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Kamanga P, Zhang B, Stones W. Factors associated with low utilisation of cervical cancer screening among urban women in Lilongwe, Malawi: a cross sectional study. BMC Womens Health 2023; 23:183. [PMID: 37069557 PMCID: PMC10111711 DOI: 10.1186/s12905-023-02324-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/01/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND In 2012, more than half a million women (528,000) were diagnosed with cervical cancer around the world. More than 80% of cervical cancer occurs in developing nations, such as Malawi, where estimates of the disease's burden show an incidence of 75.9 per 100,000 women and a mortality rate of 49.8 per 100,000 women (both age-adjusted). Despite its case fatality rate, cervical cancer can be avoided through immunization, early detection and screening. Malawi however, has low immunization and screening rates with coverage as low as 9% and 15%, respectively. Here our aim is to uncover factors that contribute to low utilization of cervical cancer screening services among women in Lilongwe, a large urban center. METHODS This was a qualitative cross-sectional study. Participants were chosen at random from a big metropolitan health center. In-depth interviews and two observations were undertaken by the researchers. Interviews were taped, transcribed verbatim, and content assessed. RESULTS A total of 24 women and 5 health workers, with an average age of 34.8 years, were questioned. 50% of women had completed secondary school, 33.3% had completed primary school, and 4% had completed no formal education. The majority of the women were housewives and entrepreneurs. 62.5% of the respondents had fewer than four children, 25% had four to six children, and 8.3% had more than six children. 91 - 6% of those surveyed were married, with 78% of Christians and 20% of Muslims. The majority of women were unaware of the importance of cervical cancer screening. Some people were concerned about marital troubles, pain during the process, "laziness," and the amount of time necessary. The majority of people would come for a test as a result of signs and symptoms. Male health personnel would be unable to screen Muslim women. All of the medical personnel had at least two years of experience. Women's low involvement in cervical cancer screening has been linked by health workers to a lack of resources and a lack of community awareness. CONCLUSION Cervical cancer can be prevented by early detection and treatment. Women, on the other hand, are uninformed about cervical cancer. Myths, misconceptions, cultural and religious beliefs, as well as service restrictions and community sensitization, influence the use of cervical cancer screening services. Addressing these issues has the potential to boost cervical cancer screening rates.
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Affiliation(s)
- Patricia Kamanga
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre Malawi, Private Bag 360, Blantyre, Malawi.
- Food Safety and Health Research Center, School of Public Health, Southern Medical University, 511505 Shaitanan Road, Guangzhou, Guangdong, China.
- Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi.
| | - Bo Zhang
- Food Safety and Health Research Center, School of Public Health, Southern Medical University, 511505 Shaitanan Road, Guangzhou, Guangdong, China
| | - William Stones
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre Malawi, Private Bag 360, Blantyre, Malawi
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Staley H, Shiraz A, Shreeve N, Bryant A, Martin-Hirsch PP, Gajjar K. Interventions targeted at women to encourage the uptake of cervical screening. Cochrane Database Syst Rev 2021; 9:CD002834. [PMID: 34694000 PMCID: PMC8543674 DOI: 10.1002/14651858.cd002834.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease. OBJECTIVES To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology. MAIN RESULTS Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases. AUTHORS' CONCLUSIONS There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.
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Affiliation(s)
- Helen Staley
- Obstetrics & Gynaecology, Queen Charlotte's & Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Norman Shreeve
- Obstetrics & Gynaecology, University of Cambridge Clinical School, Cambridge, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Pierre Pl Martin-Hirsch
- Gynaecological Oncology Unit, Royal Preston Hospital, Lancashire Teaching Hospital NHS Trust, Preston, UK
| | - Ketankumar Gajjar
- Department of Gynaecological Oncology, 1st Floor Maternity Unit, City Hospital Campus, Nottingham, UK
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Benski AC, Viviano M, Jinoro J, Alec M, Catarino R, Herniainasolo J, Vassilakos P, Petignat P. HPV self-testing for primary cervical cancer screening in Madagascar: VIA/VILI triage compliance in HPV-positive women. PLoS One 2019; 14:e0220632. [PMID: 31408474 PMCID: PMC6692065 DOI: 10.1371/journal.pone.0220632] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 07/19/2019] [Indexed: 12/02/2022] Open
Abstract
Objective To assess triage compliance and the effect of the time from screening to triage on follow-up among HPV-positive women. Methods We recruited 1232 women in a screening campaign in Madagascar from February to October 2015. In the first period (February–May), HPV tests were performed remotely using the cobas test. In the second period (May–October), testing was performed on-site using the Xpert HPV assay. HPV-positive women were invited for triage with visual inspection with acetic acid (VIA) and Lugol’s iodine (VILI). Systematic biopsy and endocervical brushing were performed on all HPV-positive women for quality control. Three groups were defined according to time from HPV testing to triage invitation for HPV-positive women—Group I: delayed (> 3 months), Group II: prompt (24–48 hours), and Group III: immediate (< 24 hours). Results A total 1232 self-sampled HPV tests were performed in the study period (496 in Group I, 512 in Group II, and 224 in Group III). Participants’ mean age was 43.2 ± 9.3 years. Mean time from screening to VIA/VILI testing was 103.5 ± 43.6 days. Overall HPV prevalence was 28.0%. HPV prevalence was 27.2% in Group I (cobas test), 29.2% in Group 2 (Xpert test), and 26,7% in Group III (Xpert test). The VIA/VILI compliance rate was 77.8% for Group I, 82.7% for Group II, and 95.0% for Group III. Of women undergoing VIA/VILI, 56.3% in Group I and 43.5% in Groups II/III had positive results. Prevalence of cervical intraepithelial neoplasia grade 2 or worse among HPV-positive women was 9.8% for Group I and 6.8% for Groups II/III. Non-adherence was higher among rural women, uneducated women, and women in Group I. Conclusion HPV-positive women with immediate VIA/VILI triage invitation had the best triage compliance. A single-day test and triage strategy is preferred for low-resource settings.
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Affiliation(s)
- Anne-Caroline Benski
- Gynecology Division, Geneva University Hospitals, Geneva, Switzerland
- Saint Damien Health Center, Ambanja, Madagascar
- * E-mail:
| | - Manuela Viviano
- Gynecology Division, Geneva University Hospitals, Geneva, Switzerland
| | | | | | - Rosa Catarino
- Gynecology Division, Geneva University Hospitals, Geneva, Switzerland
| | | | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Gynecology Division, Geneva University Hospitals, Geneva, Switzerland
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Bashar MA, Aggarwal AK. Organizing a Cancer Screening Camp in Low‑Resource Settings: Experience from North India. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_146_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- M A Bashar
- Department of Community Medicine, School of Public Health, PGIMER, Chandigarh, India
| | - A K Aggarwal
- Department of Community Medicine, School of Public Health, PGIMER, Chandigarh, India
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Cholli P, Bradford L, Manga S, Nulah K, Kiyang E, Manjuh F, DeGregorio G, Ogembo RK, Orock E, Liu Y, Wamai RG, Sheldon LK, Gona PN, Sando Z, Welty T, Welty E, Ogembo JG. Screening for cervical cancer among HIV-positive and HIV-negative women in Cameroon using simultaneous co-testing with careHPV DNA testing and visual inspection enhanced by digital cervicography: Findings of initial screening and one-year follow-up. Gynecol Oncol 2017; 148:118-125. [PMID: 29153541 DOI: 10.1016/j.ygyno.2017.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/31/2017] [Accepted: 11/02/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The World Health Organization (WHO)'s cervical cancer screening guidelines for limited-resource settings recommend sequential screening followed by same-day treatment under a "screen-and-treat" approach. We aimed to (1) assess feasibility and clinical outcomes of screening HIV-positive and HIV-negative Cameroonian women by pairing visual inspection with acetic acid and Lugol's iodine enhanced by digital cervicography (VIA/VILI-DC) with careHPV, a high-risk human papillomavirus (HR-HPV) nucleic acid test designed for low-resource settings; and (2) determine persistence of HR-HPV infection after one-year follow-up to inform optimal screening, treatment, and follow-up algorithms. METHODS We co-tested 913 previously unscreened women aged ≥30years and applied WHO-recommended treatment for all VIA/VILI-DC-positive women. Baseline prevalence of HR-HPV and HIV were 24% and 42%, respectively. RESULTS On initial screen, 44 (5%) women were VIA/VILI-DC-positive, of whom 22 had HR-HPV infection, indicating 50% of women screened false-positive and would have been triaged for unnecessary same-day treatment. VIA/VILI-DC-positive women with HIV infection were three times more likely to be HR-HPV-positive than HIV-negative women (65% vs. 20%). All women positive for either VIA/VILI-DC or HR-HPV (n=245) were invited for repeat co-testing after one year, of which 136 (56%) returned for follow-up. Of 122 women who were HR-HPV-positive on initial screen, 60 (49%) re-tested negative, of whom 6 had received treatment after initial screen, indicating that 44% of initially HR-HPV-positive women spontaneously cleared infection after one year without treatment. Women with HIV were more likely to remain HR-HPV-positive on follow-up than HIV-negative women (61% vs. 22%, p<0.001). Treatment was offered to all VIA/VILI-DC positive women on initial screen, and to all women screening VIA/VILI-DC or HR-HPV positive on follow-up. CONCLUSIONS We found careHPV co-testing with VIA/VILI-DC to be feasible and valuable in identifying false-positives, but careHPV screening-to-result time was too long to inform same-day treatment.
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Affiliation(s)
- Preetam Cholli
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States
| | - Leslie Bradford
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States
| | - Simon Manga
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Kathleen Nulah
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Edith Kiyang
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Florence Manjuh
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Geneva DeGregorio
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States
| | - Rebecca K Ogembo
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States
| | - Enow Orock
- Regional Hospital, PO Box 32, Buea, Cameroon
| | - Yuxin Liu
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States; Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Richard G Wamai
- Northeastern University, 360 Huntington Ave, Boston, MA 02115, United States
| | - Lisa Kennedy Sheldon
- Oncology Nursing Society, 125 Enterprise Drive, Pittsburgh, PA 15275, United States
| | - Philimon N Gona
- Northeastern University, 360 Huntington Ave, Boston, MA 02115, United States
| | - Zacharie Sando
- Yaoundé Gyneco-Obstetric and Pediatric Hospital, Yaoundé, PO Box 4362, Central Region, Cameroon
| | - Thomas Welty
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Edith Welty
- Cameroon Baptist Convention Health Services, PO Box 1, Bamenda, North West Region, Cameroon
| | - Javier Gordon Ogembo
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655, United States; Beckman Research Institute of City of Hope, 1500 E Duarte Road, Duarte, CA 91010, United States.
