 malignant cases. A control group of ten samples with normal cervical cytology within the normal limit (Control) (WNLc) was tested for HR-HPV. HR-HPV was detected in 20% of samples of the WNLc group, 45% of the ASCUS group, 70% of the ASC-H group, 73.07% of the LSIL group, 86.67% of the HSIL, and 83.34% of the samples in the malignant group. Overall, HR-HPV was detected in 68.83% of abnormal cervical pap smears. Conclusion Our study shows that the percentage of HR-HPV-positive case increases with the severity of cytologic morphology. HPV had 4 times higher positivity in squamous intraepithelial lesion as compared to ASCUS.
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Affiliation(s)
- Jaya Mishra
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Sweety Kalantri
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Vandana Raphael
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Biswajit Dey
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Yookarin Khonglah
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Ananya Das
- Department of Obstetrics and Gynaecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
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24
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Rayner M, Welp A, Stoler MH, Cantrell LA. Cervical Cancer Screening Recommendations: Now and for the Future. Healthcare (Basel) 2023; 11:2273. [PMID: 37628471 PMCID: PMC10454304 DOI: 10.3390/healthcare11162273] [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: 05/31/2023] [Revised: 07/08/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Leigh A. Cantrell
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA 22908, USA
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25
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Cuzick J, Adcock R, Kinney W, Castle PE, Robertson M, McDonald RM, Stoler MH, Du R, Wheeler CM. Impact of HPV testing in opportunistic cervical screening: Support for primary HPV screening in the United States. Int J Cancer 2023; 153:83-93. [PMID: 36946690 PMCID: PMC10639031 DOI: 10.1002/ijc.34519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/23/2023]
Abstract
Human papillomavirus (HPV) testing for cervical screening increases diagnosis of precancer and reduces the incidence of cervical cancer more than cytology alone. However, real-world evidence from diverse practice settings is lacking for the United States (U.S.) to support clinician adoption of primary HPV screening. Using a population-based registry, which captures all cervical cytology (with or without HPV testing) and all cervical biopsies, we conducted a real-world evidence study of screening in women aged 30 to 64 years across the entire state of New Mexico. Negative cytology was used to distinguish cotests from reflex HPV tests. A total of 264 198 cervical screening tests (with exclusions based on clinical history) were recorded as the first screening test between 2014 and 2017. Diagnoses of cervical intraepithelial neoplasia grades 2 or 3 or greater (CIN2+, CIN3+) from 2014 to 2019 were the main outcomes. Of cytology-negative screens, 165 595 (67.1%) were cotests and 4.8% of these led to biopsy within 2 years vs 3.2% in the cytology-only group. Among cytology-negative, HPV tested women, 347 of 398 (87.2%) CIN2+ cases were diagnosed in HPV-positive women, as were 147 of 164 (89.6%) CIN3+ cases. Only 29/921 (3.2%) CIN3+ and 67/1964 (3.4%) CIN2+ cases were diagnosed in HPV-negative, cytology-positive women with biopsies. Under U.S. opportunistic screening, across a diversity of health care delivery practices, and in a population suffering multiple disparities, we show adding HPV testing to cytology substantially increased the yield of CIN2+ and CIN3+. CIN3+ was rarely diagnosed in HPV-negative women with abnormal cytology, supporting U.S. primary HPV-only screening.
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Affiliation(s)
- Jack Cuzick
- Centre for Prevention, Diagnosis and Detection, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rachael Adcock
- Centre for Prevention, Diagnosis and Detection, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Center for HPV Prevention, UNM Comprehensive Cancer Center, Albuquerque, New Mexico, USA
| | | | - Philip E. Castle
- Division of Cancer Prevention and Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Michael Robertson
- Center for HPV Prevention, UNM Comprehensive Cancer Center, Albuquerque, New Mexico, USA
| | - Ruth M. McDonald
- Center for HPV Prevention, UNM Comprehensive Cancer Center, Albuquerque, New Mexico, USA
| | - Mark H. Stoler
- Department of Pathology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ruofei Du
- Center for HPV Prevention, UNM Comprehensive Cancer Center, Albuquerque, New Mexico, USA
| | - Cosette M. Wheeler
- Center for HPV Prevention, UNM Comprehensive Cancer Center, Albuquerque, New Mexico, USA
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Kundrod KA, Barra M, Wilkinson A, Smith CA, Natoli ME, Chang MM, Coole JB, Santhanaraj A, Lorenzoni C, Mavume C, Atif H, Montealegre JR, Scheurer ME, Castle PE, Schmeler KM, Richards-Kortum RR. An integrated isothermal nucleic acid amplification test to detect HPV16 and HPV18 DNA in resource-limited settings. Sci Transl Med 2023; 15:eabn4768. [PMID: 37343083 PMCID: PMC10566637 DOI: 10.1126/scitranslmed.abn4768] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/01/2023] [Indexed: 06/23/2023]
Abstract
High-risk human papillomavirus (HPV) DNA testing is widely acknowledged as the most sensitive cervical cancer screening method but has limited availability in resource-limited settings, where the burden of cervical cancer is highest. Recently, HPV DNA tests have been developed for use in resource-limited settings, but they remain too costly for widespread use and require instruments that are often limited to centralized laboratories. To help meet the global need for low-cost cervical cancer screening, we developed a prototype, sample-to-answer, point-of-care test for HPV16 and HPV18 DNA. Our test relies on isothermal DNA amplification and lateral flow detection, two technologies that reduce the need for complex instrumentation. We integrated all test components into a low-cost, manufacturable platform, and performance of the integrated test was evaluated with synthetic samples, provider-collected clinical samples in a high-resource setting in the United States, and self-collected clinical samples in a low-resource setting in Mozambique. We demonstrated a clinically relevant limit of detection of 1000 HPV16 or HPV18 DNA copies per test. The test requires six user steps, yields results in 45 min, and can be performed using a benchtop instrument and minicentrifuge by minimally trained personnel. The projected per-test cost is <$5, and the projected instrumentation cost is <$1000. These results show the feasibility of a sample-to-answer, point-of-care HPV DNA test. With the inclusion of other HPV types, this test has the potential to fill a critical gap for decentralized and globally accessible cervical cancer screening.
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Affiliation(s)
- Kathryn A Kundrod
- Department of Bioengineering, Rice University, Houston, TX, USA
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Maria Barra
- Department of Bioengineering, Rice University, Houston, TX, USA
| | | | - Chelsey A Smith
- Department of Bioengineering, Rice University, Houston, TX, USA
| | - Mary E Natoli
- Department of Bioengineering, Rice University, Houston, TX, USA
| | - Megan M Chang
- Department of Bioengineering, Rice University, Houston, TX, USA
| | - Jackson B Coole
- Department of Bioengineering, Rice University, Houston, TX, USA
| | | | - Cesaltina Lorenzoni
- Ministério da Saúde de Moçambique (MISAU), Hospital Central de Maputo, Hospital Geral de Mavalane, Universidade Eduardo Mondlane (UEM), Maputo, Mozambique
| | - Celda Mavume
- Ministério da Saúde de Moçambique (MISAU), Hospital Central de Maputo, Hospital Geral de Mavalane, Universidade Eduardo Mondlane (UEM), Maputo, Mozambique
| | - Hira Atif
- Ministério da Saúde de Moçambique (MISAU), Hospital Central de Maputo, Hospital Geral de Mavalane, Universidade Eduardo Mondlane (UEM), Maputo, Mozambique
| | | | - Michael E Scheurer
- Department of Pediatrics-Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Philip E Castle
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
- Division of Cancer Prevention, National Cancer Institute, Rockville, MD, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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de Waard J, Bhattacharya A, de Boer MT, van Hemel BM, Esajas MD, Vermeulen KM, de Bock GH, Schuuring E, Wisman GBA. Identification of a methylation panel as an alternative triage to detect CIN3+ in hrHPV-positive self-samples from the population-based cervical cancer screening programme. Clin Epigenetics 2023; 15:103. [PMID: 37322534 PMCID: PMC10273737 DOI: 10.1186/s13148-023-01517-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The Dutch population-based cervical cancer screening programme (PBS) consists of primary high-risk human papilloma virus (hrHPV) testing with cytology as triage test. In addition to cervical scraping by a general practitioner (GP), women are offered self-sampling to increase participation. Because cytological examination on self-sampled material is not feasible, collection of cervical samples from hrHPV-positive women by a GP is required. This study aims to design a methylation marker panel to detect CIN3 or worse (CIN3+) in hrHPV-positive self-samples from the Dutch PBS as an alternative triage test for cytology. METHODS Fifteen individual host DNA methylation markers with high sensitivity and specificity for CIN3+ were selected from literature and analysed using quantitative methylation-specific PCR (QMSP) on DNA from hrHPV-positive self-samples from 208 women with CIN2 or less (< CIN2) and 96 women with CIN3+. Diagnostic performance was determined by area under the curve (AUC) of receiver operating characteristic (ROC) analysis. Self-samples were divided into a train and test set. Hierarchical clustering analysis to identify input methylation markers, followed by model-based recursive partitioning and robustness analysis to construct a predictive model, was applied to design the best marker panel. RESULTS QMSP analysis of the 15 individual methylation markers showed discriminative DNA methylation levels between < CIN2 and CIN3+ for all markers (p < 0.05). The diagnostic performance analysis for CIN3+ showed an AUC of ≥ 0.7 (p < 0.001) for nine markers. Hierarchical clustering analysis resulted in seven clusters with methylation markers with similar methylation patterns (Spearman correlation> 0.5). Decision tree modeling revealed the best and most robust panel to contain ANKRD18CP, LHX8 and EPB41L3 with an AUC of 0.83 in the training set and 0.84 in the test set. Sensitivity to detect CIN3+ was 82% in the training set and 84% in the test set, with a specificity of 74% and 71%, respectively. Furthermore, all cancer cases (n = 5) were identified. CONCLUSION The combination of ANKRD18CP, LHX8 and EPB41L3 revealed good diagnostic performance in real-life self-sampled material. This panel shows clinical applicability to replace cytology in women using self-sampling in the Dutch PBS programme and avoids the extra GP visit after a hrHPV-positive self-sampling test.
