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Lavelle AE, Su D, Kahesa C, Soliman AS. Needs for Professional Education to Optimize Cervical Cancer Screenings in Low-Income Countries: a Case Study from Tanzania. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2019; 34:124-129. [PMID: 28895070 PMCID: PMC5845764 DOI: 10.1007/s13187-017-1276-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Cervical cancer is a significant health problem in many developing countries. Due to limited treatment facilities for cancer in Tanzania, a screening referral program was developed between two urban clinics and Ocean Road Cancer Institute (ORCI), the only cancer treatment center in Tanzania. This study aimed to evaluate the effectiveness of the program and to identify opportunities for professional education. The study included 139 patients who were referred to ORCI from the screening clinics of Magomeni and Temeke between January 2015 and May 2016. Abstracted data from the medical records included patient age, screening results, and treatment. Eight nurses performing screening at the three locations were interviewed about their screening experience. Over half of the referrals (51.9%) were false positives. False positive diagnosis was more common among younger patients (35.68 ± 8.6 years) (p < 0.001) and those referred from Magomeni (59.8%) (p < 0.01) than referrals of older patients (42.46 ± 11.1 years) or those from Temeke (33.3%). Interviews of nurses showed differences among clinics, including resources, experience, and documentation of screening results. The high false positive rates and the variation of accuracy of screening between the two clinics showed a need for professional education of nurses and improvement in the health systems. Continuous education of nurses may increase the effectiveness of cervical screening. Health system enhancement of screening facilities such as provision of Lugol's iodine, more space for screening, and consistency and completion of screening records are needed to increase the accuracy of cervical screening and referrals in Tanzania and other similar low-income countries.
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Affiliation(s)
- Anne E Lavelle
- Department of Health Promotion, Social and Behavioral Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dejun Su
- Department of Health Promotion, Social and Behavioral Health, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Amr S Soliman
- Department of Epidemiology, University of Nebraska Medical Center, 984395 Nebraska Medical Center, Omaha, NE, 68198-4395, USA.
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Bernstein M, Hari A, Aggarwal S, Lee D, Farfel A, Patel P, Raman K, Raja S, Fenning R, Lieber M, Minteer W, Denny S, Ries M. Implementation of a human papillomavirus screen-and-treat model in Mwanza, Tanzania: training local healthcare workers for sustainable impact. Int Health 2019; 10:197-201. [PMID: 29579207 DOI: 10.1093/inthealth/ihy014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 02/14/2018] [Indexed: 11/14/2022] Open
Abstract
Background The purpose of this study is to evaluate the development of a 1-wk screening campaign and efforts towards the implementation of a sustainable system that addresses cervical cancer in Mwanza, Tanzania with a screen-and-treat model utilizing visual inspection of the cervix with acetic acid (VIA) and cryotherapy. Methods In partnership with CureCervicalCancer (CCC), a non-profit organization based in Los Angeles, CA, USA, 11 medical students at the University of California, Irvine School of Medicine established a model for sustainable human papillomavirus screening practices in Mwanza, Tanzania. This study both quantitatively and qualitatively assesses the successes and limitations of the program model. Results During the 5-day training, a total of 614 women attended the screenings and 556 women were screened with VIA, of whom 10.6% (n=59) were VIA positive and 89.4% (n=499) were VIA negative. Of those who were VIA positive, 83.1% (n=49) received cryotherapy while 16.9% (n=10) did not due to suspicion of advanced cancer (n=7), refusal to receive cryotherapy (n=2) or pregnancy (n=1). Conclusions The screen-and-treat model for the identification and treatment of precancerous cervical lesions is an effective public health intervention with the potential to impact women by providing the tools and education needed by local healthcare professionals. However, limitations common to resource-poor settings, such as continuity of funding, loss to follow-up and transportation costs, remain barriers to sustainability.
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Affiliation(s)
- Megan Bernstein
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Anjali Hari
- University of California, Los Angeles, Department of Obstetrics and Gynecology, Los Angeles, CA, USA
| | - Sahil Aggarwal
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Debora Lee
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Allison Farfel
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Priya Patel
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Kaavya Raman
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Shella Raja
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Reece Fenning
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Mark Lieber
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - William Minteer
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Sean Denny
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Maureen Ries
- University of California, Los Angeles, Department of Obstetrics and Gynecology, Los Angeles, CA, USA
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Umukoro C, Makinde O. Perspectives of visual inspection of the cervix with acetic acid as an alternative to Pap smear test as a preventive measure of cervical cancer among female nurses in University College Hospital, Ibadan, Nigeria. JOURNAL OF CANCER RESEARCH AND PRACTICE 2019. [DOI: 10.4103/jcrp.jcrp_10_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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[Use of human papilloma virus testing in primary cervical cancer screening in rural Madagascar]. Rev Epidemiol Sante Publique 2018; 67:120-125. [PMID: 30448093 DOI: 10.1016/j.respe.2018.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/13/2018] [Accepted: 10/04/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Testing for high-risk human papilloma virus (HR-HPV) is an effective approach to the prevention of cervical cancer. This study in the Atsinanana area of Madagascar aimed to compare the management of women screened by visual inspection after coloration with acetic acid (VIA) and the management of women screened by HPV with VIA as a triage test. METHOD During the last two screening campaigns, the first patients (between 28 and 120 women par center) were sampled using a dry swab, just before the acetic acid application, to test 14 genotypes of HR-HPV using Roche Diagnostics Cobas® Test. We compared current management practices based on primary VIA to those that would have been implemented if the clinician had followed the recommendations of the World Health Organization for HPV-based primary screening. We used a regression Poisson model with random effect and robust variance. RESULTS Among the 250 screened-women, 28 (11.2%) had acidophilic lesions of the uterine cervix or suspected lesions of invasive cancer (IVA +). The HPV test was positive in 62 cases (24.8%). The HPV-based screening strategy would have reduced by 52% the number of women needing thermo-coagulation treatment: 24 women (9.6%) with primary VIA-based screening vs. 13 women (5.2%) with primary HPV-based screening; RR: 0.52 and 95%CI: 0.27-1.02. The diagnosis of severe dysplastic lesion or invasive cancer would not have changed. CONCLUSION Primary HPV-based screening is a strategy that could be useful for low-resource countries like Madagascar. It would reduce the rate of false positives and unnecessary treatments compared to the current strategy based on primary IVA. The questions of the feasibility and cost-benefit of this strategy should be further explored.
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Poli UR, Gowrishankar S, Swain M, Jeronimo J. Triage of Women Testing Positive With the careHPV Test on Self-Collected Vaginal Samples for Cervical Cancer Screening in a Low-Resource Setting. J Glob Oncol 2018; 4:1-7. [PMID: 30241206 PMCID: PMC6180797 DOI: 10.1200/jgo.2016.008078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Human papillomavirus (HPV) DNA screening reduces cervical cancer incidence and mortality in low-resource settings. Self-collected vaginal samples tested with affordable HPV tests such as careHPV can increase the rate of screening in resource-constrained settings. We report the role of visual inspection with acetic acid (VIA) as a triage test for women testing positive with the careHPV test on self-collected vaginal samples. METHODS As part of a multicountry demonstration study, 5,207 women 30 to 49 years of age were recruited from urban slums to undergo four cervical screening tests using the careHPV test on self-collected vaginal samples, provider-collected cervical samples, the Papanicolaou test, and VIA. All women who tested positive for any of the screening tests were evaluated with colposcopy and guided biopsies, followed by treatment if any cervical lesions were detected. The data from the 377 women who tested positive for HPV in the self-collected vaginal samples were also analyzed to assess the performance of VIA, conventional cytology, and colposcopy, as triage tests in the detection of cervical cancer and precancerous lesions. RESULTS Nineteen percent of women who tested positive for vaginal HPV (V-HPV) also tested positive with the VIA test; cervical intraepithelial neoplasia 2+ lesions were detected in 58% of these women. In the 30 % of the women who tested positive for V-HPV with cytology triage, cervical intraepithelial neoplasia 2+ lesions were detected in 80% of these women. The colposcopy referrals for women who tested positive for V-HPV were reduced from 7.6% to 1.5% by VIA triage, and to 2.3% by cytology triage. Although the sensitivity was reduced, the positive predictive value improved after triage with VIA and cytology. CONCLUSION This study reflects the optimal role of VIA triaging for treatment selection of lesions among those who test positive for V-HPV in screen and treat screening programs that use an HPV test in low-resource settings.
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Affiliation(s)
- Usha Rani Poli
- Usha Rani Poli, MNJ Institute of Oncology &
Regional Cancer Center; Swarnalata Gowrishankar and Meenakshi
Swain, Apollo Hospitals, Hyderabad, India; and Jose
Jeronimo, PATH, Seattle, WA
| | - Swarnalata Gowrishankar
- Usha Rani Poli, MNJ Institute of Oncology &
Regional Cancer Center; Swarnalata Gowrishankar and Meenakshi
Swain, Apollo Hospitals, Hyderabad, India; and Jose
Jeronimo, PATH, Seattle, WA
| | - Meenakshi Swain
- Usha Rani Poli, MNJ Institute of Oncology &
Regional Cancer Center; Swarnalata Gowrishankar and Meenakshi
Swain, Apollo Hospitals, Hyderabad, India; and Jose
Jeronimo, PATH, Seattle, WA
| | - Jose Jeronimo
- Usha Rani Poli, MNJ Institute of Oncology &
Regional Cancer Center; Swarnalata Gowrishankar and Meenakshi
Swain, Apollo Hospitals, Hyderabad, India; and Jose
Jeronimo, PATH, Seattle, WA
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Gabrielli S, Maggioni E, Fieschi L. Cervical cancer prevention in Senegal: an International Cooperation Project Report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:29-34. [PMID: 30038201 PMCID: PMC6357602 DOI: 10.23750/abm.v89i6-s.7460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022]
Abstract
Background: Cervical cancer is the second most common women’s cancer in less developed regions and it is the leading cause of cancer mortality among women in Senegal. Because of the high costs, cervical cancer prevention is very rare in developing countries and it is often based on visual inspection methods. The University of Parma (CUCI) and the MANI association have developed a cervical cancer screening project addressed to rural Senegal communities. The aim of the project was to disseminate the cytocervical sampling technique among Senegalese nurses and midwives, as a completion to the local visual inspection method. Other objectives were to verify the prevalence of precancerous lesions and to evaluate cervical cancer knowledge and attitudes among women who participated at the screening campaign. Interventions: A theoretical and practical training plan on cervical cancer screening was provided to the local health workers at various levels. The screening was performed through a first step visual inspection exam to 203 women, followed by a Pap smear in case of positive outcome. 20 women participated also to a structured interview. Results: The Pap smear material was adequate in all the samples collected where this indicates that the objective to disseminate cervical cancer screening techniques has been achieved. Of the 203 women involved in the screening project, 68 were tested positive at the first step and 38 of them were submitted to Pap tests. Conclusion: The difficulties encountered confirm how Pap tests have overall proved inordinately complex and expensive for developing countries. It seems more sensible to deal first with global health in terms of basic hygienic sanitation, including an educational component in screening programs in order to sensitize women to the risk factors of cervical cancer.
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Ouedraogo Y, Furlane G, Fruhauf T, Badolo O, Bonkoungou M, Pleah T, Lankoande J, Bicaba I, Bazant ES. Expanding the Single-Visit Approach for Cervical Cancer Prevention: Successes and Lessons From Burkina Faso. GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:288-298. [PMID: 29959272 PMCID: PMC6024624 DOI: 10.9745/ghsp-d-17-00326] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 01/09/2018] [Indexed: 01/13/2023]
Abstract
The single-visit approach was implemented with strong attention to systems in 14 health facilities. In the 2 largest facilities, nearly 14,000 women screened for cervical cancer over 4 years. Of approximately 9% who screened positive, about 66% received same-day cryotherapy. Attention is needed to ensure local technicians can repair cryotherapy equipment, supplies are consistently in stock, and user fees are not prohibitive to accessing care. Background: Cervical cancer accounts for 23% of cancer incidence and 22% of cancer mortality among women in Burkina Faso. These proportions are more than 2 and 5 times higher than those of developed countries, respectively. Before 2010, cervical cancer prevention (CECAP) services in Burkina Faso were limited to temporary screening campaigns. Program Description: Between September 2010 and August 2014, program implementers collaborated with the Ministry of Health and professional associations to implement a CECAP program focused on coupling visual inspection with acetic acid (VIA) for screening with same-day cryotherapy treatment for eligible women in 14 facilities. Women with larger lesions or lesions suspect for cancer were referred for loop electrosurgical excision procedure (LEEP). The program trained providers, raised awareness through demand generation activities, and strengthened monitoring capacity. Methods: Data on program activities, service provision, and programmatic lessons were analyzed. Three data collection tools, an individual client form, a client registry, and a monthly summary sheet, were used to track 3 key CECAP service indicators: number of women screened using VIA, proportion of women who screened VIA positive, and proportion of women screening VIA positive who received same-day cryotherapy. Results: Over 4 years, the program screened 13,999 women for cervical cancer using VIA; 8.9% screened positive; and 65.9% received cryotherapy in a single visit. The proportion receiving cryotherapy on the same day started at a high of 82% to 93% when services were provided free of charge, but dropped to 51% when a user fee of $10 was applied to cover the cost of supplies. After reducing the fee to $4 in November 2012, the proportion increased again to 78%. Implementation challenges included difficulties tracking referred patients, stock-outs of key supplies, difficulties with machine maintenance, and prohibitive user fees. Providers were trained to independently monitor services, identify gaps, and take corrective actions. Conclusions: Following dissemination of the results that demonstrated the acceptability and feasibility of the CECAP program, the Burkina Faso Ministry of Health included CECAP services in its minimum service delivery package in 2016. Essential components for such programs include provider training on VIA, cryotherapy, and LEEP; provider and patient demand generation; local equipment maintenance; consistent supply stocks; referral system for LEEP; non-prohibitive fees; and a monitoring data collection system.