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Wu ES, Jeronimo J, Feldman S. Barriers and Challenges to Treatment Alternatives for Early-Stage Cervical Cancer in Lower-Resource Settings. J Glob Oncol 2017; 3:572-582. [PMID: 29094097 PMCID: PMC5646895 DOI: 10.1200/jgo.2016.007369] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Cervical cancer is one of the most common cancers among women worldwide, and approximately 85% of new diagnoses occur in less-developed regions of the world. Global efforts in cervical cancer to date have focused on primary and secondary prevention strategies of human papillomavirus vaccination and cervical cancer screening. Cervical cancer screening is effective to reduce the incidence of cervical cancer and can result in diagnosis at earlier stages, but it will take time to realize its full impact. With expansion of screening programs, there is now a greater imperative to increase access to treatment for women who have cervical cancer, particularly in earlier stages of disease, when it is still curable. Resources for multimodality treatment can be limited-or even absent-in many less-developed regions of the world and may be associated with geographic, social, and financial barriers for the patient. However, there is evidence that, in many cases, less-invasive and less-resource-intensive treatment options are still effective. To this end, the National Comprehensive Cancer Network and American Society of Clinical Oncology have published guideline adaptations for specific resource constraints, and research about more conservative approaches to the treatment of cervical cancer continues. This review focuses on potential barriers and challenges to provision of safe and effective treatment of early-stage cervical cancer in lower-resource settings, and it suggests future directions for expansion of access to cervical cancer treatment around the world.
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Affiliation(s)
- Emily S Wu
- , University of Washington; , PATH, Seattle, WA; and , Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jose Jeronimo
- , University of Washington; , PATH, Seattle, WA; and , Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sarah Feldman
- , University of Washington; , PATH, Seattle, WA; and , Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Subramanian S, Sankaranarayanan R, Esmy PO, Thulaseedharan JV, Swaminathan R, Thomas S. Clinical trial to implementation: Cost and effectiveness considerations for scaling up cervical cancer screening in low- and middle-income countries. J Cancer Policy 2016. [DOI: 10.1016/j.jcpo.2015.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fitzmaurice C, Dicker D, Pain A, Hamavid H, Moradi-Lakeh M, MacIntyre MF, Allen C, Hansen G, Woodbrook R, Wolfe C, Hamadeh RR, Moore A, Werdecker A, Gessner BD, Te Ao B, McMahon B, Karimkhani C, Yu C, Cooke GS, Schwebel DC, Carpenter DO, Pereira DM, Nash D, Kazi DS, De Leo D, Plass D, Ukwaja KN, Thurston GD, Yun Jin K, Simard EP, Mills E, Park EK, Catalá-López F, deVeber G, Gotay C, Khan G, Hosgood HD, Santos IS, Leasher JL, Singh J, Leigh J, Jonas JB, Jonas J, Sanabria J, Beardsley J, Jacobsen KH, Takahashi K, Franklin RC, Ronfani L, Montico M, Naldi L, Tonelli M, Geleijnse J, Petzold M, Shrime MG, Younis M, Yonemoto N, Breitborde N, Yip P, Pourmalek F, Lotufo PA, Esteghamati A, Hankey GJ, Ali R, Lunevicius R, Malekzadeh R, Dellavalle R, Weintraub R, Lucas R, Hay R, Rojas-Rueda D, Westerman R, Sepanlou SG, Nolte S, Patten S, Weichenthal S, Abera SF, Fereshtehnejad SM, Shiue I, Driscoll T, Vasankari T, Alsharif U, Rahimi-Movaghar V, Vlassov VV, Marcenes WS, Mekonnen W, Melaku YA, Yano Y, Artaman A, Campos I, MacLachlan J, Mueller U, Kim D, Trillini M, Eshrati B, Williams HC, Shibuya K, Dandona R, Murthy K, Cowie B, Amare AT, Antonio CA, Castañeda-Orjuela C, van Gool CH, Violante F, Oh IH, Deribe K, Soreide K, Knibbs L, Kereselidze M, Green M, Cardenas R, Roy N, Tillmann T, Tillman T, Li Y, Krueger H, Monasta L, Dey S, Sheikhbahaei S, Hafezi-Nejad N, Kumar GA, Sreeramareddy CT, Dandona L, Wang H, Vollset SE, Mokdad A, Salomon JA, Lozano R, Vos T, Forouzanfar M, Lopez A, Murray C, Naghavi M. The Global Burden of Cancer 2013. JAMA Oncol 2015; 1:505-27. [PMID: 26181261 PMCID: PMC4500822 DOI: 10.1001/jamaoncol.2015.0735] [Citation(s) in RCA: 1977] [Impact Index Per Article: 219.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Cancer is among the leading causes of death worldwide. Current estimates of cancer burden in individual countries and regions are necessary to inform local cancer control strategies. OBJECTIVE To estimate mortality, incidence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 28 cancers in 188 countries by sex from 1990 to 2013. EVIDENCE REVIEW The general methodology of the Global Burden of Disease (GBD) 2013 study was used. Cancer registries were the source for cancer incidence data as well as mortality incidence (MI) ratios. Sources for cause of death data include vital registration system data, verbal autopsy studies, and other sources. The MI ratios were used to transform incidence data to mortality estimates and cause of death estimates to incidence estimates. Cancer prevalence was estimated using MI ratios as surrogates for survival data; YLDs were calculated by multiplying prevalence estimates with disability weights, which were derived from population-based surveys; YLLs were computed by multiplying the number of estimated cancer deaths at each age with a reference life expectancy; and DALYs were calculated as the sum of YLDs and YLLs. FINDINGS In 2013 there were 14.9 million incident cancer cases, 8.2 million deaths, and 196.3 million DALYs. Prostate cancer was the leading cause for cancer incidence (1.4 million) for men and breast cancer for women (1.8 million). Tracheal, bronchus, and lung (TBL) cancer was the leading cause for cancer death in men and women, with 1.6 million deaths. For men, TBL cancer was the leading cause of DALYs (24.9 million). For women, breast cancer was the leading cause of DALYs (13.1 million). Age-standardized incidence rates (ASIRs) per 100 000 and age-standardized death rates (ASDRs) per 100 000 for both sexes in 2013 were higher in developing vs developed countries for stomach cancer (ASIR, 17 vs 14; ASDR, 15 vs 11), liver cancer (ASIR, 15 vs 7; ASDR, 16 vs 7), esophageal cancer (ASIR, 9 vs 4; ASDR, 9 vs 4), cervical cancer (ASIR, 8 vs 5; ASDR, 4 vs 2), lip and oral cavity cancer (ASIR, 7 vs 6; ASDR, 2 vs 2), and nasopharyngeal cancer (ASIR, 1.5 vs 0.4; ASDR, 1.2 vs 0.3). Between 1990 and 2013, ASIRs for all cancers combined (except nonmelanoma skin cancer and Kaposi sarcoma) increased by more than 10% in 113 countries and decreased by more than 10% in 12 of 188 countries. CONCLUSIONS AND RELEVANCE Cancer poses a major threat to public health worldwide, and incidence rates have increased in most countries since 1990. The trend is a particular threat to developing nations with health systems that are ill-equipped to deal with complex and expensive cancer treatments. The annual update on the Global Burden of Cancer will provide all stakeholders with timely estimates to guide policy efforts in cancer prevention, screening, treatment, and palliation.
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Affiliation(s)
- Christina Fitzmaurice
- Division of Hematology, Department of Medicine, University of Washington, Seattle2Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Daniel Dicker
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Amanda Pain
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Hannah Hamavid
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Maziar Moradi-Lakeh
- Institute for Health Metrics and Evaluation, University of Washington, Seattle3Gastrointestinal and Liver Disease Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Michael F MacIntyre
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Christine Allen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Gillian Hansen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Rachel Woodbrook
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | | | | | - Andrea Werdecker
- Institute of Medical Sociology and Social Medicine, Marburg, Germany
| | | | - Braden Te Ao
- Department of Biostatistics and Epidemiology, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland, New Zealand
| | - Brian McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Chante Karimkhani
- College of Physicians and Surgeons, Columbia University, New York, New York
| | - Chuanhua Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Wuhan University, Wuhan, China
| | | | - David C Schwebel
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama
| | - David O Carpenter
- Institute for Health and the Environment, University at Albany, Rensselaer, New York
| | - David M Pereira
- Laboratório de Farmacognosia, Departamento de Ciências Químicas, Faculdade de Farmácia, University do Porto, REQUIMTE/LAQV, Porto, Portugal
| | - Denis Nash
- School of Public Health, Hunter College Campus, City University of New York, New York
| | | | | | - Dietrich Plass
- Federal Environment Agency Section on Exposure Assessment and Environmental Health Indicators, Berlin, Germany
| | - Kingsley N Ukwaja
- Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria
| | - George D Thurston
- Nelson Institute of Environmental Medicine, New York University School of Medicine, Tuxedo, New York
| | - Kim Yun Jin
- Faculty of Chinese Medicine, Southern University College, Johor, Malaysia
| | - Edgar P Simard
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Eun-Kee Park
- Department of Medical Humanities and Social Medicine, Kosin University College of Medicine, Busan, South Korea
| | - Ferrán Catalá-López
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Medicines and Healthcare Products Agency (AEMPS), Ministry of Health, Madrid, Spain
| | | | - Carolyn Gotay
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gulfaraz Khan
- Department of Microbiology & Immunology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | | | - Itamar S Santos
- Centre for Clinical and Epidemiological Research, University of São Paulo, São Paulo, Brazil
| | | | - Jasvinder Singh
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Jost B Jonas
- Department of Ophthalmology, University of Heidelberg, Mannheim, Germany
| | | | - Juan Sanabria
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio38Nutrition and Preventive Medicine, Chicago Medical School at Cancer Treatment Centers of America, Rosalind Franklin University, Chicago, Illinois
| | - Justin Beardsley
- Nuffield Department of Medicine, Oxford University, Ho Chi Minh City, Vietnam
| | - Kathryn H Jacobsen
- Department of Global and Community Health, George Mason University, Fairfax, Virginia
| | - Ken Takahashi
- Department of Environmental Epidemiology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Richard C Franklin
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
| | - Luca Ronfani
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Marcella Montico
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Luigi Naldi
- Azienda Ospedaliera papa Giovanni XXIII, Bergamo, Italy
| | | | - Johanna Geleijnse
- Division of Human Nutrition, Wageningen University, Wageningen, the Netherlands
| | - Max Petzold
- Centre for Applied Biostatistics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden48School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | | - Paul Yip
- The University of Hong Kong, Hong Kong, China
| | - Farshad Pourmalek
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paulo A Lotufo
- Centre for Clinical and Epidemiological Research, University of São Paulo, São Paulo, Brazil
| | - Alireza Esteghamati
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Graeme J Hankey
- School of Medicine and Pharmacology, University of Western Australia, School of Medicine and Pharmacology, Perth, Australia
| | - Raghib Ali
- Nuffield Department of Population Health, University of Oxford, Oxford, England
| | - Raimundas Lunevicius
- Department of Neuropsychopharmacology, Aintree University Hospital NHS Foundation Trust, Liverpool, England
| | - Reza Malekzadeh
- Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Robert Dellavalle
- Veterans Affairs Eastern Colorado Health Care System, Denver61Department of Dermatology, University of Colorado School of Medicine, Denver
| | - Robert Weintraub
- University of Melbourne, Melbourne, Australia63Royal Children's Hospital, Melbourne, Australia
| | - Robyn Lucas
- National Centre for Epidemiology and Population Health, Research School of Population Health, The Australian National University, Canberra, Australia