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Affiliation(s)
- J de Waard
- Department of Gynaecologic Oncology, Cancer Research Center Groningen, University of Groningen, University Medical Center Groningen, PO-Box 30001, 9700 RB, Groningen, The Netherlands
| | - A Bhattacharya
- Department of Medical Oncology, Cancer Research Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M T de Boer
- Department of Gynaecologic Oncology, Cancer Research Center Groningen, University of Groningen, University Medical Center Groningen, PO-Box 30001, 9700 RB, Groningen, The Netherlands
| | - B M van Hemel
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M D Esajas
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - K M Vermeulen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - G H de Bock
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - E Schuuring
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - G B A Wisman
- Department of Gynaecologic Oncology, Cancer Research Center Groningen, University of Groningen, University Medical Center Groningen, PO-Box 30001, 9700 RB, Groningen, The Netherlands.
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Caeiro V, Esteves B, Fonseca-Moutinho J. HPV testing for cervical cancer screening: Should reflex cytology be performed after a positive test for HPV 16 and 18? Cancer Treat Res Commun 2023; 36:100729. [PMID: 37352587 DOI: 10.1016/j.ctarc.2023.100729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 05/29/2023] [Accepted: 06/08/2023] [Indexed: 06/25/2023]
Abstract
At Portuguese-organized cervical cancer (CC) screening programs, all women testing positive for human papillomavirus (HPV) 16 and/or 18 are referred for immediate colposcopy. This study aimed to evaluate the utility of reflex cytology in women who test positive for HPV 16 and/or 18 to improve the efficiency of CC screening. A cross-sectional and retrospective study was performed based on data from the routine CC screening protocol in force at Cova da Beira University Hospital Center, Portugal between August 2012 and June 2021. The screening method was the Cobas 4800 HPV test using the liquid medium Surepath. In all the selected cases, the patient's HPV test results and the cytology and histology findings of the biopsies obtained using colposcopy were analyzed. This study included 339 women who first tested positive for HPV 16 and/or 18 and were referred for immediate colposcopy, in whom 40 (11.8%) cases of high-grade squamous intraepithelial lesion (HSIL+) were diagnosed. Of these, 12 (30%) had reflex cytology negative for intraepithelial lesion or malignancy (NILM) and 14 (35%) had HSIL+ cytology. After 3 years, 14 (9.3%) of the 150 women who were still undergoing follow-up were diagnosed with histologic HSIL+ lesions, of which 5 (35.7%) had baseline NILM cytology. Despite the small sample, the results of this study allow us to conclude that reflex cytology is not useful for discrimination to immediate referral for colposcopy in women who test positive for HPV 16 and/or 18, as most women with a histologic diagnosis of an HSIL+ lesion had
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Affiliation(s)
- Vitor Caeiro
- Health Sciences Research Centre (CICS), Faculty of Health Sciences, University of Beira Interior (UBI), Covilhã, Portugal.
| | - Bruno Esteves
- Clinical Pathology at Cova da Beira University Hospital Center (CHUCB), Covilhã, Portugal
| | - José Fonseca-Moutinho
- Health Sciences Research Centre (CICS), Faculty of Health Sciences, University of Beira Interior (UBI), Covilhã, Portugal
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Chu D, Liu T, Yao Y. Implications of viral infections and oncogenesis in uterine cervical carcinoma etiology and pathogenesis. Front Microbiol 2023; 14:1194431. [PMID: 37293236 PMCID: PMC10244558 DOI: 10.3389/fmicb.2023.1194431] [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: 03/27/2023] [Accepted: 05/05/2023] [Indexed: 06/10/2023] Open
Abstract
Background Uterine Cervical Carcinoma (UCC) is the most prevalent gynecological malignancy globally, with a rising incidence in recent years. Accumulating evidence indicates that specific viral infections, including human papillomavirus (HPV), Epstein-Barr virus (EBV), Hepatitis B and C viruses (HBV and HCV), and human herpesvirus (HHV), may contribute to UCC development and progression. Understanding the complex interplay between viral infections and UCC risk is crucial for developing novel preventative and therapeutic interventions. Methods This comprehensive review investigates the association between viral infections and UCC risk by examining the roles of various viral pathogens in UCC etiology and pathogenesis, and possible molecular mechanisms. Additionally, we evaluate current diagnostic methods and potential therapeutic strategies targeting viral infections for UCC prevention or treatment. Results The prevention of UCC has been significantly advanced by the emergence of self-sampling for HPV testing as a crucial tool, allowing for early detection and intervention. However, an essential challenge in UCC prevention lies in understanding how HPV and other viral coinfections, including EBV, HBV, HCV, HHV, HIV, or their concurrent presence, may potentially contribute to UCC development. The molecular mechanisms implicated in the association between viral infections and cervical cancer development include: (1) interference of viral oncogenes with cellular regulatory proteins, resulting in uncontrolled cell proliferation and malignant transformation; (2) inactivation of tumor suppressor genes by viral proteins; (3) evasion of host immune responses by viruses; (4) induction of a persistent inflammatory response, contributing to a tumor-promoting microenvironment; (5) epigenetic modifications that lead to aberrant gene expression; (6) stimulation of angiogenesis by viruses; and (7) activation of telomerase by viral proteins, leading to cellular immortalization. Additionally, viral coinfections can also enhance oncogenic potential through synergistic interactions between viral oncoproteins, employ immune evasion strategies, contribute to chronic inflammation, modulate host cellular signaling pathways, and induce epigenetic alterations, ultimately leading to cervical carcinogenesis. Conclusion Recognizing the implications of viral oncogenes in UCC etiology and pathogenesis is vital for addressing the escalating burden of UCC. Developing innovative preventative and therapeutic interventions requires a thorough understanding of the intricate relationship between viral infections and UCC risk.
