51
|
Liang Y, Chen M, Qin L, Wan B, Wang H. A meta-analysis of the relationship between vaginal microecology, human papillomavirus infection and cervical intraepithelial neoplasia. Infect Agent Cancer 2019; 14:29. [PMID: 31673281 PMCID: PMC6815368 DOI: 10.1186/s13027-019-0243-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/05/2019] [Indexed: 01/08/2023] Open
Abstract
Microecology is an emerging discipline in recent years. The female reproductive tract is an important microecological region, and its microecological environment can directly affect women's cervical health. This meta-analysis aimed to analyze the effects of vaginal microecology on Human papillomavirus (HPV) infection and cervical intraepithelial neoplasia (CIN). PubMed and Web of Science were systematically searched for eligible publications from January 2000 to December 2017. Articles were selected on the basis of specific inclusion and exclusion criteria. The design and quality of all studies were evaluated using the Newcastle-Ottawa Scale (NOS). Odds ratios (ORs) with a 95% confidence interval (95% CI) were calculated. Thirteen eligible studies were selected to evaluate the association of vaginal microecology with HPV infection and CIN. The factors related to HPV infection were bacterial vaginosis (BV) (OR 2.57, 95% CI 1.78-3.71, P<0.05), Candida albicans (VVC) (OR 0.63, 95% CI 0.49-0.82, P < 0.05), Chlamydia trachomatis (CT) (OR 3.16, 95% CI 2.55-3.90, P < 0.05), and Ureaplasma urealyticum (UU) (OR 1.35, 95% CI 1.20-1.51, P < 0.05). BV was also related to CIN (OR 1.56, 95% CI 1.21-2.00, P < 0.05). This meta-analysis of available literature suggested an intimate association of vaginal microecology and HPV infection with CIN. BV, CT and UU were associated to increased HPV infection, VVC was associated to decreased HPV infection, Lactobacillus is not associated to increased HPV infection, BV was associated to increased CIN development risk. Further large-scale studies are needed to confirm our findings.
Collapse
Affiliation(s)
- Yuejuan Liang
- The Department of Gynecological of Guangxi Medical University Cancer Hospital, Nanning City, 530021 Guangxi Zhuang Autonomous Region China
| | - Mengjie Chen
- The Department of Gynecological of Guangxi Medical University Cancer Hospital, Nanning City, 530021 Guangxi Zhuang Autonomous Region China
| | - Lu Qin
- The Department of Gynecological of Guangxi Medical University Cancer Hospital, Nanning City, 530021 Guangxi Zhuang Autonomous Region China
| | - Bing Wan
- The Department of Gynecological of Guangxi Medical University Cancer Hospital, Nanning City, 530021 Guangxi Zhuang Autonomous Region China
| | - He Wang
- The Department of Gynecological of Guangxi Medical University Cancer Hospital, Nanning City, 530021 Guangxi Zhuang Autonomous Region China
| |
Collapse
|
52
|
Beiersdorf J, Scheungraber C, Wunsch K, Schmitz M, Hansel A, Hoyer H, Gajda M, Greinke C, Runnebaum IB, Dürst M, Backsch C. Combined assessment of 3q26 amplification and promoter methylation in patients with high grade cervical lesions show age specific differences. Genes Chromosomes Cancer 2019; 59:168-177. [PMID: 31631454 DOI: 10.1002/gcc.22818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 12/21/2022] Open
Abstract
A considerable proportion of high grade cervical intraepithelial lesions (CIN2/3) are known to resolve on their own especially among young women. However, since reliable prognostic markers are still lacking, the diagnosis "CIN3" is still an indication for surgery which may result in overtreatment. It is conceivable that a combination of different, ideally independent molecular markers may provide more reliable results. In the present cross-sectional study two established triage markers, 3q26 amplification and a methylation signature, were evaluated in an age-dependent manner. The patient cohort comprised 60 patients with histologically confirmed CIN2/3 in two equally sized age groups (<30 years, ≥30 years). Cervical scrapes were analyzed by interphase fluorescence in situ hybridization for 3q26 amplification and methylation specific PCR (GynTect®) for six different genome regions. Both assays showed a significantly different pattern of test outcome independent of age (P = .001). Moreover, the combination of both assays differed significantly for double positive and double negative cases when comparing the two age groups: In patients <30 years there were clearly less cases with positive methylation signature and amplification of 3q26 as in women ≥30 years (23% vs 63%, Bonferroni adjusted P = .016). Of particular interest is the finding that double negative results were exclusive for the young age group (0% vs 27%, Bonferroni adjusted P = .020). Since regression of CIN2/3 characteristically occurs among young women it is tempting to speculate that a double negative test result could be prognostic for regression of CIN2/3. This will have to be investigated further in a prospective longitudinal intervention study.
Collapse
Affiliation(s)
- Josefine Beiersdorf
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Cornelia Scheungraber
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | | | | | | | - Heike Hoyer
- Institute of Medical Statistics, Information Sciences and Documentation, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Mieczyslaw Gajda
- Institute of Pathology, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Christiane Greinke
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Ingo B Runnebaum
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Matthias Dürst
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Claudia Backsch
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| |
Collapse
|
53
|
Human Papillomavirus Infection and Cervical Cancer: Epidemiology, Screening, and Vaccination-Review of Current Perspectives. JOURNAL OF ONCOLOGY 2019; 2019:3257939. [PMID: 31687023 PMCID: PMC6811952 DOI: 10.1155/2019/3257939] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/04/2019] [Accepted: 09/09/2019] [Indexed: 02/07/2023]
Abstract
Viral infections contribute as a cause of 15–20% of all human cancers. Infection by oncogenic viruses can promote different stages of carcinogenesis. Among many types of HPV, around 15 are linked to cancer. In spite of effective screening methods, cervical cancer continues to be a major public health problem. There are wide differences in cervical cancer incidence and mortality by geographic region. In addition, the age-specific HPV prevalence varies widely across different populations and showed two peaks of HPV positivity in younger and older women. There have been many studies worldwide on the epidemiology of HPV infection and oncogenic properties due to different HPV genotypes. However, there are still many countries where the population-based prevalence has not yet been identified. Moreover, cervical cancer screening strategies are different between countries. Organized cervical screening programs are potentially more effective than opportunistic screening programs. Nevertheless, screening programs have consistently been associated with a reduction in cervical cancer incidence and mortality. Developed countries have achieved such reduced incidence and mortality from cervical cancer over the past 40 years. This is largely due to the implementation of organized cytological screening and vaccination programs. HPV vaccines are very effective at preventing infection and diseases related to the vaccine-specific genotypes in women with no evidence of past or current HPV infection. In spite of the successful implementation of the HPV vaccination program in many countries all over the world, problems related to HPV prevention and treatment of the related diseases will continue to persist in developing and underdeveloped countries.
Collapse
|
54
|
Salazar KL, Duhon DJ, Olsen R, Thrall M. A review of the FDA-approved molecular testing platforms for human papillomavirus. J Am Soc Cytopathol 2019; 8:284-292. [PMID: 31320315 DOI: 10.1016/j.jasc.2019.06.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The advent of US Food and Drug Administration (FDA)-approved molecular testing for human papillomavirus (HPV) has resulted in a dramatic shift from cytological testing alone to a combination of cytology and molecular testing for primary HPV screening. HPV testing has quickly become an essential component of daily practice in most laboratories and clinical practices. Although the principle of HPV testing is now familiar, it is important to understand the mechanisms behind these platforms in order to properly interpret the results and understand the limits of each method. HPV tests are more automated and reproducible than cytology, but are by no means perfect. None of these platforms will identify every HSIL/CIN2+ or cancer. This fact must be kept in mind when correlating the results of HPV testing with cytology or biopsy findings. The goal of this paper is to review the FDA- approved molecular testing platforms for HPV, including methodology, limitations, and specifications. The concordance between the platforms will also be discussed. Package inserts of the 5 FDA- approved molecular testing platforms for HPV, as well as a literature review of the platforms, were reviewed and assimilated into the article. Due to the multiple modalities available for detection of hrHPV, the concordance between these assays becomes important. Prior publications have compared HC2, Cervista, cobas, and Aptima, with most studies comparing to HC2 because it is considered the reference standard. With the newly approved BD platform, concordance studies were reviewed as well.
Collapse
Affiliation(s)
- Katrina L Salazar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Daniel J Duhon
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas.
| | - Randall Olsen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Michael Thrall
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| |
Collapse
|
55
|
Liu D, Hu W. Combined dynamic spectral imaging and routine colposcopy strategy for the diagnosis of pre-cancerous cervical lesions. Exp Ther Med 2019; 18:1521-1526. [PMID: 31410104 PMCID: PMC6676200 DOI: 10.3892/etm.2019.7719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 12/21/2018] [Indexed: 01/01/2023] Open
Abstract
The present study aimed to investigate the sensitivity and specificity of combined dynamic spectral imaging (DySI) and routine colposcopy in diagnosing pre-cancerous lesions in subjects with abnormal cytological results. The retrospective study included 146 patients diagnosed with cervical lesions and atypical squamous cells of undetermined significance according to a colposcopy examination. Data from colposcopy clinics were used to evaluate performance of DySI in different histological types. The present study evaluated the clinical performance of two different referral strategies (single diagnosis or combined diagnosis) in combination with a smear test. The sensitivity of DySI and routine colposcopy for detecting severe pre-cancerous cervical disease in patients referred with a borderline histology or mild dyskaryosis was 69% [95% confidence interval (CI): 56-82%] and 43% (95% CI: 28-57%), respectively (P=0.01). However, for the HSIL group, the sensitivity of DySI and routine colposcopy was 64 and 61%, respectively. In the HSIL group, the sensitivity was as high as 85% when the DySI method was combined with routine colposcopy. When the conditions of new screening strategies were applied to remove those patients with a negligible risk, DySI had a higher sensitivity to detect severe pre-cancerous cervical disease than conventional colposcopy. In conclusion, the combined DySI and routine colposcopy strategy had a higher diagnostic sensitivity in subjects with low or high abnormalities on cytological examination, compared with either method separately. The present study suggests that the baseline colposcopy sensitivity may be enhanced with the adjunctive use of DySI, irrespective of the cytology result for referral.
Collapse
Affiliation(s)
- Dan Liu
- Department of Medicine, Jinggangshan University, Ji'an, Jiangxi 343009, P.R. China
| | - Wanliang Hu
- Department of Medicine, Jinggangshan University, Ji'an, Jiangxi 343009, P.R. China
| |
Collapse
|
56
|
Miralpeix E, Solé-Sedeño JM, Agramunt S, Lloveras B, Gimeno R, Alameda F, Carreras R, Mancebo G. Role of Chlamydia trachomatis serology in conservative management of cervical intraepithelial neoplasia grade 2. Int J Gynaecol Obstet 2019; 147:43-48. [PMID: 31272132 DOI: 10.1002/ijgo.12903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/21/2019] [Accepted: 07/02/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the spontaneous progression of cervical intraepithelial neoplasia grade 2 (CIN2) in accordance with Chlamydia trachomatis (chlamydia) serology. METHODS A prospective observational study included women diagnosed with CIN2 by cervical biopsy and managed conservatively for 24 months at Hospital del Mar, Barcelona, between December 2011 and October 2013. Serum anti-chlamydia immunoglobulin G (IgG), previous cytology, and high-risk human papillomavirus (HPV) genotyping were recorded at baseline. The outcome was regression, persistence, or progression of CIN2. RESULTS Overall, 93 women aged 18-56 years were enrolled. Spontaneous regression was observed for 61 (66%) women, and 21 (23%) progressed to CIN3. Eight (9%) women had chlamydia seropositivity at baseline. Multivariate analysis showed that anti-chlamydia IgG seropositivity (odds ratio [OR], 19.1; 95% confidence interval [CI], 1.9-189.7), previous high-grade squamous intraepithelial lesion cytology (OR, 5.0; 95% CI, 1.7-14.6), and HPV16 (OR, 4.8; 95% CI, 1.7-13.7) increased the risk of CIN2 persistence or progression. CONCLUSION Women with CIN2 and chlamydia IgG seropositivity had increased risk of progression to CIN2+ and immediate treatment may be recommended for these women. Larger clinical studies are needed to confirm the results, but chlamydia serology might be introduced into CIN2 management to better individualize treatment.
Collapse
Affiliation(s)
- Ester Miralpeix
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep-Maria Solé-Sedeño
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sílvia Agramunt
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Belen Lloveras
- Department of Pathology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ramon Gimeno
- Department of Immunology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Alameda
- Department of Pathology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ramon Carreras
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gemma Mancebo
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
57
|
Murall CL, Rahmoun M, Selinger C, Baldellou M, Bernat C, Bonneau M, Boué V, Buisson M, Christophe G, D’Auria G, Taroni FD, Foulongne V, Froissart R, Graf C, Grasset S, Groc S, Hirtz C, Jaussent A, Lajoie J, Lorcy F, Picot E, Picot MC, Ravel J, Reynes J, Rousset T, Seddiki A, Teirlinck M, Tribout V, Tuaillon É, Waterboer T, Jacobs N, Bravo IG, Segondy M, Boulle N, Alizon S. Natural history, dynamics, and ecology of human papillomaviruses in genital infections of young women: protocol of the PAPCLEAR cohort study. BMJ Open 2019; 9:e025129. [PMID: 31189673 PMCID: PMC6576111 DOI: 10.1136/bmjopen-2018-025129] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Human papillomaviruses (HPVs) are responsible for one-third of all cancers caused by infections. Most HPV studies focus on chronic infections and cancers, and we know little about the early stages of the infection. Our main objective is to better understand the course and natural history of cervical HPV infections in healthy, unvaccinated and vaccinated, young women, by characterising the dynamics of various infection-related populations (virus, epithelial cells, vaginal microbiota and immune effectors). Another objective is to analyse HPV diversity within hosts, and in the study population, in relation to co-factors (lifestyle characteristics, vaccination status, vaginal microbiota, human genetics). METHODS AND ANALYSIS The PAPCLEAR study is a single center longitudinal study following 150 women, aged 18-25 years, for up to 2 years. Visits occur every 2 or 4 months (depending on HPV status) during which several variables are measured, such as behaviours (via questionnaires), vaginal pH, HPV presence and viral load (via qPCR), local concentrations of cytokines (via MesoScale Discovery technology) and immune cells (via flow cytometry). Additional analyses are outsourced, such as titration of circulating anti-HPV antibodies, vaginal microbiota sequencing (16S and ITS1 loci) and human genotyping. To increase the statistical power of the epidemiological arm of the study, an additional 150 women are screened cross-sectionally. Finally, to maximise the resolution of the time series, participants are asked to perform weekly self-samples at home. Statistical analyses will involve classical tools in epidemiology, genomics and virus kinetics, and will be performed or coordinated by the Centre National de la Recherche Scientifique (CNRS) in Montpellier. ETHICS AND DISSEMINATION This study has been approved by the Comité de Protection des Personnes Sud Méditerranée I (reference number 2016-A00712-49); by the Comité Consultatif sur le Traitement de l'Information en matière de Recherche dans le domaine de la Santé (reference number 16.504); by the Commission Nationale Informatique et Libertés (reference number MMS/ABD/AR1612278, decision number DR-2016-488) and by the Agence Nationale de Sécurité du Médicament et des Produits de Santé (reference 20160072000007). Results will be published in preprint servers, peer-reviewed journals and disseminated through conferences. TRIAL REGISTRATION NUMBER NCT02946346; Pre-results.