| | - Roderick Hay
- International Foundation for Dermatology, London, England
| | - David Rojas-Rueda
- Centre of Research in Environmental Epidemiology (CREAL), Barcelona, Spain
| | | | - Sadaf G Sepanlou
- Digestive Diseases Research Institute, Shariati Hospital, Tehran, Iran
| | - Sandra Nolte
- Charité University Medicine Berlin, Berlin, Germany
| | - Scott Patten
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Ivy Shiue
- Northumbria University, Newcastle upon Tyne, England75University of Edinburgh, Edinburgh, Scotland
| | - Tim Driscoll
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Tommi Vasankari
- UKK Institute for Health Promotion Research, Tampere, Finland
| | | | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vasiliy V Vlassov
- National Research University Higher School of Economics, Moscow, Russia
| | - W S Marcenes
- Barts and The London School of Medicine and Dentistry, University of London, London, England
| | | | - Yohannes Adama Melaku
- College of Health Sciences, School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Yuichiro Yano
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | | | | | - Jennifer MacLachlan
- Victorian Infectious Diseases Reference Laboratory (VIDRL), The Peter Doherty Institute for Infection and Immunity, WHO Collaborating Centre for Viral Hepatitis, Melbourne, Australia
| | | | - Daniel Kim
- Department of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Matias Trillini
- Mario Negri Institute for pharmacological Research, Ranica, Italy
| | - Babak Eshrati
- Arak University of Medical Sciences and Health Affairs, Arak, Iran
| | | | | | - Rakhi Dandona
- Public Health Foundation of India, National Capital Region, India
| | - Kinnari Murthy
- Public Health Foundation of India, National Capital Region, India
| | - Benjamin Cowie
- Victorian Infectious Diseases Reference Laboratory (VIDRL), The Peter Doherty Institute for Infection and Immunity, WHO Collaborating Centre for Viral Hepatitis, Melbourne, Australia
| | - Azmeraw T Amare
- Department of Epidemiology, University of Groningen, Groningen, the Netherlands
| | | | | | - Coen H van Gool
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Francesco Violante
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - In-Hwan Oh
- Kyung Hee University, Seoul, South Korea
| | - Kedede Deribe
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia100Brighton and Sussex Medical School, Brighton, England
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway102University of Bergen, Stavanger, Norway
| | - Luke Knibbs
- Department of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | - Maia Kereselidze
- National Centre for Diseases Control and Public Health, Tbilisi, Georgia
| | - Mark Green
- University of Sheffield, Sheffield, England
| | | | - Nobhojit Roy
- Department of Public Health Sciences, Karolinska Institutet, Mumbai, India
| | | | | | - Yongmei Li
- Genentech Inc, San Francisco, California
| | - Hans Krueger
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lorenzo Monasta
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Subhojit Dey
- Indian Institute of Public Health, National Capital Region, India
| | - Sara Sheikhbahaei
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Hafezi-Nejad
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - G Anil Kumar
- Public Health Foundation of India, National Capital Region, India
| | | | - Lalit Dandona
- Institute for Health Metrics and Evaluation, University of Washington, Seattle93Public Health Foundation of India, National Capital Region, India
| | - Haidong Wang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Stein Emil Vollset
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway113Norwegian Institute of Public Health, Bergen, Norway
| | - Ali Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | - Rafael Lozano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle115National Institute of Public Health, Cuernavaca, Mexico
| | - Theo Vos
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | - Alan Lopez
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Christopher Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
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Sivaram S, Sanchez MA, Rimer BK, Samet JM, Glasgow RE. Implementation science in cancer prevention and control: a framework for research and programs in low- and middle-income countries. Cancer Epidemiol Biomarkers Prev 2014; 23:2273-84. [PMID: 25178984 PMCID: PMC4221499 DOI: 10.1158/1055-9965.epi-14-0472] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Implementation science is a set of tools, principles, and methodologies that can be used to bring scientific evidence into action, improve health care quality and delivery, and improve public health. As the burden of cancer increases in low- and middle-income countries, it is important to plan cancer control programs that are both evidence based and delivered in ways that are feasible, cost-effective, contextually appropriate, and sustainable. This review presents a framework for using implementation science for cancer control planning and implementation and discusses potential areas of focus for research and programs in low- and middle-income countries interested in integrating research into practice and policy.
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Affiliation(s)
- Sudha Sivaram
- Center for Global Health, National Cancer Institute, , Phone: 2402765804
| | - Michael A. Sanchez
- Division of Cancer Control and Population Sciences, National Cancer Institute,
| | | | - Jonathan M. Samet
- Department of Preventive Medicine, Keck School of Medicine, Director, Institute for Global Health, University of Southern California,
| | - Russell E. Glasgow
- Colorado Health Outcomes Program, Department of Family Medicine, University of Colorado School of Medicine,
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Gard AC, Soliman AS, Ngoma T, Mwaiselage J, Kahesa C, Chamberlain RM, Harlow SD. Most women diagnosed with cervical cancer by a visual screening program in Tanzania completed treatment: evidence from a retrospective cohort study. BMC Public Health 2014; 14:910. [PMID: 25187329 PMCID: PMC4162936 DOI: 10.1186/1471-2458-14-910] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 07/29/2014] [Indexed: 12/01/2022] Open
Abstract
Background Visual inspection with acetic acid (VIA) to identify and treat pre-cancerous lesions is effective for cervical cancer prevention. Screening programs also facilitate screening and diagnosis of invasive cancers that must be referred for radiation therapy or chemotherapy. This study compared characteristics of women diagnosed with invasive cervical cancer by a VIA screening program who did and did not follow up for treatment and who did and did not complete treatment at the Ocean Road Cancer Institute (ORCI), Dar es Salaam, Tanzania. Methods We conducted a retrospective cohort study of ORCI screening referrals from the period November 2002 to June 2011. Women referred for treatment of invasive disease (n = 980) were identified from an existing database of all women attending the screening clinic during this period (n = 20,131) and matched to a dataset of all cervical cancer patients attending ORCI in this period (n = 8,240). Treatment information was abstracted from patient records of women who followed up. Records of a random sample (n = 333) of unscreened patients were reviewed for disease stage. Results Of the 980 women referred women, 829 (84.6%) sought treatment. Most of those women (82.8%) completed their prescribed radiation. Lower disease stage, having a skilled occupation, residence in Dar es Salaam, and younger age were independently associated with loss to follow-up. Higher disease stage, residence in Dar es Salaam, older age, and later year of first treatment appointment were independently associated with incomplete treatment among those who followed up. Significantly more screened women had stage 1 disease (14.0%) than unscreened women (7.8%). Conclusions Most women referred from the screening clinic completed treatment for their cancer at ORCI. Some of those lost to follow-up may have sought treatment elsewhere. In most cases, the screening clinic appears to facilitate diagnosis and treatment, rather than screening, for women with invasive cervical cancer.
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Affiliation(s)
| | - Amr S Soliman
- University of Nebraska Medical Center College of Public Health, Omaha, NE, USA.
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Krishnan S, Madsen E, Porterfield D, Varghese B. Advancing cervical cancer prevention in India: implementation science priorities. Oncologist 2014; 18 Suppl:13-25. [PMID: 24334478 DOI: 10.1634/theoncologist.18-s2-13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Cervical cancer is the leading cause of cancer mortality in India, accounting for 17% of all cancer deaths among women aged 30 to 69 years. At current incidence rates, the annual burden of new cases in India is projected to increase to 225,000 by 2025, but there are few large-scale, organized cervical cancer prevention programs in the country. We conducted a review of the cervical cancer prevention research literature and programmatic experiences in India to summarize the current state of knowledge and practices and recommend research priorities to address the gap in services. We found that research and programs in India have demonstrated the feasibility and acceptability of cervical cancer prevention efforts and that screening strategies requiring minimal additional human resources and laboratory infrastructure can reduce morbidity and mortality. However, additional evidence generated through implementation science research is needed to ensure that cervical cancer prevention efforts have the desired impact and are cost-effective. Specifically, implementation science research is needed to understand individual- and community-level barriers to screening and diagnostic and treatment services; to improve health care worker performance; to strengthen links among screening, diagnosis, and treatment; and to determine optimal program design, outcomes, and costs. With a quarter of the global burden of cervical cancer in India, there is no better time than now to translate research findings to practice. Implementation science can help ensure that investments in cervical cancer prevention and control result in the greatest impact.
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Gupta S, Singh V, Sehgal A, Sodhani P. Cervical cancer in resource-limited settings: preventable but not yet prevented. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2.4.515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Krishnan S, Madsen E, Porterfield D, Varghese B. Advancing cervical cancer prevention in India: implementation science priorities. Oncologist 2013; 18:1285-97. [PMID: 24217555 PMCID: PMC3868423 DOI: 10.1634/theoncologist.2013-0292] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 10/04/2013] [Indexed: 12/31/2022] Open
Abstract
Cervical cancer is the leading cause of cancer mortality in India, accounting for 17% of all cancer deaths among women aged 30 to 69 years. At current incidence rates, the annual burden of new cases in India is projected to increase to 225,000 by 2025, but there are few large-scale, organized cervical cancer prevention programs in the country. We conducted a review of the cervical cancer prevention research literature and programmatic experiences in India to summarize the current state of knowledge and practices and recommend research priorities to address the gap in services. We found that research and programs in India have demonstrated the feasibility and acceptability of cervical cancer prevention efforts and that screening strategies requiring minimal additional human resources and laboratory infrastructure can reduce morbidity and mortality. However, additional evidence generated through implementation science research is needed to ensure that cervical cancer prevention efforts have the desired impact and are cost-effective. Specifically, implementation science research is needed to understand individual- and community-level barriers to screening and diagnostic and treatment services; to improve health care worker performance; to strengthen links among screening, diagnosis, and treatment; and to determine optimal program design, outcomes, and costs. With a quarter of the global burden of cervical cancer in India, there is no better time than now to translate research findings to practice. Implementation science can help ensure that investments in cervical cancer prevention and control result in the greatest impact.