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Affiliation(s)
| | | | | | | | | | | | - Jean Lankoande
- Société de Gynécologues et Obstétriciens du Burkina, Ouagadougou, Burkina Faso
| | - Isabelle Bicaba
- Ministère de la Santé du Burkina Faso, Ouagadougou, Burkina Faso
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Umulisa MC, Franceschi S, Baussano I, Tenet V, Uwimbabazi M, Rugwizangoga B, Heideman DAM, Uyterlinde AM, Darragh TM, Snijders PJF, Sayinzoga F, Clifford GM. Evaluation of human-papillomavirus testing and visual inspection for cervical cancer screening in Rwanda. BMC Womens Health 2018; 18:59. [PMID: 29699549 PMCID: PMC5921370 DOI: 10.1186/s12905-018-0549-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/09/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND A pilot screening campaign in Rwanda, based on careHPV-testing followed by visual inspection with acetic acid triage (careHPV+VIA triage), was evaluated against other WHO-recommended screening options, namely HPV screen-and-treat and VIA screen-and-treat. METHODS 764 women aged 30-69 underwent at visit 1: i) VIA, and cervical cell collection for ii) careHPV in Rwanda, and iii) liquid-based cytology and GP5+/6+ HR-HPV PCR in The Netherlands. All 177 women positive by VIA, careHPV and/or PCR were recalled, of whom 84% attended. At visit 2, VIA was again used to triage screen-positive women for treatment and to obtain biopsies from all women either from visible lesions or at 12 o'clock of the squamocolumnar junction. Cross-sectional screening indices were estimated primarily against histological high-grade squamous intraepithelial lesions or worse (hHSIL+), after imputation of missing histology data, based on 1-visit or 2-visit approaches. RESULTS In a 1-visit screen-and-treat approach, VIA had sensitivity and specificity of 41% and 96%, respectively, versus 71% and 88% for careHPV, and 88% and 86% for PCR. In a 2-visit approach (in which hHSIL+ imputed among women without visit 2 were considered untreated) careHPV sensitivity dropped to 59% due to loss of 13% of hHSIL+. For careHPV+VIA triage, sensitivity dropped further to 35%, as another 24% of hHSIL+ were triaged to no treatment. CONCLUSIONS CareHPV was not as sensitive as gold-standard PCR, but detected considerably more hHSIL+ than VIA. However, due to careHPV-positive hHSIL+ women being lost to follow-up and/or triaged to no treatment, 2-visit careHPV+VIA triage did not perform better than VIA screen-and-treat.
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Affiliation(s)
| | - Silvia Franceschi
- Cancer Epidemiology Unit, Aviano National Cancer Institute IRCCS, Aviano, Italy
| | - Iacopo Baussano
- International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon Cedex 08, France
| | - Vanessa Tenet
- International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon Cedex 08, France
| | | | - Belson Rugwizangoga
- Department of Pathology, University Teaching Hospital of Kigali, Kigali, Rwanda
- University of Rwanda School of Medicine and Pharmacy, Kigali, Rwanda
| | | | - Anne M. Uyterlinde
- Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Peter J. F. Snijders
- Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Gary M. Clifford
- International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon Cedex 08, France
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Yu L, Jiang M, Qu P, Wu Z, Sun P, Xi M, Qin Y, Liu X, Liao G, Lei X, Sun L, Zhang Y, Li Z, Chen W, Qiao YL. Clinical evaluation of human papillomavirus 16/18 oncoprotein test for cervical cancer screening and HPV positive women triage. Int J Cancer 2018. [PMID: 29524206 DOI: 10.1002/ijc.31368] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
HPV-16 and -18 account for about 80% of cervical cancers. We evaluated the performance of HPV-16/18 oncoprotein to predict precancer and cancer in corresponding tissue biopsy specimens. 1,008 women attending cervical cancer screening program and 638 women referred to colposcopy with biopsy-confirmed cervical intraepithelial neoplasia grade 2 or worse (CIN2+) from 4 hospitals were recruited (1,646 in total). All women were tested OncoE6 (AVC), Liquid-Based Cytology (Hologic) and cobas HPV test (Roche). Colposcopy was performed on women with any abnormal results. The final diagnoses were based on a consensus panel review of the histology. There were 919 normal, 69 CIN1, 53 CIN2, 91 CIN3,474 squamous cell carcinoma(SCC) and 40 adenocarcinoma (ADC) cases, the prevalence of OncoE6 was 1.7%, 10.1%, 13.2%, 44.0%, 80.4% and 65.0%, respectively. The percent positive for cobas was higher than that of OncoE6 in detection of HPV16/18 in entire population (p < 0.001). However, the disparity of positive rate between these two tests became tiny among cervical cancer patients (CIN2: 26.4% vs. 13.2%, CIN3: 73.6% vs. 44.0%, SCC: 84.0% vs. 80.4%, ADC: 67.5% vs. 65.0%). OncoE6 was less sensitive than cobas (73.9% vs. 93.6%, p < 0.001), but more specific (97.1% vs. 75.4%, p < 0.001) for CIN3+ in entire population; OncoE6 yielded a sensitivity of 77.7% and a specificity of 91.0% for CIN3+ among cobas positive women, which can reduce nearly half of the colposcopy referral numbers. OncoE6 can be considered as a useful tool for cervical cancer screening and a potential powerful biomarker for HPV positive triage.
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Affiliation(s)
- Lulu Yu
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China.,Tumor Virus RNA Biology Section, RNA Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, MD
| | - Mingyue Jiang
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Pengpeng Qu
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, People's Republic of China
| | - Zeni Wu
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Peisong Sun
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, People's Republic of China
| | - Mingrong Xi
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital, Medical College, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yu Qin
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Xin Liu
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Guangdong Liao
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital, Medical College, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xiaoqin Lei
- Department of Clinical Nutrition, Dongfeng Hospital, Hubei University of Medicine, Shiyan, Hubei, People's Republic of China
| | - Lixin Sun
- Department of Gynecological Oncology, Shanxi Cancer Hospital, Taiyuan, Shanxi, People's Republic of China
| | - Yongzhen Zhang
- Department of Epidemiology, Shanxi Cancer Hospital, Taiyuan, Shanxi, People's Republic of China
| | - Zhifang Li
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China.,The Public Health and Prevent Department, Changzhi Medical College, Changzhi, People's Republic of China
| | - Wen Chen
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - You-Lin Qiao
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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Basu P, Taghavi K, Hu SY, Mogri S, Joshi S. Management of cervical premalignant lesions. Curr Probl Cancer 2018; 42:129-136. [PMID: 29428790 DOI: 10.1016/j.currproblcancer.2018.01.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 12/27/2017] [Accepted: 01/10/2018] [Indexed: 01/08/2023]
Abstract
Treatment of cervical premalignant lesions (cervical intraepithelial neoplasia; CIN) of different grades is very effective, simple, and safe. The entire transformation zone of the cervix needs to be treated either by an ablative technique (cryotherapy or thermal ablation) or an excisional technique (large loop excision of transformation zone or cold knife conization); the choice of treatment depends on the size and location of the lesion and the type of the transformation zone. The cure rate after ablative treatment of high-grade CIN may be little lower than that after excisional treatment. The simplicity of the technique, low complication rate, and lesser cost make ablative technique the treatment of choice in the low resourced settings for the eligible lesions. In situations where organizing colposcopy and histopathology services is challenging, simple algorithms like screening with visual inspection with acetic acid test and immediate ablative treatment of the visual inspection with acetic acid-positive women has been recommended by the World Health Organization. Such a strategy is effective in preventing subsequent development of high-grade CIN and also ensures high compliance of the screen positive women to treatment.
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Affiliation(s)
- Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France.
| | - Katayoun Taghavi
- Institute of Social and Preventative medicine, University of Bern, Bern, Switzerland
| | - Shang-Ying Hu
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sushma Mogri
- Department of Obstetrics and Gynecology, American International Institute of Medical Sciences, Udaipur, India
| | - Smita Joshi
- Jehangir Clinical Development Centre, Jehangir Hospital Premises and Prayas, Pune, India
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Toliman PJ, Kaldor JM, Tabrizi SN, Vallely AJ. Innovative approaches to cervical cancer screening in low- and middle-income countries. Climacteric 2018; 21:235-238. [PMID: 29488817 DOI: 10.1080/13697137.2018.1439917] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The estimated cervical cancer burden is over ten-fold greater in low- and middle-income countries (LMICs) than in high-income countries. This health gap is thought to be primarily due to limited access to effective screening and treatment programs for cervical pre-cancer and cancer in such settings. The World Health Organization advocates a policy of 'screen and treat' approach to cervical screening in LMICs and subsequently visual inspection of the cervix with acetic acid (VIA) or Lugo's iodine (VILI), followed by ablative cervical cryotherapy if indicated, and this policy has been implemented in many high-burden settings. The performance of VIA/VILI as a primary screening tool for the detection of cervical pre-cancer and cancer has, however, been inconsistent. Recently, many high-income countries have integrated HPV-DNA testing into their cervical cancer screening programs. The comparatively high cost and resource requirements of HPV-based screening have to date prevented many LMICs from doing the same. A significant development has been the entrance of innovative, easy-to-use and highly accurate HPV tests that can be provided at point of care; these could enable LMICs to implement 'test and treat' approaches for cervical cancer screening.
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Affiliation(s)
- P J Toliman
- a Sexual and Reproductive Health Unit , Papua New Guinea Institute of Medical Research , Goroka , Papua New Guinea.,b Public Health Interventions Research Group , The Kirby Institute, UNSW , Sydney , Australia
| | - J M Kaldor
- b Public Health Interventions Research Group , The Kirby Institute, UNSW , Sydney , Australia
| | - S N Tabrizi
- c Department of Microbiology and Infectious Disease , The Royal Women's Hospital , Parkville , VIC , Australia.,d Department of Obstetrics and Gynaecology , University of Melbourne , Parkville , VIC , Australia
| | - A J Vallely
- a Sexual and Reproductive Health Unit , Papua New Guinea Institute of Medical Research , Goroka , Papua New Guinea.,b Public Health Interventions Research Group , The Kirby Institute, UNSW , Sydney , Australia
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Basu P, Mittal S, Bhadra Vale D, Chami Kharaji Y. Secondary prevention of cervical cancer. Best Pract Res Clin Obstet Gynaecol 2018; 47:73-85. [PMID: 28988647 DOI: 10.1016/j.bpobgyn.2017.08.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/27/2017] [Indexed: 01/04/2023]
Abstract
Cervical cancer affects women in their reproductive ages. Screening is an important secondary prevention strategy. The long process of carcinogenic transformation from human papillomavirus (HPV) infection to invasive cancer provides ample opportunities to detect the disease at a stage when treatment is highly effective. Suitable screening tests are cytology, visual inspection after acetic acid application and HPV detection tests. Evidence of effectiveness of the tests to reduce cervical cancer mortality and the cost-effectiveness of screening programs have been demonstrated. Cervical intraepithelial neoplasia grade 2 and grade 3 are the high-grade cervical cancer precursors and need to be treated. Treatment is safe and effective with ablative or excisional techniques. The World Health Organization recommends screening women at least once in a lifetime between 30 and 49 years of age and ensuring effective treatment of the detected abnormalities. Combination of HPV vaccination and population-based screening will be instrumental in eliminating cervical cancer.
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Affiliation(s)
- Partha Basu
- Screening Group, International Agency for Research on Cancer, Lyon, France.
| | - Srabani Mittal
- Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Diama Bhadra Vale
- Departamento de Tocoginecologia, Divisão de Oncologia, Universidade Estadual de Campinas, Brazil
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Vallely AJ, Toliman PJ, Ryan C, Rai G, Wapling J, Gabuzzi J, Kumbia A, Kombuk B, Kombati Z, Vallely LM, Kelly-Hanku A, Wand H, Tabrizi SN, Mola GDL, Kaldor JM. Association between visual inspection of the cervix with acetic acid examination and high-risk human papillomavirus infection, Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis in Papua New Guinea. Aust N Z J Obstet Gynaecol 2018; 58:576-581. [PMID: 29380356 DOI: 10.1111/ajo.12783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Papua New Guinea (PNG) has among the highest estimated burdens of cervical cancer globally but currently has no national cervical screening program. Visual inspection of the cervix with acetic acid (VIA) is a low-cost screening strategy endorsed by the World Health Organization that has been adopted in many low-resource settings but not previously evaluated in PNG. AIM To evaluate the association between VIA examination findings and high-risk HPV (hrHPV) infection; and the impact of concomitant genital Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis on the interpretation of VIA findings. METHODS A prospective clinical cohort study among women aged 30-59 years attending Well Woman Clinics in PNG. Main outcome measures were VIA examination findings and laboratory-confirmed hrHPV, C. trachomatis, N. gonorrhoeae and T. vaginalis. RESULTS A total of 614 women were enrolled, of whom 87.5% (537/614) underwent VIA, and 12.5% (77/614) did not due to pre-existing cervicitis or inability to visualise the transformation zone. Among the 537 women who underwent VIA, 21.6% were VIA positive, 63.7% VIA negative, and 14.7% had indeterminate findings. The prevalence of hrHPV infection (n = 614) was 14.7%; C. trachomatis, 7.5%; N. gonorrhoeae, 8.0%; and T. vaginalis, 15.0%. VIA positive women were more likely to have HPV16 (odds ratio: 5.0; 95%CI: 1.6-15.6; P = 0.006) but there was no association between HPV18/45, all hrHPV types (combined), C. trachomatis, N. gonorrhoeae or T. vaginalis. CONCLUSIONS VIA positivity was associated with HPV16, but not with other hrHPV infections, nor with genital C. trachomatis, N. gonorrhoeae or T. vaginalis in this setting.