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Affiliation(s)
- Daming Chu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Tengteng Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuan Yao
- Department of Oncology, The People’s Hospital of Liaoning Province, Shenyang, China
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30
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Helenius G, Lillsunde-Larsson G, Bergengren L. Molecular triage of cervical screening samples in women 55-59 years of age: a pilot study. Infect Agent Cancer 2023; 18:31. [PMID: 37221548 DOI: 10.1186/s13027-023-00510-1] [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: 03/01/2023] [Accepted: 05/12/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND With HPV screening the specificity of screening positives has decreased, even with a cytological triage test. Increases in colposcopies and detection of benign or low-grade dysplasia are reported, not least in older women. These results highlight the necessity to find other triage tests in HPV screening strategies, so that women can be more accurately selected for colposcopy, thus minimizing the clinically irrelevant findings. METHODS The study included 55- to 59-year-old women who exited the screening with normal cytology, but later in a follow-up test were positive for the HPV genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68 and had a cervical cone biopsy done. To model a screening situation with hrHPV-positive women, three different triage strategies, namely, cytology, genotyping and methylation, were performed. The study considered the effect of direct referral to colposcopy for HPV genotypes 16, 18, 31, 33, 45, 52 and 58, and methylation for FAM19A4 and hsa-mir124-2 and/or any form of abnormal cytology. RESULTS Seven out of 49 women aged 55-59 years with hrHPV had a cone biopsy with high-grade squamous intraepithelial lesion. No triage method found all cases, and when comparing positive and negative predictive value and false negative rate, cytology showed better results than genotyping and methylation. CONCLUSION This study does not support a switch in triage strategies from cytology to hrHPV genotyping and methylation for women above 55 years of age yet, but demonstrates the need for more evidence on molecular triage strategies.
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Affiliation(s)
- Gisela Helenius
- School of Health Sciences, Örebro University, Örebro, Sweden
| | - Gabriella Lillsunde-Larsson
- School of Health Sciences, Örebro University, Örebro, Sweden
- Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Lovisa Bergengren
- Department of Women's Health, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
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31
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Booth BB, Tranberg M, Gustafson LW, Christiansen AG, Lapirtis H, Krogh LM, Hjorth IMD, Hammer A. Risk of cervical intraepithelial neoplasia grade 2 or worse in women aged ≥ 69 referred to colposcopy due to an HPV-positive screening test. BMC Cancer 2023; 23:405. [PMID: 37142959 PMCID: PMC10161414 DOI: 10.1186/s12885-023-10888-1] [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: 10/26/2022] [Accepted: 04/26/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Cervical cancer incidence and mortality rates are high in older women in many developed countries, including Denmark. Therefore, Danish women aged 69 and older were invited for one additional human papilloma virus (HPV) based screening test in 2017. Here, we describe the clinical management and detection rate of cervical intraepithelial neoplasia grade 2 or worse (CIN2 +) in screen-positive women referred for colposcopy. METHODS We conducted an observational study in public gynecology departments in Central Denmark Region, Denmark. Women were eligible for enrolment if they were aged 69 + in 2017, HPV positive on a screening test taken between April 20th, 2017, and December 31st, 2017, and had been referred for direct colposcopy. Data on participants' characteristics, colposcopic findings, and histological outcomes were collected from medical records and the Danish Pathology Databank. We estimated the proportion of women with CIN2 + at the first colposcopy visit and at end of follow up including 95% confidence intervals (CIs). RESULTS A total of 191 women were included with a median age of 74 years (IQR: 71-78). Most women (74.9%) did not have a fully visible transformation zone at colposcopy. At the first visit 170 women (89.0%) had a histological sample collected, 34 of whom (20.0%, 95% CI 14.3-26.8%) had CIN2 + diagnosed, 19 had CIN3 + , and two had cervical cancer). During follow-up additional CIN2 + were detected resulting in a total of 42 women (24.4%, 95% CI: 18.2-31.5%) being diagnosed with CIN2 + , 25 with CIN3 + , and three with cervical cancer. When restricting to women with paired histologic results (i.e., biopsies and a loop electrosurgical excision procedure (LEEP) specimen), we found that CIN2 + was missed in 17.9% (95% CI 8.9-30.4%) of biopsies compared to the LEEP. CONCLUSION Our findings suggest a potential risk of underdiagnosis in older postmenopausal women referred to colposcopy. Future studies should explore potential risk-markers for discrimination of women at increased risk of CIN2 + from those at low risk, as this would reduce risk of underdiagnosis and overtreatment.
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Affiliation(s)
- Berit B Booth
- Department of Obstetrics and Gynecology, NIDO - Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 15, Herning, 7400, Denmark.
| | - Mette Tranberg
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | - Line W Gustafson
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne G Christiansen
- Department of Obstetrics and Gynecology, NIDO - Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 15, Herning, 7400, Denmark
| | - Helle Lapirtis
- Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
| | - Lisa M Krogh
- Department of Obstetrics and Gynecology, Viborg Regional Hospital, Viborg, Denmark
| | - Ina Marie D Hjorth
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
| | - Anne Hammer
- Department of Obstetrics and Gynecology, NIDO - Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 15, Herning, 7400, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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32
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Liu H, Ma H, Li Y, Zhao H. Advances in epigenetic modifications and cervical cancer research. Biochim Biophys Acta Rev Cancer 2023; 1878:188894. [PMID: 37011697 DOI: 10.1016/j.bbcan.2023.188894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/19/2023] [Accepted: 03/31/2023] [Indexed: 04/03/2023]
Abstract
Cervical cancer (CC) is an important public health problem for women, and perspectives and information regarding its prevention and treatment are quickly evolving. Human papilloma virus (HPV) has been recognized as a major contributor to CC development; however, HPV infection is not the only cause of CC. Epigenetics refers to changes in gene expression levels caused by non-gene sequence changes. Growing evidence suggests that the disruption of gene expression patterns which were governed by epigenetic modifications can result in cancer, autoimmune diseases, and various other maladies. This article mainly reviews the current research status of epigenetic modifications in CC based on four aspects, respectively DNA methylation, histone modification, noncoding RNA regulation and chromatin regulation, and we also discuss their functions and molecular mechanisms in the occurrence and progression of CC. This review provides new ideas for early screening, risk assessment, molecular targeted therapy and prognostic prediction of CC.
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Ramshankar V, Ravindran S, Arun K, Albert K, Sri SL, Ramasubramanian L, Satyaseelan B. Impact of HPV molecular testing with partial genotyping as a feasibility study in cervical cancer community screening program in South India. J Med Virol 2023; 95:e28715. [PMID: 37185837 DOI: 10.1002/jmv.28715] [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: 12/05/2022] [Revised: 03/08/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023]
Abstract
Cervical cancer can be eradicated by 2030 by the implementation of a global strategy involving the vaccination of young girls against human papillomavirus (HPV), screening 70% of women in 30-69 years of age and treating 90% of the women with precancerous lesions. For a country with a large population like India, all the three strategies can be a challenge. There is a need for implementation of a high throughput technology that can be scalable. Cobas 4800, a multiplexed assay based on quantitative polymerase chain reaction technology, identifies HPV 16 and HPV 18 along with the concurrent detection of 12 pooled other high-risk HPV infections. This technology was used to test 10 375 women from the South Indian community for the first time as a feasibility program. Upon testing, high-risk HPV was found in 595 (5.73%) women. A total of 127 women (1.2%) were found to be infected with HPV 16, 36 women (0.34%) with HPV 18 and 382 women (3.68%) with the 12 pooled high-risk HPV and multiple mixed infections were found in 50 women (0.48%). It was observed that there was a high prevalence of high-risk HPV in younger women, 30-40 years of age and a second peak was observed at 46-50 years of age. The second peak had higher mixed infections in the 46-50 years of age and this association was statistically significant. We found that 24/50 (48%) of the multiple mixed high-risk HPV infections were in the age group 46-50 years. The current study is the first attempt from India, on a completely automated platform using Cobas 4800 HPV test in a community screening program. This study shows HPV 16 and HPV 18 infections, when differentiated, can be valuable for risk stratification in community screening program. Women in the perimenopausal age (46-50yrs) showed a higher prevalence of multiple mixed infections, signifying a higher risk.