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Affiliation(s)
- Suneeta Krishnan
- RTI International, Research Triangle Park, North Carolina, USA
- St. John's Research Institute, Bangalore, India
| | - Emily Madsen
- RTI International, Research Triangle Park, North Carolina, USA
| | - Deborah Porterfield
- RTI International, Research Triangle Park, North Carolina, USA
- Department of Social Medicine, School of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina, USA
| | - Beena Varghese
- St. John's Research Institute, Bangalore, India
- Public Health Foundation of India, New Delhi, India
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Cervical cancer screening in high- and low-resource countries: implications and new developments. Obstet Gynecol Surv 2013; 67:658-67. [PMID: 23112073 DOI: 10.1097/ogx.0b013e3182732375] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The implementation of cytology-based screening programs for precancerous lesions of the cervix has decreased the incidence of and mortality from cervical cancer in much of the developed world. Countries without the resources to install such frequent and laboratory-dependent screening programs have more and more options at their disposal. A screening program based on cytology analysis requires too much training, infrastructure, and repeated screening to be feasible. Visual inspection with acetic acid, often used throughout the world, is inexpensive and both sensitive and specific, but it lacks reproducibility. Although human papillomavirus (HPV) testing is too expensive for widespread use, its negative predictive value and sensitivity make it a promising method of screening. Utilizing HPV vaccines as a primary mode of prevention may not be financially feasible and does not obviate the need for screening. Cervical cancer has been considered an AIDS-defining illness, with HPV and HIV often coexisting, and screening methods have been shown to be as reliable for women with HIV as those without. Ultimately, the most clinically effective and cost-effective methods for reducing cervical cancer incidence are those that limit the number of visits that women are required to attend. Providing immediate cryotherapy for those with a positive screen, whether by visual inspection or HPV testing, is promising to have quite an impact, although the type of program implemented will depend on the needs and expectations of each country.
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Kim YM, Ati A, Kols A, Lambe FM, Soetikno D, Wysong M, Tergas AI, Rajbhandari P, Lu E. Influencing women's actions on cervical cancer screening and treatment in Karawang District, Indonesia. Asian Pac J Cancer Prev 2013; 13:2913-21. [PMID: 22938483 DOI: 10.7314/apjcp.2012.13.6.2913] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The impact of cervical cancer prevention programs depends on persuading women to go for screening and, if needed, treatment. As part of an evaluation of a pilot project in Indonesia, qualitative research was conducted to explore the factors that influence women's decisions regarding screening and treatment and to generate practical recommendations to increase service coverage and reduce loss to follow up. METHODS Research was conducted at 7 of the 17 public health centers in Karawang District that implemented the pilot project. Interviews and focus group discussions were held with 20 women, 20 husbands, 10 doctors, 18 midwives, 3 district health officials, and 16 advocacy team members. RESULTS Free services and mobile outreach events encouraged women to go for screening, along with promotional efforts by community health workers, advocacy teams, and the mass media. Knowledge and perceptions were the most important barriers to screening: women were not aware of cervical cancer risks, did not know the disease was treatable, and were fatalistic. Factors facilitating treatment were social support from husbands, relatives, and friends and the encouragement and role modeling of health workers. Barriers to prompt treatment included limited access to services and the requirement for husband's consent for cryotherapy. CONCLUSION As cervical cancer prevention services are scaled up throughout Indonesia, the findings suggest three strategies to expand screening coverage and ensure prompt treatment: strengthening community mobilization and advocacy activities, modifying the service delivery model to encourage a single visit approach to screening and treatment, and working to gain men's support.
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The feasibilities of TruScreen for primary cervical cancer screening: a self-controlled study. Arch Gynecol Obstet 2013; 288:113-8. [PMID: 23296464 DOI: 10.1007/s00404-012-2697-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 12/20/2012] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Screening programs based on cytology testing led to the incidence reduction of cervical cancer mortality of about 70-80 % in industrialized countries. However, these favorable results have not been replicated in developing areas. Thus, we aim to evaluate the efficacy of TruScreen (Polartechnics, Sydney, Australia) in detecting of precancerous lesions in comparison with cervical cytology test. METHODS A total of 181 outpatients were screened by TruScreen using the pathological results as the gold standard. The medical records of cytological smear within 6 weeks were obtained from 169 of these participants. The reliability and yield of TruScreen and cytological smear were assessed. The screening results of TruScreen were compared with those obtained from the conventional smear. RESULTS The sensitivities for histologically confirmed cervical intraepithelial neoplasia (CIN) lesions by TruScreen and Pap, were 67.4 % (95 % CI 53.4-81.5) and 87.9 % (95 % CI 76.7-99.0), respectively. The specificities for histologically confirmed CIN lesions by TruScreen and Pap, were 68.1 % (95 % CI 60.3-75.9) and 74.3 % (95 % CI 70.0-81.4), respectively. In contrast to Pap smear, TruScreen was comparatively efficacious in screening of cervical cancer (χ (2) = 0.0133, P = 0.9081). CONCLUSION TruScreen is a potential test for initial cervical screening in developing world regions.
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Abstract
Developing countries suffer the highest burden of cervical cancers but have the lowest resources. Effective cervical cytology screening programme, along with a network of diagnostic and therapeutic colposcopy centres, like developed countries, is almost impossible to be reproduced in developing countries. Visual inspection methods [e.g., Visual inspection with Lugol’s iodine (VILI) and Visual Inspection with Acetic Acid (VIA)] which are cheaper, require less expertise and have the advantage of possible treatment in one setting have been shown to be effective alternatives. The sensitivity to detect CIN2+, by VIA and VILI, have been shown to be 80% and 91% respectively, with a specificity rate of 92% and 85% respectively. Screening by human papillomavirus (HPV) testing has high sensitivity (96.4%) but low specificity (94.1%) to detect CIN2+, when compared to Pap Smear (sensitivity, 55.4% and specificity, 96.8%). A single lifetime HPV testing in a large unscreened population has been shown to significantly reduce cervical cancer incidence and mortality when compared to cervical cytology, VIA or no screening. HPV testing of self-collected vaginal specimens also helps to overcome religious and socio-cultural barriers towards pelvic examination amongst women in developing countries. Current HPV testing methods are expensive, skill/infrastructure demanding and takes time to produce results. A cheaper HPV test, called careHPV™, which is able to provide results within 2.5 h and requires minimal skill/infrastructure to operate, was designed for use in developing countries. One stop screen and treat facilities using VIA or rapid HPV testing, and cryotherapy, can overcome non-compliance to follow-up which is a major issue in developing countries. Cure rates of 81.4% for CIN1, 71.4% for CIN2 and 68.0% for CIN3 at 6 mo after treatment have been reported. Incorporating telemedicine with cervicography of VIA or VILI or even telecolposcopy, has great potential in cervical cancer screening, especially in countries with vast geographical areas.
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Abstract
Background: We performed a cross-sectional study in Indonesia to evaluate the performance of a single-visit approach of cervical cancer screening, using visual inspection with acetic acid (VIA), histology and cryotherapy in low-resource settings. Methods: Women having limited access to health-care facilities were screened by trained doctors using VIA. If the test was positive, biopsies were taken and when eligible, women were directly treated with cryotherapy. Follow-up was performed with VIA and cytology after 6 months. When cervical cancer was suspected or diagnosed, women were referred. The positivity rate, positive predictive value (PPV) and approximate specificity of the VIA test were calculated. The detection rate for cervical lesions was given. Results: Screening results were completed in 22 040 women, of whom 92.7% had never been screened. Visual inspection with acetic acid was positive in 4.4%. The PPV of VIA to detect CIN I or greater and CIN II or greater was 58.7% and 29.7%, respectively. The approximate specificity was 98.1%, and the detection rate for CIN I or greater was 2.6%. Conclusion: The single-visit approach cervical cancer screening performed well, showing See and Treat is a promising way to reduce cervical cancer in Indonesia.
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Thulaseedharan JV, Malila N, Hakama M, Esmy PO, Cheriyan M, Swaminathan R, Muwonge R, Sankaranarayanan R. Socio Demographic and Reproductive Risk Factors for Cervical Cancer - a Large Prospective Cohort Study from Rural India. Asian Pac J Cancer Prev 2012; 13:2991-5. [DOI: 10.7314/apjcp.2012.13.6.2991] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Arora RS, Alston RD, Eden TOB, Moran A, Geraci M, O'Hara C, Birch JM. Cancer at ages 15-29 years: the contrasting incidence in India and England. Pediatr Blood Cancer 2012; 58:55-60. [PMID: 20949596 DOI: 10.1002/pbc.22738] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 06/10/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND There has been a steady increase in published research from Europe and North America on the epidemiology of cancers in young people. There are limited data from the developing world. We contrast the incidence of cancer at ages 15-29 years in India and England. PROCEDURE Malignant neoplasms in those aged 15-29 years registered during 2001-2003 in five urban population-based cancer registries (PBCRs) of India and in eight PBCRs in England were included. Site-based classification was used. Age-standardized incidence rates were expressed per 100,000 person years. RESULTS In India, 4,864 (5.8%) of 84,450 cases and in England, 8,137 (1.2%) of 65,6752 cancer cases occurred in those aged 15-29 years. For this age group, the incidence rate for males and females in India were 12.91 and 14.19, and in England were 27.75 and 28.88, respectively. In males aged 15-29 years, the three most common cancers in India were leukemia, lymphoma, and central nervous system tumors and in England were cancers of male genital organs, lymphoma, and leukemia. Cancers of female genital organs, breast, and leukemia were most common in females in India and cancers of female genital organs, lymphoma, and melanoma in England. For cancers of mouth, stomach, and gall bladder, the incidence was higher in India. CONCLUSION Incidence of cancer at ages 15-29 years in England is higher at most sites than in India. Variation in environmental exposures between the two countries might be an explanation. Under-ascertainment of cases and gender bias in seeking healthcare may also influence reported incidence rates in India.
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Affiliation(s)
- Ramandeep S Arora
- Cancer Research UK Paediatric and Familial Cancer Research Group, University of Manchester, Manchester, UK.
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Sankaranarayanan R, Sauvaget C, Ramadas K, Ngoma T, Teguete I, Muwonge R, Naud P, Nessa A, Kuhaprema T, Qiao Y. Clinical trials of cancer screening in the developing world and their impact on cancer healthcare. Ann Oncol 2011; 22 Suppl 7:vii20-vii28. [DOI: 10.1093/annonc/mdr422] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Everett T, Bryant A, Griffin MF, Martin‐Hirsch PPL, Forbes CA, Jepson RG. Interventions targeted at women to encourage the uptake of cervical screening. Cochrane Database Syst Rev 2011; 2011:CD002834. [PMID: 21563135 PMCID: PMC4163962 DOI: 10.1002/14651858.cd002834.pub2] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection. OBJECTIVES To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening. SEARCH STRATEGY We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis. MAIN RESULTS Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials. AUTHORS' CONCLUSIONS There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.