Collapse
Affiliation(s)
| | | | | | - Monique Baldellou
- Center for Free Information, Screening and Diagnosis (CGIDD), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Claire Bernat
- MIVEGEC (UMR 5290 CNRS, IRD, UM), CNRS, Montpellier, France
| | - Marine Bonneau
- Department of Obstetrics and Gynaecology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Vanina Boué
- MIVEGEC (UMR 5290 CNRS, IRD, UM), CNRS, Montpellier, France
| | - Mathilde Buisson
- Department of Research and Innovation (DRI), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Guillaume Christophe
- Center for Free Information, Screening and Diagnosis (CGIDD), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Giuseppe D’Auria
- CIBER en Epidemiología y Salud Pública (CIBEResp), Madrid, Spain
- Sequencing and Bioinformatics Service, Fundaciónpara el Fomento de la Investigación Sanitaria y Biomédica de laComunidad Valenciana (FISABIO-Salud Pública), Valencia, Spain
| | - Florence De Taroni
- Center for Free Information, Screening and Diagnosis (CGIDD), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Vincent Foulongne
- Pathogenesis and Control of Chronic Infections, INSERM, CHU, University of Montpellier, Montpellier, France
- Department of Virology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Rémy Froissart
- MIVEGEC (UMR 5290 CNRS, IRD, UM), CNRS, Montpellier, France
| | - Christelle Graf
- Department of Obstetrics and Gynaecology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Sophie Grasset
- MIVEGEC (UMR 5290 CNRS, IRD, UM), CNRS, Montpellier, France
- Center for Free Information, Screening and Diagnosis (CGIDD), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Soraya Groc
- MIVEGEC (UMR 5290 CNRS, IRD, UM), CNRS, Montpellier, France
- Department of Virology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Christophe Hirtz
- LBPC/PPC- IRMB, CHU de Montpellier and Université de Montpellier, Montpellier, France
| | - Audrey Jaussent
- Department of Medical Information (DIM), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Julie Lajoie
- Department of Medical microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frédérique Lorcy
- Department of pathology and oncobiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Eric Picot
- Center for Free Information, Screening and Diagnosis (CGIDD), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Marie-Christine Picot
- Department of Medical Information (DIM), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jacques Reynes
- Department of Infectious and Tropical Diseases, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Thérèse Rousset
- Department of pathology and oncobiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Aziza Seddiki
- Department of Research and Innovation (DRI), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Martine Teirlinck
- Center for Free Information, Screening and Diagnosis (CGIDD), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Vincent Tribout
- Center for Free Information, Screening and Diagnosis (CGIDD), Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Édouard Tuaillon
- Pathogenesis and Control of Chronic Infections, INSERM, CHU, University of Montpellier, Montpellier, France
- Department of Virology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Tim Waterboer
- German Cancer Research Center (DKFZ), Infections and Cancer Epidemiology, Heidelberg, Germany
| | - Nathalie Jacobs
- GIGA-Research, Cellular and molecular immunology, University of Liège, Liège, Belgium
| | | | - Michel Segondy
- Pathogenesis and Control of Chronic Infections, INSERM, CHU, University of Montpellier, Montpellier, France
- Department of Virology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Nathalie Boulle
- Pathogenesis and Control of Chronic Infections, INSERM, CHU, University of Montpellier, Montpellier, France
- Department of pathology and oncobiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Samuel Alizon
- MIVEGEC (UMR 5290 CNRS, IRD, UM), CNRS, Montpellier, France
| |
Collapse
|
58
|
Decker K, Baines N, Muzyka C, Lee M, Mayrand MH, Yang H, Fung S, Mercer D, McFaul S, Kupets R, Savoie R, Lotocki R, Bentley J. Measuring colposcopy quality in Canada: development of population-based indicators. ACTA ACUST UNITED AC 2019; 26:e286-e291. [PMID: 31285670 DOI: 10.3747/co.26.4709] [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] [Indexed: 11/15/2022]
Abstract
Background Colposcopy is a key part of cervical cancer control. As cervical cancer screening and prevention strategies evolve, monitoring colposcopy performance will become even more critical. In the present paper, we describe population-based colposcopy quality indicators that are recommended for ongoing measurement by cervical cancer screening programs in Canada. Methods The Pan-Canadian Cervical Cancer Screening Network established a multidisciplinary expert working group to identify population-based colposcopy quality indicators. A systematic literature review was conducted to ascertain existing population and program-level colposcopy quality indicators. A systems-level cervical cancer screening pathway describing each step from an abnormal screening test, to colposcopy, and back to screening was developed. Indicators from the literature were assigned a place on the pathway to ensure that all steps were measured. A prioritization matrix scoring system was used to score each indicator based on predetermined criteria. Proposed colposcopy quality indicators were shared with provincial and territorial screening programs and subsequently revised. Results The 10 population-based colposcopy quality indicators identified as priorities were colposcopy uptake, histologic investigation (biopsy) rate, colposcopy referral rate, failure to attend colposcopy, treatment frequency in women 18-24 years of age, re-treatment proportion, colposcopy exit-test proportion, histologic investigation (biopsy) frequency after low-grade Pap test results, length of colposcopy episode of care, and operating room treatment rate. Two descriptive indicators were also identified: colposcopist volume and number of colposcopists per capita. Summary High-quality colposcopy services are an essential component of provincial cervical cancer screening programs. The proposed quality and descriptive indicators will permit colposcopy outcomes to be compared between provinces and across Canada so as to identify opportunities for improving colposcopy services.
Collapse
Affiliation(s)
- K Decker
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB.,Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB
| | - N Baines
- Canadian Partnership Against Cancer, Toronto, ON
| | - C Muzyka
- Department of Epidemiology, CancerCare Manitoba, Winnipeg, MB
| | | | - M H Mayrand
- Departments of Obstetrics and Gynecology and Social and Preventive Medicine, Université de Montréal, Montreal, QC
| | - H Yang
- Population, Public and Aboriginal Health, Alberta Health Services, Calgary, AB
| | - S Fung
- Canadian Partnership Against Cancer, Toronto, ON
| | - D Mercer
- Cervical Screening Initiatives Program, Eastern Health, St. John's, NL
| | - S McFaul
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON
| | - R Kupets
- Ontario Cervical Screening Program, Cancer Care Ontario, Toronto, ON
| | - R Savoie
- New Brunswick Department of Health, Fredericton, NB
| | - R Lotocki
- CervixCheck Manitoba, CancerCare Manitoba, Winnipeg, MB
| | - J Bentley
- Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, NS
| |
Collapse
|
59
|
Koeneman MM, Hendriks N, Kooreman LFS, Winkens B, Kruitwagen RFPM, Kruse AJ. Prognostic factors for spontaneous regression of high-risk human papillomavirus-positive cervical intra-epithelial neoplasia grade 2. Int J Gynecol Cancer 2019; 29:1003-1009. [DOI: 10.1136/ijgc-2019-000343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/03/2019] [Accepted: 04/08/2019] [Indexed: 12/11/2022] Open
Abstract
IntroductionSince the implementation of human papillomavirus (HPV)-based screening for cervical cancer, the majority of cervical intra-epithelial neoplasia grade 2 (CIN2) lesions are high-risk (hr)HPV positive. Evidence on prognostic factors in hrHPV-positive CIN2 is lacking, hampering the individual counseling of women undergoing observation as routine management. The aim of this study is to identify prognostic factors for the spontaneous regression of hrHPV-positive CIN2.MethodsA retrospective cohort study was conducted at the Maastricht University Medical Center, the Netherlands. Women with hrHPV-positive CIN2 who underwent observation between January 1, 2000 and April 30, 2013 were included. Regression was defined as Pap 1/2 cytology (normal or atypical squamous cells of undetermined significance (ASCUS) cytology) or ≤CIN1 histology at the 24 month follow-up and no diagnosis of ≥CIN2 before the 24 month follow-up visit. Potential prognostic factors (HPV-16/18, p16 staining, KI67 staining, age, smoking status, last Pap smear result, multiple CIN2 lesions, oral contraception use, and parity) were assessed using logistic regression analysis.ResultsA total of 56 women were included in the study, of which 34 (61%) showed spontaneous regression of their lesion. Of all studied potential prognostic factors, only not smoking and nulliparity were significantly associated with disease regression (OR 3.84, 95% CI 1.04 to 14.21, and OR 5.00, 95% CI 1.32 to 19.00, respectively, in the univariate analysis). Both effects remained significant after correction for age and HPV-16/18 in a multivariable regression analysis. In women who smoked, disease regression occurred in 10 of 22 women (46%), compared with 16 of 21 women (76%) who did not smoke. In parous women, regression occurred in 12 of 27 women (44%), compared with 16 of 20 nulliparous women (80%).DiscussionSmoking status and parity may influence the likelihood of disease regression in hrHPV-positive CIN2. These factors could be considered in individual patient counseling regarding the choice between immediate treatment or conservative management.
Collapse
|
60
|
Nagele E, Trutnovsky G, Greimel E, Dorfer M, Haas J, Reich O. Do different treatment strategies influence women's level of psychosexual distress? Observational cohort study of women with premalignant HPV-associated genital lesions. Eur J Obstet Gynecol Reprod Biol 2019; 236:205-209. [PMID: 30965187 DOI: 10.1016/j.ejogrb.2019.03.028] [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: 02/12/2019] [Revised: 03/28/2019] [Accepted: 03/31/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine the impact of different treatment strategies - surgical treatment or watchful waiting- on sexual activity, psychosocial distress, and fear of progression in women with Human Papillomavirus (HPV)-associated premalignant genital lesions. STUDY DESIGN Observational cohort study of women diagnosed with HPV-associated premalignant lesions of the cervix, vagina or vulva. Patients were stratified into two groups depending on the severity of their premalignancy: surgical treatment or watchful waiting. Validated patient administered questionnaires, i.e. Fear of Progression questionnaire (FoP-Q), Cervical Dysplasia Distress Questionnaire (CDDQ), and Sexual Activity Questionnaire (SAQ) were completed after clinical evaluation (baseline), at 6- and 12-months follow-ups. RESULTS 209 women treated with surgery (N = 125) were compared with women who were monitored in regular intervals (N = 82). During an observational period of 12 months there were no significant differences in fear of progression, psychosocial distress, and sexual activity (p > 0.05). The level of concerns and anxiety about the future, and fear of progression were present, mostly at baseline. While there was a small increase of tension from visit to visit in both groups, patients generally were able to cope with their clinical situation quite well. CONCLUSIONS Fear of progression, psychosocial distress and sexual activity in women with precancerous HPV- associated premalignant genital lesions seem to be independent from type of treatment. Both treatment strategies may be applied without major psychological sequelae, as long as adequate information is provided.
Collapse
Affiliation(s)
- Eva Nagele
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
| | - Gerda Trutnovsky
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria.
| | - Elfriede Greimel
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
| | - Martha Dorfer
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
| | - Josef Haas
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
| | - Olaf Reich
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
| |
Collapse
|
61
|
Marquardt K, Ziemke P, Neumann K. Three-Tiered versus Two-Tiered Classification of Squamous Dysplasia in Cervical Cytology: Results of a Follow-Up Study. Acta Cytol 2018; 63:44-49. [PMID: 30517915 DOI: 10.1159/000494984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/29/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Regarding cytological findings of squamous dysplasia, a comparison was made between a three-tiered classification - low-grade squamous intraepithelial lesion (LSIL), high-grade SIL/cervical intraepithelial neoplasia 2 (HSIL/CIN2), and HSIL/CIN3 - and a two-tiered classification - LSIL and HSIL. The respective risk for CIN2+ and CIN3+ was calculated to make decisions regarding management. METHODS A total of 2,949 women with first-time cytologic findings of squamous dysplasia (LSIL, HSIL/CIN2, or HSIL/CIN3) between January 2013 and June 2016 were enrolled. Subsequent cytological findings and histological diagnoses were evaluated until August 2018. For each category of findings, the risk for CIN2+ and CIN3+ was determined by Kaplan-Meier estimates. The differences in risk between the cytological categories were checked for significance using the log-rank test. RESULTS For the categories LSIL, HSIL/CIN2, and HSIL/CIN3, the risk for CIN2+ after 12, 24, and 60 months was 3.4, 9.4, and 23.3%; 35.2, 44.8, and 59.8%; and 95.5, 97.8, and 98.9%, respectively. For CIN3+ the risk was 2.0, 5.5, and 13.5%; 28.6, 35.6, and 48.3%; 91.3, 95.6, and 97.9%, respectively. The differences in risk between the categories are highly significant, respectively (p < 0.001). CONCLUSION A three-tiered classification of squamous dysplasia such as the Munich Nomenclature III for cytology is suitable for risk-adapted clinical management, especially to avoid overdiagnosis and overtreatment.