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Affiliation(s)
| | - Soundharya Ravindran
- Department of Preventive Oncology (Research), Cancer Institute (WIA), Adyar, Chennai, India
| | - Komathi Arun
- Department of Preventive Oncology (Research), Cancer Institute (WIA), Adyar, Chennai, India
| | - Kanchana Albert
- Department of Preventive Oncology (Research), Cancer Institute (WIA), Adyar, Chennai, India
| | - Sakthi Lalitha Sri
- Department of Preventive Oncology (Research), Cancer Institute (WIA), Adyar, Chennai, India
| | - Lalitha Ramasubramanian
- Department of Radiation Oncology, Government Thoothukudi Medical College Hospital, Thoothukudi, India
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Choi HCW, Leung K, Chan KKL, Bai Y, Jit M, Wu JT. Maximizing the cost-effectiveness of cervical screening in the context of routine HPV vaccination by optimizing screening strategies with respect to vaccine uptake: a modeling analysis. BMC Med 2023; 21:48. [PMID: 36765349 PMCID: PMC9921628 DOI: 10.1186/s12916-023-02748-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/23/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Regarding primary and secondary cervical cancer prevention, the World Health Organization proposed the cervical cancer elimination strategy that requires countries to achieve 90% uptake of human papillomavirus (HPV) vaccines and 70% screening uptake. The optimal cervical screening strategy is likely different for unvaccinated and vaccinated cohorts upon national HPV immunization. However, health authorities typically only provide a one-size-fits-all recommendation for the general population. We aimed to evaluate the cost-effectiveness for determining the optimal screening strategies for vaccinated and unvaccinated cohorts. METHODS We considered the women population in Hong Kong which has a unique HPV infection and cervical cancer epidemiology compared to other regions in China and Asia. We used mathematical models which comprise a deterministic age-structured compartmental dynamic component and a stochastic individual-based cohort component to evaluate the cost-effectiveness of screening strategies for cervical screening. Following the recommendations in local guidelines in Hong Kong, we considered strategies that involved cytology, HPV testing, or co-testing as primary cervical screening. We also explored the impacts of adopting alternative de-intensified strategies for vaccinated cohorts. The 3-year cytology screening was used as the base comparator while no screening was also considered for vaccinated cohorts. Women's lifetime life years, quality-adjusted life years, and costs of screening and treatment were estimated from the societal perspective based on the year 2022 and were discounted by 3% annually. Incremental cost-effectiveness ratios (ICERs) were compared to a willingness to pay (WTP) threshold of one gross domestic product per capita (US $47,792). Probabilistic and one-way sensitivity analyses were conducted. RESULTS Among unvaccinated cohorts, the strategy that adds reflex HPV to triage mild cytology abnormality generated more life years saved than cytology-only screening and could be a cost-effective alternative. Among vaccinated cohorts, when vaccine uptake was 85% (based on the uptake in 2022), all guideline-based strategies (including the cytology-only screening) had ICERs above the WTP threshold when compared with no screening if the vaccine-induced protection duration was 20 years or longer. Under the same conditions, HPV testing with genotyping triage had ICERs (compared with no screening) below the WTP threshold if the routine screening interval was lengthened to 10 and 15 years or screening was initiated at ages 30 and 35 years. CONCLUSIONS HPV testing is a cost-effective alternative to cytology for vaccinated cohorts, and the associated optimal screening frequency depends on vaccine uptake. Health authorities should optimize screening recommendations by accounting for population vaccine uptake.
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Affiliation(s)
- Horace C W Choi
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China. .,Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, Hong Kong Special Administrative Region, China.
| | - Kathy Leung
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China.,Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, Hong Kong Special Administrative Region, China
| | - Karen K L Chan
- Department of Obstetrics and Gynaecology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yuan Bai
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China.,Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, Hong Kong Special Administrative Region, China
| | - Mark Jit
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,Modelling and Economics Unit, Public Health England, London, UK
| | - Joseph T Wu
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Patrick Manson Building (North Wing), 7 Sassoon Road, Hong Kong Special Administrative Region, China.,Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, Hong Kong Special Administrative Region, China
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35
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Fleider LA, de los Ángeles Tinnirello M, Gómez Cherey F, García MG, Cardinal LH, García Kamermann F, Tatti SA. High sensitivity and specificity rates of cobas® HPV test as a primary screening test for cervical intraepithelial lesions in a real-world setting. PLoS One 2023; 18:e0279728. [PMID: 36745662 PMCID: PMC9901754 DOI: 10.1371/journal.pone.0279728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/14/2022] [Indexed: 02/07/2023] Open
Abstract
Cervical carcinoma (CC) is the fourth most common malignancy among women. Screening with Papanicolau smear is linked to a reduction in CC incidence rates when screening programs have been developed. However, this technique has several limitations, including moderate sensitivity rates for detection of cervical preneoplastic HPV-related lesions. In this real-world study, we proposed to evaluate the sensitivity and specificity rates of cobas® test, which amplifies target DNA fragments by polymerase chain reaction and hybridization of nucleic acids for the detection of 14 HR-HPV types in a single analysis) used as primary screening test for CC and preneoplastic lesions in women aged 25-65 years in a large University Hospital in Buenos Aires. A total of 1044 patients were included in the sample (median age: 46 years); sensitivity and specificity rates for the HR-HPV test used as primary screening test were 98.66% (95% confidence interval [95CI]: 97.67-99.3%) and 87.15% (95CI: 84.93-89.15%), respectively. The positive predictive value was 88.47% (95CI: 86.54%-90.42%) and the negative predictive value was 98.48% (95CI: 97.75%-99.23%). The cobas® HR-HPV testing was highly sensitive and specific for the detection of CC and preneoplastic lesions in real practice.
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Affiliation(s)
- Laura Alicia Fleider
- OBGYN Department, Genital Tract Unit, Hospital de Clínicas “José de San Martín”, Buenos Aires University, Buenos Aires, Argentina
- * E-mail:
| | - María de los Ángeles Tinnirello
- OBGYN Department, Genital Tract Unit, Hospital de Clínicas “José de San Martín”, Buenos Aires University, Buenos Aires, Argentina
| | - Facundo Gómez Cherey
- OBGYN Department, Genital Tract Unit, Hospital de Clínicas “José de San Martín”, Buenos Aires University, Buenos Aires, Argentina
| | - María Gabriela García
- Molecular Infectious Disease Department, ManLab Laboratories, Buenos Aires, Argentina
| | - Lucía Helena Cardinal
- Gynecological Pathology Division, Pathology Department, Hospital de Clínicas “José de San Martín”, Buenos Aires University, Buenos Aires, Argentina
| | - Florencia García Kamermann
- Gynecological Pathology Division, Pathology Department, Hospital de Clínicas “José de San Martín”, Buenos Aires University, Buenos Aires, Argentina
| | - Silvio Alejandro Tatti
- Chief of OBGYN Department, Hospital de Clínicas “José de San Martín”, Buenos Aires University, Buenos Aires, Argentina
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Cuzick J. The importance of long-term follow up of participants in clinical trials. Br J Cancer 2023; 128:432-438. [PMID: 36456713 PMCID: PMC9938165 DOI: 10.1038/s41416-022-02038-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Jack Cuzick
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
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Bennett KF, Waller J, Bailey JV, Marlow LAV. Exploring the psychosexual impact and disclosure experiences of women testing positive for high-risk cervical human papillomavirus. Br J Health Psychol 2023; 28:62-79. [PMID: 35819012 PMCID: PMC10084302 DOI: 10.1111/bjhp.12612] [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: 01/20/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To examine the psychosexual impact and disclosure experiences of women testing HPV-positive following cervical screening. DESIGN In-depth semi-structured interviews. METHODS Interviews were conducted with 21 women of screening age (i.e. those aged 24-65 years) in England who self-reported testing HPV-positive in the context of cervical screening in the last 12 months. Data were analysed using Framework Analysis. RESULTS The sexually transmitted nature of HPV, and aspects relating to the transmission of HPV and where their HPV infection had come from, had an impact on women's current, past and future interpersonal and sexual relationships. Most women had disclosed their HPV infection to others, however the factors influencing their decision, and others' reactions to disclosure differed. The magnitude and extent of psychosexual impact was influenced by how women conceptualized HPV, their understanding of key aspects of the virus, concerns about transmitting HPV and having a persistent HPV infection. CONCLUSIONS Increasing knowledge of key aspects of HPV, such as its high prevalence and spontaneous clearance, and the differences between HPV and other STIs, may increase women's understanding of their screening result and reduce any negative psychosexual consequences of testing HPV-positive. Referring to HPV as an infection that is passed on by skin-to-skin contact during sexual activity, rather than an STI, may help to lessen any psychosexual impact triggered by the STI label.