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Affiliation(s)
- Thomas Everett
- Addenbrooke's Hospital NHS Foundation TrustDepartment of Gynaecological OncologyBOX 242, Addenbrooke's HospitalHills RoadCambridgeUKCB2 0QQ
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Michelle F Griffin
- Addenbrooke's Hospital NHS Foundation TrustDepartment of Gynaecological OncologyBOX 242, Addenbrooke's HospitalHills RoadCambridgeUKCB2 0QQ
| | - Pierre PL Martin‐Hirsch
- Royal Preston Hospital, Lancashire Teaching Hospital NHS TrustGynaecological Oncology UnitSharoe Green LaneFullwoodPrestonLancashireUKPR2 9HT
| | - Carol A Forbes
- University of YorkNHS Centre for Reviews & DisseminationHeslingtonYorkNorth YorkshireUKYO10 5DD
| | - Ruth G Jepson
- Scottish Collaboration for Public Health Research and Policy (SCPHRP)20 West Richmond StreetEdinburghScotlandUKEH8 9DX
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Chamot E, Kristensen S, Stringer JSA, Mwanahamuntu MH. Are treatments for cervical precancerous lesions in less-developed countries safe enough to promote scaling-up of cervical screening programs? A systematic review. BMC WOMENS HEALTH 2010; 10:11. [PMID: 20359354 PMCID: PMC2858093 DOI: 10.1186/1472-6874-10-11] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 04/01/2010] [Indexed: 12/21/2022]
Abstract
Background Since the mid-1990s, there have been growing efforts to prevent cervical cancer in less-developed countries through the development of innovative screening approaches such as visual inspection of the cervix associated with same day management of cervical lesions with cryotherapy or loop electrosurgical excision procedure (LEEP). In the past, promising cancer screening interventions have been widely promoted despite incomplete evidence, only to become the subject of intense controversies about ensuing net health benefit. Because the efficacy and effectiveness of the new protocols for global cervical cancer screening have not been well characterized yet, and as a contribution to the evaluation of the balance between the benefits and risks of these protocols, we reviewed the literature on the safety of cryotherapy and LEEP for cervical intraepithelial neoplasia (CIN) in low- and middle-income countries. Methods We searched 12 databases (Medline, Google Scholar, Scopus, Cochrane Library, Web of Science, OCLC, PAIS International Database, WHO Global Health Library, CINAHL, Science.gov, NYAM Grey Literature Report, and POPLINE) for original research published between January 1995 and April 2009. Both peer-reviewed publications and items of "grey" literature were retrieved; no language restriction was applied. We calculated the median (minimum, maximum) reported rate for each harm considered. Because of limitations and heterogeneity in the data, no formal meta-analysis was performed. Results The search identified 32 articles that reported safety data from 24 cryotherapy and LEEP studies. The combined sample consisted of 6,902 women treated by cryotherapy and 4,524 women treated by LEEP. Most studies were conducted in reference or research settings in Asia and Africa. Short-term harms of cryotherapy and LEEP appeared to be similar to those described in the literature from high-income countries. Information was sparse on HIV-related harms and long-term reproductive outcomes of treatment. Conclusions When performed in resource-limited settings by qualified providers, cryotherapy and LEEP are not associated with excess harm. However, available data are insufficient to propose fully evidence-based protocols for routine screening of HIV-infected women and women of reproductive age.
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Affiliation(s)
- Eric Chamot
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
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25
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Denton KJ, Desai M. Cervical screening programmes. Diagn Cytopathol 2010. [DOI: 10.1016/b978-0-7020-3154-0.00022-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Bradley J, Coffey P, Arrossi S, Agurto I, Bingham A, Dzuba I, Kleine AN, Lewis R, White SC. Women's Perspectives on Cervical Screening and Treatment in Developing Countries: Experiences with New Technologies and Service Delivery Strategies. Women Health 2008; 43:103-21. [PMID: 17194680 DOI: 10.1300/j013v43n03_06] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This review of studies conducted by partners in the Alliance for Cervical Cancer Prevention (ACCP) examines women's perspectives on, and acceptability of, new cervical cancer screening and treatment approaches, management by mid-level staff, single-visit strategies, treatment side effects, and post-treatment abstinence requirements in low-resource settings. All screening, managed by female nurses and irrespective of method or constellation of methods, appeared to be highly acceptable. Similarly, cryotherapy treatment, including cryotherapy managed by nurses immediately after screening, was well-received by women in the studies. Minor side effects, although rather prevalent, and difficulties with post-treatment abstinence, did not appear to significantly deter women from recommending the procedure to friends. Rather, a sense of relief was evident, a feeling that it was better to be treated than not treated, and better to be treated sooner rather than later. While full replication may not be possible, this does not lessen the fact that screening and treatment in developing countries, even with new technologies, immediate treatment and even using mid-level providers, can be very acceptable to women if provided in a safe, caring and preferably all-female environment.
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Affiliation(s)
- Janet Bradley
- Engender Health, 440 Ninth Avenue, New York, NY 10001, USA.
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Murray DM, Pals SL, Blitstein JL, Alfano CM, Lehman J. Design and analysis of group-randomized trials in cancer: a review of current practices. J Natl Cancer Inst 2008; 100:483-91. [PMID: 18364501 DOI: 10.1093/jnci/djn066] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Previous reviews have identified problems in the design and analysis of group-randomized trials in a number of areas. Similar problems may exist in cancer research, but there have been no comprehensive reviews. METHODS We searched Medline and PubMed for group-randomized trials focused on cancer prevention and control that were published between 2002 and 2006. We located and reviewed 75 articles to determine whether articles included evidence of taking group randomization into account in establishing the size of the trial, such as reporting the expected intraclass correlation, the group component of variance, or the variance inflation factor. We also examined the analytical approaches to determine their appropriateness. RESULTS Only 18 (24%) of the 75 articles documented appropriate methods for sample size calculations. Only 34 (45%) limited their reports to analyses judged to be appropriate. Fully 26 (34%) failed to report any analyses that were judged to be appropriate. The most commonly used inappropriate analysis was an analysis at the individual level that ignored the groups altogether. Nine articles (12%) did not provide sufficient information. CONCLUSIONS Many investigators who use group-randomized trials in cancer research do not adequately attend to the special design and analytic challenges associated with these trials. Failure to do so can lead to reporting type I errors as real effects, mislead investigators and policy-makers, and slow progress toward control and prevention of cancer. A collaborative effort by investigators, statisticians, and others will be required to ensure that group-randomized trials are planned and analyzed using appropriate methods so that the scientific community can have confidence in the published results.
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Affiliation(s)
- David M Murray
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA.
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Wright TC, Blumenthal P, Bradley J, Denny L, Esmy PO, Jayant K, Nene BM, Pollack AE, Rajkumar R, Sankaranarayanan R, Sellors JW, Shastri SS, Sherris J, Tsu V. Cervical cancer prevention for all the world's women: new approaches offer opportunities and promise. Diagn Cytopathol 2008; 35:845-8. [PMID: 18008343 DOI: 10.1002/dc.20755] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Park SY, Follen M, Milbourne A, Rhodes H, Malpica A, MacKinnon N, MacAulay C, Markey MK, Richards-Kortum R. Automated image analysis of digital colposcopy for the detection of cervical neoplasia. JOURNAL OF BIOMEDICAL OPTICS 2008; 13:014029. [PMID: 18315387 DOI: 10.1117/1.2830654] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Digital colposcopy is a promising technology for the detection of cervical intraepithelial neoplasia. Automated analysis of colposcopic images could provide an inexpensive alternative to existing screening tools. Our goal is to develop a diagnostic tool that can automatically identify neoplastic tissue from digital images. A multispectral digital colposcope (MDC) is used to acquire reflectance images of the cervix with white light before and after acetic-acid application in 29 patients. A diagnostic image analysis tool is developed to identify neoplasia in the digital images. The digital image analysis is performed in two steps. First, similar optical patterns are clustered together. Second, classification algorithms are used to determine the probability that these regions contain neoplastic tissue. The classification results of each patient's images are assessed relative to the gold standard of histopathology. Acetic acid induces changes in the intensity of reflected light as well as the ratio of green to red reflected light. These changes are used to differentiate high-grade squamous intraepithelial (HGSIL) and cancerous lesions from normal or low-grade squamous intraepithelial (LGSIL) tissue. We report diagnostic performance with a sensitivity of 79% and a specificity of 88%. We show that diagnostically useful digital images of the cervix can be obtained using a simple and inexpensive device, and that automated image analysis algorithms show a potential to identify histologically neoplastic tissue areas.
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Affiliation(s)
- Sun Young Park
- University of Texas, Department of Biomedical Engineering, Austin, Texas 78712, USA
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30
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Mayrand MH, Duarte-Franco E, Rodrigues I, Walter SD, Hanley J, Ferenczy A, Ratnam S, Coutlée F, Franco EL. Human papillomavirus DNA versus Papanicolaou screening tests for cervical cancer. N Engl J Med 2007; 357:1579-88. [PMID: 17942871 DOI: 10.1056/nejmoa071430] [Citation(s) in RCA: 704] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND To determine whether testing for DNA of oncogenic human papillomaviruses (HPV) is superior to the Papanicolaou (Pap) test for cervical-cancer screening, we conducted a randomized trial comparing the two methods. METHODS We compared HPV testing, using an assay approved by the Food and Drug Administration, with conventional Pap testing as a screening method to identify high-grade cervical intraepithelial neoplasia in women ages 30 to 69 years in Montreal and St. John's, Canada. Women with abnormal Pap test results or a positive HPV test (at least 1 pg of high-risk HPV DNA per milliliter) underwent colposcopy and biopsy, as did a random sample of women with negative tests. Sensitivity and specificity estimates were corrected for verification bias. RESULTS A total of 10,154 women were randomly assigned to testing. Both tests were performed on all women in a randomly assigned sequence at the same session. The sensitivity of HPV testing for cervical intraepithelial neoplasia of grade 2 or 3 was 94.6% (95% confidence interval [CI], 84.2 to 100), whereas the sensitivity of Pap testing was 55.4% (95% CI, 33.6 to 77.2; P=0.01). The specificity was 94.1% (95% CI, 93.4 to 94.8) for HPV testing and 96.8% (95% CI, 96.3 to 97.3; P<0.001) for Pap testing. Performance was unaffected by the sequence of the tests. The sensitivity of both tests used together was 100%, and the specificity was 92.5%. Triage procedures for Pap or HPV testing resulted in fewer referrals for colposcopy than did either test alone but were less sensitive. No adverse events were reported. CONCLUSIONS As compared with Pap testing, HPV testing has greater sensitivity for the detection of cervical intraepithelial neoplasia. (Current Controlled Trials number, ISRCTN57612064 [controlled-trials.com].).
