Pooled analysis of the accuracy of five cervical cancer screening tests assessed in eleven studies in Africa and India

Zipime-Weka-Schista study protocol: a longitudinal cohort study and economic evaluation of an integrated home-based approach for genital multipathogen screening in women, including female genital schistosomiasis, human papillomavirus, Trichomonas and HIV in Zambia

INTRODUCTION

Multiplathogen home-based self-sampling offers an opportunity to increase access to screening and treatment in endemic settings with high coinfection prevalence of sexually transmitted (HIV, Trichomonas vaginalis (Tv), human papillomavirus (HPV)) and non-sexually transmitted pathogens (Schistosoma haematobium (Sh)). Chronic coinfections may lead to disability (female genital schistosomiasis) and death (cervical cancer). The Zipime-Weka-Schista (Do self-testing sister!) study aims to evaluate the validity, acceptability, uptake, impact and cost-effectiveness of multipathogen self-sampling for genital infections among women in Zambia.

METHODS AND ANALYSIS

This is a longitudinal cohort study aiming to enrol 2500 non-pregnant, sexually active and non-menstruating women aged 15-50 years from two districts in Zambia with 2-year follow-up. During home visits, community health workers offer HIV and Tv self-testing and cervicovaginal self-swabs for (1) HPV by GeneXpert and, (2) Sh DNA detection by conventional (PCR)and isothermal (recombinase polymerase assay) molecular methods. Schistosoma ova and circulating anodic antigen are detected in urine. At a clinic follow-up, midwives perform the same procedures and obtain hand-held colposcopic images. High-risk HPV positive women are referred for a two-quadrant cervical biopsy according to age and HIV status. A cost-effectiveness analysis is conducted in parallel.

ETHICS AND DISSEMINATION

The University of Zambia Biomedical Research Ethics Committee (UNZABREC) (reference: 1858-2021), the London School of Hygiene and Tropical Medicine (reference: 25258), Ministry of Health and local superintendents approved the study in September 2021.Written informed consent was obtained from all participants prior to enrolment. Identifiable data collected are stored securely and their confidentiality is protected in accordance with the Data Protection Act 1998.

A tripartite approach toward ending cancer as we know it, for everyone: An American Cancer Society perspective

Gaps in the cancer care continuum are vast, both in the United States and globally. The American Cancer Society orchestrates an integrated, tripartite approach toward improving the lives of cancer patients and their families through research, advocacy, and patient support. With a focus on eradicating cancer disparities, the American Cancer Society aims to scale and deploy best practices worldwide through partnerships, to ensure everyone has an opportunity to prevent, detect, treat, and survive cancer.

Training health care providers to administer VIA as a screening test for cervical cancer: a systematic review of essential training components

BACKGROUND

Training health care providers to administer visual inspection after application of acetic acid (VIA) is paramount in improving cervical cancer screening services for women in low- and middle-income countries. The objective of this systematic review was to create a framework of essential VIA training components and provide illustrating examples of how VIA training programs can be carried out in different clinical settings.

METHODS

A systematic review of PubMed, Embase, and Web of Science (from 2006 to 2021) was undertaken. Our inclusion criteria comprised articles reporting on implemented cervical cancer screening programs using VIA in a screen-and-treat approach. Trained health care providers with any level of health education were included, and the outcome of interest was the reporting of training components. Data were extracted by two reviewers, and a narrative synthesis of the training programs was performed. We developed a framework of seven essential training components and applied it to assess how training courses were conducted in different settings.

RESULTS

13 primary studies were eligible for inclusion, including 2,722 trained health care providers and 342,889 screened women. Most training courses lasted 5-7 days and included theoretical education, practical skill development, and competence assessment. It was unclear how visual aids and training in client counselling and quality assessment were integrated in the training courses. After the training course, nearly all the VIA training programs made provisions for on-job training at the providers' own clinical settings through supervision, feedback, and refresher training.

CONCLUSIONS

This study demonstrates the feasibility of implementing international training recommendations for cervical cancer screening in real-world settings and provides valuable examples of training program implementation across various clinical settings. The diverse reporting practices of quality indicators in different studies hinder the establishment of direct links between these data and training program effectiveness. To enhance future reporting, authors should emphasize specific training components, delivery methods, and contextual factors. Standardized reporting of quality indicators for effective evaluation of VIA training programs is recommended, fostering comparability, facilitating research, and enhancing reporting quality in this field.

Genotypic Diversity of Human Papillomavirus (HPV) Types and Its Prevalence With Cervical Cancer (CC) in Central India

Background The high-risk human papillomavirus (hr-HPV) is linked with cervical cancer (CC), and the distinct proportional impact of each genotype on the prevalence of the disease depends on the area. Therefore, to find out the prevalence of HPV types in women with cervical lesions from central India, the current study was performed. Methodology Age, prior history of cervical disease, changes in lifestyle characteristics, menopausal status, and HPV vaccination status were all carefully gathered at enrollment for the 736 women (aged 21 to 60) screened in this cross-sectional study who were referred for regular screening of cervical during the study period. Cervix was examined for lesions by visual inspection with acetic acid (VIA) screening and HPV genotypes were identified by real-time polymerase chain reaction (RT-PCR). Result Among 736 women 215 (29.2%) were in the 21-30 age group, 321 (43.6%) in the 31-40 age group, 132 (17.9%) in the 41-50 age group, and 68 (9.3%) cases in >50 age group. According to education, there were 398 (54.1 %) with primary and below education, 115 (15.6%) with secondary education, and 223 (30.3%) with college and above education. HPV-16, 18, 31, and 45 each had a prevalence of 29.6%, 11.1%, 12.9%, and 9.2%, respectively, while the overall prevalence of hr-HP) was present in populations at 7.3% in individuals and 37.0% in combinations. Hr-HPV infection and prevalence were provocatively more (79.6%) in the VIA-positivity rate with CC. Conclusion Individual hr-HPV genotype prevalence was shown to be lower than with combinations (HPV-16, 18, 31, and 45). The HPV-16 genotype was identified to have a higher prevalence than HPV-18, 31, and 45. However, more awareness programs are needed for a better understanding of CC and HPV testing in central India.

Implementation of visual inspection with acetic acid and Lugol's iodine for cervical cancer screening in rural China

OBJECTIVE

To address the value of visual inspection where HPV-based screening is not yet available, we evaluated the real-world effectiveness of visual inspection with acetic acid (VIA) and with Lugol's iodine (VILI) as a primary screening method for cervical cancer in rural China.

METHODS

A total of 206 133 women aged 30-59 years received two rounds of VIA/VILI screening for cervical cancer in 2006-2010. Women with positive screening results underwent colposcopy and direct biopsy, and were treated if cervical intraepithelial neoplasia grade 2 or worse (CIN2+) was diagnosed. Clinical effectiveness of VIA/VILI was evaluated by process and outcome measures.

RESULTS

The VIA/VILI positivity rate, biopsy rate and detection rate of CIN2+ in the second round were significantly lower than in the first round. The 2-year cumulative detection rate of CIN2+ varied from 0.53% to 0.90% among the four cohorts initiated in 2006, 2007, 2008, and 2009. The first round of screening detected 60%-83% of CIN2, 70%-86% of CIN3, and 88%-100% of cervical cancer. Over 92% of CIN2+ were found at the early stage.

CONCLUSION

Multiple rounds of visual inspection with continuous training and quality assurance could act as a temporary substitutional screening method for cervical cancer in resource-restricted settings.

Prevention of Cervical Cancer in Low-Resource African Settings

Cervical cancer is a leading cause of cancer among women. Approximately 350,000 women die from cervical needlessly from cancer each year, and 85% of the global burden occurs in low- and middle-income countries (LMICs). Disparities in the incidence and mortality between LMICs and industrialized countries can be attributed to differences in access to human papillomavirus (HPV) vaccination and cervical cancer screening and treatment. The World Health Organization (WHO) is leading a renewed international effort to reduce the global burden of cervical cancer. In this article, we discuss recommendations for HPV vaccination, primary HPV screening, and treatment of precancerous lesions.