Collapse
Affiliation(s)
| | - Peter Ziemke
- Praxis für Pathologie Dr. Marquardt, Schwerin, Germany
| | - Konrad Neumann
- Institut für Biometrie und Klinische Epidemiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
62
|
Mesenchymal Stem Cells from Cervix and Age: New Insights into CIN Regression Rate. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2018; 2018:1545784. [PMID: 30622662 PMCID: PMC6304868 DOI: 10.1155/2018/1545784] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/01/2018] [Indexed: 02/06/2023]
Abstract
Cervical intraepithelial neoplasia (CIN) is a precancerous lesion of the uterine cervix that can regress or progress to cervical cancer; interestingly, it has been noted that young women generally seem to have higher rates of spontaneous regression and remission, suggesting a correlation between the patient's age and regression/progression rates of CIN. Even if the underlying mechanisms are still unclear, inflammation seems to play a pivotal role in CIN fate and inflammatory processes are often driven by mesenchymal stem cells (MSCs). This study was aimed at evaluating if age affects the behavior of MSCs from the cervix (C-MSCs) that in turn may modulate inflammation and, finally, regression rate. Fourteen samples of the human cervix were recovered from two groups of patients, "young" (mean age 28 ± 2) and "old" (mean age 45 ± 3), during treatment using the loop electrosurgical excision procedure (LEEP) technique. Progenitor cells were isolated, deeply characterized, and divided into young (yC-MSCs) and old cervixes (oC-MSCs); the senescence, expression/secretion of selected cytokines related to inflammation, and the effects of indirect cocultures with HeLa cells were analyzed. Our results show that isolated cells satisfy the fixed criteria for stemness and display age-related properties; yC-MSCs express a higher level of cytokines related to acute inflammation than oC-MSCs. Finally, in the crosstalk with HeLa cells, MSCs derived from the cervixes of young patients play a stronger antitumoral role than oC-MSCs. In conclusion, the immunobiology of MSCs derived from the cervix is affected by the age of donors and this can correlate with the regression rate of CIN by influencing their paracrine effect. In addition, MSCs from a young cervix drives an antitumoral effect by sustaining an acute inflammatory environment.
Collapse
|
63
|
Leinonen MK, Hansen SA, Skare GB, Skaaret IB, Silva M, Johannesen TB, Nygård M. Low proportion of unreported cervical treatments in the cancer registry of Norway between 1998 and 2013. Acta Oncol 2018; 57:1663-1670. [PMID: 30169991 DOI: 10.1080/0284186x.2018.1497296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Accurate information about treatment is needed to evaluate cervical cancer prevention efforts. We studied completeness and validity of reporting cervical treatments in the Cancer Registry of Norway (CRN). MATERIAL AND METHODS We identified 47,423 (92%) high-grade cervical dysplasia patients with and 3983 (8%) without recorded treatment in the CRN in 1998-2013. We linked the latter group to the nationwide registry of hospital discharges in 1998-2015. Of patients still without treatment records, we randomly selected 375 for review of their medical history. Factors predicting incomplete treatment records were assessed by multiple imputation and logistic regression. RESULTS Registry linkage revealed that 10% (401/3983) of patients received treatment, usually conization, within one year of their initial high-grade dysplasia diagnosis. Of those, 11% (n = 44) were missing due to unreporting and 89% (n = 357) due to misclassification at the CRN. Of all cases in medical review, patients under active surveillance contributed almost 60% (223/375). Other reasons of being without recorded treatment were uncertain dysplasia diagnosis, invasive cancer or death. Coding error occurred in 19% (73/375) of randomly selected cases. CRN undercounted receipt of treatment by 38% (n = 1526) among patients without recorded treatment which translates into 97% overall completeness of treatment data. Incomplete treatment records were particularly associated with public laboratories, patients aged 40-54 years, and the latest study years. CONCLUSIONS CRN holds accurate information on cervical treatments. Completeness and particularly validity can be further improved through the establishment of new internal routines and regular linkage to hospital discharges.
Collapse
Affiliation(s)
| | - Svenn A. Hansen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | | | | | - Monica Silva
- Department of Registration, Cancer Registry of Norway, Oslo, Norway
| | | | - Mari Nygård
- Department of Research, Cancer Registry of Norway, Oslo, Norway
| |
Collapse
|
64
|
Haley CT, Mui UN, Vangipuram R, Rady PL, Tyring SK. Human oncoviruses: Mucocutaneous manifestations, pathogenesis, therapeutics, and prevention: Papillomaviruses and Merkel cell polyomavirus. J Am Acad Dermatol 2018; 81:1-21. [PMID: 30502418 DOI: 10.1016/j.jaad.2018.09.062] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/09/2018] [Accepted: 09/10/2018] [Indexed: 12/18/2022]
Abstract
In 1964, the first human oncovirus, Epstein-Barr virus, was identified in Burkitt lymphoma cells. Since then, 6 other human oncoviruses have been identified: human papillomavirus, Merkel cell polyomavirus, hepatitis B and C viruses, human T-cell lymphotropic virus-1, and human herpesvirus-8. These viruses are causally linked to 12% of all cancers, many of which have mucocutaneous manifestations. In addition, oncoviruses are associated with multiple benign mucocutaneous diseases. Research regarding the pathogenic mechanisms of oncoviruses and virus-specific treatment and prevention is rapidly evolving. Preventative vaccines for human papillomavirus and hepatitis B virus are already available. This review discusses the mucocutaneous manifestations, pathogenesis, diagnosis, treatment, and prevention of oncovirus-related diseases. The first article in this continuing medical education series focuses on diseases associated with human papillomavirus and Merkel cell polyomavirus, while the second article in the series focuses on diseases associated with hepatitis B and C viruses, human T-cell lymphotropic virus-1, human herpesvirus-8, and Epstein-Barr virus.
Collapse
Affiliation(s)
| | | | - Ramya Vangipuram
- Center for Clinical Studies, Webster, Texas; Department of Dermatology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Peter L Rady
- Department of Dermatology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Stephen K Tyring
- Center for Clinical Studies, Webster, Texas; Department of Dermatology, University of Texas Health Science Center at Houston, Houston, Texas
| |
Collapse
|
65
|
Loopik DL, Bekkers RLM, Massuger LFAG, Melchers WJG, Siebers AG, Bentley J. Justifying conservative management of CIN2 in women younger than 25 years - A population-based study. Gynecol Oncol 2018; 152:82-86. [PMID: 30413339 DOI: 10.1016/j.ygyno.2018.10.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/08/2018] [Accepted: 10/28/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE In 2012, the joint clinical practice guideline from the Society of Obstetricians and Gynaecologists of Canada (SOGC) changed from immediate treatment to a more conservative management of Cervical Intraepithelial Neoplasia (CIN) grade 2 in young women. In this study, the outcomes before and after this management change were reviewed in Nova Scotia, Canada. METHODS A retrospective population-based cohort study was performed among women younger than 25 years with biopsy-proven CIN2, who were diagnosed in one of the colposcopy clinics in Nova Scotia between 2010 and 2014. Regression and progression rates were compared pre- and post-guideline changes. RESULTS Of the 636 women included in the study, 286 women were diagnosed with CIN2 before and 350 women after the management in Nova Scotia was changed. After implementation of the 2012 guidelines patients were more likely to receive conservative management (78.6% versus 44.1%; p < 0.001); which differs from the patients who underwent treatment during follow-up prior to the change in guidelines (73.4% versus 38.9%; p < 0.001). Regression occurred in 73.1% of all women, but women seen in the post-guideline change period had a higher regression rate and lower progression rate (p < 0.05). Histologic results from treatment specimen did not show a significant difference in low-grade or high-grade lesions before or after the guideline had been changed (p = 0.59). CONCLUSION Conservative management seems a safe and justified approach for women younger than 25 years with CIN2.
Collapse
Affiliation(s)
- Diede L Loopik
- Department of Obstetrics and Gynecology, Radboud university medical center, PO Box 9101, 6500HB Nijmegen, the Netherlands.
| | - Ruud L M Bekkers
- Department of Obstetrics and Gynecology, Catharina Hospital Eindhoven, PO Box 1350, 5602ZA, the Netherlands.
| | - Leon F A G Massuger
- Department of Obstetrics and Gynecology, Radboud university medical center, PO Box 9101, 6500HB Nijmegen, the Netherlands.
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, PO Box 9101, 6500HB Nijmegen, the Netherlands.
| | - Albert G Siebers
- Department of Pathology, Radboud University Medical Center, PO Box 9101, 6500HB Nijmegen, the Netherlands.
| | - James Bentley
- Division of Gynecologic Oncology, Queen Elizabeth II Health Sciences Centre, 5820 University Avenue, Halifax, NS B3H 1Y9, Canada.
| |
Collapse
|
66
|
Association of cervical microbial community with persistence, clearance and negativity of Human Papillomavirus in Korean women: a longitudinal study. Sci Rep 2018; 8:15479. [PMID: 30341386 PMCID: PMC6195586 DOI: 10.1038/s41598-018-33750-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 10/03/2018] [Indexed: 12/20/2022] Open
Abstract
The present study aimed to identify the cervical microbes that are associated with HPV negativity, HPV clearance and HPV persistence and to assess the microbes’ longitudinal associations as related to HPV infection dynamics among Korean women. We enrolled 41 women with 107 samples, and classified them according to the HPV infection dynamics: HPV negativity (21 samples, 10 subjects), HPV clearance (42 samples, 15 subjects), and HPV persistence (44 samples, 16 subjects). Cervical swabs were collected at the baseline and six-month-interval follow-up visits. HPV positivity was determined by HPV DNA HC2 assay, and the microbiome was analyzed using 16SrRNA pyrosequencing, linear discriminant analysis effect size and multivariate logistic analysis. In the multivariate logistic analysis results, Lactobacillus crispatus (multivariate OR (mOR) = 8.25, 95% CI 2.13~32.0) was predominant in the HPV-negative group. We observed that Eubacterium eligens (mOR = 11.5, 95% CI 1.31~101.4), Gardnerella vaginalis (mOR = 17.0, 95% CI 2.18–131.8), and Ureaplasma urealyticum (mOR = 7.42, 95% CI 1.3–42.46) had the strongest associations with HPV clearance, and Lactobacillus johnsonii (mOR = 16.4, 95% CI 1.77–152.2) with HPV persistence. Overall, greater diversity was observed in HPV-persistence than in HPV-negative women. Our findings suggest that the presence and prevalence of a specific cervical microbiome are factors involved in HPV dynamics.
Collapse
|
67
|
Abstract
Objective To inform impending postcolposcopy guidelines, this analysis examined the subsequent risk of CIN 3+ among women with a grade lower than CIN 2 (< CIN 2) colposcopy results, taking into account the referring results that brought them to colposcopy and cotest results postcolposcopy. Methods We analyzed 107,005 women from 25 to 65 years old, recommended for colposcopy at Kaiser Permanente Northern California. We estimated absolute risks of CIN 3+ among women: (1) recommended for colposcopy (precolposcopy), (2) following colposcopy and with histology results < CIN 2 (postcolposcopy), and (3) with cotest results 12 months after a < CIN 2 colposcopy (return cotest). Results After colposcopy showing < CIN 2 (n = 69,790; 87% of the women at colposcopy), the 1-year risk of CIN 3+ was 1.2%, compared with 6.3% at the time of colposcopy recommendation. Negative cotest results 1 year after colposcopy identified a large group (37.1%) of women whose risk of CIN 3+ (i.e., <0.2% at 3 years after postcolposcopy cotest) was comparable with women with normal cytology in the screening population. These risks are consistent with current guidelines recommending repeat cotesting 12 months after colposcopy < CIN 2 and a 3-year return for women with a negative postcolposcopy cotest. Conclusions Most women are at low risk of subsequent CIN 3+ after a colposcopy showing < CIN 2, especially those who are human papillomavirus–negative postcolposcopy, consistent with current management guidelines for repeat testing intervals. Before the finalizing the upcoming guidelines, we will consider additional rounds of postcolposcopy cotesting.
Collapse
|
68
|
Outcomes of Conservative Management of High Grade Squamous Intraepithelial Lesions in Young Women. J Low Genit Tract Dis 2018; 22:212-218. [PMID: 29762428 PMCID: PMC6023603 DOI: 10.1097/lgt.0000000000000399] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to determine regression rates of cervical intraepithelial neoplasia (CIN) 2 and 3 in women younger than 24 years, followed conservatively for up to 24 months. MATERIALS AND METHODS This is a retrospective chart review of colposcopy patients in clinic database based on the following: (1) younger than 24 years at first visit; (2) first visit January 1, 2010, to May 31, 2013, and at least 1 follow-up visit after diagnosis; (3) histologic diagnosis of CIN2+; and (4) optimal conservative management (observation for up to 24 months or to 24 years, whichever occurred first). Patient information and clinical/pathologic data were extracted from charts to examine patient characteristics and treatment outcomes, CIN2+ regression rates, median times to regression for CIN2 versus CIN3 (Kaplan-Meier survival analysis), and predictors of regression (multivariate logistic regression analysis). RESULTS A total of 154 women met criteria. The most severe histological diagnoses were CIN2 in 99 (64.3%), CIN3 in 51 (33.1%), and adenocarcinoma in situ in 4 (2.6%). Adenocarcinoma in situ was immediately treated. In follow-up, CIN2 regressed to CIN1 or negative in 74 women (74.7%)-median time to regression, 10.8 months. Cervical intraepithelial neoplasia 3 regressed in 11 women (21.6%)-median time to regression not reached (last follow-up censored at 52.7 months). Cervical intraepithelial neoplasia 2 on biopsy, low grade referral Pap, and younger age predicted regression. Overall, 49 women (31.8%) were treated. CONCLUSIONS Conservative management should continue to be recommended to young women with CIN2. Rigorous retention mechanisms are required to ensure that these women return for follow-up.
Collapse
|
69
|
High Rates of High-Grade Cervical Dysplasia in High-Risk Young Women With Low-Grade Cervical Cytology. J Low Genit Tract Dis 2018; 22:207-211. [PMID: 29474240 DOI: 10.1097/lgt.0000000000000381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to determine rates of cervical intraepithelial neoplasia (CIN) 2 or greater in high-risk, racially diverse, young women with low-grade cytology. MATERIALS AND METHODS After institutional review board approval, a cross-sectional study of 21- to 24-year-old women with low-grade cytology (atypical squamous cells of undetermined significance, high-risk human papillomavirus+, low-grade squamous intraepithelial lesion, or human papillomavirus+ only) managed with colposcopy at our university-based clinic between May 2011 and April 2013 were identified. Demographics and pathologic data were collected including age, race, parity, smoking status, screening history, and histology. Student t test and χ tests were used to compare women with and without CIN 2 or 3. Univariate analysis was performed with demographic data. RESULTS One thousand fifty-eight women with a mean (SD) age of 22.5 (1.1) were included. Most patients (59.5%) were parous, 36.1% were smokers, and most (52.9%) were black. These patients were considered high risk because of their lower socioeconomic status, minority status, lack of insurance, or having Medicaid and therefore had limited access to preventative health care. Based on colposcopy, the prevalence of CIN 2+ was 19.1%: 13.9% (95% CI = 11.9-16.1) CIN 2 and 5.1% (95% CI = 3.9-6.6) CIN 3. There was an overall prevalence of 4.7% (95% CI = 3.7%-6.3%) of CIN 3 from excisional pathology from the 157 of 185 patients who returned for a recommended excisional procedure. Smoking (odds ratio = 1.64, 95% CI = 1.2-2.25) and a history of high-grade cytology (odds ratio = 2.06, 95% CI = 1.02-4.01) were associated with CIN 2/3. CONCLUSIONS High prevalence of CIN 2/3 in young women with low-grade cervical cytology in this population suggests that it may be prudent to consider alternative surveillance such as colposcopy in similar high-risk populations.