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Affiliation(s)
- Marie-Hélène Mayrand
- Department of Oncology and Epidemiology & Biostatistics, McGill University, Montreal, Canada
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Miller D, Okolo CA, Mirabal Y, Guillaud M, Arulogun OS, Oladepo O, Crain B, Follen M, Adewole IF. Knowledge dissemination and evaluation in a cervical cancer screening implementation program in Nigeria. Gynecol Oncol 2007; 107:S196-207. [PMID: 17889285 DOI: 10.1016/j.ygyno.2007.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Accepted: 07/06/2007] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Our goals were to train health professionals in Nigeria using the text, "Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers", and then evaluate the knowledge dissemination process using a pre- and post-test assessment. The manual was developed by the ACCP, WHO, IARC, PATH, Engender Health, JHPIEGO, and PAHO with funding from the Gates Foundation. It is an inclusive guide to implementation and maintenance of screen-and-treat cervical cancer prevention clinics and is ideally suited for programs operating in the developing world. METHODS Training took place at a conference in Ibadan, Nigeria. Participants included teams of physicians, nurses, bioengineers, data managers, and administrators who met in joint and parallel sessions to "train the trainers". This meeting was designed to provide both training and equipment to personnel to be involved in the implementation of a cervical cancer control initiative in Nigeria. A 36 item pre-test was administered prior to a group study sessions. A slide presentation summarized salient points before the post-test was given. The results were entered into an MS Excel spreadsheet for descriptive statistics about (1) the participants, (2) the test, (3) an examination of profession, years of work experience, years of education, and gender as predictors of two outcomes (low pre-test score and large difference between pre- and post-tests) and (4) overall performance on the exam. RESULTS There were 70 participants and trainers, of which 53 took the exam. Most of the examinees were physicians. Some participants did not fill out the post-test, leaving their tests inevaluable. A closer look at the test revealed eight questions that were confusing and nine that were too easy. All participant subgroups performed better on the post-test than the pre-test; the improvements were statistically significant. While profession impacted the results, profession was not statistically significant. Years of work experience, years of education, and gender did not affect test results. CONCLUSIONS While the study suffers from a small sample size, a few ambiguous questions, and the need for pilot testing the instrument prior to the meeting, the report evaluates the manual very favorably. The authors showed a significant gain in knowledge. The manual gives "the big picture" and does so with clarity. The text and supplementary material outline the work that needs to proceed in an organized program, and the material was easily understandable in Nigeria. Future evaluations could benefit from more participants and varied learning structures.
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Affiliation(s)
- Dianne Miller
- Department of Gynecologic Oncology, British Columbia Cancer Centre, Vancouver, British Columbia, Canada
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Sankaranarayanan R, Esmy PO, Rajkumar R, Muwonge R, Swaminathan R, Shanthakumari S, Fayette JM, Cherian J. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet 2007; 370:398-406. [PMID: 17679017 DOI: 10.1016/s0140-6736(07)61195-7] [Citation(s) in RCA: 328] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cervical cancer is the most common cancer among women in developing countries. We assessed the effect of screening using visual inspection with 4% acetic acid (VIA) on cervical cancer incidence and mortality in a cluster randomised controlled trial in India. METHODS Of the 114 study clusters in Dindigul district, India, 57 were randomised to one round of VIA by trained nurses, and 57 to a control group. Healthy women aged 30 to 59 years were eligible for the study. Screen-positive women had colposcopy, directed biopsies, and, where appropriate, cryotherapy by nurses during the screening visit. Those with larger precancerous lesions or invasive cancers were referred for appropriate investigations and treatment. Cervical cancer incidence and mortality in the study groups were analysed and compared using Cox regression taking the cluster design into account, and analysis was by intention to treat. The primary outcome measures were cervical cancer incidence and mortality. RESULTS Of the 49,311 eligible women in the intervention group, 31,343 (63.6%) were screened during 2000-03; 30,958 control women received the standard care. Of the 3088 (9.9%) screened positive, 3052 had colposcopy, and 2539 directed biopsy. Of the 1874 women with precancerous lesions in the intervention group, 72% received treatment. In the intervention group, 274,430 person years, 167 cervical cancer cases, and 83 cervical cancer deaths were accrued compared with 178,781 person-years, 158 cases, and 92 deaths and in the control group during 2000-06 (incidence hazard ratio 0.75 [95% CI 0.55-0.95] and mortality hazard ratio 0.65 [0.47-0.89]). INTERPRETATION VIA screening, in the presence of good training and sustained quality assurance, is an effective method to prevent cervical cancer in developing countries.
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Gaffikin L, McGrath JA, Arbyn M, Blumenthal PD. Visual inspection with acetic acid as a cervical cancer test: accuracy validated using latent class analysis. BMC Med Res Methodol 2007; 7:36. [PMID: 17663796 PMCID: PMC2018715 DOI: 10.1186/1471-2288-7-36] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Accepted: 07/31/2007] [Indexed: 01/17/2023] Open
Abstract
Background The purpose of this study was to validate the accuracy of an alternative cervical cancer test – visual inspection with acetic acid (VIA) – by addressing possible imperfections in the gold standard through latent class analysis (LCA). The data were originally collected at peri-urban health clinics in Zimbabwe. Methods Conventional accuracy (sensitivity/specificity) estimates for VIA and two other screening tests using colposcopy/biopsy as the reference standard were compared to LCA estimates based on results from all four tests. For conventional analysis, negative colposcopy was accepted as a negative outcome when biopsy was not available as the reference standard. With LCA, local dependencies between tests were handled through adding direct effect parameters or additional latent classes to the model. Results Two models yielded good fit to the data, a 2-class model with two adjustments and a 3-class model with one adjustment. The definition of latent disease associated with the latter was more stringent, backed by three of the four tests. Under that model, sensitivity for VIA (abnormal+) was 0.74 compared to 0.78 with conventional analyses. Specificity was 0.639 versus 0.568, respectively. By contrast, the LCA-derived sensitivity for colposcopy/biopsy was 0.63. Conclusion VIA sensitivity and specificity with the 3-class LCA model were within the range of published data and relatively consistent with conventional analyses, thus validating the original assessment of test accuracy. LCA probably yielded more likely estimates of the true accuracy than did conventional analysis with in-country colposcopy/biopsy as the reference standard. Colpscopy with biopsy can be problematic as a study reference standard and LCA offers the possibility of obtaining estimates adjusted for referent imperfections.
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Affiliation(s)
- Lynne Gaffikin
- Cervical Cancer Prevention Program, JHPIEGO, Baltimore, USA
- Evaluation and Research Technologies for Health Incorporated, Stanford USA
| | - John A McGrath
- Cervical Cancer Prevention Program, JHPIEGO, Baltimore, USA
- Department of Psychiatry, Johns Hopkins Medical Institution, Baltimore, USA
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Scientific Institute of Public Health, Brussels Belgium
| | - Paul D Blumenthal
- Cervical Cancer Prevention Program, JHPIEGO, Baltimore, USA
- Department of Obstetrics and Gynecology, Stanford University, Stanford, USA
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Ansink AC. Cervical cancer in developing countries: how can we reduce the burden? Awareness raising, screening, treatment and palliation. Trop Doct 2007; 37:67-70. [PMID: 17540080 DOI: 10.1177/004947550703700202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cervical cancer is an important health problem in developing countries. Most women present with advanced disease, resulting in low cure rates. Screening by Visual Inspection with the Aid of Acetic Acid and optionally HPV DNA detection as a second test is technically feasible. However, the majority of women appear to be reluctant to attend a screening clinic. This is probably due to lack of knowledge and a low priority of women's health in local communities. There is an obvious need to obtain more knowledge on communities' perceptions and understanding of cervical cancer. Furthermore, we need more information on what issues should be addressed in order to perform cervical cancer screening in an acceptable manner. Treatment of cervical cancer in developing countries is highly dependent on the resources and skills available. Efforts to provide adequate palliation should be enhanced as relief of troublesome symptoms can often be achieved by relatively simple and low-cost measures.
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Affiliation(s)
- Anca C Ansink
- Gynaecological Oncologist, ErasmusMC Daniel den Hoed Oncology Centre, PO Box 5201, AE Rotterdam 3008, The Netherlands.
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Gomez-Gutierrez JG, Elpek KG, Montes de Oca-Luna R, Shirwan H, Sam Zhou H, McMasters KM. Vaccination with an adenoviral vector expressing calreticulin-human papillomavirus 16 E7 fusion protein eradicates E7 expressing established tumors in mice. Cancer Immunol Immunother 2007; 56:997-1007. [PMID: 17146630 PMCID: PMC11030956 DOI: 10.1007/s00262-006-0247-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 09/26/2006] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cervical cancer remains a leading cause of cancer-related mortality in women, particularly in developing countries. The causal association between genital human papilloma virus (HPV) infection and cervical cancer has been firmly established, and the oncogenic potential of certain HPV types has been clearly demonstrated. Vaccines targeting the oncogenic proteins, E6 and E7 of HPV-16 and -18 are the focus of current vaccine development. Previous studies have shown that calreticulin (CRT) enhances the MHC class I presentation of linked peptide/protein and may serve as an effective vaccination strategy for antigen-specific cancer treatment. METHODS Two replication-deficient adenoviruses, one expressing HPV-16 E7 (Ad-E7) and the other expressing CRT linked to E7 (Ad-CRT/E7), were assessed for their ability to induce cellular immune response and tested for prophylactic and therapeutic effects in an E7-expressing mouse tumor model. RESULTS Vaccination with Ad-CRT/E7 led to a dramatic increase in E7-specific T cell proliferation, interferon (IFN)-gamma-secretion, and cytotoxic activity. Immunization of mice with Ad-CRT/E7 was effective in preventing E7-expressing tumor growth, as well as eradicating established tumors with long-term immunological memory. CONCLUSION Vaccination with an adenoviral vector expressing CRT-E7 fusion protein represents an effective strategy for immunotherapy of cervical cancer in rodents, with possible therapeutic potential in clinical settings.