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Affiliation(s)
- Kirsty F Bennett
- Cancer Communication and Screening Group, Department of Behavioural Science and Health, University College London, London, UK
| | - Jo Waller
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Julia V Bailey
- e-Health Unit, Department of Primary Care and Population Health, University College London, London, UK
| | - Laura A V Marlow
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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Snyman LC, Richter KL, Lukhwareni A, Dreyer G, Botha MH, Van Der Merwe FH, Visser C, Dreyer G. Cytology compared with Hybrid Capture 2 human papilloma virus cervical cancer screening in HIV positive and HIV negative South African women. Int J Gynecol Cancer 2023; 33:669-675. [PMID: 36650011 DOI: 10.1136/ijgc-2022-003897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Cervical cancer is preventable and caused by persistent infection with oncogenic human papilloma virus (HPV) types. HPV screening is more sensitive and is the preferred screening test. HPV screening data are mainly from developed settings, and the purpose of this study was to investigate the performance of HPV screening in previously unscreened HIV positive and negative women. METHODS In this cross sectional multicenter study, liquid based cytology and HPV testing were performed on women attending different clinics. Patients with positive screening tests had colposcopy and biopsy or large loop excision of the transformation zone. Some women with normal screening had colposcopy and biopsy. Data of women with histology results, and data of HIV positive and negative women were analyzed for comparison. For women without histology results, data were imputed using a statistical model. RESULTS In 903 women with known HIV status, 683 (75.6%) had negative cytology, 202 women (22.4%) had abnormal cytology, and in 18 patients (2.0%) the results were uncertain. Mean age was 41.4 years (range 25-65). HPV tests were negative in 621 women (68.8%). In HIV positive women, 54.5% tested negative compared with 79.7% HIV negative women (p<0.0001). HPV screening had higher sensitivity (60.9%), but lower specificity (82.4%), compared with cytology (48.6% and 86.7%) for detection of cervical intraepithelial neoplasia (CIN) 2+ in all women. For detection of CIN 3+, HPV screening had higher sensitivity (70.4%) compared with cytology (62.9%), and specificity (75.5%) was lower compared with cytology at a threshold of atypical squamous cells of undetermined significance (ASCUS+) (82.4%). CONCLUSION HPV screening was more sensitive than cytology in HIV positive and HIV negative women, but specificity was lower. Although HPV screening should be the preferred screening test, cytology is a suitable screening test in HIV positive women in low resource settings. TRIAL REGISTRATION NUMBER NCT02956031.
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Affiliation(s)
- Leon Cornelius Snyman
- Obstetrics and Gynaecology, University of Pretoria Faculty of Health Sciences, Pretoria, South Africa
| | - Karin Louise Richter
- Department Medical Virology, University of Pretoria Faculty of Health Sciences, Pretoria, South Africa
| | - Azwidowi Lukhwareni
- Department Medical Virology, University of Pretoria Faculty of Health Sciences, Pretoria, South Africa
| | - Gerrit Dreyer
- Department of Statistics and Actuarial Science, Stellenbosch University, Stellenbosch, South Africa
| | - Matthys Hendrik Botha
- Obstetrics and Gynaecology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - F Haynes Van Der Merwe
- Obstetrics and Gynaecology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Cathy Visser
- Obstetrics and Gynaecology, University of Pretoria Faculty of Health Sciences, Pretoria, South Africa
| | - Greta Dreyer
- Obstetrics and Gynaecology, University of Pretoria Faculty of Health Sciences, Pretoria, South Africa
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Sokale IO, Montealegre JR, Oluyomi AO, Thrift AP. Trends and Racial/Ethnic Differences in Predictors of Cervical Cancer Screening among US Women Ages 30-64 Years. Cancer Epidemiol Biomarkers Prev 2023; 32:82-90. [PMID: 36306382 PMCID: PMC9839647 DOI: 10.1158/1055-9965.epi-22-0970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cervical cancer screening (CCS) participation has decreased in the United States over the last several decades, contributing to cervical cancer's sustained incidence and mortality. This study examined recent trends and racial/ethnic differences in predictors of CCS uptake among US women. METHODS We analyzed combined data from the 2016 to 2020 Behavioral Risk Factor Surveillance System (BRFSS) and included 235,713 women ages 30 to 64 years without a hysterectomy. We used simple linear regression to assess trends over time and multivariable logistic regression models to evaluate racial/ethnic differences in predictors of up-to-date CCS. RESULTS We found little change in CCS over the 5-year interval and screening rates disparities among racial minority women. The overall population showed stable CCS completion rates from 2016 to 2018 (84.2% vs. 84.6%), and then a small dip from 2018 to 2020 (from 84.6% to 83.3%). Despite a slight decline in 2020, HPV-based testing increased significantly among all subgroups and overall, from 2016 to 2020 (from 43.4% to 52.7%). Multivariable regression models showed racial/ethnic differences in predictors of CCS. Across all racial/ethnic subgroups, older women were less likely to receive timely screening. Women who had routine check-ups had higher odds of being up to date. However, the link between CCS and socioeconomic status varied. CONCLUSIONS Age and racial/ethnic disparities persist in CCS, and predictors of screening vary. Notwithstanding, routine health examinations was positively associated with screening regardless of race/ethnicity. IMPACT Our analyses suggest that leveraging primary care to optimize CCS uptake may reduce gaps in screening.
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Affiliation(s)
- Itunu O. Sokale
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, TX 77030, USA
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA
- Corresponding Author. Itunu O. Sokale, MBBS, MPH, DrPH, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 307, Room 613D, Houston, TX 77030-3498, Phone: 713-798-2972,
| | - Jane R. Montealegre
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Abiodun O. Oluyomi
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, TX 77030, USA
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA
| | - Aaron P. Thrift
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, TX 77030, USA
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA
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Ma K, Li S, Wu S, Zhu J, Yang Y. Impact of smoking exposure on human papillomavirus clearance among Chinese women: A follow-up propensity score matching study. Tob Induc Dis 2023; 21:42. [PMID: 36949733 PMCID: PMC10026377 DOI: 10.18332/tid/161026] [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: 10/07/2022] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION Smoking has been proven to increase the risk of cervical cancer, but it is still controversial whether smoking reduces women's ability to clear human papillomavirus (HPV) infection. This study investigated the association between smoking behaviors during follow-up and clearance of HPV infection in women with HPV-positive and pathologically normal uterine cervix in China, using a propensity score matching (PSM) analysis. METHODS The present prospective study included data from women examined in the Gynecology Department of Shanghai General Hospital from January 2018 to June 2020. Twenty patients who smoked throughout follow-up were selected and matched with 60 patients using the 1:3 PSM method on age, marital status, and whether infected with high-risk HPV (HR-HPV). At each visit, smoking and sexual behaviors were collected. The Kaplan-Meier method and a Cox proportional hazard regression model were used to evaluate the probability of clearing HPV infection within a 2-year follow-up. RESULTS A total of 80 patients were included in the study, all of whom were infected with at least one HR-HPV type at baseline. Current smokers had a lower likelihood of clearing the HPV infection than current non-smokers, after adjusting for a history of sexually transmitted diseases (STD), HPV infection status, and sexual behaviors during follow-up (AHR=0.478; 95% CI: 0.239-0.958, p=0.037). Additionally, longer duration, higher frequency and larger doses of smoking correlated with the lower clearance possibility of HPV infection (p for trend=0.029, 0.022 and 0.026, respectively). CONCLUSIONS This study showed that the use of tobacco throughout follow-up could increase the risk of a persistent HPV infection, this risk being higher for smokers with heavier tobacco consumption. Our results should alert HPV-positive women to reiterate the advice to cut-back on or stop smoking.