Cervical cancer in Nepal: Current screening strategies and challenges

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

Diagnostic accuracy of cervical cancer screening strategies for high-grade cervical intraepithelial neoplasia (CIN2+/CIN3+) among women living with HIV: A systematic review and meta-analysis

BACKGROUND

We systematically reviewed the diagnostic accuracy of cervical cancer screening and triage strategies in women living with HIV (WLHIV).

METHODS

Cochrane Library, Embase, Global Health and Medline were searched for randomised controlled trials, prospective or cross-sectional studies published from database inception to 15 July 2022 reporting diagnostic accuracy of tests in cervical cancer screening and triage of screen-positive WLHIV. Studies were included if they reported the diagnostic accuracy of any cervical cancer screening or triage strategies for the detection of histologically-confirmed high-grade cervical intraepithelial neoplasia (CIN2+/CIN3+) among WLHIV. Summary data were extracted from published reports. Authors were contacted for missing data where applicable. Sensitivity and specificity estimates for CIN2/3+ were pooled using models for meta-analysis of diagnostic accuracy data. Study quality was assessed using the QUADAS-2 tool for the quality assessment of diagnostic accuracy studies. PROSPERO registration:CRD42020189031.

FINDINGS

In 38 studies among 18,737 WLHIV, the majority (n=19) were conducted in sub-Saharan Africa. The pooled prevalence was 12.0% (95%CI:9.8-14.1) for CIN2+ and 6.7% (95%CI:5.0-8.4) for CIN3+. The proportion of screen-positive ranged from 3-31% (visual inspection using acetic acid[VIA]); 2-46% (high-grade squamous intraepithelial lesions, and greater [HSIL+] cytology); 20-64% (high-risk[HR]-HPV DNA). In 14 studies, sensitivity and specificity of VIA were variable limiting the reliability of pooled estimates. In 5 studies where majority had histology-confirmed CIN2+, pooled sensitivity was 56.0% (95%CI:45.4-66.1; I²=65%) for CIN2+ and 65.0% (95%CI:52.9-75.4; I² =42%) for CIN3+; specificity for <CIN2 was 73.8% (95%CI:59.8-84.2, I²=94%). Cytology was similarly variable (sensitivity of ASCUS+ for CIN2+ range: 58-100%; specificity: 9-96%). In 28 studies, sensitivity of tests targeting 14-HR-HPV types was high (91.6%, 95%CI:88.1-94.1; I²=45% for CIN2+ and 92.5%, 95%CI:88.4-95.2; I²=32%) for CIN3+); but specificity for <CIN2 was low (62.2% (95%CI:57.9-66.4;I²=92%). Restriction to 8-HR-HPV increased specificity (65.8%; Relative specificity[RSpec] vs. 14-HR-HPV=1.17; 95%CI:1.10-1.24) with no significant change in sensitivity (CIN2+:85.5%; Relative Sensitivity[RSens]=0.94, 95%CI: 0.89-1.00; CIN3+:90%; RSens=0.96, 95%CI:0.89-1.03). VIA triage of 14-HR-HPV positive women decreased sensitivity for CIN2+ compared to HPV-DNA test alone (64.4% vs. 91.6%; RSens=0.68, 95%CI:0.62-0.75).

INTERPRETATION

HPV-DNA based approaches consistently showed superior sensitivity for CIN2+/CIN3+ compared to VIA or cytology. The low specificity of HPV-DNA based methods targeting up to 14-HR-HPV could be improved significantly by restricting to 8-HR-HPV with only minor losses in sensitivity, limiting requirement for triage for which optimal approaches are less clear.

FUNDING

World Health Organisation; National Cancer Institute; European Union's Horizon 2020 and Marie Skłodowska-Curie Actions programme.

Liquid-Based Cytology in the Detection of Premalignant Lesions in Patients with "Atypia in Squamous Cells" in Conventional Cytology

Background

The management of patients with "Atypical Squamous Cells" (ASC) in conventional papanicolaou smears (CPS) is based on the risk of high-grade squamous intraepithelial lesion (HSIL). The efficacy of liquid-based cytology (LBC) to detect this premalignant lesion is variable, with little evidence of its performance in Colombian patients.

Aims

The aim of this study is to determine the performance of LBC in the detection of premalignant lesions, in patients with ASC in CPS.

Materials and Methods

Were obtained patients who attended colposcopy clinic due the result of ASC in CPS. An LBC was taken, which was interpreted by two pathologists without access to other results. The performance of LBC to detect HSIL, was determined, considering as a gold standard: histopathological study/negative-satisfactory colposcopy.

Results

Were included 114 patients, with a mean age of 38.4 years (SD ± 13.3). LBC had abnormal results in 40.36% (n = 46), with a slightly higher proportion of low-grade squamous intraepithelial lesion (LSIL) than HSIL. The total of abnormal diagnoses by colposcopy and/or biopsy was 51.75% (n = 59), with a predominance of LSIL (36.84%). The sensitivity of the liquid-based cytology to detect premalignant lesions was 76.5%, specificity: 66.0%, positive predictive value: 28.3% and negative predictive value: 94.1%; The Cohen's kappa index of LBC for detecting HSIL was 0.2492 for the total population and 0.2907 for ≥30 years.

Discussion

Although LBC decreases abnormal cytology and increases the detection of HSIL, which improves diagnostic accuracy; sensitivity and predictive values for detecting HSIL are not significantly different between CPS and LBC.

The Effectiveness of Pap and Visual Inspection With Acetic Acid (VIAA) Tests in Cervical Dysplasia Screenings During the COVID-19 Pandemic

Objective

This study was aimed at analyzing the validity and reliability of the Papanicolaou (Pap) test and visual inspection with acetic acid (VIAA) tests for cervical dysplasia screenings during the COVID-19 pandemic.

Material and methods

This was a retrospective study of patients 21 years or older seen at the Luis Negreiros Primary Care Center in Lima, Peru between 2020 and 2021, who underwent cervical dysplasia screening (Pap or VIAA). Relevant information regarding patient age, date of service, and Pap and VIAA results were collected. Parallel form reliability was analyzed with chi-square tests, and phi, contingency and Cramer's V coefficients. The validity of these tests was analyzed through the calculation of the sensitivity, specificity, and positive and negative predictive values with confidence intervals. A p-value less than 0.05 indicated statistical significance.

Results

From 4,503 records, the sensitivity, specificity, and positive and negative predictive values for Pap were 0.87 (0.81-0.92), 1.0 (1.0-1.0), 1.0 (1.0-1.0) and 0.99 (0.98-0.99), respectively, and those for VIAA were 0.22 (0.14-0.31), 0.10 (0.10-0.10), 0.53 (0.38-0.69) and 0.10 (0.10-0.10), respectively. Test validity varied slightly according to patient age and the year of testing. The correlation, although significant, was inverse; chi-square = 39.18, p <0.001, phi = -0.60, contingency = 0.51 and Cramer’s V = -0.59.

Conclusion

The validity and reliability of Pap testing and VIAA for cervical dysplasia screening significantly decreased during the COVID-19 pandemic. The correlation between these tests, although significant, was inverse. More larger-scale studies are needed to confirm these findings and understand the reasons underlying the decreased effectiveness of these tests.

False Negative Results in Cervical Cancer Screening-Risks, Reasons and Implications for Clinical Practice and Public Health

False negative (FN) results in cervical cancer (CC) screening pose serious risks to women. We present a comprehensive literature review on the risks and reasons of obtaining the FN results of primary CC screening tests and triage methods and discuss their clinical and public health impact and implications. Misinterpretation or true lack of abnormalities on a slide are the reasons of FN results in cytology and p16/Ki-67 dual-staining. For high-risk human papillomavirus (HPV) molecular tests, those include: truly non-HPV-associated tumors, lesions driven by low-risk HPV types, and clearance of HPV genetic material before sampling. Imprecise disease threshold definition lead to FN results in visual inspection with acetic acid. Lesions with a discrete colposcopic appearance are a source of FN in colposcopic procedures. For FAM19A4 and hsa-miR124-2 genes methylation, those may originate from borderline methylation levels. Histological misinterpretation, sampling, and laboratory errors also play a role in all types of CC screening, as well as reproducibility issue, especially in methods based on human-eye evaluation. Primary HPV-based screening combined with high quality-assured immunocytochemical and molecular triage methods seem to be an optimal approach. Colposcopy with histological evaluation remains the gold standard for diagnosis but requires quality protocols and assurance measures.