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Affiliation(s)
- Jorge G. Gomez-Gutierrez
- Louisville, KY USA
- Department of Surgery, University of Louisville School of Medicine; James Graham Brown Cancer Center, 40292 Louisville, KY USA
- Facultad de Ciencias Biológicas, Departamanto de Microbiología e Inmunología, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, NL México
| | - Kutlu G. Elpek
- Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY USA
- Institute for Cellular Therapeutics, University of Louisville School of Medicine, Louisville, KY USA
| | - Roberto Montes de Oca-Luna
- Departamento de Histología, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, NL México
| | - Haval Shirwan
- Louisville, KY USA
- Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY USA
- Institute for Cellular Therapeutics, University of Louisville School of Medicine, Louisville, KY USA
- Microbiology and Immunology, University of Louisville School of Medicine; James Graham Brown Cancer Center, Louisville, KY USA
| | - H. Sam Zhou
- Louisville, KY USA
- Department of Medicine, University of Louisville School of Medicine; James Graham Brown Cancer Center, Louisville, KY USA
- Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY USA
- Microbiology and Immunology, University of Louisville School of Medicine; James Graham Brown Cancer Center, Louisville, KY USA
| | - Kelly M. McMasters
- Louisville, KY USA
- Department of Surgery, University of Louisville School of Medicine; James Graham Brown Cancer Center, 40292 Louisville, KY USA
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Mutyaba T, Faxelid E, Mirembe F, Weiderpass E. Influences on uptake of reproductive health services in Nsangi community of Uganda and their implications for cervical cancer screening. Reprod Health 2007; 4:4. [PMID: 17594474 PMCID: PMC1936416 DOI: 10.1186/1742-4755-4-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Accepted: 06/26/2007] [Indexed: 11/10/2022] Open
Abstract
Background Cervical cancer is the most common female cancer in Uganda. Over 80% of women diagnosed or referred with cervical cancer in Mulago national referral and teaching hospital have advanced disease. Plans are underway for systematic screening programmes based on visual inspection, as Pap smear screening is not feasible for this low resource country. Effectiveness of population screening programmes requires high uptake and for cervical cancer, minimal loss to follow up. Uganda has poor indicators of reproductive health (RH) services uptake; 10% postnatal care attendance, 23% contraceptive prevalence, and 38% skilled attendance at delivery. For antenatal attendance, attendance to one visit is 90%, but less than 50% for completion of care, i.e. three or more visits. Methods We conducted a qualitative study using eight focus group discussions with a total of 82 participants (16 men, 46 women and 20 health workers). We aimed to better understand factors that influence usage of available reproductive health care services and how they would relate to cervical cancer screening, as well as identify feasible interventions to improve cervical cancer screening uptake. Results Barriers identified after framework analysis included ignorance about cervical cancer, cultural constructs/beliefs about the illness, economic factors, domestic gender power relations, alternative authoritative sources of reproductive health knowledge, and unfriendly health care services. We discuss how these findings may inform future planned screening programmes in the Ugandan context. Conclusion Knowledge about cervical cancer among Ugandan women is very low. For an effective cervical cancer-screening programme, awareness about cervical cancer needs to be increased. Health planners need to note the power of the various authoritative sources of reproductive health knowledge such as paternal aunts (Sengas) and involve them in the awareness campaign. Cultural and economic issues dictate the perceived reluctance by men to participate in women's reproductive health issues; men in this community are, however, potential willing partners if appropriately informed. Health planners should address the loss of confidence in current health care units, as well as consider use of other cervical cancer screening delivery systems such as mobile clinics/camps.
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Affiliation(s)
- Twaha Mutyaba
- Department of Obstetrics and Gynaecology, Makerere University Medical School, P.O.Box 7072, Kampala, Uganda
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Elisabeth Faxelid
- Department of Public Health Sciences, Division of International Health Care and Research, Karolinska Institutet, Stockholm, Sweden
| | - Florence Mirembe
- Department of Obstetrics and Gynaecology, Makerere University Medical School, P.O.Box 7072, Kampala, Uganda
| | - Elisabete Weiderpass
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Etiological Research, The Cancer Registry of Norway, Oslo, Norway
- Samfundet Folkhälsan, Helsinki, Finland
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Sankaranarayanan R, Rajkumar R, Esmy PO, Fayette JM, Shanthakumary S, Frappart L, Thara S, Cherian J. Effectiveness, safety and acceptability of 'see and treat' with cryotherapy by nurses in a cervical screening study in India. Br J Cancer 2007; 96:738-43. [PMID: 17311015 PMCID: PMC2360066 DOI: 10.1038/sj.bjc.6603633] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We evaluated a ‘see and treat’ procedure involving screening, colposcopy, biopsy and cryotherapy by trained nurses in one-visit in field clinics in a cervical screening study in South India for its acceptability, safety and effectiveness in curing cervical intraepithelial neoplasia (CIN). Women positive on visual inspection with acetic acid (VIA) were advised colposcopy, directed biopsies and cryotherapy if they had colposcopic impression of CIN in one visit by nurses in field clinics supervised by a doctor. Side effects and complications were assessed and cure rates were evaluated with VIA, colposcopy and biopsy if colposcopic abnormalities were suspected. Cure was defined as no clinical or histological evidence of CIN at ⩾6 months from treatment. Of the 2513 women offered ‘see and treat’ procedure, 1879 (74.8%) accepted. Of the 1397 women with histologically proved CIN treated with cryotherapy, 1026 reported for follow-up evaluation. Cure rates were 81.4% (752 out of 924) for women with CIN 1; 71.4% (55 out of 77) for CIN 2 and 68.0% (17 out of 25) for CIN 3. Minor side effects and complications were documented in less than 3% of women. ‘See and treat’ with cryotherapy by nurses under medical supervision is acceptable, safe and effective for cervical cancer prevention in low-resource settings.
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Affiliation(s)
- R Sankaranarayanan
- Screening Group, International Agency for Research on Cancer, 150 Cours Albert Thomas, Lyon, France.
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Denny L, Sankaranarayanan R. CHAPTER 6 Secondary prevention of cervical cancer. Int J Gynaecol Obstet 2007; 94 Suppl 1:S65-S70. [PMID: 29644636 DOI: 10.1016/s0020-7292(07)60012-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cervical cancer continues to be the commonest cause of death among women in developing countries, largely due to the failure to initiate or sustain effective cytology-based screening programs. Experience from countries with successful screening programs indicates that target age and the extent of coverage of the target group are key indicators of success in reducing cervical cancer. Alternative methods for the secondary prevention of cervical cancer have been evaluated in numerous studies over the past 10 years in different countries. These include visual inspection with acetic acid and linking screening to treatment. Although longitudinal data are scanty, these alternative approaches have been shown to be feasible, acceptable, and effective in reducing cervical cancer.
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Suba EJ, Donnelly AD, Furia LM, Huynh MLD, Raab SS. Cervical cancer prevention for all the world's women: Genuine promise resides in skilled quality management rather than novel screening approaches. Diagn Cytopathol 2007; 35:187-91. [PMID: 17304532 DOI: 10.1002/dc.20575] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The debate over the best route for cervical cancer prevention in developing countries may be considered part of a larger debate over whether the global health community has become enamored with the promise of new approaches at the expense of delivering available preventives today. Pap screening, which is feasible anywhere cervical screening is appropriate, is the only intervention currently available for the prevention of cervical cancer in developing countries, and the Pap test will be an essential component of future novel preventive approaches. Cervical cancer vaccination, the long-term effectiveness of which is uncertain, will not eliminate screening requirements and is currently not affordable in developing countries. Root cause analyses, which may appropriately inform the best routes for improving health in developing countries, document that failures of cervical cancer prevention efforts are not attributable to factors specific to the Pap test but to lapses in programmatic quality management to which all screening tests are vulnerable. The genuine promise of cervical cancer prevention for all the world's women therefore resides in skilled quality management rather than novel screening approaches. We propose a global consensus policy by which Pap screening services will be provided in any setting where cervical screening is appropriate but unavailable, with consideration given to novel preventive approaches as they mature. Opportunity costs, borne by the underserved, are associated with prioritizing research on new approaches in any setting where established preventives are feasible but unavailable.
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Affiliation(s)
- Eric J Suba
- Kaiser Permanente Medical Center, South San Francisco, CA 94080, USA.
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40
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Affiliation(s)
- R Sankaranarayanan
- Head, Screening Group, World Health Organization - International Agency for Research on Cancer, Lyon 69008, France
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41
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Guillaud M, Benedet JL, Cantor SB, Staerkel G, Follen M, MacAulay C. DNA ploidy compared with human papilloma virus testing (Hybrid Capture II) and conventional cervical cytology as a primary screening test for cervical high-grade lesions and cancer in 1555 patients with biopsy confirmation. Cancer 2006; 107:309-18. [PMID: 16773634 DOI: 10.1002/cncr.21993] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Because 80% of cervical cancers arise in low-resource settings, many inexpensive strategies are being tested. In that spirit, the authors are testing large-scale genomic or DNA ploidy measurements as an inexpensive and semiautomated strategy. METHODS Patients entered either a screening or diagnostic study of several optical technologies: quantitative cytology, quantitative histopathology, and fluorescence and reflectance spectroscopy using a point probe, a multispectral digital colposcope, or a combination of the two. We calculated sensitivities, specificities, positive and negative predictive values, and their confidence interval testing conventional cytology, Hybrid Capture (HC) II testing, and DNA ploidy measured on the Feulgen-stained quantitative Pap smear. RESULTS The current investigation reports on 1555 patients for whom colposcopically directed biopsies were read 3 times by study pathologists. The final histopathologic diagnosis was high grade (cervical intraepithelial neoplasia [CIN] 2, CIN 3, carcinoma in situ [CIS], and cancer) in 16% of patients. Using high-grade squamous intraepithelial lesions (SILs) histopathology as the threshold and gold standard, the sensitivity and specificity, respectively, were: 0.47 and 0.96 for conventional cytology, 0.91 and 0.80 for HC II, and 0.59 and 0.93 for DNA ploidy. The positive and negative predictive values (PPV, NPV) for conventional cytology were 0.70 and 0.90, 0.46 and 0.98 for HC II, and 0.63 and 0.92 for DNA ploidy. CONCLUSIONS DNA ploidy shows comparable sensitivity, specificity, PPV, and NPV values to conventional cytology and HC II. Unlike conventional cytology, DNA ploidy is semiautomated and can be performed in less than 8 hours. Cost effectiveness studies are under way, but in the authors' laboratory DNA ploidy is inexpensive.
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Affiliation(s)
- Martial Guillaud
- Department of Cancer Imaging, British Columbia Cancer Research Centre, Vancouver, British Columbia
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Mayrand MH, Duarte-Franco E, Coutlée F, Rodrigues I, Walter SD, Ratnam S, Franco EL. Randomized controlled trial of human papillomavirus testing versus Pap cytology in the primary screening for cervical cancer precursors: Design, methods and preliminary accrual results of the Canadian cervical cancer screening trial (CCCaST). Int J Cancer 2006; 119:615-23. [PMID: 16572425 DOI: 10.1002/ijc.21897] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since infection with oncogenic human papillomavirus (HPV) has been considered a necessary cause of cervical cancer, tests for oncogenic HPV types have been proposed as adjuncts or replacements to Pap cytology. We designed the Canadian Cervical Cancer Screening Trial (CCCaST) to compare the relative efficacy of HPV DNA testing and Pap cytology in primary screening for cervical cancer and its high-grade precursors. CCCaST randomized women aged 30-69 years in Montreal (Quebec) and in St. John's (Newfoundland) to 1 of 2 screening groups: focus on Pap (conventional) or focus on HPV testing (Hybrid Capture 2). Women in both arms received both tests, but were randomized as to their order, the first test being the index test. Women with an abnormal Pap test or a positive HPV test underwent colposcopy and biopsy, as did a random sample of women with a negative index test. CCCaST enrolled 9,667 women between October 2002 and October 2004. At enrolment, 2.8% had an abnormal Pap test, 6.1% had a positive HPV test and 1.1% were abnormal in both tests. ASC-US was the most frequent cytological abnormality, representing 64% of abnormal Pap results. The frequency of abnormal Pap and HPV results decreased with increasing age and the proportion of HPV-positive results increased with the severity of Pap abnormality. Efficacy analysis will determine if the extra referrals with HPV DNA testing will translate into a relevant increase in high-grade cervical cancer precursor detection. Because of its design, CCCaST will provide sound evidence for formulating cervical cancer screening strategies.