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Affiliation(s)
- Kangli Ma
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Shu Li
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Sufang Wu
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Jingfen Zhu
- School of Public Health, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Yongbin Yang
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
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Zaridze DG, Stilidi IS, Mukeria AF. Scientific evidence for the effectiveness of primary and secondary (screening) prevention of cervical cancer. Public Health 2022. [DOI: 10.21045/2782-1676-2022-2-4-15-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The evidence of HPV vaccination effectiveness is overwhelming. The randomized clinical trials showed that all three vaccines currently in use, bivalent (CERVARIX), quadrivalent (GARDASIL) and nanvalent (GARDASIL9) effectively prevent HPV infection, cervical intraepithelial neoplasia (CIN) 1–3 and invasive cervical cancer. The results of clinical trials have been confirmed by real life evidence – population data from countries were vaccination of 12–13 girls started in 2006–08. HPV vaccination is safe. This is proven by long term follow up of the cohorts of vaccinated women. In 2020 the WHO Director-General has issued a call for action to eliminate cervical cancer as a public health problem. The document includes the interim targets for 2030: vaccination of 90% of girls by 15 years; HPV testing based screening at age 35 and 45 of 70% of women; treatment of 90% of women with screening detected cervical pathology; treatment of 90% of women with precancerous lesions and cancer of the cervix. Under elimination of cervical cancer WHO means the decrease in its incidence down to 4 cases per 100 000 population. This goal will be achieved by 2030 in countries that started HPV vaccination 15 years ago in 2006–2007.In Russia incidence of cervical cancer is on increase since 1993 from 10, 2 to 16, 1 in 2018. It is predicted that the increase will continue and in 2030 the age standardized incidence rate will reach 20 per 100 000 women. HPV vaccination and HPV test based screening will change the direction of the trend from increase to decrease and save several hundreds of lives
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Affiliation(s)
- D. G. Zaridze
- N.N. Blokhin National Medical Research Center of Oncology
| | - I. S. Stilidi
- N.N. Blokhin National Medical Research Center of Oncology
| | - A. F. Mukeria
- N.N. Blokhin National Medical Research Center of Oncology
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Rol ML, Picconi MA, Ferrera A, Sánchez GI, Hernández MDLL, Lineros J, Peraza A, Brizuela M, Mendoza L, Mongelós P, Cabrera Y, Rodríguez de la Peña M, Correa RM, Terán C, Colque Reynaga D, García L, Ramírez AT, Hernández-Nevarez P, Doimi F, Ramón M, Arias-Stella J, Zúñiga M, Villagra V, Bobadilla ML, Cardinal L, Valls J, Lucas E, Baena A, Fleider L, Venegas G, Cruz-Valdez A, Rodríguez G, Calderón A, Wiesner C, Luciani S, Broutet N, Herrero R, Almonte M. Implementing HPV testing in 9 Latin American countries: The laboratory perspective as observed in the ESTAMPA study. Front Med (Lausanne) 2022; 9:1006038. [PMID: 36465901 PMCID: PMC9714610 DOI: 10.3389/fmed.2022.1006038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/24/2022] [Indexed: 11/18/2022] Open
Abstract
Background Replacement of cytology screening with HPV testing is recommended and essential for cervical cancer elimination. HPV testing for primary screening was implemented in 12 laboratories within 9 Latin American countries, as part of the ESTAMPA cervical cancer screening study. Our observations provide information on critical operational aspects for HPV testing implementation in diverse resource settings. Methods We describe the implementation process of HPV testing in ESTAMPA, focusing on laboratory aspects. We assess the readiness of 12 laboratories to start HPV testing and their continuity capacity to maintain good quality HPV testing until end of recruitment or up to December 2021. Readiness was based on a checklist. Information from the study database; regular meetings and monitoring visits; and a questionnaire on laboratory operational aspects sent in May 2020 were used to assess continuity capacity. Compliance with seven basic requirements (readiness) and eight continuity requirements (continuity capacity) was scored (1 = compliant, 0 = not compliant) and totaled to classify readiness and continuity capacity as very limited, limited, moderate or high. Experiences, challenges, and enablers of the implementation process are also described. Results Seven of 12 laboratories had high readiness, three moderate readiness, and of two laboratories new to HPV testing, one had limited readiness and the other very limited readiness. Two of seven laboratories with high readiness also showed high continuity capacity, one moderate continuity capacity, and the other four showed limited continuity capacity since they could not maintain good quality HPV testing over time. Among three laboratories with moderate readiness, one kept moderate continuity capacity and two reached high continuity capacity. The two laboratories new to HPV testing achieved high continuity capacity. Based on gained expertise, five laboratories have become part of national screening programs. Conclusion High readiness of laboratories is an essential part of effective implementation of HPV testing. However, high readiness is insufficient to guarantee HPV testing high continuity capacity, for which a "culture of quality" should be established with regular training, robust monitoring and quality assurance systems tailored to local context. All efforts to strengthen HPV laboratories are valuable and crucial to guarantee effective implementation of HPV-based cervical screening.
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Affiliation(s)
- Mary Luz Rol
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Annabelle Ferrera
- Instituto de Investigaciones en Microbiología, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras
| | | | - María de la Luz Hernández
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
- SMS-Oncology, Amsterdam, Netherlands
| | - Joana Lineros
- Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Ana Peraza
- Caja Costarricense de Seguro Social (CCSS), Región Pacífico Central, San José, Costa Rica
| | - Marisol Brizuela
- Caja Costarricense de Seguro Social (CCSS), Región Pacífico Central, San José, Costa Rica
| | - Laura Mendoza
- Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Pamela Mongelós
- Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Yessy Cabrera
- Grupo de Infección y Cáncer, Universidad de Antioquia, Medellín, Colombia
| | | | - Rita Mariel Correa
- Instituto de Investigaciones en Microbiología, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras
| | - Carolina Terán
- Facultad de Medicina, Universidad Mayor, Real y Pontificia de San Francisco Xavier de Chuquisaca, Sucre, Bolivia
| | - Deisy Colque Reynaga
- Facultad de Medicina, Universidad Mayor, Real y Pontificia de San Francisco Xavier de Chuquisaca, Sucre, Bolivia
| | - Laura García
- Laboratorio de Biología Molecular, Departamento de Patología Clínica, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Arianis Tatiana Ramírez
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Franco Doimi
- Laboratorio de Patología Oncológica SAC, Lima, Peru
| | - María Ramón
- Laboratorio de Patología Oncológica SAC, Lima, Peru
| | | | - Michael Zúñiga
- Agencia Costarricense de Investigaciones Biomédicas (ACIB), Fundación Inciensa, San José, Guanacaste, Costa Rica
| | | | | | - Lucía Cardinal
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Joan Valls
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Eric Lucas
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Armando Baena
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Laura Fleider
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Gino Venegas
- Clínica Angloamericana, Lima, Peru
- Liga contra el Cáncer, Lima, Peru
| | | | | | - Alejandro Calderón
- Caja Costarricense de Seguro Social (CCSS), Región Pacífico Central, San José, Costa Rica
| | | | - Silvana Luciani
- Pan American Health Organization (PAHO), Washington, DC, United States
| | - Nathalie Broutet
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Rolando Herrero
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
- Agencia Costarricense de Investigaciones Biomédicas (ACIB), Fundación Inciensa, San José, Guanacaste, Costa Rica
| | - Maribel Almonte
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Brewer N, Foliaki S, Gray M, Potter JD, Douwes J. Pasifika women's knowledge and perceptions of cervical-cancer screening and the implementation of self-testing in Aotearoa New Zealand: A qualitative study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 28:100551. [PMID: 35991536 PMCID: PMC9389298 DOI: 10.1016/j.lanwpc.2022.100551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND In Aotearoa New Zealand, Pasifika women have a higher rate of cervical cancer incidence and mortality than European/Other women and a lower screening rate. Despite actions to reduce the barriers, there has been little change in screening coverage for Pasifika women since 2007. Novel strategies are therefore required. Persistent cervical infection with oncogenic human papillomavirus (HPV) causes virtually all cervical cancers and HPV testing will be implemented in Aotearoa in 2023, with women being able to choose to self-test. We undertook a qualitative focus group (FG) study with Pasifika women to explore their perspectives on the barriers to, and facilitators of, HPV self-testing and how best to implement this in Aotearoa. METHODS A trained female Pasifika Research Assistant facilitated participant recruitment and the FGs. Eligible participants self-identified as Pasifika, were aged 30-69 years, in the Wellington area, who had never been screened or who were overdue (≥5 years) for cervical-cancer screening. Recruitment was predominantly through Pasifika key-informant networks and in collaboration with Pasifika primary care providers. Participants were offered face-to-face FGs but, due to occasional Covid-19 restrictions and personal preferences, FGs via Zoom were also used. The FGs were audio-recorded and transcribed verbatim. The FG transcripts were thematically analysed. FINDINGS Seven FGs were conducted with 24 participants. We identified five main themes around barriers and potential facilitators of HPV self-testing in Pasifika women: 1) perceptions and knowledge of cervical-cancer screening; 2) challenges to engaging in organised cervical screening; 3) perceptions of self-testing for HPV and challenges women face when deciding to self-test; 4) enthusiasm for an HPV self-test; and 5) information and communication. Knowledge about cervical cancer and screening varied considerably among participants, with some never having heard about cervical-cancer screening. The main challenges that were raised were personal privacy and confidentiality and time management. There was consensus around the need for adequate, consistent, and accurate accessible information to boost the confidence of women undertaking self-testing. In general, the participants were eager for self-testing to be made available soon. This was accompanied by the need for the promotion and implementation of self-testing to include a collective/community approach consistent with Pasifika worldviews. INTERPRETATION Although participants were enthusiastic about HPV self-testing, multi-level and interacting barriers exist to participation by Pasifika women in HPV self-testing. Implementation of self-testing in Aotearoa New Zealand should be accompanied by clear information about the entire process, using culturally appropriate tailored educational campaigns in different Pasifika languages. FUNDING The study was supported by the Collaboration for Cancer Research Aotearoa New Zealand (CCR).