Collapse
|
70
|
Halec G, Scott ME, Farhat S, Darragh TM, Moscicki AB. Toll-like receptors: Important immune checkpoints in the regression of cervical intra-epithelial neoplasia 2. Int J Cancer 2018; 143:2884-2891. [PMID: 30121951 DOI: 10.1002/ijc.31814] [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] [Received: 03/29/2018] [Revised: 07/20/2018] [Accepted: 07/30/2018] [Indexed: 02/06/2023]
Abstract
Toll-like receptors (TLRs) are innate immune defenders thought to be critical for the clearance of human papillomavirus (HPV) infections hence preventing the development of HPV-associated high-grade cervical intra-epithelial neoplasia (CIN2 or 3), a potential cervical cancer precursor. However, the role of TLRs in the regression of established cervical lesions, such as CIN2, is hindered by a lack of prospective design studies. Using SYBR green real-time PCR assays, we have examined the gene expression of TLR2, TLR3, TLR7, TLR8 and TLR9, in cytobrush collected endocervical cells of 63 women diagnosed with CIN2 at study entry (baseline) and followed over a 3-year period. Wilcoxon rank-sum test was used to examine the association between TLR expression levels, measured at baseline, and CIN2 outcome (regression vs. persistence/progression) over time. HPV genotyping was performed using Roche Linear Array Assay detecting 37 HPV types. Women with CIN2 regression showed significantly higher baseline levels of TLR2 (p = 0.006) and TLR7 (p = 0.007), as well as a non-significant trend for a higher TLR8 expression (p = 0.053) compared to women with CIN2 persistence/progression. Six women with CIN2 regression, who presented with an HR-HPV DNA-negative CIN2 lesion at study entry, had significantly higher baseline levels of TLR2 (p = 0.005), TLR7 (p = 0.013) and TLR8 (p = 0.012), compared to women with CIN2 persistence/progression, suggesting their role in clearance of HPV prior to clearance of the lesion. Our results confirm a key role of TLRs in regression of CIN2 and support the potential use of TLR-agonists for treatment of these lesions.
Collapse
Affiliation(s)
- Gordana Halec
- Division of Adolescent Medicine, Department of Pediatrics, University of California, Los Angeles, CA
| | - Mark E Scott
- Department of Pediatrics, University of California, San Francisco, CA
| | - Sepideh Farhat
- Department of Pediatrics, University of California, San Francisco, CA
| | - Teresa M Darragh
- Department of Pathology, University of California, San Francisco, CA
| | - Anna-Barbara Moscicki
- Division of Adolescent Medicine, Department of Pediatrics, University of California, Los Angeles, CA
| |
Collapse
|
71
|
Cervical cancer screening and subsequent procedures in women under the age of 25 years between 2007 and 2013 in France: a nationwide French healthcare database study. Eur J Cancer Prev 2018; 27:479-485. [DOI: 10.1097/cej.0000000000000360] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
72
|
Choi HCW, Jit M, Leung GM, Tsui KL, Wu JT. Simultaneously characterizing the comparative economics of routine female adolescent nonavalent human papillomavirus (HPV) vaccination and assortativity of sexual mixing in Hong Kong Chinese: a modeling analysis. BMC Med 2018; 16:127. [PMID: 30115065 PMCID: PMC6097427 DOI: 10.1186/s12916-018-1118-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 07/04/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Although routine vaccination of females before sexual debut against human papillomavirus (HPV) has been found to be cost-effective around the world, its cost-benefit has rarely been examined. We evaluate both the cost-effectiveness and cost-benefit of routine female adolescent nonavalent HPV vaccination in Hong Kong to guide its policy, and by extension that of mainland China, on HPV vaccination. One major obstacle is the lack of data on assortativity of sexual mixing. Such difficulty could be overcome by inferring sexual mixing parameters from HPV epidemiologic data. METHODS We use an age-structured transmission model coupled with stochastic individual-based simulations to estimate the health and economic impact of routine nonavalent HPV vaccination for girls at age 12 on cervical cancer burden and consider vaccine uptake at 25%, 50%, and 75% with at least 20 years of vaccine protection. Bayesian inference was employed to parameterize the model using local data on HPV prevalence and cervical cancer incidence. We use the human capital approach in the cost-benefit analysis (CBA) and GDP per capita as the indicative willingness-to-pay threshold in the cost-effectiveness analysis (CEA). Finally, we estimate the threshold vaccine cost (TVC), which is the maximum cost for fully vaccinating one girl at which routine female adolescent nonavalent HPV vaccination is cost-beneficial or cost-effective. RESULTS As vaccine uptake increased, TVC decreased (i.e., economically more stringent) in the CBA but increased in the CEA. When vaccine uptake was 75% and the vaccine provided only 20 years of protection, the TVC was US$444 ($373-506) and $689 ($646-734) in the CBA and CEA, respectively, increasing by approximately 2-4% if vaccine protection was assumed lifelong. TVC is likely to be far higher when non-cervical diseases are included. The inferred sexual mixing parameters suggest that sexual mixing in Hong Kong is highly assortative by both age and sexual activity level. CONCLUSIONS Routine HPV vaccination of 12-year-old females is highly likely to be cost-beneficial and cost-effective in Hong Kong. Inference of sexual mixing parameters from epidemiologic data of prevalent sexually transmitted diseases (i.e., HPV, chlamydia, etc.) is a potentially fruitful but largely untapped methodology for understanding sexual behaviors in the population.
Collapse
Affiliation(s)
- Horace C W Choi
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 1/F North Wing, Patrick Manson Building, 7 Sassoon Road, Pok Fu Lam, Hong Kong.,Department of Systems Engineering and Engineering Management, City University of Hong Kong, Kowloon Tong, Hong Kong.,Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Mark Jit
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 1/F North Wing, Patrick Manson Building, 7 Sassoon Road, Pok Fu Lam, Hong Kong.,Modelling and Economics Unit, Public Health England, London, UK.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Gabriel M Leung
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 1/F North Wing, Patrick Manson Building, 7 Sassoon Road, Pok Fu Lam, Hong Kong
| | - Kwok-Leung Tsui
- Department of Systems Engineering and Engineering Management, City University of Hong Kong, Kowloon Tong, Hong Kong
| | - Joseph T Wu
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 1/F North Wing, Patrick Manson Building, 7 Sassoon Road, Pok Fu Lam, Hong Kong.
| |
Collapse
|
73
|
Kim SC, Feldman S, Moscicki AB. Risk of human papillomavirus infection in women with rheumatic disease: cervical cancer screening and prevention. Rheumatology (Oxford) 2018; 57:v26-v33. [PMID: 30137592 PMCID: PMC6099129 DOI: 10.1093/rheumatology/kex523] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/06/2017] [Indexed: 01/06/2023] Open
Abstract
Human Papillomavirus (HPV) is the most common sexually transmitted infection in the USA, with over 14 million people acquiring HPV each year. HPV is also the cause of most anogenital cancers. About 90% of HPV infections spontaneously resolve over 3 years. However, about 10% remain as persistent infection defined as repeatedly detected in cervical samples. As HPV is controlled by local and systemic immune responses, individuals with immunosuppression are at risk for cervical cancer. It is hypothesized that immunosuppressed individuals are more likely to have HPV persistence, which is necessary for malignant transformation. Accordingly, women with rheumatic diseases such as SLE and RA are likely vulnerable to HPV infection and the progression of cervical disease. The HPV vaccine, given as a series of vaccinations, is safe and effective that can prevent HPV infection and cervical cancer. There is no contraindication to HPV vaccination for women to age 26 with rheumatic disease, as it is not live. As in the general population, timing is key for the efficacy of the HPV vaccine as the goal is to vaccinate prior to sexual debut and exposure to HPV. There are no formal recommendations for cervical cancer screening in women with rheumatic disease but recommendations for the HIV-positive population can be adopted, meaning to screen with a Pap test annually for three consecutive years and if all normal, to extend the interval to every 3 years with the option of co-testing with HPV at 30 years and older.
Collapse
Affiliation(s)
- Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics
- Division of Rheumatology, Immunology and Allergy, Department of Medicine
| | - Sarah Feldman
- Department of Obstetrics Gynecology & Reproductive Biology, Brigham and Women’s Hospital, Boston, MA
| | | |
Collapse
|
74
|
Ginindza TG, Sartorius B. Projected cervical Cancer incidence in Swaziland using three methods and local survey estimates. BMC Cancer 2018; 18:639. [PMID: 29879943 PMCID: PMC5992849 DOI: 10.1186/s12885-018-4540-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 05/21/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The scarcity of country data (e.g. a cancer registry) for the burden of cervical cancer (CC) in low-income countries (LCIs) such as Swaziland remains a huge challenge. Such data are critical to inform local decision-making regarding resource allocation [1]. We aimed to estimate likely cervical cancer incidence in Swaziland using three different methodologies (triangulation), to help better inform local policy guidance regarding likely higher "true" burden and increased resource allocation required for treatment, cervical cancer screening and HPV vaccine implementation. METHODS Three methods were applied to estimate CC incidence, namely: 1) application of age-specific CC incidence rates for Southern African region from GLOBOCAN 2012 extrapolated to the 2014 Swaziland female population; 2) a linear regression based model with transformed age-standardised CC incidence against hr-HPV (with and without HIV as a covariate) prevalence among women with normal cervical cytology; and 3) a mathematical model, using a natural history approach based on parameter estimates from various available literature and local survey estimates. We then triangulated estimates and uncertainty from the three models to estimate the most likely CC incidence rate for Swaziland in 2015. RESULTS The projected incidence estimates for models 1-3 were 69.4 (95% CI: 66.7-72.1), 62.6 per 100,000 (95%CI: 53.7-71.8) and 44.6 per 100,000 (41.5 to 52.1) respectively. Model 2 with HIV prevalence as covariate estimated a higher CC incidence rate estimate of 101.1 per 100,000 (95%CI: 90.3-112.2). The triangulated ('averaged') age-standardized CC incidence based across the 3 models for 2015 was estimated at 69.4 per 100,000 (95% CI: 63.0-77.1) in Swaziland. CONCLUSION It is widely accepted that cancer incidence (and in this case CC) is underestimated in settings with poor and lacking registry data. Our findings suggest that the projected burden of CC is higher than that suggested from other sources. Local health policy decisions and decision-makers need to re-assess resource allocation to prevent and treat CC effectively, which is likely to persist given the very high burden of hr-HPV within the country.
Collapse
Affiliation(s)
- Themba G Ginindza
- Discipline of Public Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College Campus, 2nd Floor George Campbell Building, Mazisi Kunene Road, Durban, 4041, South Africa.
| | - Benn Sartorius
- Discipline of Public Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College Campus, 2nd Floor George Campbell Building, Mazisi Kunene Road, Durban, 4041, South Africa
| |
Collapse
|
75
|
Bekos C, Schwameis R, Heinze G, Gärner M, Grimm C, Joura E, Horvat R, Polterauer S, Polterauer M. Influence of age on histologic outcome of cervical intraepithelial neoplasia during observational management: results from large cohort, systematic review, meta-analysis. Sci Rep 2018; 8:6383. [PMID: 29686397 PMCID: PMC5913272 DOI: 10.1038/s41598-018-24882-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 04/06/2018] [Indexed: 12/22/2022] Open
Abstract
Aim of this study was to investigate the histologic outcome of cervical intraepithelial neoplasia (CIN) during observational management. Consecutive women with histologically verified CIN and observational management were included. Histologic findings of initial and follow-up visits were collected and persistence, progression and regression rates at end of observational period were assessed. Uni- and multivariate analyses were performed. A systematic review of the literature and meta-analysis was performed. In 783 women CIN I, II, and III was diagnosed by colposcopically guided biopsy in 42.5%, 26.6% and 30.9%, respectively. Younger patients had higher rates of regression (p < 0.001) and complete remission (< 0.001) and lower rates of progression (p = 0.003). Among women aged < 25, 25 < 30, 30 < 35, 35 < 40 years, and > 40 years, regression rates were 44.7%, 33.7%, 30.9%, 27.3%, and 24.9%, respectively. Pooled analysis of published data showed similar results. Multivariable analysis showed that with each five years of age, the odds for regression reduced by 21% (p < 0.001) independently of CIN grade (p < 0.001), and presence of HPV high-risk infection (p < 0.001). Patient's age has a considerable influence on the natural history of CIN - independent of CIN grade and HPV high-risk infection. Observational management should be considered for selected young patients with CIN.
Collapse
Affiliation(s)
- Christine Bekos
- Medical University of Vienna, Comprehensive Cancer Center, Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Viennna, Austria
| | - Richard Schwameis
- Medical University of Vienna, Comprehensive Cancer Center, Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Viennna, Austria
| | - Georg Heinze
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Viennna, Austria
| | - Marina Gärner
- Medical University of Vienna, Comprehensive Cancer Center, Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Viennna, Austria
| | - Christoph Grimm
- Medical University of Vienna, Comprehensive Cancer Center, Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Viennna, Austria
| | - Elmar Joura
- Medical University of Vienna, Comprehensive Cancer Center, Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Viennna, Austria
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Viennna, Austria
| | - Reinhard Horvat
- Medical University of Vienna, Department of Pathology, Viennna, Austria
| | - Stephan Polterauer
- Medical University of Vienna, Comprehensive Cancer Center, Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Viennna, Austria.