Screening for Early Detection of Cervical Cancer in Women Living with HIV in Mumbai, India - Retrospective Cohort Study from a Tertiary Cancer Center

Introduction Women living with human immunodeficiency virus (HIV) have an increased risk of persistent human papillomavirus infection (HPV) of developing cervical cancer precursors and are, therefore, considered at higher risk for cervical cancer. Despite the higher risk, screening for cervical cancer is extremely low among HIV-positive women in India.

Objectives Given the limited usefulness of cytology-based screening programs, the current study retrospectively evaluated the comparative performance of visual inspection with 5% acetic acid (VIA), conventional cytology, and human papillomavirus (HPV) testing among HIV-positive women attending the cancer screening clinic at the tertiary cancer center.

Materials and Methods Retrospective analysis of 291 HIV-positive women attending cervical cancer screening services in a tertiary cancer center in Mumbai was undertaken. All underwent simultaneous screening with VIA, Pap cytology, and HPV DNA testing, followed by diagnostic colposcopy and histopathology. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to detect cervical intraepithelial neoplasia (CIN) 2/3 on histology were estimated.

Results The screen positivity rate for cervical cancer screening by VIA, high-risk HPV DNA, and Pap cytology was 35.7, 34.4, and 6.2% respectively. At the CIN2+ disease threshold, the sensitivity, specificity, PPV, and NPV estimates were 80.00% (59.30–93.17), 68.42% (62.46–73.96), 19.23% (15.46–23.67), 97.33% (94.30–98.77) for VIA; 80.00% (68.78–97.45), 70.68% (64.81–76.08), 22.00% (18.22–26.32), 98.43% (95.58–99.45) for HPV DNA; and 64.00% (42.52–82.03), 98.12% (95.67–99.39), 76.19% (56.13–88.89), 96.67% (94.50–98.00) for cytology (HSIL cutoff).

Conclusion The diagnostic performance of VIA and HPV DNA was comparable and better than cytology indicating that VIA as a cost-effective cervical cancer screening test can be incorporated within the services under sexually transmitted diseases /HIV testing and counseling centers within the country.

Cross-Sectional Study of HPV Self-Sampling among Indian Women—A Way Forward

Molecular human papillomavirus (HPV) DNA is a recommended test for any country planning cervical cancer screening as a national policy. The emerging literature proposes HPV self-sampling (HPV-SS) as a feasible implementing strategy in low-income settings. The success of this strategy would depend on developing impactful health education materials, understanding modalities toward generating awareness, and precision in performing the screening test among beneficiaries. The current paper is an interim analysis of ongoing research undertaken to understand the acceptability of HPV-SS among Indian women across different community settings. The study design has two modalities for generating awareness: (1) health education arm wherein the awareness and steps of collecting self-sample are explained by health personnel, and (2) the pamphlet arm wherein pictorial illustrations depicting the steps to conduct HPV-SS are distributed among women. The quality of samples is compared with primary health worker samples (PHW-S). Initial results of this study support the acceptance of HPV-SS (97%) among urban slum settings. An agreement between HPV-SS and PHW-S was demonstrated to be 95.1%. The results of the pamphlet arm were comparable to the health education arm in every aspect. The art-based strategy seems like a promising communication modality for generating awareness toward cervical cancer screening using HPV-SS in low-resource settings.

Diagnostic accuracy for alternative cervical cancer screening strategies: A systematic review and meta-analysis

We performed a systematic review and meta-analysis to evaluate the accuracy of screening cervical cancer tests as alternative standalone methods. The combined estimates of sensitivity of visual inspection with acetic acid, visual inspection with lugol's iodine, conventional pap smear, liquid-based cytology, High risk HPV testing by clinician, High risk HPV testing by self- sampling, cervicography were 64%, 80%, 55%, 70%, 70% and 67% respectively; the combine values of specificity of these screening strategies were 88%, 88%, 96%, 59%, 94%, and 95% respectively. Our findings draw attention to an attractive opinion to facilitate the collection of specimens for DNA HPV by patients in settings where they don't have access to a regular screening programs.

Deep learning based cervical screening by the cross-modal integration of colposcopy, cytology, and HPV test

PURPOSE

To develop and evaluate the colposcopy based deep learning model using all kinds of cervical images for cervical screening, and investigate the synergetic benefits of the colposcopy, the cytology test, and the HPV test for improving cervical screening performance.

METHODS

This study consisted of 2160 women who underwent cervical screening, there were 442 cases with the histopathological confirmed high-grade squamous intraepithelial lesion (HSIL) or cancer, and the remained 1718 women were controls. Three kinds of cervical images were acquired from colposcopy including the saline image of cervix after saline irrigation, the acetic acid image of cervix after applying acetic acid solution, and the iodine image of cervix after applying Lugol's iodine solution. Each kind of image was used to build a single-image based deep learning model by the VGG-16 convolutional neural network, respectively. A multiple-images based deep learning model was built using multivariable logistic regression (MLR) by combining the single-image based models. The performance of the visual inspection was also obtained. The results of the cytology test and HPV test were used to build a Cytology-HPV joint diagnostic model by MLR. Finally, a cross-modal integrated model was built using MLR by combining the multiple-images based deep learning model, the cytology test results, and the HPV test results. The performances of models were tested in an independent test set using the area under the receiver operating characteristic curve (AUC).

RESULTS

The saline image, acetic acid image, and iodine image based deep learning models had AUC of 0.760, 0.791, and 0.840. The multiple-images based deep learning model achieved an improved AUC of 0.845. The AUC of the visual inspection was 0.751. The Cytology-HPV joint diagnostic model had an AUC of 0.837, which was higher than the cytology test (AUC = 0.749) and the HPV test (AUC = 0.742). The cross-modal integrated model achieved the best performance with AUC of 0.921.

CONCLUSIONS

Combining all kinds of cervical images were benefit for improving the performance of the colposcopy based deep learning model, and more accurate cervical screening could be achieved by incorporating the colposcopy based deep learning model, the cytology test results, and the HPV test results.

Accuracy of Smartphone Images of the Cervix After Acetic Acid Application for Diagnosing Cervical Intraepithelial Neoplasia Grade 2 or Greater in Women With Positive Cervical Screening: A Systematic Review and Meta-Analysis

PURPOSE

Smartphones are used in cervical screening for visual inspection after acetic acid or Lugol's iodine (VIA/VILI) application to capture and share images to improve the sensitivity and interobserver variability of VIA/VILI. We undertook a systematic review and meta-analysis assessing the diagnostic accuracy of smartphone images of the cervix at the time of VIA/VILI (termed S-VIA) in the detection of precancerous lesions in women undergoing cervical screening.

METHODS

This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies from January 1, 2010, to June 30, 2020, were assessed. MEDLINE/PubMed, Embase, CINAHL, Cochrane, and LILACS were searched. Cohort and cross-sectional studies were considered. S-VIA was compared with the reference standard of histopathology. We excluded studies where additional technology was added to the smartphone including artificial intelligence, enhanced visual assessment, and other algorithms to automatically diagnose precancerous lesions. The primary outcome was the accuracy of S-VIA for the diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN 2+). Data were extracted, and we plotted the sensitivity, specificity, negative predictive value, and positive predictive value of S-VIA using forest plots. This study was prospectively registered with The International Prospective Register of Systematic Reviews:CRD42020204024.

RESULTS

Six thousand three studies were screened, 71 full texts assessed, and eight studies met criteria for inclusion, with six included in the final meta-analysis. The sensitivity of S-VIA for the diagnosis of CIN 2+ was 74.56% (95% CI, 70.16 to 78.95; I² 61.30%), specificity was 61.75% (95% CI, 56.35 to 67.15; I² 95.00%), negative predictive value was 93.71% (95% CI, 92.81 to 94.61; I² 0%), and positive predictive value was 26.97% (95% CI, 24.13 to 29.81; I² 61.3%).

CONCLUSION

Our results suggest that S-VIA has accuracy in the detection of CIN 2+ and may provide additional support to health care providers delivering care in low-resource settings.