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Affiliation(s)
- Andrew J Vallely
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Pamela J Toliman
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Claire Ryan
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.,The Burnet Institute, Melbourne, Victoria, Australia
| | - Glennis Rai
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Johanna Wapling
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.,The Burnet Institute, Melbourne, Victoria, Australia
| | - Josephine Gabuzzi
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Antonia Kumbia
- Eastern Highlands Provincial Hospital, Goroka, Papua New Guinea
| | - Benny Kombuk
- Mt Hagen General Hospital, Mount Hagen, Papua New Guinea
| | - Zure Kombati
- Mt Hagen General Hospital, Mount Hagen, Papua New Guinea
| | - Lisa M Vallely
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Angela Kelly-Hanku
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Handan Wand
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sepehr N Tabrizi
- Department of Microbiology and Infectious Diseases, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Glen D L Mola
- Department of Obstetrics and Gynaecology, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - John M Kaldor
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
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64
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Purwoto G, Dianika HD, Putra A, Purbadi S, Nuranna L. Modified Cervicography and Visual Inspection With Acetic Acid as an Alternative Screening Method for Cervical Precancerous Lesions. J Cancer Prev 2017; 22:254-259. [PMID: 29302584 PMCID: PMC5751844 DOI: 10.15430/jcp.2017.22.4.254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 11/09/2022] Open
Abstract
Background We compared the diagnostic accuracy between visual inspection with acetic acid (VIA) and modified cervicography as an alternative screening method for cervical precancerous lesions. Methods A diagnostic cross-sectional study was performed at the outpatient clinic at an Indonesian national referral hospital from February until April 2015. We collected samples from patients who sequentially underwent VIA examination, modified cervicography, and colposcopy. Results A total of 185 patients were included in this study. Modified cervicography showed positive results in 7.6% of patients, while 7.0% of patients had a VIA positive result. This is compared to 5.4% of patients showing abnormal colposcopy results. From those results, we obtained that sensitivity and specificity of VIA were 96.0% and 90.9%. Meanwhile, sensitivity and specificity of modified cervicography were 97.7% and 90.9%, respectively, compared to colposcopy as a gold standard. Conclusions Modified cervicography and VIA are reliable tools for cervical cancer screening, with comparable sensitivity and specificity. Modified cervicography can be used as a supplementary tool to improve the documentation of VIA and as an alternative to VIA alone.
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Affiliation(s)
- Gatot Purwoto
- Oncology Gynecology Division, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.,Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Hasra Depiesa Dianika
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Andre Putra
- Oncology Gynecology Division, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.,Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Sigit Purbadi
- Oncology Gynecology Division, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.,Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Laila Nuranna
- Oncology Gynecology Division, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.,Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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65
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Clinical, laboratory and epidemiological aspects of HPV infection in a low-income population from South Bahia, Brazil. Epidemiol Infect 2017; 145:3398-3404. [PMID: 29166976 DOI: 10.1017/s0950268817002448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The aim of this study was to determine the prevalence and risk factors for human papillomavirus (HPV) infection in the Southern region of the State of Bahia, evaluating the performance of alternative complementary methods for cervical lesion detection. Cervical samples from women who attended healthcare units were collected and diagnosed by visual inspection, cervical cytology and nested polymerase chain reaction (PCR). Moreover, hemi-nested PCR was performed to detect different HPV genotypes. The prevalence of HPV infection was 47·7%, with genotype 16 detected in most cases. Infection was associated with dyspareunia and bleeding (P < 0·001, odds ratio (OR) 5·6, 95% confidence interval (CI) 2·815-11·14) and hormonal contraceptive use (P = 0·007, OR 2·33, 95% CI 1·25-4·34). There was a positive correlation between positive PCR and positive visual inspection, cervical cytology and symptoms reported. Furthermore, visual inspection was twice as specific, and had a greater positive predictive value than cytology. We showed a high prevalence of HPV infection in Southern Bahia, with HPV 16 being the most common type, and visual inspection being most effective at detecting HPV lesions, corroborating the suggestion that it can be applied in routine gynecologic examinations for low-income populations.
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66
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Dong L, Wang MZ, Zhao XL, Feng RM, Hu SY, Zhang Q, Smith JS, Qiao YL, Zhao FH. Human papillomavirus viral load as a useful triage tool for non-16/18 high-risk human papillomavirus positive women: A prospective screening cohort study. Gynecol Oncol 2017; 148:103-110. [PMID: 29169614 DOI: 10.1016/j.ygyno.2017.11.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/06/2017] [Accepted: 11/10/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE ASCCP cervical cancer screening guidelines recommend triaging high-risk human papillomavirus (hrHPV) positive women with cytology and genotyping, but cytology is often unavailable in resource-limited areas. We compared the long-term risk of cervical cancer and precancers among type-specific hrHPV-positive women triaged by viral load to cytology and visual inspection with acetic acid (VIA). METHODS A cohort of 1742 Chinese women was screened with cytology, VIA, and Hybrid Capture 2 (HC2) test and followed for ten years. All HC2-positive samples were genotyped. Viral load was measured by HC2 relative light units/cutoff (RLU/CO). Ten-year cumulative incidence rate (CIR) of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) for type-specific hrHPV viral load was estimated using Kaplan-Meier methods. RESULTS Baseline hrHPV viral load stratified by specific genotypes was positively correlated with prevalent cytological lesions. Ten-year CIR of CIN2+ was associated with cytological lesions and viral load. Among HPV 16/18-positive women, ten-year CIR of CIN2+ was high, even with normal cytology (15.3%), normal VIA (32.4%), viral load with RLU/CO<10 (23.6%) or RLU/CO<100 (33.8%). Among non-16/18 hrHPV positive women, ten-year CIR of CIN2+ was significantly stratified by cytology grade of atypical squamous cell of undetermined significance or higher (2.0% VS. 34.6%), viral load cutoffs at 10 RLU/CO (5.1% VS. 27.2%), at 100 RLU/CO (11.0% VS. 35.5%), but not by VIA (19.1% VS. 19.0%). CONCLUSIONS Our findings support the guidelines in referring all HPV16/18 positive women to colposcopy and suggest triaging non-16/18 hrHPV positive women using viral loads in resource-limited areas where cytology screening was inaccessible.
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Affiliation(s)
- Li Dong
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China; Institutes of Biomedical Sciences, Shanxi University, Taiyuan, China
| | - Margaret Z Wang
- Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA; UJMT Fogarty Consortium, NIH Fogarty International Center, Bethesda, MD, USA
| | - Xue-Lian Zhao
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Rui-Mei Feng
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Shang-Ying Hu
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Qian Zhang
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Jennifer S Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA; UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - You-Lin Qiao
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Fang-Hui Zhao
- Department of Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China.
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Cholli P, Bradford L, Manga S, Nulah K, Kiyang E, Manjuh F, DeGregorio G, Ogembo RK, Orock E, Liu Y, Wamai RG, Sheldon LK, Gona PN, Sando Z, Welty T, Welty E, Ogembo JG. Screening for cervical cancer among HIV-positive and HIV-negative women in Cameroon using simultaneous co-testing with careHPV DNA testing and visual inspection enhanced by digital cervicography: Findings of initial screening and one-year follow-up. Gynecol Oncol 2017; 148:118-125. [PMID: 29153541 DOI: 10.1016/j.ygyno.2017.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/31/2017] [Accepted: 11/02/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The World Health Organization (WHO)'s cervical cancer screening guidelines for limited-resource settings recommend sequential screening followed by same-day treatment under a "screen-and-treat" approach. We aimed to (1) assess feasibility and clinical outcomes of screening HIV-positive and HIV-negative Cameroonian women by pairing visual inspection with acetic acid and Lugol's iodine enhanced by digital cervicography (VIA/VILI-DC) with careHPV, a high-risk human papillomavirus (HR-HPV) nucleic acid test designed for low-resource settings; and (2) determine persistence of HR-HPV infection after one-year follow-up to inform optimal screening, treatment, and follow-up algorithms. METHODS We co-tested 913 previously unscreened women aged ≥30years and applied WHO-recommended treatment for all VIA/VILI-DC-positive women. Baseline prevalence of HR-HPV and HIV were 24% and 42%, respectively. RESULTS On initial screen, 44 (5%) women were VIA/VILI-DC-positive, of whom 22 had HR-HPV infection, indicating 50% of women screened false-positive and would have been triaged for unnecessary same-day treatment. VIA/VILI-DC-positive women with HIV infection were three times more likely to be HR-HPV-positive than HIV-negative women (65% vs. 20%). All women positive for either VIA/VILI-DC or HR-HPV (n=245) were invited for repeat co-testing after one year, of which 136 (56%) returned for follow-up. Of 122 women who were HR-HPV-positive on initial screen, 60 (49%) re-tested negative, of whom 6 had received treatment after initial screen, indicating that 44% of initially HR-HPV-positive women spontaneously cleared infection after one year without treatment. Women with HIV were more likely to remain HR-HPV-positive on follow-up than HIV-negative women (61% vs. 22%, p<0.001). Treatment was offered to all VIA/VILI-DC positive women on initial screen, and to all women screening VIA/VILI-DC or HR-HPV positive on follow-up. CONCLUSIONS We found careHPV co-testing with VIA/VILI-DC to be feasible and valuable in identifying false-positives, but careHPV screening-to-result time was too long to inform same-day treatment.
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Affiliation(s)
- Preetam Cholli
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States
| | - Leslie Bradford
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States
| | - Simon Manga
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Kathleen Nulah
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Edith Kiyang
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Florence Manjuh
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Geneva DeGregorio
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States
| | - Rebecca K Ogembo
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States
| | - Enow Orock
- Regional Hospital, PO Box 32, Buea, Cameroon
| | - Yuxin Liu
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States; Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Richard G Wamai
- Northeastern University, 360 Huntington Ave, Boston, MA 02115, United States
| | - Lisa Kennedy Sheldon
- Oncology Nursing Society, 125 Enterprise Drive, Pittsburgh, PA 15275, United States
| | - Philimon N Gona
- Northeastern University, 360 Huntington Ave, Boston, MA 02115, United States
| | - Zacharie Sando
- Yaoundé Gyneco-Obstetric and Pediatric Hospital, Yaoundé, PO Box 4362, Central Region, Cameroon
| | - Thomas Welty
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Edith Welty
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Javier Gordon Ogembo
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States; Beckman Research Institute of City of Hope, 1500 E Duarte Road, Duarte, CA 91010, United States.
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Efficacy of antiviral drug AV2 in the treatment of human papillomavirus-associated precancerous lesions of the uterine cervix: A randomized placebo-controlled clinical trial in Kinshasa, DR Congo. (KINVAV study). Contemp Clin Trials Commun 2017; 8:135-139. [PMID: 29696202 PMCID: PMC5898533 DOI: 10.1016/j.conctc.2017.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 09/12/2017] [Accepted: 09/24/2017] [Indexed: 11/25/2022] Open
Abstract
Background Cervical Cancer (CC) is a major public health problem in DR Congo; the high incidence of CC is due to the inexistence of effective screening programs based on cytology and/or HPV detection followed by appropriate treatments. This situation highlights the need to implement efficacious and inexpensive treatment methods. This study aims at evaluating the efficacy of a topical antiviral drug named AV2® as a treatment for HPV-associated lesions of the cervix. Methods Women will undergo cytology sampling, HPV testing and Visual inspection of the cervix after application of 5% acetic acid (VIA). VIA-positive women will be randomized to one of two groups to receive treatment by either AV2®or placebo. They will undergo control examinations after two months and after six months. In case of persistent lesions on VIA, treatment by cryotherapy will be done. The primary outcomes will be the change of lesions, the clearance of HPV DNA, and the correlation of the two 2 months after treatment with AV2®. Conclusion This study is the first large-scale study in Africa to evaluate systematically the efficacy and safety of a topical antiviral drug for the treatment of HPV— associated lesions of the cervix. Its findings will direct the planning of suitable algorithms for CC screening and treatment. Clinical trial registration ClinicalTrials.gov – Unique identifier: NCT02346227, registered on November 8, 2014.
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Campos NG, Tsu V, Jeronimo J, Mvundura M, Kim JJ. Evidence-based policy choices for efficient and equitable cervical cancer screening programs in low-resource settings. Cancer Med 2017; 6:2008-2014. [PMID: 28707435 PMCID: PMC5548874 DOI: 10.1002/cam4.1123] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/25/2017] [Indexed: 01/25/2023] Open
Abstract
Women in developing countries disproportionately bear the burden of cervical cancer. The availability of prophylactic vaccines against human papillomavirus (HPV) types 16 and 18, which cause approximately 70% of cervical cancers, provides reason for optimism as roll-out begins with support from Gavi, the Vaccine Alliance. However, for the hundreds of millions of women beyond the target age for HPV vaccination, cervical cancer screening to detect and treat precancerous lesions remains the only form of prevention. Here we describe the challenges that confront screening programs in low-resource settings, including (1) optimizing screening test effectiveness; (2) achieving high screening coverage of the target population; and (3) managing screen-positive women. For each of these challenges, we summarize the tradeoffs between resource utilization and programmatic attributes. We then highlight opportunities for efficient and equitable programming, with supporting evidence from recent mathematical modeling analyses informed by data from the PATH demonstration projects in India, Nicaragua, and Uganda.
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Affiliation(s)
- Nicole G. Campos
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
| | - Vivien Tsu
- PATHReproductive Health ProgramSeattleWashington
| | | | | | - Jane J. Kim
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
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70
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Catarino R, Schäfer S, Vassilakos P, Petignat P, Arbyn M. Accuracy of combinations of visual inspection using acetic acid or lugol iodine to detect cervical precancer: a meta-analysis. BJOG 2017; 125:545-553. [PMID: 28603909 DOI: 10.1111/1471-0528.14783] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Visual inspection of the cervix with acetic acid (VIA) or with Lugol's iodine (VILI) have been evaluated for cervical cancer screening in developing countries. OBJECTIVES To assess the diagnostic accuracy and clinical utility of visual methods to detect cervical intraepithelial neoplasia grade 2+ (CIN2+) using: (1) VIA alone; (2) VILI alone; (3) co-testing; and (4) VILI as a triage test of a positive VIA result. SEARCH STRATEGY PubMed, EMBASE, and the Cochrane Library were searched up to May 2016. SELECTION CRITERIA All reports on the accuracy of VIA and VILI, or combinations of VIA/VILI, to detect CIN2+ were identified. Histology and colposcopy when no biopsy was taken were used as the reference standard. DATA COLLECTION AND ANALYSIS Selected studies were scored on methodological quality, and sensitivity and specificity were computed. Clinical utility was assessed from the positive predictive value (PPV) and the complement of the negative predictive value (cNPV). MAIN RESULTS We included 23 studies comprising 101 273 women. The pooled sensitivity and specificity of VILI was 88 and 86%, respectively. VILI was more sensitive, but not less specific, compared with VIA (relative sensitivity = 1.11; 95% confidence interval, 95% CI, 1.06-1.16; relative specificity = 0.98; 95% CI 0.95-1.01). Co-testing was hardly more sensitive, but significantly less specific, than VILI alone. VILI to triage VIA-POSITIVE women was not less sensitive, but more specific, compared with VIA alone (relative sensitivity = 0.98, 95% CI 0.96-1.01; relative specificity = 1.04, 95% CI 1.02-1.05). The average PPVs were low (range 11-16%), whereas the cNPV varied between 0.3% (VILI, co-testing) and 0.6% (triage). CONCLUSIONS Although imperfect, VILI alone appeared to be the most useful visual screening strategy. TWEETABLE ABSTRACT VILI alone seems to be the most useful visual screening test for cervical cancer screening.