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Viennna, Austria.
| | - Mariella Polterauer
- Medical University of Vienna, Comprehensive Cancer Center, Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Viennna, Austria
| |
Collapse
|
76
|
Bruno MT, Ferrara M, Fava V, Rapisarda A, Coco A. HPV genotype determination and E6/E7 mRNA detection for management of HPV positive women. Virol J 2018; 15:52. [PMID: 29587778 PMCID: PMC5870089 DOI: 10.1186/s12985-018-0957-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/06/2018] [Indexed: 12/29/2022] Open
Abstract
Background Clinical management of HPV positive women is difficult since many of the infections, including high-risk oncogene genotypes (hr-HPV), are transient. Therefore only a limited number of patients have a high-grade lesion and sending all HPV positive women for colposcopy would only increase costs and unnecessary treatment, with serious psychological consequences for patients. The need has emerged to identify other HPV related markers able to correctly detect women with a high-risk of developing high-grade lesions. Genotyping and the search for E6/E7 mRNA are among the possible candidates. Methods The study was carried out by means of an observational analysis of the data relative to 674 HR-HPV positive women who we had observed from January 2013 to June 2015; the data had been gathered in a database at the HPV Center of the University Hospital of Catania, Italy. Women were considered eligible for this study if the following data was present in the database: Pap TEST, histologic evaluation, HPV TEST and E6/E7 mRNA detection. We calculated the Odds Ratio (OR) of woman who were mRNA positive, with CIN2+ lesions, and Odds Ratio of HPV16 positive women. Results Transcripts were detected in 23.6% (69/292) of the women with CIN1 and in 97.2% (210/220) of those with CIN2 + . Regarding genotyping, the 81,8% (180/220) of the women with CIN2+ had genotype 16, while only 18.1% (40/220) had genotype 18, 31, 33, 45. We calculated the OR in the group of HPV16 women with CIN2+ (OR = 4.62; 95% CI = 3.13 to 6.82), this value increased (OR = 106.12; 95% CI = 53.71 to 209.69) in women with CIN2+ and positive mRNA. Discussion The presence of the HPV16 genotype in our study was associated with a risk 5 times greater of developing a high-grade lesion (CIN2+) (OR = 4.62 95% CI:3.13–6.82); this supports the hypothesis that it would be opportune to have targeted protocols for the management of HPV 16 positive women. The results showed that there was an association between E6/E7 mRNA expression and histology (OR = 106.12; 95% CI = 53.71 to 209.69). The E6/E7 mRNA test showed a higher prevalence of E6 and E7 transcripts in patients with higher-grade lesions. Conclusion The results of this study suggest that the HPV genotype determination and E6/E7 mRNA detection would find an important application for management of HPV positive women.
Collapse
Affiliation(s)
- Maria Teresa Bruno
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic of the University of Catania. Policlinico, Via Santa Sofia 78, 95124, Catania, Italy.
| | - Martina Ferrara
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic of the University of Catania. Policlinico, Via Santa Sofia 78, 95124, Catania, Italy
| | - Valentina Fava
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic of the University of Catania. Policlinico, Via Santa Sofia 78, 95124, Catania, Italy
| | - Agnese Rapisarda
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic of the University of Catania. Policlinico, Via Santa Sofia 78, 95124, Catania, Italy
| | - Angela Coco
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic of the University of Catania. Policlinico, Via Santa Sofia 78, 95124, Catania, Italy
| |
Collapse
|
77
|
Tainio K, Athanasiou A, Tikkinen KAO, Aaltonen R, Cárdenas J, Hernándes, Glazer-Livson S, Jakobsson M, Joronen K, Kiviharju M, Louvanto K, Oksjoki S, Tähtinen R, Virtanen S, Nieminen P, Kyrgiou M, Kalliala I. Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis. BMJ 2018; 360:k499. [PMID: 29487049 PMCID: PMC5826010 DOI: 10.1136/bmj.k499] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To estimate the regression, persistence, and progression of untreated cervical intraepithelial neoplasia grade 2 (CIN2) lesions managed conservatively as well as compliance with follow-up protocols. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 1 January 1973 to 20 August 2016. ELIGIBILITY CRITERIA Studies reporting on outcomes of histologically confirmed CIN2 in non-pregnant women, managed conservatively for three or more months. DATA SYNTHESIS Two reviewers extracted data and assessed risk of bias. Random effects model was used to calculate pooled proportions for each outcome, and heterogeneity was assessed using I2 statistics. MAIN OUTCOME MEASURES Rates of regression, persistence, or progression of CIN2 and default rates at different follow-up time points (3, 6, 12, 24, 36, and 60 months). RESULTS 36 studies that included 3160 women were identified (seven randomised trials, 16 prospective cohorts, and 13 retrospective cohorts; 50% of the studies were at low risk of bias). At 24 months, the pooled rates were 50% (11 studies, 819/1470 women, 95% confidence interval 43% to 57%; I2=77%) for regression, 32% (eight studies, 334/1257 women, 23% to 42%; I2=82%) for persistence, and 18% (nine studies, 282/1445 women, 11% to 27%; I2=90%) for progression. In a subgroup analysis including 1069 women aged less than 30 years, the rates were 60% (four studies, 638/1069 women, 57% to 63%; I2=0%), 23% (two studies, 226/938 women, 20% to 26%; I2=97%), and 11% (three studies, 163/1033 women, 5% to 19%; I2=67%), respectively. The rate of non-compliance (at six to 24 months of follow-up) in prospective studies was around 10%. CONCLUSIONS Most CIN2 lesions, particularly in young women (<30 years), regress spontaneously. Active surveillance, rather than immediate intervention, is therefore justified, especially among young women who are likely to adhere to monitoring. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2014: CRD42014014406.
Collapse
Affiliation(s)
- Karoliina Tainio
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antonios Athanasiou
- Department of Obstetrics and Gynaecology, University Hospital of Ioannina, Ioannina, Greece
| | - Kari A O Tikkinen
- Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riikka Aaltonen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Hernándes
- National Center for Health Technology Excellence (CENETEC) Direction of Health Technologies assessment, Mexico City, Mexico
| | - Sivan Glazer-Livson
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maija Jakobsson
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Joronen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Mari Kiviharju
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karolina Louvanto
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Sanna Oksjoki
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Riikka Tähtinen
- Department of Obstetrics and Gynaecology, Kuopio University Hospital, Kuopio, Finland
| | - Seppo Virtanen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pekka Nieminen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maria Kyrgiou
- Institute of Reproduction and Developmental Biology, Department of Surgery & Cancer, Imperial College, London W12 0NN, UK
- West London Gynaecological Cancer Center, Queen Charlotte's & Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust, London, UK
| | - Ilkka Kalliala
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute of Reproduction and Developmental Biology, Department of Surgery & Cancer, Imperial College, London W12 0NN, UK
| |
Collapse
|
78
|
Hazenberg HMJL, de Boer NKH, Mulder CJJ, Mom SH, van Bodegraven AA, Tack Md PhD GJ. Neoplasia and Precursor Lesions of the Female Genital Tract in IBD: Epidemiology, Role of Immunosuppressants, and Clinical Implications. Inflamm Bowel Dis 2018; 24:510-531. [PMID: 29462389 DOI: 10.1093/ibd/izx062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Indexed: 12/13/2022]
Abstract
In this review the risk of breast, ovarian, and endometrial cancer and cervical and vulvovaginal (pre)malignant abnormalities in patients with inflammatory bowel disease (IBD) with or without immune suppressive treatment will be discussed. So far, this has not been studied thoroughly and large studies taking into account diverse potential confounding factors are lacking. IBD per se has not been associated with development of cervical cancer, yet patients with Crohn's disease who smoke, have a younger age at diagnosis or who use(d) thiopurines might be more at risk. Other immunosuppressive medication seems not to increase this risk, however, as evidence at this point is incomplete, physician awareness and prevention by lifestyle counseling, HPV vaccination and (intensified) screening are warranted. The risk for breast, endometrial, ovarian, and vulvovaginal cancer in IBD patients appears to be comparable to the background population, although for breast cancer this may even be decreasedin Crohn's disease specifically. Immunosuppressive medication in general does not seem to alter this risk. Earlier and more frequent screening for breast cancer than currently conducted in general nationwide screening programs is not recommended at this moment. Current literature suggests a much lower overall malignancy recurrence rate in IBD patients than has been observed previously. More importantly, immune suppressive medication does not appear to increase the recurrence risk. Robust epidemiologic data on female genital tract cancer are needed.
Collapse
Affiliation(s)
- Hanna M J L Hazenberg
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam
| | - Stijn H Mom
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam
| | - Ad A van Bodegraven
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam.,Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Center, Heerlen-Sittard-Geleen
| | - Greetje J Tack Md PhD
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam.,Department of Gastroenterology and Hepatology, Medical Center Leeuwarden, Leeuwarden
| |
Collapse
|
79
|
Silver MI, Gage JC, Schiffman M, Fetterman B, Poitras NE, Lorey T, Cheung LC, Katki HA, Locke A, Kinney WK, Castle PE. Clinical Outcomes after Conservative Management of Cervical Intraepithelial Neoplasia Grade 2 (CIN2) in Women Ages 21-39 Years. Cancer Prev Res (Phila) 2018; 11:165-170. [PMID: 29437696 DOI: 10.1158/1940-6207.capr-17-0293] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/07/2017] [Accepted: 01/25/2018] [Indexed: 11/16/2022]
Abstract
Cervical intraepithelial neoplasia grade 2 (CIN2) frequently regresses, is typically slow-growing, and rarely progresses to cancer. Some women forgo immediate treatment, opting for conservative management (heightened surveillance with cytology and colposcopy), to minimize overtreatment and increased risk of obstetric complications; however, there are limited data examining clinical outcomes in these women. We performed a retrospective cohort analysis of younger women diagnosed with initially untreated CIN1/2, CIN2 and CIN2/3 lesions at Kaiser Permanente Northern California between 2003 and 2015. Clinical outcomes were categorized into five mutually exclusive hierarchical groups: cancer, treated, returned to routine screening, persistent high-grade lesion, or persistent low-grade lesion. Median follow-up for the 2,417 women was 48 months. Six women were diagnosed with cancer (0.2%), all with history of high-grade cytology, and none after a negative cotest. Thirty percent of women were treated, and only 20% returned to routine screening; 50% remained in continued intensive follow-up, of which 86% had either low-grade cytology/histology or high-risk human papillomavirus (HPV) positivity, but not necessarily persistence of a single HPV type. No cancers were detected after a single negative cotest in follow-up. Almost half of initially untreated women did not undergo treatment, but remained by protocol in colposcopy clinic for 2 or more years in the absence of persisting CIN2+ Their incomplete return to total negativity was possibly due to sequential new and unrelated low-grade abnormalities. The prolonged colposcopic surveillance currently required to return to routine screening in the absence of persisting CIN2+ might not be necessary after a negative cotest.Significance: Many younger women under conservative management following an initial CIN2 result remain in a clinical protocol of prolonged intensified surveillance without a subsequent diagnosis of CIN2 or more severe diagnoses. More research is needed to determine whether such prolonged management might be unnecessary following a negative cotest for those women with an initial CIN2 but otherwise only low-grade findings. Cancer Prev Res; 11(3); 165-70. ©2018 AACR.
Collapse
Affiliation(s)
- Michelle I Silver
- Division of Cancer Epidemiology and Genetics, NCI, NIH, DHHS, Bethesda, Maryland.
| | - Julia C Gage
- Division of Cancer Epidemiology and Genetics, NCI, NIH, DHHS, Bethesda, Maryland
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, NCI, NIH, DHHS, Bethesda, Maryland
| | - Barbara Fetterman
- Regional Laboratory, Kaiser Permanente Northern California, Berkeley, California
| | - Nancy E Poitras
- Regional Laboratory, Kaiser Permanente Northern California, Berkeley, California
| | - Thomas Lorey
- Regional Laboratory, Kaiser Permanente Northern California, Berkeley, California
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, NCI, NIH, DHHS, Bethesda, Maryland
| | - Hormuzd A Katki
- Division of Cancer Epidemiology and Genetics, NCI, NIH, DHHS, Bethesda, Maryland
| | - Alexander Locke
- Department of Women's Health, Kaiser Permanente Medical Care Program, South Sacramento, California
| | - Walter K Kinney
- Regional Laboratory, Kaiser Permanente Northern California, Berkeley, California
| | - Philip E Castle
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York.,Global Coalition Against Cervical Cancer, Arlington, Virginia
| |
Collapse
|
80
|
Martingano D, Renson A, Martingano AJ, Martingano FX. Variations in Progression and Regression of Precancerous Lesions of the Uterine Cervix on Cytology Testing Among Women of Different Races. J Osteopath Med 2018; 118:8-18. [PMID: 29309102 DOI: 10.7556/jaoa.2018.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Although not incorporated into current cervical cancer screening guidelines, racial differences are known to persist in both occurrence of and outcomes related to cervical cancer. Objective To compare the differences in progression and regression of precancerous lesions of the uterine cervix on cervical cytologic analysis among women of different races who adhered to cervical cancer screening recommendations and follow-up. Methods Retrospective cohort study comparing differences in precancerous lesion diagnoses for patients receiving adequate evaluation according to the American Society for Colposcopy and Cervical Pathology guidelines. The authors fit Markov multistate models to estimate self-reported race-specific expected wait times and hazard ratios for each possible regression and progression and compared a race model with an intercept-only model using a likelihood ratio test. Results The sample included 5472 women receiving a Papanicolaou test between January 2006 and September 2016, contributing a total of 24,316 person-years of follow-up. Of 21 hazard ratios tested for significance, the following 4 hazard ratios (95% CIs) were statistically significant: atypical squamous cells of undetermined significance (ASC-US) progression to low-grade squamous intraepithelial lesion (LSIL) for Hispanic patients (0.72; 95% CI, 0.54-0.96); LSIL regression to ASC-US for Hispanic patients (1.55; 95% CI, 1.04-2.31), LSIL regression to ASC-US for Asian patients (1.91; 95% CI, 1.08-3.36), and high-grade squamous intraepithelial lesion regression to LSIL for black patients (0.39; 95% CI, 0.16-0.96). There is an observed trend that all racial groups other than white had a slower rate of progression from ASC-US to LSIL, with Hispanics having demonstrated the slowest rate from ASC-US to LSIL. Hispanics also demonstrated the fastest rate from LSIL to HSIL when compared with all other race categories. In regressions, blacks had the slowest rate of regression from HSIL to LSIL, and Asians had the fastest rate from LSIL to ASC-US. The Hispanic group demonstrated the fastest expected progression (17.6 months; 95% CI, 11.5-25.5), as well as the fastest regression (27.6 months; 95% CI, 21.5-35.6), and the black group has the slowest expected times for both progression (28.1 months; 95% CI, 14.6-47.2) and regression (49 months; 95% CI, 29.1-86.2). The number of visits (1 vs ≥2) in the study was differentially distributed both by race (P=.033) and by last diagnosis (P<.001). Conclusion Variations in precancerous lesions of the uterine cervix are not uniform across races.