Use of Smartphones for the Detection of Uterine Cervical Cancer: A Systematic Review

Little is known regarding the usefulness of the smartphone in the detection of uterine cervical lesions or uterine cervical cancer. Therefore, we evaluated the usefulness of the smartphone in the detection of uterine cervical lesions and measured its diagnostic accuracy by comparing its findings with histological findings. We conducted a systematic review to identify studies on the usefulness of the smartphone in detecting uterine cervical lesions indexed in SCOPUS, MEDLINE/PubMed, Cochrane, OVID, Web of Science, and SciELO until November 2020. The risk of bias and applicability was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A total of 16 studies that evaluated the usefulness of the smartphone in the detection of uterine cervical lesions based on the images clicked after visual inspection with acetic acid (VIA), Lugol's iodine (VILI), or VIA/VILI combination were included in the study. Five studies estimated diagnostic sensitivity and specificity, nine described diagnostic concordance, and five described the usefulness of mobile technology. Among the five first studies, the sensitivity ranged between 66.7% (95% confidence interval (CI); 30.0-90.3%) and 94.1% (95% CI; 81.6-98.3%), and the specificity ranged between 24.0% (95% CI; 9.0-45.0%) and 85.7% (95% CI; 76.7-91.6%). The risk of bias was low (20%), and the applicability was high. In conclusion, the smartphone images clicked after a VIA were found to be more sensitive than those following the VILI method or the VIA/VILI combination and naked-eye techniques in detecting uterine cervical lesions. Thus, a smartphone may be useful in the detection of uterine cervical lesions; however, its sensitivity and specificity are still limited.

Human papillomavirus-based cervical precancer screening with visual inspection with acetic acid triage to achieve same-day treatments among women living with human immunodeficiency virus infection: test-of-concept study in Ibadan, Nigeria

Introduction

cervical precancer screening with same day treatment facilitates maximization of benefits of secondary prevention of cervical cancer. This is particularly important for women living with human immunodeficiency virus (WLHIV) infection because of their exceptional risk for cervical cancer. The availability of HIV programmes in low- and middle-income countries (LMICs) provide unique opportunity for possible introduction “human papillomavirus (HPV) screening followed by visual inspection after application of acetic acid (VIA) with same day treatment of eligible patients”. This study piloted this concept.

Methods

in this prospective, cohort study, 98 WLHIV had HPV and VIA screening for cervical precancer lesions in a HIV clinic in Nigeria. Participants positive to HPV and/or VIA had biopsies from the visible lesions or quadrant of transformation zone. Participants positive to VIA and/or HPV16 or HPV18/45 had same-day thermal ablation treatment and the number of cases documented. The HPV, VIA and scenario of HPV followed by VIA results were compared with histologically confirmed cervical lesion grade 2 or worse statistically.

Results

same day treatment was achieved in 95.0% of eligible cases. Statistically, sensitivity and specificity of VIA was 25.0% and 50.0% and HPV had 95.5% and 75.0%, respectively. In the HPV screening with VIA triage, sensitivity dropped to 45.5% but specificity improved to 100.0%.

Conclusion

triaging HPV positive test with VIA for same-day treatment in cervical precancer screening among PLWHIV looks feasible. The improved specificity will reduce the overtreatment rate, loss to follow-up associated with repeat clinic visits and improve completion of continuum of care.

Prevention and Screening of HPV Malignancies

It is estimated that 5% of the global cancer burden, or approximately 690,000 cancer cases annually, is attributable to human papillomavirus (HPV). Primary prevention through prophylactic vaccination is the best option for reducing the burden of HPV-related cancers. Most high-income countries (HICs) have introduced the HPV vaccine and are routinely vaccinating adolescent boys and girls. Unfortunately, although they suffer the greatest morbidity and mortality due to HPV-related cancers, many lower- and middle-income countries (LMICs) have been unable to initiate and sustain vaccination programs. Secondary prevention in the form of screening has led to substantial declines in cervical cancer incidence in areas with established screening programs, but LMICs with absent or inadequate screening programs have high incidence rates. Meanwhile, HICs have seen incidence rates of anal and oropharyngeal cancers rise owing to the limited availability of organized screening for anal cancer and no validated screening options for oropharyngeal cancer. The implementation of screening programs for individuals at high risk of these cancers has the potential to reduce the burden of cervical cancer in LMICs, of anal and oropharyngeal cancers in HICs, and of anal cancer for highly selected HIV+ populations in LMICs. This review will discuss primary prevention of HPV-related cancers through vaccination and secondary prevention through screening of cervical, anal, and oropharyngeal cancers. Areas of concern and highlights of successes already achieved are included.

Cervical cancer screening outcomes in Zambia, 2010-19: a cohort study

BACKGROUND

Globally, cervical cancer is the fourth leading cause of cancer-related death among women. Poor uptake of screening services contributes to the high mortality. We aimed to examine screening frequency, predictors of screening results, and patterns of sensitisation strategies by age group in a large, programmatic cohort.

METHODS

We did a cohort study including 11 government health facilities in Lusaka, Zambia, in which we reviewed routine programmatic data collected through the Cervical Cancer Prevention Program in Zambia (CCPPZ). Participants who underwent cervical cancer screening in one of the participating study sites were considered for study inclusion if they had a screening result. Follow-up was accomplished per national guidelines. We did descriptive analyses and mixed-effects logistic regression for cervical cancer screening results allowing random effects at the individual and clinic level.

FINDINGS

Between Jan 1, 2010, and July 31, 2019, we included 183 165 women with 204 225 results for visual inspection with acetic acid and digital cervicography (VIAC) in the analysis. Of all those screened, 21 326 (10·4%) were VIAC-positive, of whom 16 244 (76·2%) received treatment. Of 204 225 screenings, 92 838 (45·5%) were in women who were HIV-negative, 76 607 (37·5%) were in women who were HIV-positive, and 34 780 (17·0%) had an unknown HIV status. Screening frequency increased 65·7% between 2010 and 2019 with most appointments being first-time screenings (n=158 940 [77·8%]). Women with HIV were more likely to test VIAC-positive than women who were HIV-negative (adjusted odds ratio 3·60, 95% CI 2·14-6·08). Younger women (≤29 years) with HIV had the highest predictive probability (18·6%, 95% CI 14·2-22·9) of screening positive.

INTERPRETATION

CCPPZ has effectively increased women's engagement in screening since its inception in 2006. Customised sensitisation strategies relevant to different age groups could increase uptake and adherence to screening. The high proportion of screen positivity in women younger than 20 years with HIV requires further consideration. Our data are not able to discern if women with HIV have earlier disease onset or whether this difference reflects misclassification of disease in an age group with a higher sexually transmitted infection prevalence. These data inform scale-up efforts required to achieve WHO elimination targets.

FUNDING

US President's Emergency Plan for AIDS Relief.

A Framework for Cervical Cancer Elimination in Low-and-Middle-Income Countries: A Scoping Review and Roadmap for Interventions and Research Priorities

The World Health Organization announced an ambitious call for cervical cancer elimination worldwide. With existing prevention and treatment modalities, cervical cancer elimination is now within reach for high-income countries. Despite limited financing and capacity constraints in low-and-middle-income countries (LMICs), prevention and control efforts can be supported through integrated services and new technologies. We conducted this scoping review to outline a roadmap toward cervical cancer elimination in LMICs and highlight evidence-based interventions and research priorities to accelerate cervical cancer elimination. We reviewed and synthesized literature from 2010 to 2020 on primary and secondary cervical cancer prevention strategies. In addition, we conducted expert interviews with gynecologic and infectious disease providers, researchers, and LMIC health officials. Using these data, we developed a logic model to summarize the current state of science and identified evidence gaps and priority research questions for each prevention strategy. The logic model for cervical cancer elimination maps the needs for improved collaboration between policy makers, production and supply, healthcare systems, providers, health workers, and communities. The model articulates responsibilities for stakeholders and visualizes processes to increase access to and coverage of prevention methods. We discuss the challenges of contextual factors and highlight innovation needs. Effective prevention methods include HPV vaccination, screening using visual inspection and HPV testing, and thermocoagulation. However, vaccine coverage remains low in LMICs. New strategies, including single-dose vaccination could enhance impact. Loss to follow-up and treatment delays could be addressed by improved same-day screen-and-treat technologies. We provide a practical framework to guide cervical cancer elimination in LMICs. The scoping review highlights existing and innovative strategies, unmet needs, and collaborations required to achieve elimination across implementation contexts.