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Genotyping and Cytology Triage of High-Risk HPV DNA Positive Women for Detection of Cervical High-Grade Lesions. J Low Genit Tract Dis 2022; 27:12-18. [PMID: 36205321 DOI: 10.1097/lgt.0000000000000706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE A demonstration project of primary human papillomavirus (HPV) testing was initiated in 2011 among more than 23,000 women attending routine cervical cancer screening. We examined the additional diagnostic performance of HPV genotyping for detecting disease in women with abnormal cytology. METHODS Women aged 30 to 65 years were originally screened for HPV using Hybrid Capture II test. Women with positive results were triaged using conventional cytology, and those with atypical squamous cells of undetermined significance or worse (≥ASC-US) were referred to colposcopy. We retrospectively genotyped (Roche cobas 4800 HPV system [Roche Molecular Systems Inc, Pleasanton, CA]) cervical specimens that were HPV+ with Hybrid Capture II test and extracted women's medical history postbaseline screening. We calculated positive predictive values (PPVs) and 95% confidence intervals (CIs) of triage tests to detect histologically confirmed cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) within the first year of follow-up among women positive for HPV16, HPV18, and HPV16 and/or HPV18 as well as among those negative for HPVs 16 and 18. RESULTS Of 1,396 HPV-positive women, 1,092 (78%) were classified as normal, 136 (10%) had CIN1, 80 (6%) had CIN2, 81 (6%) had CIN3, and 7 women had cancer throughout the entire follow-up period. Seventy CIN2+ cases were detected within the first year of follow-up. The PPV for detecting CIN2+ was 20.9% (63/239; 95% CI = 16.4-25.9) for ASC-US+ cytology. In women with ASC-US+, PPVs were 31.2% (24/77; 95% CI = 21.1-42.7) for HPV16+, 27.8% (5/18; 95% CI = 9.7-53.5) for HPV18+, 30.8% (28/91; 95% CI = 21.5-41.3) for HPV16+ and/or HPV18+ women, and 16.6% (35/211; 95% CI = 11.8-22.3) in women testing negative for HPVs 16 and 18. CONCLUSION Partial genotyping as an additional triage strategy to cytology can markedly improve clinical diagnostic performance.
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Adcock R, Nedjai B, Lorincz AT, Scibior‐Bentkowska D, Banwait R, Torrez‐Martinez N, Robertson M, Cuzick J, Wheeler CM. DNA methylation testing with S5 for triage of high-risk HPV positive women. Int J Cancer 2022; 151:993-1004. [PMID: 35477862 PMCID: PMC9543033 DOI: 10.1002/ijc.34050] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/31/2022] [Accepted: 04/08/2022] [Indexed: 11/10/2022]
Abstract
Methylation of host and viral genes is promising for triage of women with high-risk human papillomavirus infections (hrHPV). Using a population-based sample of hrHPV positive women with cervical biopsies within 12 months after cervical screening, the clinical value of the S5 methylation classifier (S5), HPV genotyping and cytology were compared as potential triage tests, for outcomes of cervical intraepithelial neoplasia (CIN) grade 3 or greater (CIN3+), CIN2+ and CIN2, and the area under the curve (AUC) calculated. S5 scores increased with histopathology severity (Ptrend < .001). For CIN3+, the AUC was 0.780 suggesting S5 provides good discrimination between
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Affiliation(s)
- Rachael Adcock
- Centre for Cancer Prevention, Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
- Center for HPV PreventionUniversity of New Mexico Comprehensive Cancer CenterAlbuquerqueNew MexicoUSA
| | - Belinda Nedjai
- Centre for Cancer Prevention, Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
| | - Attila T. Lorincz
- Centre for Cancer Prevention, Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
| | - Dorota Scibior‐Bentkowska
- Centre for Cancer Prevention, Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
| | - Rawinder Banwait
- Centre for Cancer Prevention, Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
| | - Norah Torrez‐Martinez
- Center for HPV PreventionUniversity of New Mexico Comprehensive Cancer CenterAlbuquerqueNew MexicoUSA
| | - Michael Robertson
- Center for HPV PreventionUniversity of New Mexico Comprehensive Cancer CenterAlbuquerqueNew MexicoUSA
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
| | - Cosette M. Wheeler
- Center for HPV PreventionUniversity of New Mexico Comprehensive Cancer CenterAlbuquerqueNew MexicoUSA
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Ebisch RMF, Rijstenberg LL, Soltani GG, van der Horst J, Vedder JEM, Hermsen M, Bosgraaf RP, Massuger LFAG, Meijer CJLM, Heideman DAM, van Kemenade FJ, Melchers WJG, Bekkers RLM, Siebers AG, Bulten J. Adjunctive use of p16 immunohistochemistry for optimizing management of CIN lesions in a high-risk human papillomavirus-positive population. Acta Obstet Gynecol Scand 2022; 101:1328-1336. [PMID: 36177908 PMCID: PMC9812205 DOI: 10.1111/aogs.14459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/12/2022] [Accepted: 08/25/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Immunostaining with p16INK4a (p16), a tumor-suppressor surrogate protein biomarker for high-risk human papillomavirus (hrHPV) oncogenic activity, may complement standard hematoxylin and eosin (H&E) histology review, and provide more objective criteria to support the cervical intraepithelial neoplasia (CIN) diagnosis. With this study we assessed the impact of p16 immunohistochemistry on CIN grading in an hrHPV-based screening setting. MATERIAL AND METHODS In this post-hoc analysis, 326 histology follow-up samples from a group of hrHPV-positive women were stained with p16 immunohistochemistry. All H&E samples were centrally revised. The pathologists reported their level of confidence in classifying the CIN lesion. RESULTS Combining H&E and p16 staining resulted in a change of diagnosis in 27.3% (n = 89) of cases compared with the revised H&E samples, with a decrease of 34.5% (n = 18) in CIN1 and 22.7% (n = 15) in CIN2 classifications, and an increase of 18.3% (n = 19) in no CIN and 20.7% (n = 19) in CIN3 diagnoses. The level of confidence in CIN grading by the pathologist increased with adjunctive use of p16 immunohistochemistry to standard H&E. CONCLUSIONS This study shows that adjunctive use of p16 immunohistochemistry to H&E morphology reduces the number of CIN1 and CIN2 classifications with a proportional increase in no CIN and CIN3 diagnoses, compared with standard H&E-based CIN diagnosis alone. The pathologists felt more confident in classifying the material with H&E and p16 immunohistochemistry than by using H&E alone, particularly during assessment of small biopsies. Adjunctive use of p16 immunohistochemistry to standard H&E assessment of CIN would be valuable for the diagnostic accuracy, thereby optimizing CIN management and possibly decreasing overtreatment.