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Affiliation(s)
- R Catarino
- Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - S Schäfer
- Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - P Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - P Petignat
- Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - M Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Scientific Institute of Public Health, Brussels, Belgium
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Implementing community-based cervical cancer screening programs using visual inspection with acetic acid in India: A systematic review. Cancer Epidemiol 2017; 49:161-174. [PMID: 28704717 DOI: 10.1016/j.canep.2017.06.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/13/2017] [Accepted: 06/15/2017] [Indexed: 11/20/2022]
Abstract
The objective of this review was to systematically appraise the existing published literature about community-based cervical cancer screening programs that have used visual inspection methods using acetic acid (VIA) in India. All peer reviewed journal articles till December 2015 were searched per PRISMA guidelines. Articles reporting results from cervical cancer screening programs in community-based settings, conducted in India, and using VIA were included in this review. The search resulted in 20 articles to be included in the review with a total of 313,553 women at 12 unique urban and rural sites across India. Seventeen (85%) studies were cross-sectional and three studies were randomized controlled trials; most studies compared accuracy of VIA with other screening tests such as visual inspection using Lugol's Iodine (VILI), HPV DNA, and cytology. Of studies that reported test accuracy for CIN Grade 2+, the VIA sensitivity values ranged from 16.6-82.6% and specificity ranged from 82.1-96.8%. Women between age groups of 30-59 years were recruited using motivational one-on-one counseling and local support staff. All studies conducted diagnostic follow-up using colposcopy and guided biopsies, when necessary. Three major themes were identified that facilitated implementation of screening programs in a community-based setting: standardized training that maintained competency of test providers; collaborations with community-based organizations that used health education for recruitment of participants; and employing the screen-and-treat method to reduce loss to follow-up. Summarized evidence presented in this review could substantially influence future implementation and sustainment of cervical cancer screening programs at a national level.
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Dykens JA, Linn AM, Irwin T, Peters KE, Pyra M, Traoré F, Touré Diarra M, Hasnain M, Wallner K, Linn P, Ndiaye Y. Implementing visual cervical cancer screening in Senegal: a cross-sectional study of risk factors and prevalence highlighting service utilization barriers. Int J Womens Health 2017; 9:59-67. [PMID: 28184171 PMCID: PMC5291333 DOI: 10.2147/ijwh.s115454] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Senegal ranks 15th in the world in incidence of cervical cancer, the number one cause of cancer mortality among women in this country. The estimated participation rate for cervical cancer screening throughout Senegal is very low (6.9% of women 18-69 years old), especially in rural areas and among older age groups (only 1.9% of women above the age of 40 years). There are no reliable estimates of the prevalence of cervical dysplasia or risk factors for cervical dysplasia specific to rural Senegal. The goals of this study were to estimate the prevalence of cervical dysplasia in a rural region using visual inspection of the cervix with acetic acid (VIA) and to assess risk factors for cervical cancer control. PATIENTS AND METHODS We conducted a cross-sectional study in which we randomly selected 38 villages across the Kédougou region using a three-stage clustering process. Between October 2013 and March 2014, we collected VIA screening results for women aged 30-50 years and cervical cancer risk factors linked to the screening result. RESULTS We screened 509 women; 5.6% of the estimated target population (9,041) in the region. The point prevalence of cervical dysplasia (positive VIA test) was 2.10% (95% confidence interval [CI]: 0.99-3.21). Moreover, 287 women completed the cervical cancer risk factor survey (56.4% response rate) and only 38% stated awareness of cervical cancer; 75.9% of the screened women were less than 40 years of age. CONCLUSION The overall prevalence of dysplasia in this sample was lower than anticipated. Despite both overall awareness and screening uptake being less than expected, our study highlights the need to address challenges in future prevalence estimates. Principally, we identified that the highest-risk women are the ones least likely to seek screening services, thus illustrating a need to fully understand demand-side barriers to accessing health services in this population. Targeted efforts to educate and motivate older women to seek screenings are needed to sustain an effective cervical cancer screening program.
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Affiliation(s)
- J Andrew Dykens
- Department of Family Medicine, College of Medicine; Center for Global Health; Institute for Health Research and Policy; Cancer Center, Hospital and Health Sciences System, University of Illinois at Chicago, IL, USA
| | - Annē M Linn
- Master's International Graduate School Program, Peace Corps, Dakar, Senegal; Rutgers School of Nursing, Newark, NJ
| | | | - Karen E Peters
- School of Public Health, University of Illinois at Chicago, IL, USA
| | - Maria Pyra
- School of Public Health, University of Illinois at Chicago, IL, USA
| | - Fatoumata Traoré
- Regional Ministry of Health and Social Affairs, Kédougou, Senegal
| | | | - Memoona Hasnain
- Department of Family Medicine, College of Medicine; Foundation for Advancement of International Medical Education and Research, Philadelphia, PA, USA
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Xie Y, Tan X, Shao H, Liu Q, Tou J, Zhang Y, Luo Q, Xiang Q. VIA/VILI is more suitable for cervical cancer prevention in Chinese poverty-stricken region: a health economic evaluation. BMC Public Health 2017; 17:118. [PMID: 28122530 PMCID: PMC5264329 DOI: 10.1186/s12889-017-4054-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 01/19/2017] [Indexed: 01/01/2023] Open
Abstract
Background Screening is the main preventive method for cervical cancer in developing countries, but each type of screening has advantages and disadvantages. To investigate the most suitable method for low-income areas in China, we conducted a health economic analysis comparing three methods: visual inspection with acetic acid and Lugol’s iodine (VIA/VILI), ThinPrep cytology test (TCT), and human papillomavirus (HPV) test. Methods We recruited 3086 women aged 35–65 years using cluster random sampling. Each participant was randomly assigned to one of three cervical cancer screening groups: VIA/VILI, TCT, or HPV test. In order to calculate the number of disability-adjusted life years (DALYs) averted by each screening method, we used Markov models to estimate the natural development of cervical cancer over a 15-year period to estimate the age of onset and duration of each disease stage. The cost-effectiveness ratios (CERs), net present values (NPVs), benefit-cost ratios (BCRs), and cost-utility ratios (CURs) were used as outcomes in the health economic analysis. Results The positive detection rate in the VIA/VILI group was 1.39%, which was 4.6 and 2.0 times higher than the rates in the TCT and HPV test groups, respectively. The positive predictive value of VIA/VILI (10.53%) was highest while the rate of referral for colposcopy was lowest for those in the HPV + TCT group (0.60%). VIA/VILI performed the best in terms of health economic evaluation results, as the cost of per positive case detected was 8467.9 RMB, which was 24503.0 RMB lower than that for TCT and 5755.9 RMB lower than that for the HPV test. In addition, the NPV and BCR values were 258011.5 RMB and 3.18 (the highest), and the CUR was 2341.8 RMB (the lowest). The TCT performed the worst, since its NPV was <0 and the BCR was <1, indicative of being poorly cost-beneficial. Conclusions With the best economic evaluation results and requiring minimum medical resources, VIA/VILI is recommended for cervical cancer screening in poverty-stricken areas in China with high incidence of cervical cancer and lack of medical resources.
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Affiliation(s)
- Yu Xie
- School of Public Health, Wuhan University, Hubei, China
| | - Xiaodong Tan
- School of Public Health, Wuhan University, Hubei, China.
| | - Haiyan Shao
- School of Public Health, Wuhan University, Hubei, China
| | - Qing Liu
- School of Public Health, Wuhan University, Hubei, China
| | - Jiyu Tou
- Institute of Cancer Prevention and Control, Hubei, China
| | - Yuling Zhang
- Institute of Cancer Prevention and Control, Hubei, China
| | - Qiong Luo
- Maternal and Child Health Care Hospital, Wufeng, China
| | - Qunying Xiang
- Maternal and Child Health Care Hospital, Wufeng, China
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Chanthavilay P, Reinharz D, Mayxay M, Phongsavan K, Marsden DE, Moore L, White LJ. Economic Evaluation of Screening Strategies Combined with HPV Vaccination of Preadolescent Girls for the Prevention of Cervical Cancer in Vientiane, Lao PDR. PLoS One 2016; 11:e0162915. [PMID: 27631732 PMCID: PMC5025134 DOI: 10.1371/journal.pone.0162915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 08/30/2016] [Indexed: 11/19/2022] Open
Abstract
Background Several approaches to reduce the incidence of invasive cervical cancers exist. The approach adopted should take into account contextual factors that influence the cost-effectiveness of the available options. Objective To determine the cost-effectiveness of screening strategies combined with a vaccination program for 10-year old girls for cervical cancer prevention in Vientiane, Lao PDR. Methods A population-based dynamic compartment model was constructed. The interventions consisted of a 10-year old girl vaccination program only, or this program combined with screening strategies, i.e., visual inspection with acetic acid (VIA), cytology-based screening, rapid human papillomavirus (HPV) DNA testing, or combined VIA and cytology testing. Simulations were run over 100 years. In base-case scenario analyses, we assumed a 70% vaccination coverage with lifelong protection and a 50% screening coverage. The outcome of interest was the incremental cost per Disability-Adjusted Life Year (DALY) averted. Results In base-case scenarios, compared to the next best strategy, the model predicted that VIA screening of women aged 30–65 years old every three years, combined with vaccination, was the most attractive option, costing 2 544 international dollars (I$) per DALY averted. Meanwhile, rapid HPV DNA testing was predicted to be more attractive than cytology-based screening or its combination with VIA. Among cytology-based screening options, combined VIA with conventional cytology testing was predicted to be the most attractive option. Multi-way sensitivity analyses did not change the results. Compared to rapid HPV DNA testing, VIA had a probability of cost-effectiveness of 73%. Compared to the vaccination only option, the probability that a program consisting of screening women every five years would be cost-effective was around 60% and 80% if the willingness-to-pay threshold is fixed at one and three GDP per capita, respectively. Conclusions A VIA screening program in addition to a girl vaccination program was predicted to be the most attractive option in the health care context of Lao PDR. When compared with other screening methods, VIA was the primary recommended method for combination with vaccination in Lao PDR.
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Affiliation(s)
- Phetsavanh Chanthavilay
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Lao PDR
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada
- * E-mail:
| | - Daniel Reinharz
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada
- Institut de la Francophonie pour la Médecine tropicale, Vientiane, Lao PDR
| | - Mayfong Mayxay
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Lao PDR
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | | | - Donald E. Marsden
- Centre for Tropical Medicine and Global Health, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Lynne Moore
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada
| | - Lisa J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Negulescu RA, Catarino R, De Vuyst H, Undurraga-Malinverno M, Meyer-Hamme U, Alec M, Campana A, Vassilakos P, Petignat P. Web-based instrument to assess skills in visual inspection of the cervix among healthcare providers. Int J Gynaecol Obstet 2016; 134:107-13. [PMID: 27126908 DOI: 10.1016/j.ijgo.2015.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 11/15/2015] [Accepted: 03/23/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To validate a web-based instrument for assessing healthcare providers' skills in visual inspection with acetic acid or Lugol iodine (VIA/VILI) for the diagnosis and management of cervical intraepithelial neoplasia. METHODS An observational cross-sectional study enrolled healthcare providers in a web-based assessment of VIA/VILI skills between August and November 2014. Participants participated in a four-module training course, followed by a multiple-choice test with 70 questions based on cervical photographs of HPV-positive women participating in cervical screening. Logistic regression was used to identify relationships between independent variables and success on the test. RESULTS Overall, 255 participants completed the test and 99 (38.8%) passed. No correlation was found between age or sex and test performance. Compared with other healthcare workers, physicians (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.01-3.63; P=0.048), and participants with more colposcopy experience (OR 3.62, 95% CI 1.91-6.85; P<0.001) and postgraduate VIA/VILI training (OR 1.95, 95% CI 1.16-3.29; P=0.012) were more likely to pass the test. Participants who repeated the test (31/255 [12.2%]) were five times more likely to succeed on their second repeat (OR 5.89, 95% CI 1.46-23.73; P=0.013). CONCLUSION Web-based training for VIA/VILI is feasible and can identify healthcare workers who are proficient in this technique.
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Affiliation(s)
- Raluca-Anca Negulescu
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.
| | - Rosa Catarino
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Hugo De Vuyst
- International Agency for Research on Cancer, Lyon, France
| | - Manuela Undurraga-Malinverno
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Ulrike Meyer-Hamme
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Milena Alec
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Aldo Campana
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
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Cervical Cancer Screening in Cameroon: Interobserver Agreement on the Interpretation of Digital Cervicography Results. J Low Genit Tract Dis 2016; 19:288-94. [PMID: 26164295 DOI: 10.1097/lgt.0000000000000133] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The World Health Organization recommends visual inspection with acetic acid (VIA) for cervical cancer screening in resource-limited settings. In Cameroon, we use digital cervicography (DC) to capture images of the cervix after VIA. This study evaluated interobserver agreement of DC results, compared DC with histopathologic results, and examined interobserver agreement among screening methods. METHOD Three observers, blinded to each other's interpretations, evaluated 540 DC photographs as follows: (1) negative/positive for acetowhite lesions or cancer and (2) assigned a presumptive diagnosis of histopathologic lesion grade in the 91 cases that had a histopathologic diagnosis. Observer A was the actual screening nurse; B, a reproductive health nurse; C, a gynecologic oncologist; and D, the histopathologic diagnosis. We compared inter-rater agreement of DC impressions among observers A, B, and C, and with D, with Cohen kappas. RESULTS For interpretations of DC, (negative/positive) strengths of agreement of paired observers were the following: A/B, moderate [K, 0.54; 95% confidence interval (CI), 0.47-0.61], A/C, fair (K, 0.37; 95% CI, 0.29-0.44), and B/C, moderate (K, 0.45; 95% CI, 0.37-0.53). For presumptive pathologic grading, strengths of agreement for weighted Ks were as follows: A/B, moderate (K, 0.42; 95% CI, 0.28-0.56); A/C, fair (K, 0.33; 95% CI, 0.20-0.46); B/C, fair (K, 0.54; 95% CI, 0.40-0.67); A/D, moderate (K, 0.59; 95% CI, 0.45-0.74); B/D, moderate (K, 0.58; 95% CI, 0.46-0.70); and C/D, moderate (K, 0.50; 95% CI, 0.37-0.63). CONCLUSIONS Interobserver agreement of DC interpretations was mostly moderate among the 3 observers, between them and histopathology, and comparable to that of other visual-based screening methods, i.e., VIA, cytology, or colposcopy.