Collapse
|
81
|
Agarwal M, Trimble C. Cancer Vaccines for HPV Malignancies. Oncoimmunology 2018. [DOI: 10.1007/978-3-319-62431-0_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
82
|
Standardized Digital Colposcopy with Dynamic Spectral Imaging for Conservative Patient Management. Case Rep Obstet Gynecol 2017; 2017:5269279. [PMID: 29435378 PMCID: PMC5757110 DOI: 10.1155/2017/5269279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/02/2017] [Indexed: 11/17/2022] Open
Abstract
Background Colposcopy is subjective and management of young patients with high-grade disease is challenging, as treatments may impair subsequent pregnancies and adversely affect obstetric outcomes. Conservative management of selected patients is becoming more popular amongst clinicians; however it requires accurate assessment and documentation. Novel adjunctive technologies for colposcopy could improve patient care and help individualize management decisions by introducing standardization, increasing sensitivity, and improving documentation. Case A nulliparous 27-year-old woman planning pregnancy underwent colposcopy following high-grade cytology. The colposcopic impression was of low-grade changes, whilst the Dynamic Spectral Imaging (DSI) map of the cervix suggested potential high-grade. A DSI-directed biopsy confirmed CIN2. At follow-up, both colposcopy and DSI were suggestive of low-grade disease only, and image comparison confirmed the absence of previously present acetowhite epithelium areas. Histology of the transformation zone following excisional treatment, as per patient's choice, showed no high-grade changes. Conclusion Digital colposcopy with DSI mapping helps standardize colposcopic examinations, increase diagnostic accuracy, and monitor cervical changes over time, improving patient care. When used for longitudinal tracking of disease and when it confirms a negative colposcopy, it can help towards avoiding overtreatment and hence decrease morbidity related to cervical excision.
Collapse
|
83
|
Mbatha JN, Galappaththi-Arachchige HN, Mtshali A, Taylor M, Ndhlovu PD, Kjetland EF, Baay MFD, Mkhize-Kwitshana ZL. Self-sampling for human papillomavirus testing among rural young women of KwaZulu-Natal, South Africa. BMC Res Notes 2017; 10:702. [PMID: 29208043 PMCID: PMC5717820 DOI: 10.1186/s13104-017-3045-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 11/30/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Cervical cancer is a major problem in women and it is important to find a suitable and acceptable screening method, especially among young in low-resource areas for future human papillomavirus (HPV) vaccine follow-up investigations. The study sought to test the acceptability of self-sampling as well as the suitability of the specimen collecting devices. METHODS Ninety-eight young women from rural KwaZulu-Natal were enrolled between March and July 2014. Collected genital specimens were transferred to colour indicator cards for HPV detection. Participants answered a questionnaire where they described their experiences with self-sampling. Samples were tested for high-risk HPV using GP5/6+ PCR. RESULTS Of the enrolled participants, 91 answered questionnaires and indicated that self-sampling was preferred by 51/91 (56%) women while 40/91 (44%) indicated preference for sampling by a doctor (p = 0.023). The majority, 64% were comfortable using a swab, 22% preferred a brush while 11% were comfortable with both devices. Of the 98 self-sampled specimens 61 were negative for HPV in both specimens while 37 were HPV-positive in either brush or swab. Of the 37, 26 (70%) were HPV-positive in both brush and swab (kappa = 0.743) and 11 (30%) were discordant. CONCLUSIONS Self-sampling was acceptable to the majority of participants in this rural area. The Dacron swab was the preferred device, and can be used in combination with colour indicator cards for comfortable self-sampling, easy storage and transport of specimens plus detection.
Collapse
Affiliation(s)
- J N Mbatha
- School Laboratory Medicine and Medical Science, University of KwaZulu-Natal, Durban, South Africa. .,Department of Biomedical and Clinical Technology, Durban University of Technology, PO Box 1334, Durban, 4000, South Africa.
| | - H N Galappaththi-Arachchige
- Norwegian Centre for Imported and Tropical Diseases, Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - A Mtshali
- School Laboratory Medicine and Medical Science, University of KwaZulu-Natal, Durban, South Africa
| | - M Taylor
- Discipline of Public Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - P D Ndhlovu
- Claybrook Center, Imperial College London, London, UK
| | - E F Kjetland
- Norwegian Centre for Imported and Tropical Diseases, Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Discipline of Public Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - M F D Baay
- Norwegian Centre for Imported and Tropical Diseases, Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Laboratory of Cancer Research and Clinical Oncology, University of Antwerp, Antwerp, Belgium
| | - Z L Mkhize-Kwitshana
- School Laboratory Medicine and Medical Science, University of KwaZulu-Natal, Durban, South Africa.,Department of Biomedical Sciences, Mangosuthu University of Technology, Durban, South Africa
| |
Collapse
|
84
|
Hakem E, Ibrahim E, Tanyous E, Astbury K, Purandare N. Association between grade of referral smear and high-grade disease among women with biopsy samples showing cervical intraepithelial neoplasia grade 2. Int J Gynaecol Obstet 2017; 140:223-227. [PMID: 29049873 DOI: 10.1002/ijgo.12357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 08/30/2017] [Accepted: 10/19/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether the grade of referral smear reflects the frequency of cervical intraepithelial neoplasia (CIN) grade 3 (CIN3) or worse lesions among patients with CIN2 on punch biopsy. METHODS In a retrospective study, data were reviewed from women with a punch biopsy sample showing CIN2 and a known referral smear who underwent large loop excision of the transformation zone (LLETZ) between January 1, 2013, and January 1, 2016, at Galway University Hospital, Ireland. Data were analyzed by patient age (≤30 and >30 years), referral smear (low and high grade), and LLETZ histology (≤CIN2 and ≥CIN3). RESULTS Overall, 264 women were included. LLETZ histology of CIN3 or worse was more common among women with high-grade referral smears (63/144 [43.8%]) than among those with low-grade smears (26/120 [21.7%]; relative risk 2.02, 95% confidence interval 1.37-2.96; P<0.001). Among patients younger than 30 years, underlying CIN3 and above was again more frequent among women with high-grade (44/95 [46.3%]) versus low-grade smears (12/56 [21.4%]; relative risk 2.16, 95% confidence interval 1.25-3.73; P=0.004). No difference was recorded in the older age group. CONCLUSION Although LLETZ can be performed for a CIN2 biopsy and high-grade smear, consideration should be given among young women (<30 years) with low-grade smears whose biopsy histology is incidentally CIN2.
Collapse
Affiliation(s)
- Emmanuel Hakem
- Department of Obstetrics and Gynaecology, University College Hospital Galway, Galway, Ireland
| | - Elzahra Ibrahim
- Department of Obstetrics and Gynaecology, University College Hospital Galway, Galway, Ireland
| | - Emmanuel Tanyous
- Ministry of Health, General Directorate of Primary Health Care, Central Supervision Unit, Riyadh, Saudi Arabia
| | - Katharine Astbury
- Department of Obstetrics and Gynaecology, University College Hospital Galway, Galway, Ireland
| | - Nikhil Purandare
- Department of Obstetrics and Gynaecology, University College Hospital Galway, Galway, Ireland
| |
Collapse
|
85
|
Velentzis LS, Caruana M, Simms KT, Lew JB, Shi JF, Saville M, Smith MA, Lord SJ, Tan J, Bateson D, Quinn M, Canfell K. How will transitioning from cytology to HPV testing change the balance between the benefits and harms of cervical cancer screening? Estimates of the impact on cervical cancer, treatment rates and adverse obstetric outcomes in Australia, a high vaccination coverage country. Int J Cancer 2017; 141:2410-2422. [PMID: 28801947 DOI: 10.1002/ijc.30926] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 07/08/2017] [Accepted: 07/20/2017] [Indexed: 01/20/2023]
Abstract
Primary HPV screening enables earlier diagnosis of cervical lesions compared to cytology, however, its effect on the risk of treatment and adverse obstetric outcomes has not been extensively investigated. We estimated the cumulative lifetime risk (CLR) of cervical cancer and excisional treatment, and change in adverse obstetric outcomes in HPV unvaccinated women and cohorts offered vaccination (>70% coverage in 12-13 years) for the Australian cervical screening program. Two-yearly cytology screening (ages 18-69 years) was compared to 5-yearly primary HPV screening with partial genotyping for HPV16/18 (ages 25-74 years). A dynamic model of HPV transmission, vaccination, cervical screening and treatment for precancerous lesions was coupled with an individual-based simulation of obstetric complications. For cytology screening, the CLR of cervical cancer diagnosis, death and treatment was estimated to be 0.649%, 0.198% and 13.4% without vaccination and 0.182%, 0.056% and 6.8%, in vaccinated women, respectively. For HPV screening, relative reductions of 33% and 22% in cancer risk for unvaccinated and vaccinated women are predicted, respectively, compared to cytology. Without the implementation of vaccination, a 4% increase in treatment risk for HPV versus cytology screening would have been expected, implying a possible increase in pre-term delivery (PTD) and low birth weight (LBW) events of 19 to 35 and 14 to 37, respectively, per 100,000 unvaccinated women. However, in vaccinated women, treatment risk will decrease by 13%, potentially leading to 4 to 41 fewer PTD events and from 2 more to 52 fewer LBW events per 100,000 vaccinated women. In unvaccinated women in cohorts offered vaccination as 12-13 year olds, no change to lifetime treatment risk is expected with HPV screening. In unvaccinated women in cohorts offered vaccination as 12-13 year olds, no change to lifetime treatment risk is expected with HPV screening. HPV screening starting at age 25 in populations with high vaccination coverage, is therefore expected to both improve the benefits (further decrease risk of cervical cancer) and reduce the harms (reduce treatments and possible obstetric complications) associated with cervical cancer screening.
Collapse
Affiliation(s)
- Louiza S Velentzis
- Cancer Research Division, Cancer Council NSW, Australia.,Melbourne School of Population and Global Health, Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Kate T Simms
- Cancer Research Division, Cancer Council NSW, Australia
| | - Jie-Bin Lew
- Cancer Research Division, Cancer Council NSW, Australia
| | - Ju-Fang Shi
- National Cancer Centre of China, Cancer Hospital of Chinese Academy of Medical Sciences, Beijing, China
| | - Marion Saville
- Victorian Cytology Service, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Megan A Smith
- Cancer Research Division, Cancer Council NSW, Australia.,School of Public Health, University of Sydney, NSW, Australia
| | - Sarah J Lord
- NHMRC Clinical Trials Centre, Sydney Medical School, University of Sydney, NSW, Australia.,School of Medicine, Department of Epidemiology and Medical Statistics, University of Notre Dame, NSW, Australia
| | - Jeffrey Tan
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Victoria, Australia.,Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Deborah Bateson
- Family Planning NSW, NSW, Australia.,Sydney Medical School, Discipline: Gynaecology & Neonatology, University of Sydney, NSW, Australia
| | | | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Australia.,School of Public Health, University of Sydney, NSW, Australia.,Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, NSW, Australia
| |
Collapse
|
86
|
Bodenschatz N, Poh CF, Lam S, Lane P, Guillaud M, MacAulay CE. Dual-mode endomicroscopy for detection of epithelial dysplasia in the mouth: a descriptive pilot study. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:1-10. [PMID: 28823113 DOI: 10.1117/1.jbo.22.8.086005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 07/25/2017] [Indexed: 05/25/2023]
Abstract
Dual-mode endomicroscopy is a diagnostic tool for early cancer detection. It combines the high-resolution nuclear tissue contrast of fluorescence endomicroscopy with quantified depth-dependent epithelial backscattering as obtained by diffuse optical microscopy. In an in vivo pilot imaging study of 27 oral lesions from 21 patients, we demonstrate the complementary diagnostic value of both modalities and show correlations between grade of epithelial dysplasia and relative depth-dependent shifts in light backscattering. When combined, the two modalities provide diagnostic sensitivity to both moderate and severe epithelial dysplasia in vivo.
Collapse
Affiliation(s)
- Nico Bodenschatz
- British Columbia Cancer Research Centre, Department of Integrative Oncology, Vancouver, British Colu, Canada
| | - Catherine F Poh
- British Columbia Cancer Research Centre, Department of Integrative Oncology, Vancouver, British Colu, Canada
- The University of British Columbia, Faculty and Dentistry, Vancouver, British Columbia, Canada
| | - Sylvia Lam
- British Columbia Cancer Research Centre, Department of Integrative Oncology, Vancouver, British Colu, Canada
| | - Pierre Lane
- British Columbia Cancer Research Centre, Department of Integrative Oncology, Vancouver, British Colu, Canada
| | - Martial Guillaud
- British Columbia Cancer Research Centre, Department of Integrative Oncology, Vancouver, British Colu, Canada
| | - Calum E MacAulay
- British Columbia Cancer Research Centre, Department of Integrative Oncology, Vancouver, British Colu, Canada
| |
Collapse
|
87
|
Taghavi K, Morell S, Lamb J, MacNab H, Innes C, Coffey K, Williman J, Simcock B, Sykes P. Initial observation of CIN2 does not appear to reduce quality of life in women under 25 years of age. Aust N Z J Obstet Gynaecol 2017; 57:473-478. [PMID: 28508566 DOI: 10.1111/ajo.12633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/16/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although the patient perspective is implicit in the practice of medicine, research evaluating this remains scarce. In a climate where clinicians and policy-makers constantly strive to achieve more patient-centred models of care, this omission warrants attention. AIM To assess health-related quality of life (HrQoL) in women under 25 years of age with cervical intra-epithelial neoplasia grade 2 (CIN2) receiving conservative management (colposcopy follow-up, with treatment if necessary) compared with those receiving immediate excisional treatment with large loop excision of the transformation zone (LLETZ). METHODS An observational study evaluating HrQoL was conducted at Christchurch Women's Hospital, New Zealand. Women undergoing conservative management for CIN2 were compared with those undergoing immediate excisional treatment in an age-matched sample. The Short Form Health Survey 12 version 2 (SF-12v2) was used to evaluate HrQoL. Secondary outcomes of anxiety and sexual function were also assessed. RESULTS One hundred and four women with CIN2 participated in the study. Of these, 63 (60%) received conservative management and 41 (40%) received immediate excisional treatment with LLETZ. We found no significant difference in HrQoL between the groups in a multivariate regression analysis adjusted for parity, smoking and socioeconomic status. There were also no significant differences in sexual function or anxiety. CONCLUSION We found no difference in HrQoL by management strategy. Conservative management of CIN2 in women under 25 is unlikely to have an adverse impact on self-reported HrQoL, anxiety or sexual functioning compared with conventional management.