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Affiliation(s)
- Renée M. F. Ebisch
- Department of Obstetrics and GynecologyRadboud University Medical CenterNijmegenThe Netherlands,Department of Obstetrics and GynecologyCatharina Hospital EindhovenEindhovenThe Netherlands
| | | | - Gilda Ghazi Soltani
- Department of PathologyRadboud University Medical CenterNijmegenThe Netherlands
| | | | - Judith E. M. Vedder
- Department of PathologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Meyke Hermsen
- Department of PathologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Remko P. Bosgraaf
- Department of Obstetrics and GynecologyCatharina Hospital EindhovenEindhovenThe Netherlands
| | - Leon F. A. G. Massuger
- Department of Obstetrics and GynecologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Chris J. L. M. Meijer
- Amsterdam UMCVrije Universiteit Amsterdam, Pathology, Cancer Center AmsterdamAmsterdamThe Netherlands
| | - Daniëlle A. M. Heideman
- Amsterdam UMCVrije Universiteit Amsterdam, Pathology, Cancer Center AmsterdamAmsterdamThe Netherlands
| | | | - Willem J. G. Melchers
- Department of Medical MicrobiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Ruud L. M. Bekkers
- Department of Obstetrics and GynecologyCatharina Hospital EindhovenEindhovenThe Netherlands,GROW, School for Oncology and Developmental BiologyMaastricht UniversityMaastrichtThe Netherlands
| | - Albert G. Siebers
- Department of PathologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Johan Bulten
- Department of PathologyRadboud University Medical CenterNijmegenThe Netherlands
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Practical Model for Residual/Recurrent Cervical Intraepithelial Lesions in Patients with Negative Margins after Cold-Knife Conization. J Clin Med 2022; 11:jcm11195634. [PMID: 36233503 PMCID: PMC9573483 DOI: 10.3390/jcm11195634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/04/2022] [Accepted: 09/20/2022] [Indexed: 11/30/2022] Open
Abstract
Objective: This study aimed to identify reliable risk factors for residual/recurrent cervical intraepithelial lesions in patients with negative margins after cold-knife conization. Methods: A total of 2352 women with HSILs (high-grade squamous intraepithelial lesions) with negative margins who underwent cold-knife conization between January 2014 and December 2020 were included; in total, 1411 women were assigned to the development cohort, and 941 women were assigned to the validation cohort. Multivariate logistic regression was used to build four predictive models based on the different combinations of follow-up data (Model A: preoperative factors; Model B: first-follow-up data; Model C: second-follow-up data; Model D: data from both follow-ups). The accuracy, sensitivity, specificity, false-positive rate (FPR), false-negative rate (FNR), and area under the receiver operating characteristic curve (AUC) were evaluated on the validation cohort. The predictive power of risk factors was further validated using six machine learning algorithms. Results: Model D demonstrated the highest AUC of 0.91 (95% CI, 0.87 to 0.96) in the validation cohort, whereas Models A, B, and C achieved AUCs of 0.69 (95% CI, 0.59 to 0.78), 0.88 (95% CI, 0.80 to 0.95), and 0.89 (95% CI, 0.81 to 0.97) respectively. The six machine learning methods achieved consistent results. Kaplan-Meier (KM) survival curves demonstrated that our models could effectively stratify patients with all models (p < 0.05 for all models). Conclusion: Our model, which is based on preoperative and follow-up factors, can serve as a complementary screening procedure for the early detection or prediction of recurrence after cold-knife conization in HSIL patients.
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Okunade KS, Adejimi AA, John-Olabode SO, Oshodi YA, Oluwole AA. An Overview of HPV Screening Tests to Improve Access to Cervical Cancer Screening Amongst Underserved Populations: From Development to Implementation. Risk Manag Healthc Policy 2022; 15:1823-1830. [PMID: 36176779 PMCID: PMC9514784 DOI: 10.2147/rmhp.s296914] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 09/14/2022] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Kehinde S Okunade
- Department of Obstetrics & Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Adebola A Adejimi
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Sarah O John-Olabode
- Department of Haematology and Blood Transfusion, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Yusuf A Oshodi
- Department of Obstetrics & Gynaecology, Lagos State University College of Medicine, Lagos, Nigeria
| | - Ayodeji A Oluwole
- Department of Obstetrics & Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria
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Park NJY, Park CSY, Jeong JY, Kim M, Yoo SH, Chong GO, Hong DG, Park JY. Strategic Significance of Low Viral Load of Human Papillomavirus in Uterine Cervical Cytology Specimens. Diagnostics (Basel) 2022; 12:diagnostics12081855. [PMID: 36010208 PMCID: PMC9406681 DOI: 10.3390/diagnostics12081855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022] Open
Abstract
Infection with high-risk (HR) Human Papillomavirus (HPV) is associated with the development of precancerous lesions or invasive carcinoma of the uterine cervix. Thus, the high viral load (VL) of HR-HPV DNA currently serves as a representative quantitative marker for cervical cancer. However, the clinical significance of low HPV DNA VL remains undetermined. This study aimed to evaluate the clinical association between the low HPV DNA VL and cytology/histologic diagnosis of cervical samples. We searched the electronic medical databases for the resultant analyses of HPV genotyping among patients who underwent treatment for any cervical lesion or who had undergone gynecological examinations with any positive HPV results according to the national cancer screening service between 2015 and 2016. HPV testing with genotyping and semi-quantitative VL measurement was conducted using an AnyplexTM II H28 Detection assay (H28 assay, Seegene, Seoul, Republic of Korea). The H28 assay is a multiplex semi-quantitative real-time PCR test using the tagging of oligonucleotide cleavage and extension (TOCE) technology. The VL was semi-quantified as high (3+; positive signal before 31 PCR cycles), intermediate (2+; positive between 31 and 39 PCR cycles), or low (1+; positive after 40 PCR cycles). Out of 5940 HPV VL analyses, 356 assays (5.99%) were reported as low VL (1+) of HPV DNA. Matched cytology diagnoses were mostly negative findings (n = 347, 97.5%), except for seven cases of atypical squamous cells of undetermined significance (1.9%) and two cases of atypical glandular cells (0.6%). During the follow-up periods, abnormal cytologic diagnoses were identified, including one case of high-grade squamous intraepithelial lesion (HSIL) and two low-grade squamous intraepithelial lesions (LSILs). The matched, confirmative histologic diagnosis of HSIL cytology was compatible with chronic inflammation, wherein the two LSILs had regular check-ups. None revealed clinically concerned outcomes associated with HPV-related squamous lesions. The cytology was most likely negative for malignancy when the VL of HPV DNA was low (1+). Additional strategic monitoring and management may thus be unnecessary.
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Affiliation(s)
- Nora Jee-Young Park
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu 41404, Korea; (N.J.-Y.P.); (J.Y.J.); (M.K.)
- Clinical Omics Research Center, School of Medicine, Kyungpook National University, Daegu 41405, Korea;
- KNU Convergence Educational Program of Biomedical Sciences for Creative Future Talents, Department of Biomedical Science, Kyungpook National University, Daegu 41566, Korea
| | | | - Ji Yun Jeong
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu 41404, Korea; (N.J.-Y.P.); (J.Y.J.); (M.K.)
| | - Moonsik Kim
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu 41404, Korea; (N.J.-Y.P.); (J.Y.J.); (M.K.)
| | - Su Hyun Yoo
- Department of Pathology, National Police Hospital, Seoul 05715, Korea;
| | - Gun Oh Chong
- Clinical Omics Research Center, School of Medicine, Kyungpook National University, Daegu 41405, Korea;
- KNU Convergence Educational Program of Biomedical Sciences for Creative Future Talents, Department of Biomedical Science, Kyungpook National University, Daegu 41566, Korea
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu 41404, Korea;
| | - Dae Gy Hong
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu 41404, Korea;
| | - Ji Young Park
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu 41404, Korea; (N.J.-Y.P.); (J.Y.J.); (M.K.)
- Correspondence: ; Tel.: +82-53-200-3405; Fax: +82-53-200-3399
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Sultanov M, Zeeuw JD, Koot J, der Schans JV, Beltman JJ, Fouw MD, Majdan M, Rusnak M, Nazrul N, Rahman A, Nakisige C, Rao AP, Prasad K, Guruvare S, Biesma R, Versluis M, de Bock GH, Stekelenburg J. 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). BMC Public Health 2022; 22:1356. [PMID: 35840949 PMCID: PMC9284962 DOI: 10.1186/s12889-022-13488-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/20/2022] [Indexed: 11/29/2022] Open
Abstract
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).
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Affiliation(s)
- Marat Sultanov
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| | - Janine de Zeeuw
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jaap Koot
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jurjen van der Schans
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, Netherlands
| | - Jogchum J Beltman
- Department of Gynecology, Leiden University Medical Centre, Leiden University, Leiden, Netherlands
| | - Marlieke de Fouw
- Department of Gynecology, Leiden University Medical Centre, Leiden University, Leiden, Netherlands
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovak Republic
| | - Martin Rusnak
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovak Republic
| | | | - Aminur Rahman
- Health System and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | | | - Arathi P Rao
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Keerthana Prasad
- Manipal School of Information Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Shyamala Guruvare
- Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Regien Biesma
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Marco Versluis
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden, Netherlands
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