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Chanthavilay P, Mayxay M, Phongsavan K, Marsden DE, White LJ, Moore L, Reinharz D. Accuracy of Combined Visual Inspection with Acetic Acid and Cervical Cytology Testing as a Primary Screening Tool for Cervical Cancer: a Systematic Review and Meta-Analysis. Asian Pac J Cancer Prev 2016; 16:5889-97. [PMID: 26320468 DOI: 10.7314/apjcp.2015.16.14.5889] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The performance of combined testing visual inspection with acetic acid (VIA) and cervical cytology tests might differ from one setting to another. The average estimate of the testing accuracy across studies is informative, but no meta-analysis has been carried out to assess this combined method. OBJECTIVE The objective of this study was to estimate the average sensitivity and specificity of the combined VIA and cervical cytology tests for the detection of cervical precancerous lesions. MATERIALS AND METHODS We conducted a systematic review and a meta-analysis, according to the Cochrane Handbook for Systematic Review of Diagnostic Test Accuracy. We considered two cases. In the either-positive result case, a positive result implies positivity in at least one of the tests. A negative result implies negativity in both tests. In the both-positive case, a positive result implies having both tests positive. Eligible studies were identified using Pubmed, Embase, Website of Science, CINHAL and COCRANE databases. True positive, false positive, false negative and true negative values were extracted. Estimates of sensitivity and specificity, positive and negative likelihood (LR) and diagnostic odds ratios (DOR) were pooled using a hierarchical random effect model. Hierarchical summary receiver operating characteristics (HSROC) were generated and heterogeneity was verified through covariates potentially influencing the diagnostic odds ratio. FINDINGS Nine studies fulfilled inclusion criteria and were included in the analysis. Pooled estimates of the sensitivities of the combined tests in either-positive and both-positive cases were 0.87 (95% CI: 0.83-0.90) and 0.38 (95% CI: 0.29-0.48), respectively. Corresponding specificities were 0.79 (95% CI: 0.63-0.89) and 0.98 (95% CI: 0.96-0.99) respectively. The DORs of the combined tests in either-positive or both-positive result cases were 27.7 (95% CI: 12.5-61.5) and 52 (95% CI: 22.1-122.2), respectively. When including only articles without partial verification bias and also a high-grade cervical intraepithelial neoplasia as a threshold of the disease, DOR of combined test in both-positive result cases remained the highest. However, DORs decreased to 12.1 (95% CI: 6.05-24.1) and 13.8 (95% CI: 7.92-23.9) in studies without partial verification bias for the combined tests in the either-positive and both-positive result cases, respectively. The screener, the place of study and the size of the population significantly influenced the DOR of combined tests in the both-positive result case in restriction analyses that considered only articles with CIN2+ as disease threshold. CONCLUSIONS The combined test in the either-positive result case has a high sensitivity, but a low specificity. These results suggest that the combined test should be considered in developing countries as a primary screening test if facilities exist to confirm, through colposcopy and biopsy, a positive result.
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Affiliation(s)
- Phetsavanh Chanthavilay
- Faculty of Postgraduate Studies, University of Health Sciences, 3Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR E-mail :
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Finocchario-Kessler S, Wexler C, Maloba M, Mabachi N, Ndikum-Moffor F, Bukusi E. Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective. BMC Womens Health 2016; 16:29. [PMID: 27259656 PMCID: PMC4893293 DOI: 10.1186/s12905-016-0306-6] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 05/21/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa. METHODS We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories. RESULTS A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts. CONCLUSIONS Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.
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Affiliation(s)
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, USA
| | - May Maloba
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Florence Ndikum-Moffor
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, USA
| | - Elizabeth Bukusi
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya
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Pathak N, Dodds J, Zamora J. Could urine testing be the future of cervical cancer screening? ACTA ACUST UNITED AC 2016; 11:265-7. [PMID: 26102464 DOI: 10.2217/whe.15.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Neha Pathak
- Women's Health Research Unit, Centre for Primary Care & Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Julie Dodds
- Women's Health Research Unit, Centre for Primary Care & Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Javier Zamora
- Women's Health Research Unit, Centre for Primary Care & Public Health, Blizard Institute, Queen Mary University of London, London, UK.,Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS), Madrid, Spain.,CIBER Epidemiologia y Salud Publica (CIBERESP), Madrid, Spain
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Shiferaw N, Salvador-Davila G, Kassahun K, Brooks MI, Weldegebreal T, Tilahun Y, Zerihun H, Nigatu T, Lulu K, Ahmed I, Blumenthal PD, Asnake M. The Single-Visit Approach as a Cervical Cancer Prevention Strategy Among Women With HIV in Ethiopia: Successes and Lessons Learned. GLOBAL HEALTH: SCIENCE AND PRACTICE 2016; 4:87-98. [PMID: 27016546 PMCID: PMC4807751 DOI: 10.9745/ghsp-d-15-00325] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/20/2016] [Indexed: 01/02/2023]
Abstract
With the single-visit approach for cervical cancer prevention, women with positive “visual inspection of the cervix with acetic acid wash” (VIA) test results receive immediate treatment of the precancerous lesion with cryotherapy. The approach worked successfully for women with HIV in Ethiopia in secondary and tertiary health facilities, with high screening and cryotherapy treatment rates. Sustainability and appropriate scale-up of such programs must address wider health system challenges including human resource constraints and shortage of essential supplies. Introduction: Cervical cancer is the second most common form of cancer for women in Ethiopia. Using a single-visit approach to prevent cervical cancer, the Addis Tesfa (New Hope) project in Ethiopia tested women with HIV through visual inspection of the cervix with acetic acid wash (VIA) and, if tests results were positive, offered immediate cryotherapy of the precancerous lesion or referral for loop electrosurgical excision procedure (LEEP). The objective of this article is to review screening and treatment outcomes over nearly 4 years of project implementation and to identify lessons learned to improve cervical cancer prevention programs in Ethiopia and other resource-constrained settings. Methods: We analyzed aggregate client data from August 2010 to March 2014 to obtain the number of women with HIV who were counseled, screened, and treated, as well as the number of annual follow-up visits made, from the 14 tertiary- and secondary-level health facilities implementing the single-visit approach. A health facility assessment (HFA) was also implemented from August to December 2013 to examine the effects of the single-visit approach on client flow, staff workload, and facility infrastructure 3 years after initiating the approach. Results: Almost all (99%) of the 16,632 women with HIV counseled about the single-visit approach were screened with VIA during the study period; 1,656 (10%) of them tested VIA positive (VIA+) for precancerous lesions. Among those who tested VIA+ and were thus eligible for cryotherapy, 1,481 (97%) received cryotherapy treatment, but only 80 (63%) women eligible for LEEP actually received the treatment. The HFA results showed frequent staff turnover, some shortage of essential supplies, and rooms that were judged by providers to be too small for delivery of cervical cancer prevention services. Conclusion: The high proportions of VIA screening and cryotherapy treatment in the Addis Tesfa project suggest high acceptance of such services by women with HIV and feasibility of implementation in secondary- and tertiary-level health facilities. However, success of cervical cancer prevention programming must address wider health system challenges to ensure sustainability and appropriate scale-up to the general population of Ethiopia and other resource-constrained settings.
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Affiliation(s)
| | | | | | - Mohamad I Brooks
- Pathfinder International, Watertown, MA, and Boston University School of Public Health, Boston, MA, USA
| | | | | | | | | | - Kidest Lulu
- Pathfinder International, Addis Ababa, Ethiopia
| | - Ismael Ahmed
- Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Paul D Blumenthal
- Stanford Program for International Reproductive Education and Services (SPIRES), Stanford University School of Medicine, Stanford, CA, USA
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Subramanian S, Sankaranarayanan R, Esmy PO, Thulaseedharan JV, Swaminathan R, Thomas S. Clinical trial to implementation: Cost and effectiveness considerations for scaling up cervical cancer screening in low- and middle-income countries. J Cancer Policy 2016. [DOI: 10.1016/j.jcpo.2015.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lee H, Kang Y, Ju W. Cervical Cancer Screening in Developing Countries: Using Visual Inspection Methods. Clin J Oncol Nurs 2016; 20:79-83. [DOI: 10.1188/16.cjon.79-83] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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83
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HPV detection-based cervical cancer screening program in low-resource setting: lessons learnt from a community-based demonstration project in India. Cancer Causes Control 2015; 27:351-8. [DOI: 10.1007/s10552-015-0708-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022]
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Catarino R, Petignat P, Dongui G, Vassilakos P. Cervical cancer screening in developing countries at a crossroad: Emerging technologies and policy choices. World J Clin Oncol 2015; 6:281-290. [PMID: 26677441 PMCID: PMC4675913 DOI: 10.5306/wjco.v6.i6.281] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/03/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023] Open
Abstract
Cervical cancer (CC) represents the fourth most common malignancy affecting women all over the world and is the second most common in developing areas. In these areas, the burden from disease remains important because of the difficulty in implementing cytology-based screening programmes. The main obstacles inherent to these countries are poverty and a lack of healthcare infrastructures and trained practitioners. With the availability of new technologies, researchers have attempted to find new strategies that are adapted to low- and middle-income countries (LMIC) to promote early diagnosis of cervical pathology. Current evidence suggests that human papillomavirus (HPV) testing is more effective than cytology for CC screening. Therefore, highly sensitive tests have now been developed for primary screening. Rapid molecular methods for detecting HPV DNA have only recently been commercially available. This constitutes a milestone in CC screening in low-resource settings because it may help overcome the great majority of obstacles inherent to previous screening programmes. Despite several advantages, HPV-based screening has a low positive predictive value for CC, so that HPV-positive women need to be triaged with further testing to determine optimal management. Visual inspection tests, cytology and novel biomarkers are some options. In this review, we provide an overview of current and emerging screening approaches for CC. In particular, we discuss the challenge of implementing an efficient cervical screening adapted to LMIC and the opportunity to introduce primary HPV-based screening with the availability of point-of-care (POC) HPV testing. The most adapted screening strategy to LMIC is still a work in progress, but we have reasons to believe that POC HPV testing makes part of the future strategies in association with a triage test that still needs to be defined.
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85
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Denny L, Prendiville W. Cancer of the cervix: Early detection and cost-effective solutions. Int J Gynaecol Obstet 2015; 131 Suppl 1:S28-32. [PMID: 26433500 DOI: 10.1016/j.ijgo.2015.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cervical cancer is known to be a preventable disease through the detection of cervical cancer precursors, historically using cytology of the cervix as the primary screening test. Over 85% of cervical cancer cases and deaths occur in low-resource countries. Alternatives to cytology have been investigated with the strongest possibilities being visual inspection with acetic acid (VIA) and HPV DNA testing. HPV DNA testing has been shown in randomized trials to be significantly more sensitive for the detection of cervical cancer precursors than either cytology or VIA. In this paper we argue that prevention really does cost less than cure, or that prevention and treatment of cancer costs less than no prevention, in effect just treatment, of cancer. The true cost savings of prevention will include a more difficult assessment of the socioeconomic savings associated with longer, healthier lives for women in their prime who have a major role in supporting their families.
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Affiliation(s)
- Lynette Denny
- University of Cape Town/Groote Schuur Hospital, Cape Town, South Africa.
| | - Walter Prendiville
- International Agency for Research on Cancer, 150 Cours Albert Thomas, Lyon, France
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Anderson J, Wysong M, Estep D, Besana G, Kibwana S, Varallo J, Sun K, Lu E. Evaluation of Cervical Cancer Screening Programs in Côte d'Ivoire, Guyana, and Tanzania: Effect of HIV Status. PLoS One 2015; 10:e0139242. [PMID: 26405784 PMCID: PMC4583505 DOI: 10.1371/journal.pone.0139242] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 09/09/2015] [Indexed: 11/18/2022] Open
Abstract
Background HIV infection increases a woman’s risk for cervical cancer, and cervical cancer incidence and mortality rates are higher in countries with high HIV prevalence and limited resources for screening. Visual inspection with acetic acid (VIA) allows screening and treatment of cervical lesions in a single-visit approach (SVA), but data on its performance in HIV-infected women are limited. This study’s objective was to examine cervical cancer screening using VIA/SVA in programs serving HIV-infected women. Methods A VIA/SVA program with cryotherapy for VIA-positive lesions was implemented in Côte d’Ivoire, Guyana, and Tanzania from 2009 to 2012. The effect of HIV status on VIA positivity and on presence of cryotherapy-eligible lesions was examined using a cross-sectional study design, with Chi-square tests for comparisons and constructed multivariate logistic regression models. A P-value of < 0.05 was significant. Findings VIA was performed on 34,921 women, 10% (3,580) were VIA positive; 2,508 (85%) eligible women received cryotherapy during the same visit; only 234 (52%) of those who postponed returned for treatment; 622 (17%) VIA-positive women had lesions too large to be treated with cryotherapy and were referred for excisional treatment. In multivariate analysis—controlling for HIV status, location of the screening clinic, facility location, facility type, and country—compared to HIV-uninfected/unknown women, HIV-infected women had higher odds of being VIA positive (OR 1.95, 95% CI 1.76, 2.16, P<0.0001) and of having large lesions requiring referral (OR 1.93, 95% CI 1.49, 2.51, P< 0.0001). Minor treatment complications occurred in 19 of 3,032 (0.63%) women; none required further intervention. Conclusions This study found that compared to HIV-uninfected/unknown women, HIV-infected women had nearly twice the odds of being VIA-positive and to require referral for large lesions. SVA was safe and resulted in significant reductions in loss to follow-up. There is increased need for excisional treatment in countries with high HIV prevalence.