Collapse
Affiliation(s)
- Katayoun Taghavi
- Department of Obstetrics and Gynecology, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Sára Morell
- Department of Obstetrics and Gynecology, University of Otago, Christchurch, New Zealand
| | - Jillian Lamb
- Department of Obstetrics and Gynecology, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Helene MacNab
- Department of Obstetrics and Gynecology, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Carrie Innes
- Department of Obstetrics and Gynecology, University of Otago, Christchurch, New Zealand
| | - Kate Coffey
- Department of Obstetrics and Gynecology, Dunedin Public Hospital, Dunedin, New Zealand
| | - Jonathan Williman
- Department of Population Health, University of Otago, Christchurch, New Zealand
| | - Bryony Simcock
- Department of Obstetrics and Gynecology, Dunedin Public Hospital, Dunedin, New Zealand
| | - Peter Sykes
- Department of Obstetrics and Gynecology, Christchurch Women's Hospital, Christchurch, New Zealand
| |
Collapse
|
88
|
Rousselin A, Dion L, Racin A, Lavoué V, Levêque J, Nyangoh Timoh K. [Pap smear before 25 years old]. ACTA ACUST UNITED AC 2017; 45:309-315. [PMID: 28479075 DOI: 10.1016/j.gofs.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Current French recommendations advocate cervical-vaginal screening for cervical cancer from age 25 whereas earlier screening is mostly found in current clinical practice although its consequences are not well understood. METHODS A literature review using the MedLine database on the natural history of HPV infections, cytological screening, management of cytological and histological anomalies in adolescents and young women. RESULTS The adolescent and young woman have some characteristics that distinguish them from adult women: a high prevalence of HPV infections (making the use of the HPV test unprofitable), accompanied by a higher clearance; frequency of minor cytological abnormalities (for which a cytological surveillance without colposcopy is sufficient) and low-grade histological lesions of low grade the usual prognosis of which is complete recovery; and rarity of CIN3 lesions and absence of invasive lesions, allowing no treatment in patients with CIN2 lesions and compliant to cytological and colposcopic surveillance. CONCLUSION Cervical screening in the adolescent and young woman is not a logical attitude and the discovery of cytological or histological lesions requires specific behavior in this particular population.
Collapse
Affiliation(s)
- A Rousselin
- Département de gynécologie obstétrique et reproduction humaine, CHU Anne-de-Bretagne, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
| | - L Dion
- Département de gynécologie obstétrique et reproduction humaine, CHU Anne-de-Bretagne, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
| | - A Racin
- Département de gynécologie obstétrique et reproduction humaine, CHU Anne-de-Bretagne, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
| | - V Lavoué
- Département de gynécologie obstétrique et reproduction humaine, CHU Anne-de-Bretagne, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
| | - J Levêque
- Département de gynécologie obstétrique et reproduction humaine, CHU Anne-de-Bretagne, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France.
| | - K Nyangoh Timoh
- Département de gynécologie obstétrique et reproduction humaine, CHU Anne-de-Bretagne, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France
| |
Collapse
|
89
|
Tota JE, Bentley J, Blake J, Coutlée F, Duggan MA, Ferenczy A, Franco EL, Fung-Kee-Fung M, Gotlieb W, Mayrand MH, McLachlin M, Murphy J, Ogilvie G, Ratnam S. Approaches for triaging women who test positive for human papillomavirus in cervical cancer screening. Prev Med 2017; 98:15-20. [PMID: 28279257 DOI: 10.1016/j.ypmed.2016.11.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/26/2016] [Indexed: 12/28/2022]
Abstract
Substantial evidence exists to support the introduction of molecular testing for human papillomavirus (HPV) as the primary technology in cervical cancer screening. While HPV testing is much more sensitive than cytology for detection of high-grade precancerous lesions, it is less specific. To improve efficiency, it is therefore recommended that a specific test (like cytology) be used in triaging HPV positive women to colposcopy. A number of studies have been conducted that support the use of cytology alone or in conjunction with HPV genotyping for triage. The decision to incorporate genotyping also depends on the commercial HPV test that is selected since not all tests provide results for certain individual high-risk types. Regardless of whether policy officials decide to adopt a triage approach that incorporates genotyping, the use of liquid based cytology (LBC) may also improve screening performance by reducing diagnostic delays. With LBC, the same cell suspension from a single collection may be used for HPV testing and a smear can be immediately prepared if HPV status is positive. This was a critical lesson from a community based demonstration project in Montreal (VASCAR study), where conventional cytology exists and specimen co-collection was not permitted for ethical reasons, requiring HPV positive women to return for an additional screening visit prior to colposcopy.
Collapse
Affiliation(s)
- Joseph E Tota
- Division of Cancer Epidemiology and Genetics, US National Cancer Institute, Rockville, MD, United States; Department of Oncology, McGill University, Montréal, Québec, Canada.
| | - James Bentley
- Department of Obstetrics & Gynecology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer Blake
- Society of Obstetricians and Gynaecologists of Canada, Ottawa, Ontario, Canada
| | - François Coutlée
- Département de microbiologie et infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Máire A Duggan
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alex Ferenczy
- Departments of Pathology, Obstetrics & Gynecology, McGill University, Montréal, Québec, Canada
| | - Eduardo L Franco
- Department of Oncology, McGill University, Montréal, Québec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Michael Fung-Kee-Fung
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Walter Gotlieb
- Departments of Oncology, Obstetrics & Gynecology, McGill University, Montréal, Québec, Canada
| | - Marie-Hélène Mayrand
- Département d'obstétrique-gynécologie et Médecine Sociale et Préventive, Université de Montréal, Montréal, Québec, Canada
| | - Meg McLachlin
- Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada
| | - Joan Murphy
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Gina Ogilvie
- Departments of Family Practice, Obstetrics & Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sam Ratnam
- Department of Oncology, McGill University, Montréal, Québec, Canada; Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
| |
Collapse
|
90
|
Abstract
Age younger than 25 year at the time of loop electrosurgical excision procedure is associated with a more frequent occurrence of preterm labor before 26 weeks of amenorrhea. Objective The aim of the study was to assess whether an age younger than 25 years at conization affected future pregnancy outcome as an independent factor. Materials and Methods A retrospective study of 115 women who underwent both loop electrosurgical excision procedure (LEEP) and subsequent pregnancy follow-up in a referral center was conducted. Two groups were considered: patients younger than 25 years at the time of LEEP (n = 42) and 25 years or older (n = 73). Analyzed data were occurrence of preterm adverse obstetrical event and, specifically, preterm labor (PL) and preterm rupture of membranes; stratification based on term of occurrence was performed: less than 37 weeks of amenorrhea (WA), less than 34 WA, and less than 26 WA. Results Patients characteristics were comparable in terms of excised specimen thickness and pathological analysis, as well as for tobacco intoxication during pregnancy. Although there was no difference of term at delivery or total number of preterm adverse obstetrical events, we found a significant increase of events (19% vs 4.1%) and PL (19% vs 0%) before 26 WA in the group of patients younger than 25 years. After adjusting for excised specimen thickness, the same results were found for thickness of 15 mm or less (respectively, 16.7% vs 3.3% and 16.7% vs 0%). For thickness of greater than 15 mm, only ratio of PL before 26 WA was higher in the group of patients younger than 25 years (33.3% vs 0%). Conclusions Age younger than 25 years at the time of LEEP seems to be is associated with a more frequent occurrence of extremely early preterm adverse obstetrical events, particularly PL.
Collapse
|
91
|
Mbatha JN, Taylor M, Kleppa E, Lillebo K, Galappaththi-Arachchige HN, Singh D, Kjetland EF, Baay MFD, Mkhize-Kwitshana ZL. High-risk human papillomavirus types in HIV-infected and HIV-uninfected young women in KwaZulu-Natal, South Africa: implications for vaccination. Infect Dis (Lond) 2017; 49:601-608. [PMID: 28403727 DOI: 10.1080/23744235.2017.1312513] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND High-risk human papillomavirus (hr-HPV) infections and low-grade squamous intraepithelial lesions occur frequently in young women. The available vaccines cover up to seven hr-HPV genotypes (HPV16, HPV18, HPV31, HPV33, HPV45, HPV52 and HPV58) and two low-risk HPV types (HPV6 and HPV11). The objective of this study was to describe the hr-HPV genotypes present among HIV-uninfected and HIV-infected young women in rural high schools. METHODS Cervicovaginal lavages were obtained from sexually active young women recruited from high schools in KwaZulu-Natal (n = 1223). HPV testing was done by the polymerase chain reaction using GP5+/GP6 + primers and enzyme immunoassay. HIV testing was done using rapid test kits. RESULTS Of the 1223 cervicovaginal lavages, 301 (25%) were positive for hr-HPV. The HPV prevalence was higher in HIV infected (32.20%, 95% CI: 0.27-0.38) than in HIV-uninfected women (22.50%, 95% CI: 0.21-0.26), (p = .001). Similarly, multiple infections were slightly more common in HIV infected (59.32%) than in HIV-uninfected women (53.51%), (p = .37). The nine predominant genotypes in descending order were HPV types 16 (n = 99, 22.10%), 51 (n = 58, 12.91%), 18 (n = 56, 12.50%), 35 (n = 50, 11.10%), 33 (n = 47, 10.82%), 56 (n = 42, 9.31%), 45 (n = 34, 7.60%), 52 (n = 32, 7.14%) and 59 (n = 31, 6.91%). HPV 35, 51, 56 and 59 (40.62%), which are not covered by any vaccine, were among the most prevalent in the schools of KwaZulu-Natal. CONCLUSION Four of the most predominant high-risk HPV types in this region are not covered by the new nine-valent HPV vaccine.
Collapse
Affiliation(s)
- Joyce N Mbatha
- a Department of Infection, Prevention and Control , University of KwaZulu-Natal, School of Laboratory Medicine and Medical Science , Durban , South Africa.,b Department of Biomedical and Clinical Technology , Durban University of Technology , Durban , South Africa
| | - Myra Taylor
- c Discipline of Public Health , Nelson R Mandela School of Medicine, University of KwaZulu-Natal , Durban , South Africa
| | - Elisabeth Kleppa
- d Department of Infectious Diseases , Norwegian Centre for Imported and Tropical Diseases, Oslo University Hospital , Oslo , Norway.,e Faculty of Medicine , University of Oslo , Norway
| | - Kristine Lillebo
- d Department of Infectious Diseases , Norwegian Centre for Imported and Tropical Diseases, Oslo University Hospital , Oslo , Norway
| | - Hashini N Galappaththi-Arachchige
- d Department of Infectious Diseases , Norwegian Centre for Imported and Tropical Diseases, Oslo University Hospital , Oslo , Norway.,e Faculty of Medicine , University of Oslo , Norway
| | - Deepak Singh
- f Department of Physics , Durban University of Technology , Durban , South Africa
| | - Eyrun F Kjetland
- c Discipline of Public Health , Nelson R Mandela School of Medicine, University of KwaZulu-Natal , Durban , South Africa.,d Department of Infectious Diseases , Norwegian Centre for Imported and Tropical Diseases, Oslo University Hospital , Oslo , Norway.,e Faculty of Medicine , University of Oslo , Norway
| | - Marc F D Baay
- d Department of Infectious Diseases , Norwegian Centre for Imported and Tropical Diseases, Oslo University Hospital , Oslo , Norway.,g University of Antwerp , Laboratory of Cancer Research and Clinical Oncology , Antwerp , Belgium
| | - Zilungile L Mkhize-Kwitshana
- a Department of Infection, Prevention and Control , University of KwaZulu-Natal, School of Laboratory Medicine and Medical Science , Durban , South Africa.,h Department of Biomedical Sciences , Mangosuthu University of Technology , Faculty of Natural Sciences , Durban , South Africa
| |
Collapse
|
92
|
Papoutsis D, Underwood M, Parry-Smith W, Panikkar J. Does CIN2 Have the Same Aggressive Potential As CIN3? A Secondary Analysis of High-Grade Cytology Recurrence in Women Treated with Cold-Coagulation Cervical Treatment. Geburtshilfe Frauenheilkd 2017; 77:284-289. [PMID: 28392582 DOI: 10.1055/s-0042-119993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Introduction To determine whether women with CIN2 versus CIN3 on pretreatment cervical punch biopsy have less high-grade cytology recurrence following cold-coagulation cervical treatment. Materials and Methods This was a retrospective study of women having had cold coagulation between 2001-2011 in our colposcopy unit. Women with previous cervical treatment were excluded. Results We identified 402 women with 260 (64.7 %) cases of CIN2 and 142 (35.3 %) cases of CIN3 on pretreatment cervical punch biopsy. In the total sample, the mean age of women was 27.5 years (SD = 4.9), 75.1 % were nulliparous and 36.6 % were smokers. Referral cytology and pretreatment colposcopic appearance were high-grade in 62.7 % and 57.1 %. The mean follow-up period was 2.8 years (SD = 2.1). Women with CIN2 on pretreatment cervical biopsy when compared to those with CIN3 had less frequently high-grade referral cytology and high-grade pretreatment colposcopic appearances, and had less pretreatment cervical biopsies taken. During the follow-up period, women with CIN2 on pretreatment cervical biopsy had less high-grade cytology recurrence when compared to those women with CIN3 (1.9 vs. 5.6 %, p = 0.046). Multiple stepwise Cox regression analysis showed that women with CIN3 on pretreatment cervical biopsy had 3.21 times greater hazard for high-grade cytology recurrence (HR = 3.21, 95 % CI: 1.05-9.89; p = 0.041) in comparison with CIN2 cases. Conclusion We found that women with CIN2 on pretreatment cervical punch biopsy had less high-grade cytology recurrence following cold-coagulation treatment in comparison to those with CIN3. This finding lends support to the theory that CIN2 even though a high-grade abnormality might not have the same aggressive potential as CIN3.