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Affiliation(s)
- Marie-Hélène Mayrand
- Division of Cancer Epidemiology, Department of Oncology, McGill University, and Département de Microbiologie-Infectiologie, Hôpital Notre-Dame du Centre Hospitalier Universitaire de l'Université de Montréal, QC, Canada
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Abstract
OBJECTIVE The aim of the study was to evaluate the test parameters of visual inspection with acetic acid (VIA) and cervical cytology in 3 Mongolian aimags. METHODS From February 18, 2002, to December 12, 2004, sexually active women, 30 years or older who had never been screened, underwent cervical cytology and VIA in the aimags' central hospital. Women with abnormal test results and 5% of women with normal results were recommended to have colposcopy with or without biopsy. RESULTS Two thousand nine women underwent both tests. Visual inspection with acetic acid was abnormal in 254 (12.6%); Pap smear showed atypical squamous cells of undetermined significance or worse in 3%. Using cervical intraepithelial neoplasia 2 or higher disease on biopsy as the end point, the test parameters for VIA are sensitivity of 82.9% (95% CI = 81.3%-84.5%), specificity of 88.6% (95% CI = 87.2%-90.0%), positive predictive value of 12.2% (95% CI = 10.8%-13.6%), and negative predicative value of 99.7% (95% CI = 99.5%-99.9%). The test parameters for Pap smear are sensitivity of 88.6% (95% CI = 87.2%-90.0%), specificity of 98.5% (95% CI = 98.0%-99.0%), positive predictive value of 51.7% (95% CI = 49.5%-53.9%), and negative predicative value of 99.8% (95% CI = 99.6%-100%). CONCLUSION Visual inspection with acetic acid has an acceptable test parameter for population-based cervical screening in Mongolia.
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Affiliation(s)
- L Elit
- Division of Gynecologic Oncology, McMaster University, Hamilton, Ontario, Canada.
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Sankaranarayanan R, Ferlay J. Worldwide burden of gynaecological cancer: the size of the problem. Best Pract Res Clin Obstet Gynaecol 2005; 20:207-25. [PMID: 16359925 DOI: 10.1016/j.bpobgyn.2005.10.007] [Citation(s) in RCA: 438] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The estimation of cancer burden is valuable to set up priorities for disease control. The comprehensive global cancer statistics from the International Agency for Research on Cancer indicate that gynaecological cancers accounted for 19% of the 5.1 million estimated new cancer cases, 2.9 million cancer deaths and 13 million 5-year prevalent cancer cases among women in the world in 2002. Cervical cancer accounted for 493 000 new cases and 273 000 deaths; uterine body cancer for 199 000 new cases and 50 000 deaths; ovarian cancer for 204 000 new cases and 125 000 deaths; cancers of the vagina, vulva and choriocarcinoma together constituted 45 900 cases. More than 80% of the cervical cancer cases occurred in developing countries and two-thirds of corpus uteri cases occurred in the developed world. Political will and advocacy to invest in healthcare infrastructure and human resources to improve service delivery and accessibility are vital to reduce the current burden in low- and medium-resource countries.
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Affiliation(s)
- R Sankaranarayanan
- International Agency for Research on Cancer, 150 Cours Albert Thomas, Lyon 69008, France.
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Goldhaber-Fiebert JD, Denny LE, De Souza M, Wright TC, Kuhn L, Goldie SJ. The costs of reducing loss to follow-up in South African cervical cancer screening. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2005; 3:11. [PMID: 16288646 PMCID: PMC1308836 DOI: 10.1186/1478-7547-3-11] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 11/15/2005] [Indexed: 11/10/2022] Open
Abstract
Background This study was designed to quantify the resources used in reestablishing contact with women who missed their scheduled cervical cancer screening visits and to assess the success of this effort in reducing loss to follow-up in a developing country setting. Methods Women were enrolled in this Cape Town, South Africa-based screening study between 2000 and 2003, and all had scheduled follow-up visits in 2003. Community health worker (CHW) time, vehicle use, maintenance, and depreciation were estimated from weekly logs and cost accounting systems. The percentage of women who attended their scheduled visit, those who attended after CHW contact(s), and those who never returned despite attempted contact(s) were determined. The number of CHW visits per woman was also estimated. Results 3,711 visits were scheduled in 2003. Of these, 2,321 (62.5%) occurred without CHW contact, 918 (24.8%) occurred after contact(s), and 472 (12.7%) did not occur despite contact(s). Loss to follow-up was reduced from 21% to 6%, 39% to 10%, and 50% to 24% for 6, 12, and 24-month visits. CHWs attempted 3,200 contacts in 530 trips. On average, 3 CHWs attempted to contact 6 participants over each 111 minute trip. The per-person cost (2003 Rand) for these activities was 12.75, 24.92, and 40.50 for 6, 12, and 24-month visits. Conclusion CHW contact with women who missed scheduled visits increased their return rate. Cost-effectiveness analyses aimed at policy decisions about cervical cancer screening in developing countries should incorporate these findings.
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Affiliation(s)
| | - Lynette E Denny
- Department of Obstetrics and Gynecology, University of Cape Town, South Africa
| | - Michelle De Souza
- Department of Obstetrics and Gynecology, University of Cape Town, South Africa
| | - Thomas C Wright
- Department of Pathology, College of Physicians and Surgeons of Columbia University, New York, USA
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons, and Division of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, USA
| | - Sue J Goldie
- Harvard Initiative for Global Health, Harvard University, Massachusetts, USA
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Sankaranarayanan R, Gaffikin L, Jacob M, Sellors J, Robles S. A critical assessment of screening methods for cervical neoplasia. Int J Gynaecol Obstet 2005; 89 Suppl 2:S4-S12. [PMID: 15823266 DOI: 10.1016/j.ijgo.2005.01.009] [Citation(s) in RCA: 189] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The objective of cervical cancer screening is to reduce cervical cancer incidence and mortality by detecting and treating precancerous lesions. Conventional cytology is the most widely used cervical cancer screening test. Although cytology has been effective in reducing the incidence of and mortality from cervical cancer in developed countries in both opportunistic and--more dramatically--organized national programs, it has been less successful and largely ineffective in reducing disease burden in low-resource settings where it has been implemented. Liquid-based cytology, testing for infection with oncogenic types of human papillomaviruses, visual inspection with 3-5% acetic acid, magnified visual inspection with acetic acid, and visual inspection with Lugol's iodine have been evaluated as alternative tests. Their test characteristics, and the applications and limitations in screening, are discussed with an emphasis on the work of the Alliance for Cervical Cancer Prevention over the past 5 years.
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Affiliation(s)
- R Sankaranarayanan
- International Agency for Research on Cancer (IARC), 150 cours Albert Thomas, 69372 Lyon Cedex 08, France.
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Sherris J, Agurto I, Arrossi S, Dzuba I, Gaffikin L, Herdman C, Limpaphayom K, Luciani S. Advocating for cervical cancer prevention. Int J Gynaecol Obstet 2005; 89 Suppl 2:S46-54. [PMID: 15823267 DOI: 10.1016/j.ijgo.2005.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cervical cancer is a significant health problem among women in developing countries. Contributing to the cervical cancer health burden in many countries is a lack of understanding and political will to address the problem. Broad-based advocacy efforts that draw on research and program findings from developing-country settings are key to gaining program and policy support, as are cost-effectiveness analyses based on these findings. The Alliance for Cervical Cancer Prevention (ACCP) has undertaken advocacy efforts at the international, regional, national, and local levels to raise awareness and understanding of the problem (and workable solutions), galvanize funders and governments to take action, and engage local stakeholders in ensuring program success. ACCP experience demonstrates the role that evidence-based advocacy efforts play in the ultimate success of cervical cancer prevention programs, particularly when new screening and treatment approaches-and, ultimately, radically new approaches such as a human papillomavirus vaccine-are available.
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Affiliation(s)
- J Sherris
- PATH, 1455 NW Leary Way, Seattle, WA 98107, USA.
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Tsu VD, Pollack AE. Preventing cervical cancer in low-resource settings: how far have we come and what does the future hold? Int J Gynaecol Obstet 2005; 89 Suppl 2:S55-9. [PMID: 15823268 DOI: 10.1016/j.ijgo.2005.01.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The Alliance for Cervical Cancer Prevention (ACCP) came together in 1999 to answer key research questions and to advocate for greater global and national interest in reducing the heavy burden of morbidity and mortality caused by this preventable disease. Visual inspection with acetic acid (VIA), visual inspection with Lugol's iodine (VILI), and human papillomavirus (HPV) tests have been shown to be viable alternatives to traditional cytology. ACCP experience confirmed that cryotherapy is a safe and effective method that is acceptable to women and can be delivered by a range of health providers, including nonphysicians. Programs can maximize coverage by accommodating local needs and involving community leaders and women in planning and implementation. Advocacy efforts have led to significant policy changes and galvanized support for cervical cancer prevention. Despite the prospect of new HPV vaccines, screening will be needed for at least the next 30-40 years. Our experience has shown that with creativity, flexibility, and well-focused use of resources, the inequitable burden of cervical cancer borne by women in poor countries can be sharply reduced.
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Affiliation(s)
- V D Tsu
- Program for Appropriate Technology in Health (PATH), 1455 NW Leary Way, Seattle, WA 98107-5136, USA.
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Bradley J, Barone M, Mahé C, Lewis R, Luciani S. Delivering cervical cancer prevention services in low-resource settings. Int J Gynaecol Obstet 2005; 89 Suppl 2:S21-9. [PMID: 15823263 DOI: 10.1016/j.ijgo.2005.01.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The goals of any cervical cancer prevention program should be threefold: to achieve high coverage of the population at risk, to screen women with an accurate test as part of high-quality services, and to ensure that women with positive test results are properly managed. This article focuses on the experiences of the Alliance for Cervical Cancer Prevention (ACCP) in delivery of screening and treatment services as part of cervical cancer prevention projects in Africa, Latin America, and Asia. Research and experience show that cervical cancer can be prevented when strategies and services are well planned and well managed and when attention is paid to program monitoring and evaluation. Coordination of program components, reduction of the number of visits, improvement of service quality, and flexibility in how services are delivered are all essential features of an effective service.
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Affiliation(s)
- J Bradley
- EngenderHealth, 440 Ninth Avenue, New York, NY 10001, USA.
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50
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Abstract
Cervical cancer remains the commonest cancer cause of death among women in developing countries, largely due to the failure to establish cytologically based cervical cancer screening programmes. There are many barriers to the establishment of screening programmes in poor countries ranging from limited financial, human and health resources to the complex infrastructural requirements of traditional screening programmes. Alternative approaches to cervical cancer prevention are currently being investigated, including primary prevention with prophylactic vaccines against human papillomavirus to alternative screening tests and protocols. These will be explored in this review.
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Affiliation(s)
- Lynette Denny
- Department of Obstetics and Gynaecology, Facult of Health and Gynaecology, Faculty of Health Science, University of Cape Town/Groote Schuur Hospital, South Africa
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