Visual inspection with acetic acid (VIA) positivity among female sex workers: a cross-sectional study highlighting one-year experiences in early detection of pre-cancerous and cancerous cervical lesions in Kampala, Uganda

BACKGROUND

Although cervical cancer is preventable, most women in sub-Saharan Africa (SSA) do not receive routine screening and few treatment options exist. Female Sex Workers (FSWs) are among the Ugandan female population at highest risk of acquiring sexually transmitted infections (STIs) including HIV and human papilloma viruses (HPV), the cause of cervical cancer. We report one-year experiences of visual inspection with acetic acid (VIA) positivity among FSWs in the early detection of pre-cancerous and cancerous cervical lesions in Kampala, Uganda.

METHODS

Between June 2014 and July 2015, we enrolled FSWs into a cross-sectional study at a research clinic. The women were screened using the VIA method (application of 3-5 % acetic acid to the cervix). All VIA positive women were referred to a tertiary hospital for colposcopy, biopsy, and immediate treatment (if indicated) at the same visit according to national guidelines. Data on socio-demographic, sexual behaviour, sexual reproductive health and clinical characteristics were collected. We used logistic regression to identify factors associated with VIA positivity.

RESULTS

Of 842 women assessed for eligibility, 719 (85 %) of median age 30 (IQR 26, 35) were screened, and 40 (6 %) women were VIA positive. Of the 24 histology specimens analysed, 6 showed inflammation, only 1 showed cervical intraepithelial neoplasia (CIN) 1, 13 women showed CIN2/3, while 4 women already had invasive cervical cancer. The overall prevalence of HIV was 43 %, of whom only 35 % were receiving ART. In the age-adjusted analysis, VIA positivity was more likely among women who reported having > 100 life-time partners (aOR = 3.34, 95 %CI: 1.38-8.12), and HIV positive women (aOR = 4.55; 95 %CI: 2.12-9.84).

CONCLUSIONS

We found a relatively low proportion of VIA positivity in this population. The experience from our program implies that the VIA results are poorly reproducible even among a category of trained professional health workers. VIA positivity was more likely among women with a high number of sexual partners and HIV infection. Interventions for improving cervical cancer screening should be recommended as part of HIV care for FSWs to reduce the disease burden in this population.

Prevalence of oncogenic human papillomavirus (HPV 16/18) infection, cervical lesions and its associated factors among women aged 21-49 years in Amhara region, Northern Ethiopia

Background

Human papillomavirus (HPV) infection is considered as the major risk factor for the development of cervical cancer, second most frequent cancer in Ethiopia. However, the magnitude of the problem and the associated factors remain unrevealed in the Amhara region. This study aimed to determine the prevalence of HPV infection and factors contributing to the progression of HPV infection to cervical cancer.

Methods

Facility-based cross-sectional study design was employed among women aged 21 to 49 years of age who came for routine cervical cancer screening to 4 randomly selected hospitals (2 general and 2 referral) of Amhara region from May to October, 2019. The sample size was calculated by using the single population proportion formula, proportionated to hospitals, and women were recruited consecutively. Socio demographic and clinical data were collected using a pretested questionnaire and detection of HPV infection was done using HPV test (OncoE6^TM Cervical Test) specific to HPV16/18 in cervical swabs. Visual inspection with acetic acid (VIA) was used to determine cervical lesions (precancerous and cancerous). Descriptive statistics and bivariate and multivariate logistic regression were used to describe HR-HPV and cervical lesions burden and association between HR-HPV, and cervical lesions and potential risk factors.

Results

Among 337 women 21 to 49 years (median age of 35 years ±SD = 7.1 years) of age enrolled in the study, The overall prevalence of oncogenic HPVs (HPV16/18) and the VIA-positivity rate, possible an indicative of cervical lesions, were 7.1% and 13.1%, respectively. Logistic regression analysis showed a significant association between early age of first sexual intercourse (COR = 2.26; 95% CI: 1.0–5.05) and level of education (COR = 0.31; 95% CI: 0.12–0.78) with cervical lesions. Higher odds of HPV positivity (COR = 1.56; 95% CI: 0.59–4.11, p = 0.36) and VIA positivity (COR = 1.39; 95% CI: 0.64–3.00, p = 0.39) were observed among participants who had a history of sexually transmitted illnesses (STIs).

Conclusions

There was a relatively low prevalence of oncogenic HPV 16/18 and VIA-positivity in women attending four hospitals in the Amhara Region. Early age sexual contact, high parity, and being uneducated/low level of education were independently associated factors with HR-HPV infection and development of cervical lesions, highlighting the importance of prioritizing the limited HPV testing to those risk groups.

Uptake and safety of community-based "screen-and-treat" with thermal ablation preventive therapy for cervical cancer prevention in rural Lilongwe, Malawi

Malawi has the highest invasive cervical cancer (ICC) mortality rate worldwide, and ICC is the leading cause of cancer death among women. In 2004, Malawi adopted visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy. However, screening coverage has remained low (<30%) and few women (<50%) who require ablative treatment receive it. Additional barriers include long distances to health facilities and challenges with maintaining gas supplies. Thermal ablation is a safe and effective alternative to cryotherapy. We assessed the safety and uptake of community-based ICC screening with VIA and same-day treatment using a handheld thermocoagulator (HTU) in rural Malawi. We held educational talks alongside community leaders and conducted VIA screening in nonclinic community settings to nonpregnant women aged 25 to 49 years without history of hysterectomy or genital cancer/precancer. Eligible women received same-day thermal ablation and HIV testing/counseling. We collected cervical biopsies before treatment and followed up women at Weeks 6 and 12, with repeat biopsy at Week 12. Between July and August 2017, 408 (88%) of 463 eligible women underwent VIA. Overall, 7% (n = 30) of women had a positive VIA, of whom 93% (n = 28) underwent same-day thermal ablation. Among the 30 VIA-positive women, 5 had cervical intraepithelial neoplasia (CIN) 1, 4 had CIN 2/3 and 21 had benign histologic findings. Abnormal vaginal discharge (60%) and light vaginal bleeding (52%) were the most reported adverse events. There was high uptake of the community-based ICC screening in the study population and treatment was safe in this setting. Similar strategies that minimize false-positive results are urgently needed in Malawi.

Reliability and diagnostic performance of smartphone colposcopy

OBJECTIVE

To evaluate the interobserver and intraobserver reliability of smartphone colposcopy (SPC) versus conventional colposcopy and to determine diagnostic performance.

METHODS

A smartphone back camera was used to capture cervical images before and after application of acetic acid, and after application of lugol solution. Captured images were reviewed independently by two experienced colposcopists and findings were noted as per colposcopy. Smartphone-based diagnostic performance was calculated, and kappa statistics were used for measurement of agreement between SPC and conventional colposcopy findings.

RESULTS

A total of 114 women were included in the study. The kappa statistic for intraobserver reliability was 0.77 for both normal colposcopic findings and the transformation zone, indicating substantial agreement. Kappa values were 0.54 for acetowhite epithelium, 0.51 for lugol staining, and 0.51-0.60 for atypical vascularization. Kappa values for interobserver reliability were 0.76 for normal colposcopic findings, 0.56 for acetowhite epithelium, and 0.60 for lugol staining. The sensitivity, specificity, PPV, and NPV of SPC for CIN2+ were 88.2 (95% CI, 72.5-96.7), 48.7 (95% CI, 37.4-60.2), 0.42 (95% CI, 0.36-0.48), and 0.91 (95% CI, 0.79-0.96), respectively.

CONCLUSION

SPC showed substantial agreement between the histologic diagnoses based on the captured images and conventional colposcopic findings.