Collapse
Affiliation(s)
- D Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, United Kingdom
| | - M Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, United Kingdom
| | - W Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, United Kingdom
| | - J Panikkar
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, United Kingdom
| |
Collapse
|
93
|
See-and-Treat for High-Grade Cytology: Do Young Women Have Different Rates of High-Grade Histology? J Low Genit Tract Dis 2017; 20:243-6. [PMID: 27243140 DOI: 10.1097/lgt.0000000000000229] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare rates of cervical intraepithelial neoplasia grade 3 or greater (CIN3+) between women aged 21 to 24 and women aged 25 or older undergoing a see-and-treat strategy for high-grade squamous intraepithelial lesion (HSIL) cytology. METHODS In this retrospective cohort study, women treated with a see-and-treat loop electrosurgical excisional procedure (LEEP) for HSIL cytology at our university-based colposcopy clinic between 2008 and 2013 were identified. Data collected included age, race, parity, smoking status, method of contraception, history of abnormal cytology, HIV status, and LEEP histology. Cohorts were compared using Pearson chi-squared test of association and Fisher exact test. RESULTS Three hundred sixty-nine women were included in this analysis. The mean age was 30 (SD, 7.2; range, 21-56). Ninety-seven women (26.3%) were 21 to 24 years old. The rate of CIN3 in all women undergoing a see-and-treat LEEP for HSIL cytology was 65.9% (95% CI, 60.8-70.5). The rate of CIN 2 was 15.2% (95% CI, 11.9-19.2). Three women (1.1%) had invasive carcinoma. There was no difference in risk of CIN3+ in the young women compared with women aged 25 years or older (RR, 1.37; 95% CI, 0.92-2.02). Within this see-and-treat population, there was no correlation between presence of CIN3+ and race, smoking, contraception, or HIV status. CONCLUSIONS Most women undergoing see-and-treat for HSIL cytology will have CIN3 on final histology. In this large cohort, women aged 21 to 24 did not have lower rates of CIN3 compared with women aged 25 and older, suggesting that see-and-treat is still a valid treatment option for the prevention of invasive disease in young women.
Collapse
|
94
|
Dickinson JA, Ogilvie G, Van Niekerk D, Popadiuk C. Evidence that supports policies to delay cervical screening until after age 25 years. CMAJ 2017; 189:E380-E381. [PMID: 28385818 DOI: 10.1503/cmaj.160636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- James A Dickinson
- Family Medicine and Community Health Sciences (Dickinson), University of Calgary, Calgary, Alta; Faculty of Medicine, The University of British Columbia, and Women's Health Research Institute, BC Centre for Disease Control (Ogilvie); Department of Pathology, The University of British Columbia, and Cervical Screening Program of the British Columbia Cancer Agency (Van Niekerk), Vancouver, BC; Department of Obstetrics and Gynecology, Faculty of Medicine, Memorial University, and Provincial Cervical Screening Initiative Program (Popadiuk), St. John's, NL
| | - Gina Ogilvie
- Family Medicine and Community Health Sciences (Dickinson), University of Calgary, Calgary, Alta; Faculty of Medicine, The University of British Columbia, and Women's Health Research Institute, BC Centre for Disease Control (Ogilvie); Department of Pathology, The University of British Columbia, and Cervical Screening Program of the British Columbia Cancer Agency (Van Niekerk), Vancouver, BC; Department of Obstetrics and Gynecology, Faculty of Medicine, Memorial University, and Provincial Cervical Screening Initiative Program (Popadiuk), St. John's, NL
| | - Dirk Van Niekerk
- Family Medicine and Community Health Sciences (Dickinson), University of Calgary, Calgary, Alta; Faculty of Medicine, The University of British Columbia, and Women's Health Research Institute, BC Centre for Disease Control (Ogilvie); Department of Pathology, The University of British Columbia, and Cervical Screening Program of the British Columbia Cancer Agency (Van Niekerk), Vancouver, BC; Department of Obstetrics and Gynecology, Faculty of Medicine, Memorial University, and Provincial Cervical Screening Initiative Program (Popadiuk), St. John's, NL
| | - Cathy Popadiuk
- Family Medicine and Community Health Sciences (Dickinson), University of Calgary, Calgary, Alta; Faculty of Medicine, The University of British Columbia, and Women's Health Research Institute, BC Centre for Disease Control (Ogilvie); Department of Pathology, The University of British Columbia, and Cervical Screening Program of the British Columbia Cancer Agency (Van Niekerk), Vancouver, BC; Department of Obstetrics and Gynecology, Faculty of Medicine, Memorial University, and Provincial Cervical Screening Initiative Program (Popadiuk), St. John's, NL
| |
Collapse
|
95
|
Miralpeix E, Genovés J, Maria Solé-Sedeño J, Mancebo G, Lloveras B, Bellosillo B, Alameda F, Carreras R. Usefulness of p16 INK4a staining for managing histological high-grade squamous intraepithelial cervical lesions. Mod Pathol 2017; 30:304-310. [PMID: 27739439 DOI: 10.1038/modpathol.2016.168] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 01/09/2023]
Abstract
p16INK4a (p16) tumor-suppressor protein is a biomarker of human papillomavirus (HPV) oncogenic activity that has revealed a high rate of positivity in histological high-gade squamous intraepithelial lesion/cervical intraepithelial neoplasia grade 2 (HSIL/CIN2) lesions. However, there is a paucity of data regarding p16 status as a surrogate marker of HSIL/CIN2 evolution. The aim of this study was to evaluate the outcome of HSIL/CIN2 patients followed up without treatment for 12 months according to p16 immunohistochemical staining. Patients diagnosed with HSIL/CIN2 colposcopy-directed biopsy, were recruited prospectively between December 2011 and October 2013. p16 staining was performed in all HSIL/CIN2 diagnostic biopsies. Follow-up was conducted every 4 months by cytology, colposcopy and biopsy if suspicion of progression and once the 12 months of follow-up completed. Complete regression, partial regression, persistence, and progression rates of HSIL/CIN2 were defined as a final outcome. A total of 96 patients were included in the analysis. The rate of spontaneous regression was 64%, while 28% had persistent disease, and 8% progressed at 12 months of follow-up. p16 was positive in 81 (84%) initial HSIL/CIN2 biopsies. Regression was observed in all 15 p16 negative cases and in 46 of 81 (57%) p16 positive cases (P=0.001). In conclusion, patients with p16 negative HSIL/CIN2 biopsy had a high rate of regression during first 12 months of follow-up. Status of p16 staining could be considered for HSIL/CIN2 management.
Collapse
Affiliation(s)
- Ester Miralpeix
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Genovés
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep Maria Solé-Sedeño
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gemma Mancebo
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Belen Lloveras
- Department of Pathology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Beatriz Bellosillo
- Department of Pathology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Alameda
- Department of Pathology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ramon Carreras
- Department of Obstetrics and Gynecology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
96
|
Bentley J. Prise en charge colposcopique des résultats cytologiques et histologiques anormaux en ce qui concerne le col utérin. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S171-S188. [PMID: 28063532 DOI: 10.1016/j.jogc.2016.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
97
|
Onisko A, Druzdzel MJ, Austin RM. How to interpret the results of medical time series data analysis: Classical statistical approaches versus dynamic Bayesian network modeling. J Pathol Inform 2016; 7:50. [PMID: 28163973 PMCID: PMC5248402 DOI: 10.4103/2153-3539.197191] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 11/17/2016] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Classical statistics is a well-established approach in the analysis of medical data. While the medical community seems to be familiar with the concept of a statistical analysis and its interpretation, the Bayesian approach, argued by many of its proponents to be superior to the classical frequentist approach, is still not well-recognized in the analysis of medical data. AIM The goal of this study is to encourage data analysts to use the Bayesian approach, such as modeling with graphical probabilistic networks, as an insightful alternative to classical statistical analysis of medical data. MATERIALS AND METHODS This paper offers a comparison of two approaches to analysis of medical time series data: (1) classical statistical approach, such as the Kaplan-Meier estimator and the Cox proportional hazards regression model, and (2) dynamic Bayesian network modeling. Our comparison is based on time series cervical cancer screening data collected at Magee-Womens Hospital, University of Pittsburgh Medical Center over 10 years. RESULTS The main outcomes of our comparison are cervical cancer risk assessments produced by the three approaches. However, our analysis discusses also several aspects of the comparison, such as modeling assumptions, model building, dealing with incomplete data, individualized risk assessment, results interpretation, and model validation. CONCLUSION Our study shows that the Bayesian approach is (1) much more flexible in terms of modeling effort, and (2) it offers an individualized risk assessment, which is more cumbersome for classical statistical approaches.
Collapse
Affiliation(s)
- Agnieszka Onisko
- Department of Pathology, University of Pittsburgh Medical Center, Magee-Womens Hospital, Pittsburgh, PA 15213, USA
- Faculty of Computer Science, Bialystok University of Technology, 15-351 Bialystok, Poland
| | - Marek J. Druzdzel
- Faculty of Computer Science, Bialystok University of Technology, 15-351 Bialystok, Poland
- Decision Systems Laboratory, School of Information Sciences and Intelligent Systems Program, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - R. Marshall Austin
- Department of Pathology, University of Pittsburgh Medical Center, Magee-Womens Hospital, Pittsburgh, PA 15213, USA
| |
Collapse
|
98
|
p16ink4 and cytokeratin 7 immunostaining in predicting HSIL outcome for low-grade squamous intraepithelial lesions: a case series, literature review and commentary. Mod Pathol 2016; 29:1501-1510. [PMID: 27515495 DOI: 10.1038/modpathol.2016.141] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 06/20/2016] [Accepted: 06/20/2016] [Indexed: 01/11/2023]
Abstract
p16ink4 and cytokeratin 7 (CK7) have been proposed to identify low-grade squamous intraepithelial lesions (LSIL) at greater or lesser risk for an outcome of high-grade squamous intraepithelial lesion (HSIL). We correlated CK7 and p16ink4 staining in LSILs with outcome on follow-up and placed this information in the context of prior reports. Cervical LSIL biopsies with at least 1-year follow-up information were immunostained for CK7 and p16ink4. Follow-up outcomes included no SIL, LSIL (persistence) or HSIL (CIN2+). In all, 109 LSILs were studied and 18.3% stained positive for CK7. Ninety-one percent of CK7-negative LSILs regressed, 4.5% persisted, and 4.5% had an HSIL outcome, versus 60, 20, and 20% of CK7-positive LSILs, respectively (P=0.036). p16ink4 status did not significantly associate with outcome. Review of the literature revealed a highly variable rate of both positive p16ink4 immunoreactivity in LSIL and CIN2+ outcome for p16-positive LSIL but a consistently high negative predictive value (>90%) in the case of no/low p16 expression. Inter-observer reproducibility for the diagnosis of CIN2 in the literature ranged from poor to good, with unanimous agreement on the diagnosis of CIN2 occurring in less than 25% of cases. As with high-risk human papillomavirus testing, the most clinically useful result of p16ink4 staining is a negative test, implying no lesion or CIN1 and conferring a low risk of HSIL outcome. HSIL outcomes ('progression') are highly variable and are subject to wide differences in inter-observer interpretation for CIN2. This argues against the wisdom of relying on p16ink4 to both predict CIN2+ or upgrade CIN1 to CIN2. It also begs the question of whether CIN2 should be replaced by an alternate and less pejorative term (SIL of intermediate grade) for lesions that are not reproducibly classified as LSIL or HSIL, with an appropriate management scheme.
Collapse
|
99
|
Cost-Effectiveness of Primary HPV Testing, Cytology and Co-testing as Cervical Cancer Screening for Women Above Age 30 Years. J Gen Intern Med 2016; 31:1338-1344. [PMID: 27418345 PMCID: PMC5071282 DOI: 10.1007/s11606-016-3772-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 05/02/2016] [Accepted: 06/07/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cervical cancer screening guidelines for women aged ≥30 years allow for co-testing or primary cytology testing. Our objective was to determine the test characteristics and costs associated with Cytology, HPV and Co-testing screening strategies. MAIN METHODS Retrospective cohort study of women undergoing cervical cancer screening with both cytology and HPV (Hybrid Capture 2) testing from 2004 to 2010 in an integrated health system. The electronic health record was used to identify women aged ≥30 years who had co-testing. Unsatisfactory or unavailable test results and incorrectly ordered tests were excluded. The main outcome was biopsy-proven cervical intraepithelial neoplasia grade 3 or higher (CIN3+). KEY RESULTS The final cohort consisted of 99,549 women. Subjects were mostly white (78.4 %), married (70.7 %), never smokers (61.3 %) and with private insurance (86.1 %). Overall, 5121 (5.1 %) tested positive for HPV and 6115 (6.1 %) had cytology ≥ ASCUS; 1681 had both and underwent colposcopy and 310 (0.3 %) had CIN3+. Sensitivity for CIN3+ was 91.9 % for Primary Cytology, 99.4 % for Co-testing, and 94.8 % for Primary HPV; specificity was 97.3 % for Co-testing and Primary Cytology and 97.9 % for Primary HPV. Over a 3-year screening interval, Primary HPV detected more cases of CIN3+ and was less expensive than Primary Cytology. Co-testing detected 14 more cases of CIN3+ than Primary HPV, but required an additional 100,277 cytology tests and 566 colposcopies at an added cost of $2.38 million, or $170,096 per additional case detected. CONCLUSIONS Primary HPV was more effective and less expensive than Primary Cytology. Primary HPV screening appears to represent a cost-effective alternative to Co-testing.
Collapse
|
100
|
Clinical Utility of Molecular Biomarkers in Cervical Squamous Intraepithelial Lesions in a Young Adult Population. J Low Genit Tract Dis 2016; 20:26-30. [PMID: 26579841 DOI: 10.1097/lgt.0000000000000163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although human papillomavirus (HPV) infection is necessary for cervical squamous intraepithelial lesion (SIL/CIN) and cancer to develop, exposure to HPV is not predictive of which women will develop SIL/CIN and cancer. This study examines mRNA expression of several potential biomarkers in exfoliated cervical cells collected from college-aged women. MATERIALS AND METHODS Freshman female students were recruited into the Carolina Women's Care Study, which was designed to prospectively evaluate factors that contribute to persistent HPV infections. One component of this study was to extract mRNA from exfoliated cervical cells. In this study, mRNA expression of Frizzled (FZD), growth differentiating factor 15, interleukin 1 beta (IL1β), and N-cadherin was assessed through real-time polymerase chain reaction. Statistical analysis was performed with a Student t test; all results were standardized with glyceraldehyde 3-phosphate dehydrogenase. RESULTS Fifty samples were selected that reflected the demographics of the Carolina Women's Care Study participants. IL1β mRNA expression was 9.4-fold higher in cervical cells from women with abnormal Pap tests (p = .0018); low-grade squamous intraepithelial lesion had 12.7-fold higher expression than negatives (p = .0011). The FZD mRNA expression was 5.7-fold higher in CIN 2 as compared with CIN 1 (p = .0041) and 8.5-fold higher compared with cytology/pathology negative (p = .0014). Other differences in mRNA expression showed trends but not reaching statistical significance for each condition. CONCLUSIONS It seems that several biomarkers involved in the cytokine/inflammatory pathway (IL1β), cell adhesion pathway (N-cadherin), growth factor (growth differentiating factor 15), and Wingless (WNT) signaling pathway (FZD) may be potential biomarkers in conjunction with the Pap test and HPV that help predict which women are at highest risk for developing CIN 3 and cervical cancer.
Collapse
|