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Affiliation(s)
- Jean Anderson
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States of America
- * E-mail:
| | - Megan Wysong
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Deb Estep
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Giulia Besana
- Jhpiego/Tanzania, an affiliate of Johns Hopkins University, Dar es Salaam, Tanzania
| | - Sharon Kibwana
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
| | - John Varallo
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kai Sun
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States of America
| | - Enriquito Lu
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
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Makuza JD, Nsanzimana S, Muhimpundu MA, Pace LE, Ntaganira J, Riedel DJ. Prevalence and risk factors for cervical cancer and pre-cancerous lesions in Rwanda. Pan Afr Med J 2015; 22:26. [PMID: 26664527 PMCID: PMC4662515 DOI: 10.11604/pamj.2015.22.26.7116] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/02/2015] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Cervical cancer prevalence in Rwanda has not been well-described. Visual inspection with acetic acid or Lugol solution has been shown to be effective for cervical cancer screening in low resource settings. The aim of the study is to understand the prevalence and risk factors for cervical cancer and pre- cancerous lesions among Rwandan women between 30 and 50 old undergoing screening. METHODS This cross-sectional analytical study was done in 3 districts of Rwanda from October 2010 to June 2013. Women aged 30 to 50 years screened for cervical cancer by trained doctors, nurses and midwives. Prevalence of pre-cancerous and cancerous cervical lesions was determined. Bivariate and multivariate logistic regressions were used to assess risk factors associated with cervical cancer. RESULTS The prevalence of pre-cancer and invasive cervical cancer was 5.9% (95% CI 4.5, 7.5) and 1.7% (95% CI 0.9, 2.5), respectively. Risk factors associated with cervical cancer in multivariate analysis included initiation of sexual activity at less than 20 years (OR=1.75; 95% CI=(1.01, 3.03); being unmarried (single, divorced and widowed) (OR=3.29; 95% CI=( 1.26, 8.60)); Older age of participants (OR= 0.52; 95% CI= (0.28, 0.97)), older age at the first pregnancy (OR=2.10; 95% CI=(1.20, 3.67) and higher number of children born (OR=0.42; 95%CI =(0.23, 0.76)) were protective. CONCLUSION Cervical cancer continues to be a public health problem in Rwanda, but screening using VIA is practical and feasible even in rural settings.
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Affiliation(s)
| | | | | | | | - Joseph Ntaganira
- University of Rwanda, College of Medicine and Other Health Sciences, School of Public Health, Rwanda
| | - David James Riedel
- Institute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Demment MM, Peters K, Dykens JA, Dozier A, Nawaz H, McIntosh S, Smith JS, Sy A, Irwin T, Fogg TT, Khaliq M, Blumenfeld R, Massoudi M, De Ver Dye T. Developing the Evidence Base to Inform Best Practice: A Scoping Study of Breast and Cervical Cancer Reviews in Low- and Middle-Income Countries. PLoS One 2015; 10:e0134618. [PMID: 26325181 PMCID: PMC4556679 DOI: 10.1371/journal.pone.0134618] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 07/12/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Breast and cervical cancers have emerged as major global health challenges and disproportionately lead to excess morbidity and mortality in low- and middle-income countries (LMICs) when compared to high-income countries. The objective of this paper was to highlight key findings, recommendations, and gaps in research and practice identified through a scoping study of recent reviews in breast and cervical cancer in LMICs. METHODS We conducted a scoping study based on the six-stage framework of Arskey and O'Malley. We searched PubMed, Cochrane Reviews, and CINAHL with the following inclusion criteria: 1) published between 2005-February 2015, 2) focused on breast or cervical cancer 3) focused on LMIC, 4) review article, and 5) published in English. RESULTS Through our systematic search, 63 out of the 94 identified cervical cancer reviews met our selection criteria and 36 of the 54 in breast cancer. Cervical cancer reviews were more likely to focus upon prevention and screening, while breast cancer reviews were more likely to focus upon treatment and survivorship. Few of the breast cancer reviews referenced research and data from LMICs themselves; cervical cancer reviews were more likely to do so. Most reviews did not include elements of the PRISMA checklist. CONCLUSION Overall, a limited evidence base supports breast and cervical cancer control in LMICs. Further breast and cervical cancer prevention and control studies are necessary in LMICs.
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Affiliation(s)
- Margaret M. Demment
- Clinical and Translational Research Institute, University of Rochester, Rochester, New York, United States of America
| | - Karen Peters
- Division of Community Health Sciences, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - J. Andrew Dykens
- Department of Family Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Ann Dozier
- Department of Public Health Sciences, University of Rochester, Rochester, New York, United States of America
| | - Haq Nawaz
- Department of Medicine, Griffin Hospital & Yale University-Griffin Prevention Research Center, New Haven, Connecticut, United States of America
| | - Scott McIntosh
- Department of Public Health Sciences, University of Rochester, Rochester, New York, United States of America
| | - Jennifer S. Smith
- Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Angela Sy
- School of Nursing and Dental Hygiene, University of Hawai’i at Mānoa, Honolulu, Hawaii, United States of America
| | - Tracy Irwin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Thomas T. Fogg
- Clinical and Translational Research Institute, University of Rochester, Rochester, New York, United States of America
| | - Mahmooda Khaliq
- Department of Community and Family Health, University of South Florida, Tampa, Florida, United States of America
| | - Rachel Blumenfeld
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Mehran Massoudi
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Timothy De Ver Dye
- Clinical and Translational Research Institute, University of Rochester, Rochester, New York, United States of America
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- * E-mail:
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Visual Inspection of Cervix With Acetic Acid as a Screening Modality for Cervical Cancer. J Low Genit Tract Dis 2015; 19:340-4. [PMID: 26247262 DOI: 10.1097/lgt.0000000000000145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess feasibility and suitability of visual inspection of cervix with acetic acid (VIA) in detecting cervical intraepithelial neoplasia (CIN), and compare it with Papanicolaou test. METHODS This was a diagnostic accuracy cross-sectional study conducted at an Egyptian teaching hospital, where 784 women were offered Papanicolaou test, VIA, colposcopy, and cervical biopsy. RESULTS Histopathologically confirmed CIN 2/3 was noted in 26 cases (3.3%) and cervical cancer in 3 cases (0.4%). Twenty-seven (93.1%) of these 29 cases of CIN 2+, including one invasive cancer, were suggested by VIA. The test sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to detect CIN 2+ were 93.1%, 90.6%, 26.6%, and 99.7%, respectively. Positive likelihood ratio (LR +) and negative likelihood ratio (LR-) for VIA were 9.90 (95% confidence interval [CI], 7.77-12.62) and 0.08 (95% CI, 0.02-0.29), respectively. Twenty-six cases (89.7%) of CIN 2+ were suggested by Papanicolaou test, whereas all 3 cancers were missed by this test. Papanicolaou test sensitivity, specificity, PPV, and NPV to detect CIN 2+ were 89.7%, 99.1%, 78.8%, and 99.6%, respectively. Positive likelihood ratio and LR- for the Papanicolaou test were 96.7 (95% CI, 45.78-204.23) and 0.10 (95% CI, 0.04-0.3), respectively. Colposcopy suggested 28 cases (96.6%) of CIN 2+, including 2 cancers. Colposcopy sensitivity, specificity, PPV, and NPV to detect CIN 2+ were 96.6%, 99.2%, 82.4%, and 99.9%, respectively. CONCLUSION Visual inspection of the cervix with acetic acid is a feasible and suitable screening test for cervical cancer in under-resourced settings in developing countries. Its performance is comparable to the Papanicolaou test.
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Poli UR, Bidinger PD, Gowrishankar S. Visual Inspection with Acetic Acid (VIA) Screening Program: 7 Years Experience in Early Detection of Cervical Cancer and Pre-Cancers in Rural South India. Indian J Community Med 2015; 40:203-7. [PMID: 26170547 PMCID: PMC4478664 DOI: 10.4103/0970-0218.158873] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 11/05/2014] [Indexed: 12/27/2022] Open
Abstract
Cervical cancer continues to be a major public health problem in India in the absence of wide spread organised cervical screening programs. Visual inspection of the cervix with acetic acid (VIA) is an effective, inexpensive screening test that can be combined with simple treatment procedures for early cervical lesions, provided by trained health workers. We report 7 years experience in early detection of cervical cancer and pre-cancers using the VIA test in a community-based program in rural Andhra Pradesh, India where there are no existing organised cervical screening programs.
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Affiliation(s)
- Usha Rani Poli
- Associate Professor of Gynaecological Oncology, Department of Gynaecological Oncology, Mehdi Nawaz Jung Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India
| | - P D Bidinger
- Director, Institute for Rural Health Studies, Hyderabad, Telangana, India
| | - Swarnalata Gowrishankar
- Chief Pathologist, Department of Pathology, Apollo Hospital, Jubilee Hills, Hyderabad, Telangana, India
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Fokom-Domgue J, Combescure C, Fokom-Defo V, Tebeu PM, Vassilakos P, Kengne AP, Petignat P. Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies. BMJ 2015; 351:h3084. [PMID: 26142020 PMCID: PMC4490835 DOI: 10.1136/bmj.h3084] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess and compare the accuracy of visual inspection with acetic acid (VIA), visual inspection with Lugol's iodine (VILI), and human papillomavirus (HPV) testing as alternative standalone methods for primary cervical cancer screening in sub-Saharan Africa. DESIGN Systematic review and meta-analysis of diagnostic test accuracy studies. DATA SOURCES Systematic searches of multiple databases including Medline, Embase, and Scopus for studies published between January 1994 and June 2014. REVIEW METHODS Inclusion criteria for studies were: alternative methods to cytology used as a standalone test for primary screening; study population not at particular risk of cervical cancer (excluding studies focusing on HIV positive women or women with gynaecological symptoms); women screened by nurses; reference test (colposcopy and directed biopsies) performed at least in women with positive screening results. Two reviewers independently screened studies for eligibility and extracted data for inclusion, and evaluated study quality using the quality assessment of diagnostic accuracy studies 2 (QUADAS-2) checklist. Primary outcomes were absolute accuracy measures (sensitivity and specificity) of screening tests to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+). RESULTS 15 studies of moderate quality were included (n=61,381 for VIA, n=46,435 for VILI, n=11,322 for HPV testing). Prevalence of CIN2+ did not vary by screening test and ranged from 2.3% (95% confidence interval 1.5% to 3.3%) in VILI studies to 4.9% (2.7% to 7.8%) in HPV testing studies. Positivity rates of VILI, VIA, and HPV testing were 16.5% (9.8% to 24.7%), 16.8% (11.0% to 23.6%), and 25.8% (17.4% to 35.3%), respectively. Pooled sensitivity was higher for VILI (95.1%; 90.1% to 97.7%) than VIA (82.4%; 76.3% to 87.3%) in studies where the reference test was performed in all women (P<0.001). Pooled specificity of VILI and VIA were similar (87.2% (78.1% to 92.8%) v 87.4% (77.1% to 93.4%); P=0.85). Pooled sensitivity and specificity were similar for HPV testing versus VIA (both P ≥ 0.23) and versus VILI (both P ≥ 0.16). Accuracy of VIA and VILI increased with sample size and time period. CONCLUSIONS For primary screening of cervical cancer in sub-Saharan Africa, VILI is a simple and affordable alternative to cytology that demonstrates higher sensitivity than VIA. Implementation studies are needed to assess the effect of these screening strategies on the incidence and outcomes of cervical cancer in the region.
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Affiliation(s)
- Joël Fokom-Domgue
- Department of Gynecology and Obstetrics, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaoundé, Cameroon Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, 1211 Geneva 14, Switzerland
| | | | - Victoire Fokom-Defo
- Division of Infectious and Chronic Diseases, Department of Internal Medicine, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Pierre Marie Tebeu
- Department of Gynecology and Obstetrics, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaoundé, Cameroon
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - André Pascal Kengne
- South African Medical Research Council and University of Cape Town, Cape Town, South Africa
| | - Patrick Petignat
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, 1211 Geneva 14, Switzerland
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Fitzmaurice C, Dicker D, Pain A, Hamavid H, Moradi-Lakeh M, MacIntyre MF, Allen C, Hansen G, Woodbrook R, Wolfe C, Hamadeh RR, Moore A, Werdecker A, Gessner BD, Te Ao B, McMahon B, Karimkhani C, Yu C, Cooke GS, Schwebel DC, Carpenter DO, Pereira DM, Nash D, Kazi DS, De Leo D, Plass D, Ukwaja KN, Thurston GD, Yun Jin K, Simard EP, Mills E, Park EK, Catalá-López F, deVeber G, Gotay C, Khan G, Hosgood HD, Santos IS, Leasher JL, Singh J, Leigh J, Jonas JB, Jonas J, Sanabria J, Beardsley J, Jacobsen KH, Takahashi K, Franklin RC, Ronfani L, Montico M, Naldi L, Tonelli M, Geleijnse J, Petzold M, Shrime MG, Younis M, Yonemoto N, Breitborde N, Yip P, Pourmalek F, Lotufo PA, Esteghamati A, Hankey GJ, Ali R, Lunevicius R, Malekzadeh R, Dellavalle R, Weintraub R, Lucas R, Hay R, Rojas-Rueda D, Westerman R, Sepanlou SG, Nolte S, Patten S, Weichenthal S, Abera SF, Fereshtehnejad SM, Shiue I, Driscoll T, Vasankari T, Alsharif U, Rahimi-Movaghar V, Vlassov VV, Marcenes WS, Mekonnen W, Melaku YA, Yano Y, Artaman A, Campos I, MacLachlan J, Mueller U, Kim D, Trillini M, Eshrati B, Williams HC, Shibuya K, Dandona R, Murthy K, Cowie B, Amare AT, Antonio CA, Castañeda-Orjuela C, van Gool CH, Violante F, Oh IH, Deribe K, Soreide K, Knibbs L, Kereselidze M, Green M, Cardenas R, Roy N, Tillmann T, Tillman T, Li Y, Krueger H, Monasta L, Dey S, Sheikhbahaei S, Hafezi-Nejad N, Kumar GA, Sreeramareddy CT, Dandona L, Wang H, Vollset SE, Mokdad A, Salomon JA, Lozano R, Vos T, Forouzanfar M, Lopez A, Murray C, Naghavi M. The Global Burden of Cancer 2013. JAMA Oncol 2015; 1:505-27. [PMID: 26181261 PMCID: PMC4500822 DOI: 10.1001/jamaoncol.2015.0735] [Citation(s) in RCA: 1977] [Impact Index Per Article: 219.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Cancer is among the leading causes of death worldwide. Current estimates of cancer burden in individual countries and regions are necessary to inform local cancer control strategies. OBJECTIVE To estimate mortality, incidence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 28 cancers in 188 countries by sex from 1990 to 2013. EVIDENCE REVIEW The general methodology of the Global Burden of Disease (GBD) 2013 study was used. Cancer registries were the source for cancer incidence data as well as mortality incidence (MI) ratios. Sources for cause of death data include vital registration system data, verbal autopsy studies, and other sources. The MI ratios were used to transform incidence data to mortality estimates and cause of death estimates to incidence estimates. Cancer prevalence was estimated using MI ratios as surrogates for survival data; YLDs were calculated by multiplying prevalence estimates with disability weights, which were derived from population-based surveys; YLLs were computed by multiplying the number of estimated cancer deaths at each age with a reference life expectancy; and DALYs were calculated as the sum of YLDs and YLLs. FINDINGS In 2013 there were 14.9 million incident cancer cases, 8.2 million deaths, and 196.3 million DALYs. Prostate cancer was the leading cause for cancer incidence (1.4 million) for men and breast cancer for women (1.8 million). Tracheal, bronchus, and lung (TBL) cancer was the leading cause for cancer death in men and women, with 1.6 million deaths. For men, TBL cancer was the leading cause of DALYs (24.9 million). For women, breast cancer was the leading cause of DALYs (13.1 million). Age-standardized incidence rates (ASIRs) per 100 000 and age-standardized death rates (ASDRs) per 100 000 for both sexes in 2013 were higher in developing vs developed countries for stomach cancer (ASIR, 17 vs 14; ASDR, 15 vs 11), liver cancer (ASIR, 15 vs 7; ASDR, 16 vs 7), esophageal cancer (ASIR, 9 vs 4; ASDR, 9 vs 4), cervical cancer (ASIR, 8 vs 5; ASDR, 4 vs 2), lip and oral cavity cancer (ASIR, 7 vs 6; ASDR, 2 vs 2), and nasopharyngeal cancer (ASIR, 1.5 vs 0.4; ASDR, 1.2 vs 0.3). Between 1990 and 2013, ASIRs for all cancers combined (except nonmelanoma skin cancer and Kaposi sarcoma) increased by more than 10% in 113 countries and decreased by more than 10% in 12 of 188 countries. CONCLUSIONS AND RELEVANCE Cancer poses a major threat to public health worldwide, and incidence rates have increased in most countries since 1990. The trend is a particular threat to developing nations with health systems that are ill-equipped to deal with complex and expensive cancer treatments. The annual update on the Global Burden of Cancer will provide all stakeholders with timely estimates to guide policy efforts in cancer prevention, screening, treatment, and palliation.