Human Papillomavirus-Associated Cancers

Human Papillomavirus (HPV) is the causative agent in the majority of anal, head and neck, oral, oropharyngeal, penile, vaginal, vulvar, and cervical cancers. Cervical cancer is the fourth most common cancer among women worldwide. Of all diagnosed human malignant neoplasms, approximately 4.5% are attributable to HPV, including cervical, anal cancers, vaginal, vulvar, penile, and oropharyngeal cancers. Over 182 HPV types have been identified and sequenced to date however, only certain types of HPV are more frequent in malignant lesions and considered to be a major risk factor in the development of some cancers. Because most HPV infections are transient, and an individual's immunocompetent may clear the infection, HPV infection has received little attention from clinicians, the general public, or policy makers. This lack of attention may underpin a deadly and increasing problem because each newly acquired infection has the potential to persist and become an incurable, lifelong affliction. In addition, no successful treatment of HPV infection currently exists despite the great strides toward understanding the mechanisms underlying HPV pathogenesis. Moreover, ample research has proven that the use of prophylactic vaccines, such as Gardasil and Cervarix, have led to documented progress in decreasing the burden of HPV infection, however not all countries introduced a government-funded National HPV Vaccination Program to protect young men and women. This chapter summarizes the HPV infection, detection and prevention. We also shed light on non-cervical HPV-related cancers, which is rapidly increasing in more developed countries toward cervical cancer.

Cervical Cancer Screening: Comparison of Conventional Pap Smear Test, Liquid-Based Cytology, and Human Papillomavirus Testing as Stand-alone or Cotesting Strategies

BACKGROUND

Some countries have implemented stand-alone human papillomavirus (HPV) testing while others consider cotesting for cervical cancer screening. We compared both strategies within a population-based study.

METHODS

The MARZY cohort study was conducted in Germany. Randomly selected women from population registries aged ≥30 years (n = 5,275) were invited to screening with Pap smear, liquid-based cytology (LBC, ThinPrep), and HPV testing (Hybrid Capture2, HC2). Screen-positive participants [ASC-US+ or high-risk HC2 (hrHC2)] and a random 5% sample of screen-negatives were referred to colposcopy. Post hoc HPV genotyping was conducted by GP5+/6+ PCR-EIA with reverse line blotting. Sensitivity, specificity (adjusted for verification bias), and potential harms, including number of colposcopies needed to detect 1 precancerous lesion (NNC), were calculated.

RESULTS

In 2,627 screened women, cytological sensitivities (Pap, LBC: 47%) were lower than HC2 (95%) and PCR (79%) for CIN2+. Cotesting demonstrated higher sensitivities (HC2 cotesting: 99%; PCR cotesting: 84%), but at the cost of lower specificities (92%-95%) compared with HPV stand-alone (HC2: 95%; PCR: 94%) and cytology (97% or 99%). Cotesting versus HPV stand-alone showed equivalent relative sensitivity [HC2: 1.06, 95% confidence interval (CI), 1.00-1.21; PCR: 1.07, 95% CI, 1.00-1.27]. Relative specificity of Pap cotesting with either HPV test was inferior to stand-alone HPV. LBC cotesting demonstrated equivalent specificity (both tests: 0.99, 95% CI, 0.99-1.00). NNC was highest for Pap cotesting.

CONCLUSIONS

Cotesting offers no benefit in detection over stand-alone HPV testing, resulting in more false positive results and colposcopy referrals.

IMPACT

HPV stand-alone screening offers a better balance of benefits and harms than cotesting.See related commentary by Wentzensen and Clarke, p. 432.

Design and implementation of a portable colposcope Mueller matrix polarimeter

SIGNIFICANCE

Mueller matrix polarimetry can provide useful information about the function and structure of the extracellular matrix. A portable and low-cost system could facilitate the clinical assessment of cervical anomalies in low-resource settings.

AIM

We introduce a low-cost snapshot Mueller matrix polarimeter that does not require external power, has no moving parts, and can acquire a full Mueller matrix in ∼1  s, to conduct a feasibility study for cervical imaging in the low-resource setting.

APPROACH

A snapshot system based on two sets of Savart plates, a ring illuminator with polarizing elements (generating four polarization states), and one camera is introduced. Stokes vectors are formulated to recover the polarization properties of the sample. Then, using Mueller matrix decomposition, the depolarization and retardance information is extracted.

RESULTS

We report the results on 16 healthy individuals (out of 22 patients imaged), whose Pap smear showed no malignant findings from mobile clinics in rural region of Mysore, India. The depolarization and retardance information was in agreement with previous reports.

CONCLUSIONS

We introduce an imaging system and conducted a feasibility study on healthy individuals. This work could futurely translate into diagnostic applications to provide a quantitative platform in the clinical environment (e.g., cervical cancer screening).

A systematic review and meta-analysis of diagnostic accuracy of HPV tests for the screening of cervical cancer in low-resource settings

BACKGROUND

HPV tests for the screening of cervical cancer in low-income countries (LICs) might improve early detection and preventive efforts.

OBJECTIVES

To determine the diagnostic accuracy of HPV tests for detecting cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) in LICs.

SEARCH STRATEGY

The Cochrane Library, MEDLINE, and CINAHL databases were searched on June 1, 2020. References of relevant studies were hand-searched.

SELECTION CRITERIA

Diagnostic test accuracy studies were included if women had an HPV test for cervical cancer screening, followed by verification with colposcopy and colposcopy-directed biopsy. The primary target was CIN2+.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies, extracted data, and assessed methodological quality. Bivariate diagnostic random-effects meta-analysis was used.

MAIN RESULTS

Eleven studies including 82 556 women were eligible, most of which were at low risk of bias. The pooled diagnostic odds ratio of hybrid capture test of samples collected from the cervix by healthcare providers for detecting CIN2+ and CIN3+ was 42.0 (95% confidence interval [CI] 20.7-76.3) and 97.1 (95% CI 35.3-215.0), respectively.

CONCLUSIONS

Evidence indicates that hybrid capture tests can be used for screening of cervical cancer in LICs. Future studies are warranted for self-sampling and for low-cost HPV tests.

Novel concepts in cervical cancer screening: a comparison of VIA, HPV DNA test and p16INK4a/Ki-67 dual stain cytology in Western Kenya

Background

Screening of unvaccinated women remains essential to mitigate the high morbidity/mortality of cervical cancer. Here, we compared visual inspection with acetic acid (VIA), recommended by WHO as the most cost-effective screening approach in LMICs, with HPV-based screening, and usage of p16^INK4a/Ki-67 dual stain cytology.

Methods

We prospectively enrolled women participating in a VIA-based cervical cancer screening program in two peri-urban health centers of Kenya. Consenting women had a VIA examination preceded by collection of a liquid-based cytology sample from the cervix stored in PreservCyt medium (Hologic®). Analysis of all samples included a hrHPV DNA test and evaluation of a p16^INK4a /Ki-67 (CINtecPLUS®) dual stained slide that was prepared using the ThinPrep® 2000 Processor and evaluated by a pathologist trained in the methodology.

Results

In 701 of a total of 800 women aged 18–64 years, all three investigations were performed and data could be analyzed. The HPV, VIA and dual stain cytology positivity were 33%, 7%, and 2% respectively. The HPV positivity rate of VIA positive cases was 32%. The five most common HPV types were HPV16, 52, 68, 58 and 35. The OR among HIV infected women of an HPV infection, VIA positivity and positive dual stain cytology were 2.6 (95%CI 1.5–4.3), 1.9 (95%CI 0.89–4.4) and 3.4 (95%CI 1.07–10.9) respectively. The sensitivity of VIA to detect a p16^INK4a/Ki-67 positive transforming infection was 13% (95%CI 2–38).

Conclusions

Primary HPV testing appears feasible and should be considered as a primary screening test also in LMICs. The poor sensitivity of VIA renders it unsuitable as a triage test for HPV positive women. The utility of p16^INK4a/Ki-67 dual stain cytology as a triage test for HPV positive women in LMICs should be further studied.

Screening for cervical cancer in Africa: A proposal of a different combination of VIA test and cervical smear in Uganda

OBJECTIVE

To evaluate the efficacy of visual inspection with acetic acid (VIA) screening combined with a cervical smear in Uganda.

METHODS

Nine screening campaigns were held in Uganda between January 2011 and October 2019. In the last three campaigns, a new approach was used: the cervical smear was performed before the VIA test and, in case of a positive VIA test, the slide was sent for examination. The data collected were divided into two groups: the first six campaigns and the last three campaigns.