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Affiliation(s)
- Christina Fitzmaurice
- Division of Hematology, Department of Medicine, University of Washington, Seattle2Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Daniel Dicker
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Amanda Pain
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Hannah Hamavid
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Maziar Moradi-Lakeh
- Institute for Health Metrics and Evaluation, University of Washington, Seattle3Gastrointestinal and Liver Disease Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Michael F MacIntyre
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Christine Allen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Gillian Hansen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Rachel Woodbrook
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | | | | | - Andrea Werdecker
- Institute of Medical Sociology and Social Medicine, Marburg, Germany
| | | | - Braden Te Ao
- Department of Biostatistics and Epidemiology, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland, New Zealand
| | - Brian McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Chante Karimkhani
- College of Physicians and Surgeons, Columbia University, New York, New York
| | - Chuanhua Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Wuhan University, Wuhan, China
| | | | - David C Schwebel
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama
| | - David O Carpenter
- Institute for Health and the Environment, University at Albany, Rensselaer, New York
| | - David M Pereira
- Laboratório de Farmacognosia, Departamento de Ciências Químicas, Faculdade de Farmácia, University do Porto, REQUIMTE/LAQV, Porto, Portugal
| | - Denis Nash
- School of Public Health, Hunter College Campus, City University of New York, New York
| | | | | | - Dietrich Plass
- Federal Environment Agency Section on Exposure Assessment and Environmental Health Indicators, Berlin, Germany
| | - Kingsley N Ukwaja
- Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria
| | - George D Thurston
- Nelson Institute of Environmental Medicine, New York University School of Medicine, Tuxedo, New York
| | - Kim Yun Jin
- Faculty of Chinese Medicine, Southern University College, Johor, Malaysia
| | - Edgar P Simard
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Eun-Kee Park
- Department of Medical Humanities and Social Medicine, Kosin University College of Medicine, Busan, South Korea
| | - Ferrán Catalá-López
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Medicines and Healthcare Products Agency (AEMPS), Ministry of Health, Madrid, Spain
| | | | - Carolyn Gotay
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gulfaraz Khan
- Department of Microbiology & Immunology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | | | - Itamar S Santos
- Centre for Clinical and Epidemiological Research, University of São Paulo, São Paulo, Brazil
| | | | - Jasvinder Singh
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Jost B Jonas
- Department of Ophthalmology, University of Heidelberg, Mannheim, Germany
| | | | - Juan Sanabria
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio38Nutrition and Preventive Medicine, Chicago Medical School at Cancer Treatment Centers of America, Rosalind Franklin University, Chicago, Illinois
| | - Justin Beardsley
- Nuffield Department of Medicine, Oxford University, Ho Chi Minh City, Vietnam
| | - Kathryn H Jacobsen
- Department of Global and Community Health, George Mason University, Fairfax, Virginia
| | - Ken Takahashi
- Department of Environmental Epidemiology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Richard C Franklin
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
| | - Luca Ronfani
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Marcella Montico
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Luigi Naldi
- Azienda Ospedaliera papa Giovanni XXIII, Bergamo, Italy
| | | | - Johanna Geleijnse
- Division of Human Nutrition, Wageningen University, Wageningen, the Netherlands
| | - Max Petzold
- Centre for Applied Biostatistics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden48School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | | - Paul Yip
- The University of Hong Kong, Hong Kong, China
| | - Farshad Pourmalek
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paulo A Lotufo
- Centre for Clinical and Epidemiological Research, University of São Paulo, São Paulo, Brazil
| | - Alireza Esteghamati
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Graeme J Hankey
- School of Medicine and Pharmacology, University of Western Australia, School of Medicine and Pharmacology, Perth, Australia
| | - Raghib Ali
- Nuffield Department of Population Health, University of Oxford, Oxford, England
| | - Raimundas Lunevicius
- Department of Neuropsychopharmacology, Aintree University Hospital NHS Foundation Trust, Liverpool, England
| | - Reza Malekzadeh
- Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Robert Dellavalle
- Veterans Affairs Eastern Colorado Health Care System, Denver61Department of Dermatology, University of Colorado School of Medicine, Denver
| | - Robert Weintraub
- University of Melbourne, Melbourne, Australia63Royal Children's Hospital, Melbourne, Australia
| | - Robyn Lucas
- National Centre for Epidemiology and Population Health, Research School of Population Health, The Australian National University, Canberra, Australia
| | - Roderick Hay
- International Foundation for Dermatology, London, England
| | - David Rojas-Rueda
- Centre of Research in Environmental Epidemiology (CREAL), Barcelona, Spain
| | | | - Sadaf G Sepanlou
- Digestive Diseases Research Institute, Shariati Hospital, Tehran, Iran
| | - Sandra Nolte
- Charité University Medicine Berlin, Berlin, Germany
| | - Scott Patten
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Ivy Shiue
- Northumbria University, Newcastle upon Tyne, England75University of Edinburgh, Edinburgh, Scotland
| | - Tim Driscoll
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Tommi Vasankari
- UKK Institute for Health Promotion Research, Tampere, Finland
| | | | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vasiliy V Vlassov
- National Research University Higher School of Economics, Moscow, Russia
| | - W S Marcenes
- Barts and The London School of Medicine and Dentistry, University of London, London, England
| | | | - Yohannes Adama Melaku
- College of Health Sciences, School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Yuichiro Yano
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | | | | | - Jennifer MacLachlan
- Victorian Infectious Diseases Reference Laboratory (VIDRL), The Peter Doherty Institute for Infection and Immunity, WHO Collaborating Centre for Viral Hepatitis, Melbourne, Australia
| | | | - Daniel Kim
- Department of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Matias Trillini
- Mario Negri Institute for pharmacological Research, Ranica, Italy
| | - Babak Eshrati
- Arak University of Medical Sciences and Health Affairs, Arak, Iran
| | | | | | - Rakhi Dandona
- Public Health Foundation of India, National Capital Region, India
| | - Kinnari Murthy
- Public Health Foundation of India, National Capital Region, India
| | - Benjamin Cowie
- Victorian Infectious Diseases Reference Laboratory (VIDRL), The Peter Doherty Institute for Infection and Immunity, WHO Collaborating Centre for Viral Hepatitis, Melbourne, Australia
| | - Azmeraw T Amare
- Department of Epidemiology, University of Groningen, Groningen, the Netherlands
| | | | | | - Coen H van Gool
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Francesco Violante
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - In-Hwan Oh
- Kyung Hee University, Seoul, South Korea
| | - Kedede Deribe
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia100Brighton and Sussex Medical School, Brighton, England
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway102University of Bergen, Stavanger, Norway
| | - Luke Knibbs
- Department of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | - Maia Kereselidze
- National Centre for Diseases Control and Public Health, Tbilisi, Georgia
| | - Mark Green
- University of Sheffield, Sheffield, England
| | | | - Nobhojit Roy
- Department of Public Health Sciences, Karolinska Institutet, Mumbai, India
| | | | | | - Yongmei Li
- Genentech Inc, San Francisco, California
| | - Hans Krueger
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lorenzo Monasta
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Subhojit Dey
- Indian Institute of Public Health, National Capital Region, India
| | - Sara Sheikhbahaei
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Hafezi-Nejad
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - G Anil Kumar
- Public Health Foundation of India, National Capital Region, India
| | | | - Lalit Dandona
- Institute for Health Metrics and Evaluation, University of Washington, Seattle93Public Health Foundation of India, National Capital Region, India
| | - Haidong Wang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Stein Emil Vollset
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway113Norwegian Institute of Public Health, Bergen, Norway
| | - Ali Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | - Rafael Lozano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle115National Institute of Public Health, Cuernavaca, Mexico
| | - Theo Vos
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | - Alan Lopez
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Christopher Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
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Qiao L, Li B, Long M, Wang X, Wang A, Zhang G. Accuracy of visual inspection with acetic acid and with Lugol's iodine for cervical cancer screening: Meta-analysis. J Obstet Gynaecol Res 2015; 41:1313-25. [PMID: 26014371 DOI: 10.1111/jog.12732] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 02/16/2015] [Accepted: 03/14/2015] [Indexed: 11/28/2022]
Abstract
The aim of this review was to provide an updated summary estimation of the accuracy of visual inspection with acetic acid (VIA) and with Lugol's iodine (VILI) in detecting cervical cancer and precancer. Studies on VIA/VILI accuracy were eligible in which VIA/VILI was performed on asymptomatic women who all underwent confirmatory testing of histology, combination of colposcopy and histology, or combination of multiple screening tests, colposcopy and histology, to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+ or CIN3+). A bivariate model was fitted to estimate the accuracy of VIA/VILI and provide estimates of heterogeneity. Subgroup analysis was used to investigate the source of heterogeneity. A total of 29 studies on VIA and 19 studies on VILI were included finally in the meta-analysis. The summary sensitivity and specificity of VIA for CIN2+ were 73.2% (95%CI: 66.5-80.0%) and 86.7% (95%CI: 82.9-90.4%), respectively, and those for VILI were 88.1% (95%CI: 81.5-94.7%) and 85.9% (95%CI: 81.7-90.0%), respectively. VIA and VILI were both more sensitive in detecting more severe outcome, although there was a slight loss in specificity. Apparent heterogeneity existed in sensitivity and specificity for both VIA and VILI. High sensitivity of both VIA and VILI for CIN2+ was found when a combination of colposcopy and histology was used as disease confirmation. VIA, VILI, even a combination of them in parallel, could be good options for cervical screening in low-resource settings. Significant differences in sensitivity between different gold standards might provide a proxy for optimization of ongoing cervical cancer screening programs.
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Affiliation(s)
- Liang Qiao
- Department of Cancer Prevention and Treatment, Sichuan Cancer Hospital and Institute and Sichuan Cancer Prevention and Treatment Center, Chengdu, China
| | - Bo Li
- Department of Cancer Prevention and Treatment, Sichuan Cancer Hospital and Institute and Sichuan Cancer Prevention and Treatment Center, Chengdu, China
| | - Mei Long
- Department of Cancer Prevention and Treatment, Sichuan Cancer Hospital and Institute and Sichuan Cancer Prevention and Treatment Center, Chengdu, China
| | - Xiao Wang
- Department of Cancer Prevention and Treatment, Sichuan Cancer Hospital and Institute and Sichuan Cancer Prevention and Treatment Center, Chengdu, China
| | - Anrong Wang
- Department of Cancer Prevention and Treatment, Sichuan Cancer Hospital and Institute and Sichuan Cancer Prevention and Treatment Center, Chengdu, China
| | - Guonan Zhang
- Department of Gynecologic Oncology, Sichuan Cancer Hospital and Institute and Sichuan Cancer Prevention and Treatment Center, Chengdu, China
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94
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Thulaseedharan JV, Malila N, Esmy PO, Muwonge R, Hakama M, Sankaranarayanan R. Risk of invasive cancer among women visually screened and colposcopy triaged by trained nurses in rural South India. Int J Gynaecol Obstet 2015; 129:104-8. [PMID: 25661324 DOI: 10.1016/j.ijgo.2014.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 11/11/2014] [Accepted: 01/22/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To estimate the long-term risk of cervical cancer among women screened by visual inspection with acetic acid (VIA) and to evaluate the benefit of additional colposcopy triage in rural south India. METHODS A retrospective analysis was conducted among 31 343 women who had undergone VIA at Dindigul district, India between January 1, 2000, and August 5, 2003, as part of a randomized screening trial. Women with positive VIA test results were offered colposcopy triage by trained nurses. Cervical cancer incidence data during follow-up (January 1, 2000, to December 31, 2012) were obtained from a regional cancer registry. RESULTS Among 3021 screen-positive women free of cancer at baseline, 2974 women underwent colposcopy; colposcopic abnormalities suggestive of precancerous lesions were detected among 2792 of these women (93.9%). Compared with the women with negative VIA screening results, the hazard ratio (HR) of cervical cancer during follow-up among the VIA-positive women without colposcopic abnormalities was 6.5 (95% confidence interval [CI], 1.6-27.1). The risk was similar among VIA-positive women with colposcopic abnormalities but without histological confirmation (HR5.2; 95% CI, 1.9-14.6). CONCLUSION The high risk of cancer among women without colposcopic abnormalities who tested positive by VIA suggested that screening without triage is potentially effective.