RESULTS

During the study period, 10 520 women were screened, of whom 911 had a positive VIA test. The VIA test showed 84.2% false positives. In the first group, the VIA test was positive in 516 women, of whom 93% were referred for further examinations. In the second group, the VIA test was positive in 395 women, but the cervical smear was positive in only 65 women. Thus, only 16.5% women were referred for further examinations.

CONCLUSION

Combining cervical smear, VIA test, and slide analysis in positive VIA tests may allow women who need treatment to be selected more effectively, while waiting for other more expensive solutions to become more affordable for this setting.

The value of microendoscopy in the diagnosis of cervical precancerous lesions and cervical microinvasive carcinoma

PURPOSE

Cervical cancer is still one of the main causes of death in females. Conventional diagnostic tools such as colposcopy are still unsatisfactory, so accurate diagnostic tools for cervical diseases are needed. Therefore, the purpose of this study was to perform a clinical study to evaluate the value of microendoscopic imaging systems in the diagnosis of cervical precancerous lesions and cervical microinvasive carcinoma (MIC).

METHODS

Totally 106 patients ranging in age from 23 to 67 years were recruited. All patients had abnormal thin-layer cytology (TCT) results (≥ low-grade squamous intraepithelial lesions) and high-risk human papillomavirus (HPV) positivity. Each patient was first subjected to ordinary colposcopy, followed by microendoscopy and biopsy. All results of the colposcopy and microendoscopy images were compared to the histopathological diagnosis.

RESULTS

Characteristics of pathological blood vessels were easily distinguished by microendoscopy compared with ordinary colposcopy. The diagnostic agreement rate of microendoscopy with the pathological diagnosis was higher (95.3%) than that of ordinary colposcopy (37.7%) (weighted kappa = 0.863, P < .01). When diagnosing HSIL and more advanced disease, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the microendoscopic diagnosis were significantly higher than those of ordinary colposcopy (97.6 and 38.1%), (95.5 and 63.6%), (98.8 and 80.0%), (91.3 and 21.2%) and (97.7 and 43.4%), respectively.

CONCLUSION

This study shows that microendoscopy has important value in the diagnosis of cervical lesions which can provide real-time diagnosis in vivo without staining, particularly for lesions that are not sensitive to acetic acid staining.

Clinical Performance of Human Papillomavirus Testing and Visual Inspection With Acetic Acid in Primary, Combination, and Sequential Cervical Cancer Screening in China

BACKGROUND

World Health Organization guidelines recommend screening with human papillomavirus (HPV) testing followed by either treatment of all HPV-positives, or by visual inspection (VIA) for triage to treatment, citing insufficient evidence to recommend either strategy over the other.

METHODS

We assessed VIA and HPV testing individually, in combination (HPV-VIA cotesting), and as triage models. Three thousand women were screened in Inner Mongolia, China, concurrently with HPV testing and VIA in a real population setting. Screen-positive women underwent colposcopy, and biopsy, if indicated. Accuracy of screening algorithms for cervical intraepithelial neoplasia grade 2 or higher (CIN-2+) was calculated after controlling for verification bias. HPV testing followed by VIA triage for CIN-2+ detection was compared with Hybrid Capture 2 viral loads triage, measured in relative light units/cutoff.

RESULTS

CIN-2+ prevalence was 1.0%. Corrected sensitivity, false negative rate, and specificity for CIN-2+, respectively, for primary HPV testing were 89.7%, 10.3%, and 83.3%; 44.8%, 55.2%, and 92·3% for VIA; 93.1%, 6.9%, and 80.2% for HPV-VIA cotesting; and 41.4%, 58.6, and 95.4% for HPV with VIA triage scenarios. Using relative light units/cutoff of 5 or greater to triage HPV-positive women had twice the sensitivity as VIA triage, with comparable specificity for CIN-2+.

CONCLUSIONS

When VIA performs relatively poorly and HPV testing is available, adding VIA to sequential (ie, HPV followed by VIA triage) or primary (HPV-VIA cotesting) screening does not significantly improve CIN-2+ detection beyond primary HPV screening alone. Sequential screening (ie, HPV followed by VIA triage) reduces sensitivity too low for population-based screening programs. The HPV viral loads could offer an alternative low-resource country triage strategy.

Multicentric study of cervical cancer screening with human papillomavirus testing and assessment of triage methods in Latin America: the ESTAMPA screening study protocol

INTRODUCTION

Human papillomavirus (HPV) testing is replacing cytology in primary screening. Its limited specificity demands using a second (triage) test to better identify women at high-risk of cervical disease. Cytology represents the immediate triage but its low sensitivity might hamper HPV testing sensitivity, particularly in low-income and middle-income countries (LMICs), where cytology performance has been suboptimal. The ESTAMPA (EStudio multicéntrico de TAMizaje y triaje de cáncer de cuello uterino con pruebas del virus del PApiloma humano; Spanish acronym) study will: (1) evaluate the performance of different triage techniques to detect cervical precancer and (2) inform on how to implement HPV-based screening programmes in LMIC.

METHODS AND ANALYSIS

Women aged 30-64 years are screened with HPV testing and Pap across 12 study centres in Latin America. Screened positives have colposcopy with biopsy and treatment of lesions. Women with no evident disease are recalled 18 months later for another HPV test; those HPV-positive undergo colposcopy with biopsy and treatment as needed. Biological specimens are collected in different visits for triage testing, which is not used for clinical management. The study outcome is histological high-grade squamous intraepithelial or worse lesions (HSIL+) under the lower anogenital squamous terminology. About 50 000 women will be screened and 500 HSIL+ cases detected (at initial and 18 months screening). Performance measures (sensitivity, specificity and predictive values) of triage techniques to detect HSIL+ will be estimated and compared with adjustment by age and study centre.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ethics Committee of the International Agency for Research on Cancer (IARC), of the Pan American Health Organisation (PAHO) and by those in each participating centre. A Data and Safety Monitoring Board (DSMB) has been established to monitor progress of the study, assure participant safety, advice on scientific conduct and analysis and suggest protocol improvements. Study findings will be published in peer-reviewed journals and presented at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT01881659.

Evaluation of the effectiveness of high-risk human papilloma self-sampling test for cervical cancer screening in Bolivia

BACKGROUND

In Bolivia the incidence and mortality rates of uterine cervix cancer are the highest in America. The main factor contributing to this situation is the difficulty of establishing and maintaining quality prevention programs based on cytology. We aimed to evaluate the effectiveness of HR-HPV testing on self-collected samples to detect cervical intra-epithelial neoplasia and identify the best combination of screening tests.

METHODS

A total of 469 women, divided in two groups, were included in this study. The first group included 362 women that underwent three consecutively primary screening tests: self-collected sampling for HR-HPV detection, conventional cervical cytology and visual inspection under acetic acid (VIA). The second group included 107 women referred with a positive HR-HPV test that underwent conventional cervical cytology and VIA. The presence of high grade intraepithelial lesion (CIN 2+) or invasive cancer was verified by colposcopy and biopsy.

RESULT

In the screening group the sensitivity to detect high grade intraepithelial lesion (CIN 2+) or invasive cancer were 100, 76, 44% for the VIA, HR-HPV test and cytology, respectively. In the referred group, the sensitivity to detect high grade intraepithelial lesion (CIN 2+) or invasive cancer by VIA and cytology were 100 and 81%, respectively.

CONCLUSIONS

VIA and HR-HPV self-sampling were the best combination to detect CIN2+ lesions. Cytology analysis gave the poorest performance.

A comparison of the associations of Reid Colposcopic Index and Swede Score with cervical histology

AIM

Cervical cancer, the fourth most common cancer in women, is preventable. Colposcopy and colposcopic scoring systems are helpful tools to guide the treatment of precancerous lesions. This study was done to compare the association between Reid colposcopic index (RCI) and Swede score.

METHODS

This prospective study enrolled 159 subjects aged 18 years or over with abnormal pap smears or high-risk HPV (types 16 and/or 18). All women underwent colposcopies, and the findings were classified by RCI and Swede score. Biopsies were done in all cases. The performance of both scores was evaluated.