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Affiliation(s)
- Jissa V Thulaseedharan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India; School of Health Sciences, University of Tampere, Tampereen Yliopisto, Finland
| | - Nea Malila
- School of Health Sciences, University of Tampere, Tampereen Yliopisto, Finland; Finnish Cancer Registry, Pieni Roobertinkatu, Helsinki, Finland
| | - Pulikottil O Esmy
- Christian Fellowship Community Health Centre, Ambilikkai, Tamil Nadu, India
| | - Richard Muwonge
- Screening Group, International Agency for Research on Cancer, Lyon, France.
| | - Matti Hakama
- School of Health Sciences, University of Tampere, Tampereen Yliopisto, Finland; Finnish Cancer Registry, Pieni Roobertinkatu, Helsinki, Finland
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95
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McCree R, Giattas MR, Sahasrabuddhe VV, Jolly PE, Martin MY, Usdan SL, Kohler C, Lisovicz N. Expanding Cervical Cancer Screening and Treatment in Tanzania: Stakeholders' Perceptions of Structural Influences on Scale-Up. Oncologist 2015; 20:621-6. [PMID: 25926351 DOI: 10.1634/theoncologist.2013-0305] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 01/23/2015] [Indexed: 12/29/2022] Open
Abstract
UNLABELLED Tanzania has the highest burden of cervical cancer in East Africa. This study aims to identify perceived barriers and facilitators that influence scale-up of regional and population-level cervical cancer screening and treatment programs in Tanzania. Convenience sampling was used to select participants for this qualitative study among 35 key informants. Twenty-eight stakeholders from public-sector health facilities, academia, government, and nongovernmental organizations completed in-depth interviews, and a seven-member municipal health management team participated in a focus group discussion. The investigation identified themes related to the infrastructure of health services for cervical cancer prevention, service delivery, political will, and sociocultural influences on screening and treatment. Decentralizing service delivery, improving access to screening and treatment, increasing the number of trained health workers, and garnering political will were perceived as key facilitators for enhancing and initiating screening and treatment services. In conclusion, participants perceived that system-level structural factors should be addressed to expand regional and population-level service delivery of screening and treatment. IMPLICATIONS FOR PRACTICE Tanzanian women have a high burden of cervical cancer. Understanding the perceived structural factors that may influence screening coverage for cervical cancer and availability of treatment may be beneficial for program scale-up. This study showed that multiple factors contribute to the challenge of cervical cancer screening and treatment in Tanzania. In addition, it highlighted systematic developments aimed at expanding services. This study is important because the themes that emerged from the results may help inform programs that plan to improve screening and treatment in Tanzania and potentially in other areas with high burdens of cervical cancer.
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Affiliation(s)
- Renicha McCree
- Center for Global Health, National Cancer Institute, Rockville, Maryland, USA;
| | | | - Vikrant V Sahasrabuddhe
- National Cancer Institute, Rockville, Maryland, USA; Department of Global Health, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | | | - Connie Kohler
- Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Martin CE, Tergas AI, Wysong M, Reinsel M, Estep D, Varallo J. Evaluation of a single-visit approach to cervical cancer screening and treatment in Guyana: feasibility, effectiveness and lessons learned. J Obstet Gynaecol Res 2015; 40:1707-16. [PMID: 24888938 DOI: 10.1111/jog.12366] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 12/02/2013] [Indexed: 11/29/2022]
Abstract
AIM To evaluate a cervical cancer prevention project in Guyana utilizing visual inspection with acetic acid (VIA) and immediate cryotherapy in a single-visit approach; and to identify lessons learned to inform the improvement of cervical cancer prevention programs in Guyana and other low-resource settings. METHODS Service records from January 2009 to June 2012 were analyzed for 18 cervical cancer prevention sites across Guyana. Records included women's HIV status, data on visual inspection with acetic acid screening and treatment status for women's initial and 1-year follow-up screenings, provider training and retention. A process evaluation was conducted in 2011 to identify programmatic strengths and interventions for integration, scale-up and sustainability. RESULTS During the 42-month interval, 21,597 new screenings were performed, reaching 95% of HIV(+) women enrolled in care and 17% of women aged 25-49 years in Guyana. The VIA(+) rate was 13% (n = 2806); 85% of women eligible for cryotherapy received immediate treatment. Half of VIA(+) women treated with cryotherapy or loop electrosurgical excision procedure returned for a 1-year follow-up screening (n = 1027); 95% were VIA(-) at the second screening. Non-physician providers were more likely to continue offering services than physicians. Most programmatic challenges were related to systemic rather than technical/clinical issues. CONCLUSION The single-visit approach-based program is feasible, effective, and when scaled up, likely to have an impact on overall incidence of cervical cancer. Services can be shifted to non-physicians for scale-up of high-quality cervical cancer prevention services nationally. To ensure sustainability and expansion, support structures should be prioritized.
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Affiliation(s)
- Caitlin E Martin
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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Poomtavorn Y, Suwannarurk K. Accuracy of visual inspection with acetic acid in detecting high-grade cervical intraepithelial neoplasia in pre- and post-menopausal Thai women with minor cervical cytological abnormalities. Asian Pac J Cancer Prev 2015; 16:2327-31. [PMID: 25824759 DOI: 10.7314/apjcp.2015.16.6.2327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To determine the accuracy of visual inspection with acetic acid (VIA) in detecting high-grade cervical intraepithelial neoplasia (CIN) in pre- and post-menopausal women with atypical squamous cells of undetermined significance (ASC-US) and low grade squamous intraepithelial lesion (LSIL) Papanicolaou (Pap) smears. MATERIALS AND METHODS Two hundred women (150 pre-menopausal and 50 post-menopausal) with ASC- US and LSIL cytology who attended the colposcopy clinic, Thammasat University Hospital, between March 2013 and August 2014 were included. All women underwent VIA testing and colposcopy by gynecologic oncologists. Diagnostic values of VIA testing including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for detecting high-grade CIN were determined using the histopathology obtained from colposcopic-directed biopsy as a gold standard. RESULTS VIA testing was positive in 54/150 (36%) pre-menopausal women and 5/50 (10%) post-menopausal women. Out of 54 pre-menopausal women with positive VIA testing, 15 (27.8%) had high-grade CIN and 39 (72.2%) had either CIN 1 or insignificant pathology. Ten (10.4%), 43 (44.8%) and 43 (44.8%) out of the remaining 96 pre-menopausal women with negative VIA testing had high- grade CIN, CIN 1 and insignificant pathology, respectively. Out of 5 post-menopausal women with positive VIA testing, there were 4 (80%) women with high-grade CIN, and 1 (20%) women with insignificant pathology. Out of 45 VIA-negative post-menopausal women, 42 (93.3%) women had CIN 1 and insignificant pathology, and 3 (6.7%) had high-grade CIN. Sensitivity, specificity, PPV and NPV of the VIA testing were 59.4%, 76.2%, 32.2% and 90.8%, respectively (60%, 68.8%, 27.8% and 89.6% in pre-menopausal women and 57.1%, 97.7%, 80% and 93.3% in post-menopausal women). CONCLUSIONS VIA testing may be used as a screening tool for detecting high-grade CIN in women with minor cervical cytological abnormalities in a low-resource setting in order to lower the rate of colposcopy referral.
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Affiliation(s)
- Yenrudee Poomtavorn
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University Hospital, Pathumthani, Thailand E-mail :
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A multicountry evaluation of careHPV testing, visual inspection with acetic acid, and papanicolaou testing for the detection of cervical cancer. Int J Gynecol Cancer 2015; 24:576-85. [PMID: 24557438 PMCID: PMC4047307 DOI: 10.1097/igc.0000000000000084] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental digital content is available in the text. Objective This study evaluates the feasibility and performance of careHPV, a novel human papillomavirus (HPV) DNA test, when used for screening women for cervical cancer in low-resource settings. Methods and Materials Clinician-collected (cervical) and self-collected (vaginal) careHPV specimens, visual inspection with acetic acid (VIA), and Papanicolaou test were evaluated among 16,951 eligible women in India, Nicaragua, and Uganda. Women with positive screening results received colposcopy and histologic follow-up as indicated. The positivity of each screening method was calculated overall, by site, and age. In addition, the clinical performance of each screening test was determined for detection of cervical intraepithelial neoplasia (CIN) grade 2 (CIN2+) and CIN grade 3. Results Moderate or severe dysplasia or cancer (taken together as CIN2+) was diagnosed in 286 women. The positivity rate ranged between 2.4% to 19.6% for vaginal careHPV, 2.9% to 20.2% for cervical careHPV, 5.5% to 34.4% for VIA, and 2.8% to 51.8% for Papanicolaou test. Cervical careHPV was the most sensitive for CIN2+ (81.5%; 95% confidence interval [CI], 76.5–85.8) and CIN grade 3 (85.3%; 95% CI, 78.6–90.6) at all sites, followed by vaginal careHPV (69.6% and 71.3%, respectively). The sensitivity of VIA ranged from 21.9% to 73.6% and Papanicolaou test from 40.7% to 73.7%. The pooled specificities of cervical careHPV, vaginal careHPV, VIA, and Papanicolaou test were 91.6%, 90.6%, 84.2%, and 87.7%, respectively. Conclusions careHPV performed well in large multicountry demonstration studies conducted in resource-limited settings that have not previously been conducted this type of testing; its sensitivity using cervical samples or vaginal self-collected samples was better than VIA or Papanicolaou test. The feasibility of using careHPV in self-collected vaginal samples opens the possibility of increasing coverage and early detection in resource-constrained areas.
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Crofts V, Flahault E, Tebeu PM, Untiet S, Fosso GK, Boulvain M, Vassilakos P, Petignat P. Education efforts may contribute to wider acceptance of human papillomavirus self-sampling. Int J Womens Health 2015; 7:149-54. [PMID: 25674016 PMCID: PMC4321569 DOI: 10.2147/ijwh.s56307] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Information about women's acceptance of new screening methods in Sub-Saharan Africa is limited. The aim of this study was to report on women's acceptance of human papillomavirus (HPV) self-sampling following an educational intervention on cervical cancer and HPV. METHODS Women were recruited from the city of Tiko and a low-income neighborhood of Yaoundé, both in Cameroon. Written and oral instructions about how to perform an unsupervised HPV self-sample were given to participants, who performed the test in a private room. Acceptability of HPV self-sampling was evaluated by questionnaire. Participants previously screened for cervical cancer by a physician were asked additional questions to assess their personal preferences about HPV self-sampling. RESULTS A sample of 540 women were prospectively enrolled in the study; median age was 43 years old (range 30-65 years). Participants expressed a high level of acceptance of HPV self-sampling as a screening method following information sessions about cervical cancer and HPV. Most expressed no embarrassment, pain, anxiety, or discomfort (95.6%, 87.8%, 91.3%, and 85.0%, respectively) during the information sessions. Acceptance of the method had no correlation with education, knowledge, age, or socio-professional class. Eighty-six women (16%) had a history of previous screening; they also reported high acceptance of HPV self-sampling. CONCLUSION Educational interventions on cancer and HPV were associated with high acceptability of HPV self-testing by Cameroonian women. Further evaluation of the intervention in a larger sample and using a control group is recommended.
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Affiliation(s)
- Victoria Crofts
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Pierre-Marie Tebeu
- Department of Gynecology and Obstetrics, University Center Hospital, Yaoundé, Cameroon
| | - Sarah Untiet
- Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Gisèle Kengne Fosso
- Department of Gynecology and Obstetrics, University Center Hospital, Yaoundé, Cameroon
| | - Michel Boulvain
- Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
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100
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Almonte M, Ferreccio C, Luciani S, Gonzales M, Delgado JM, Santos C, Alvarez M, Cuzick J, Sasieni P. Visual inspection after acetic acid (VIA) is highly heterogeneous in primary cervical screening in Amazonian Peru. PLoS One 2015; 10:e0115355. [PMID: 25635965 PMCID: PMC4312028 DOI: 10.1371/journal.pone.0115355] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 11/22/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Conventional cytology (Pap) and visual inspection after the application of acetic acid (VIA) are currently used in primary screening in Peru. Studies suggest that the quality of VIA is highly variable. Over 36 000 women were screened with Pap and VIA in the TATI (Tamizaje y Tratamiento Inmediato de Lesiones Cervico-uterinas) project conducted in Amazonian Peru. Within a nested study to compare several screening techniques (C-TATI), a total of 5435 women were additionally screened with liquid-based cytology (LBC) and high-risk human papillomavirus testing (HR-HPV). We investigate the variation of positivity rates of VIA, Pap, LBC and HR-HPV in C-TATI and of VIA in the full TATI intervention. METHODS At the screening visit, midwives collected three cervical samples for Pap, LBC and HC2 before performing VIA. The dispersion factor "D" (D = Pearson chi-square value/degrees-of-freedom) was used to measure the variability of tests results. Within C-TATI, the variability of positivity rates of VIA, Pap, LBC and HR-HPV was also graphically assessed with box- and scatter plots by midwife and month of screening. Funnel plots and smoothed scatter plots were used to correlate the variation of VIA by the number of examinations performed by each midwife over the full TATI intervention. RESULTS Consistently over TATI, VIA results were highly variable, independently of the examiner, the time when the test was performed and the number of tests the examiner performed (D>6, p-values<0.001). In C-TATI, VIA results varied the most while those of HR-HPV varied the least (Ds>25, p-values<0.001 for VIA, Ds<1.6, p-values>0.05 for HR-HPV). No evidence for correlation between the number of VIAs done per midwife and the variability of VIA results was observed. CONCLUSION The lack of over-dispersion for HR-HPV detection suggests that the variable VIA results do not reflect true variation in underlying disease, but a lack of consistency in human judgement.
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Affiliation(s)
- Maribel Almonte
- International Agency for Research on Cancer, Lyon, France
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Catterina Ferreccio
- Advanced Center for Chronic Diseases, ACCDIS-FONDAP, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Silvana Luciani
- Pan American Health Organization (PAHO), Washington, DC, United States of America
| | | | | | - Carlos Santos
- Instituto Nacional de Enfermedades Neoplásicas, Lima, Perú
| | - Manuel Alvarez
- Instituto Nacional de Enfermedades Neoplásicas, Lima, Perú
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Peter Sasieni
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
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