RESULTS

A total of 43 (27.0%) high-grade lesions were detected. AUC of ROC of both tests showed excellent performance with 0.906 for RCI and 0.902 for Swede score. The correlation coefficient was 0.986. At a cutoff of 5, RCI had a sensitivity, specificity, positive predictive value, and negative predictive value for detected CIN2+ lesions of 83.7%, 89.7%, 75.0%, and 93.7%, respectively. At a cutoff of 7 for RCI score, the corresponding figures were 46.5%, 99.1%, 95.2%, and 83.3%. At a cutoff of 5, Swede score had a sensitivity, specificity, positive predictive value, and negative predictive value of 88.4%, 87.1%, 71.7%, and 95.3%. At a cutoff of 9 for Swede score, those values were 14.0%, 99.1%, 85.7%, and 75.7%.

CONCLUSION

There was a good association between RCI and Swede score. Both scoring systems had the good performance. Swede score is effective for practical use and applied in Thailand.

Screening and management of preinvasive lesions of the cervix: Good clinical practice recommendations from the Federation of Obstetrics and Gynaecologic Societies of India (FOGSI)

In India, there are marked variations in resources for cervical cancer screening. For the first time, resource-stratified screening guidelines have been developed that will be suitable for low middle-income countries with similar diversities. The current article describes the process and outcomes of these resource stratified guidelines for screening and treatment of preinvasive lesions of cervix. Evidence from literature was collated and various guidelines were reviewed by an expert panel. Based on the level of evidence, guidelines were developed for screening by human papillomavirus (HPV) testing, cytology and visual inspection after application of acetic acid (VIA), and management of screen positive lesions in different resource settings. Expert opinion was used for certain country-specific situations. The healthcare system was stratified into two resource settings - good or limited. The mode of screening and treatment for each was described. HPV testing is the preferred method for cervical cancer screening. VIA by trained providers is especially suitable for low resource settings until an affordable HPV test becomes available. Healthcare providers can choose the most appropriate screening and treatment modality. A single visit approach is encouraged and treatment may be offered based on colposcopy diagnosis ('see and treat') or even on the basis of HPV test or VIA results ('screen and treat'), if compliance cannot be ensured. The Federation of Obsterician and Gynaecologists of India Good Clinical Practice Recommendations (FOGSI) GCPR are appropriately designed for countries with varied resource situations to ensure an acceptable cervical cancer prevention strategy.

Evaluation of portable colposcopy and human papillomavirus testing for screening of cervical cancer in rural China

OBJECTIVE

To evaluate the use of a portable, rechargeable colposcope combined with human papillomavirus (HPV) testing, as compared with HPV testing alone, for screening of cervical cancer and pre-cancerous lesions.

METHODS

This was a cross-sectional study among 488 women in Baoshan County, Yunnan. The women underwent HPV testing followed by Gynocular portable colposcopy with visual inspection with acetic acid. Obvious lesions were biopsied. If portable colposcopy testing was negative but HPV testing was positive, the women underwent follow-up testing with thin-prep cytology and traditional colposcopy. Cervical biopsies were performed for any abnormalities. Histopathology was followed up with diagnosis and treatment.

RESULTS

Among 488 women screened with portable colposcopy, 24 women underwent biopsy based on positive colposcopy screening. Of these 24 women, three were HPV positive and 21 were HPV negative. Five women had cervical intra-epithelial neoplasia (CIN) I and one had advanced cervical cancer. Forty-six women tested positive for HPV. Three of these women had screened positive on preliminary colposcopy, with one positive for CIN III/squamous cell carcinoma and one woman with CIN I. Forty-three women underwent follow-up testing with thin-prep cytology. Two women had atypical squamous cells of undetermined significance and five had low-grade squamous intra-epithelial lesions and were biopsied; three women had CIN I, one had CIN II and one had CIN III. HPV testing and portable colposcopy was more sensitive but slightly less specific than portable colposcopy or HPV testing alone.

CONCLUSION

While HPV testing has high sensitivity and specificity for the detection of pre-cancerous and cancerous lesions and portable colposcopy has lower specificity, both methods of detection have low positive predictive value and high negative predictive value. In tandem, HPV testing and portable colposcopy had higher sensitivity for detection among women who underwent biopsies. In clinical practice, portable colposcopy was an effective, easy and affordable tool to transport to villages where cytology is not currently feasible.

The use of molecular markers for cervical screening of women living with HIV in South Africa

Supplemental Digital Content is available in the text

To determine the performance of molecular screening strategies for detection of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) in comparison with cytology screening in women living with HIV.

Performance of DNA methylation assays for detection of high-grade cervical intraepithelial neoplasia (CIN2+): a systematic review and meta-analysis

Background

To conduct a meta-analysis of performance of DNA methylation in women with high-grade cervical intraepithelial neoplasia (CIN2+).

Methods

Medline and Embase databases were searched for studies of methylation markers versus histological endpoints. Pooled sensitivity, specificity and positive predictive value (PPV) for CIN2+ were derived from bivariate models. Relative sensitivity and specificity for CIN2+ compared to cytology and HPV16/18 genotyping were pooled using random-effects models.

Results

Sixteen thousand three hundred thirty-six women in 43 studies provided data on human genes (CADM1, MAL, MIR-124-2, FAM19A4, POU4F3, EPB41L3, PAX1, SOX1) and HPV16 (L1/L2). Most (81%) studies evaluated methylation assays following a high-risk (HR)-HPV-positive or abnormal cytology result. Pooled CIN2+ and CIN3+ prevalence was 36.7% and 21.5%. For a set specificity of 70%, methylation sensitivity for CIN2+ and CIN3+ were 68.6% (95% CI: 62.9–73.8) and 71.1% (95% CI: 65.7–76.0) and PPV were 53.4% (95% CI: 44.4–62.1) and 35.0% (95% CI: 28.9–41.6). Among HR-HPV+ women, the relative sensitivity of methylation for CIN2+ was 0.81 (95% CI: 0.63–1.04) and 1.22 (95% CI: 1.05–1.42) compared to cytology of atypical squamous cells of undetermined significance, or greater (ASCUS+) and HPV16/18 genotyping, respectively, while relative specificity was 1.25 (95% CI: 0.99–1.59) and 1.03 (95% CI: 0.94–1.13), respectively.

Conclusion

DNA methylation is significantly higher in CIN2+ and CIN3+ compared to ≤CIN1. As triage test, DNA methylation has higher specificity than cytology ASCUS+ and higher sensitivity than HPV16/18 genotyping.

Cervical cancer screening knowledge and barriers among women in Addis Ababa, Ethiopia

INTRODUCTION

Routine cervical screening has been shown to greatly reduce both the number of new cervical cancers diagnosed each year and the number of deaths resulting from the disease. Nevertheless, cervical screening knowledge and screening uptake is very low in developing countries. In Ethiopia, the coverage of cervical cancer screening is only 1%. In this study, we aimed to assess cervical cancer screening knowledge and barriers for screening uptake among women in Addis Ababa Ethiopia.

METHODS

A facility-based cross-sectional study was conducted from February to March 2015 in Addis Ababa, Ethiopia. A total of 520 women were selected by a multi-stage sampling procedure. Interview based questioner was used to collect the data. Descriptive statistics was used to describe the socio-demographic and clinical profiles of the women. Multivariate logistic regression using adjusted odds ratio (AOR) and 95% confidence interval (CI) was used to identify independent predictors for cervical screening knowledge. A p-value of <0.05 was set to determine level of statistical significance.

RESULTS

Among all women, 42.7% had heard of cervical cancer screening and 144 (27.7%) women had adequate knowledge of cervical cancer screening. The mean (±SD) age of women was 27.7 (±5.49) years. In total, a quarter (25%) of eligible women had experience of cervical cancer screening. Not being married (adjusted odds ratio (AOR) = 1.8, 1.1-3.3), having an awareness of cervical cancer (AOR = 5.0, 2.7-9.1) and receiving information from health professionals (AOR = 1.9, 1.1-3.2) were the predictors for good cervical cancer screening knowledge. An absence of symptoms (57%), a lack of knowledge about screening (56.3%) and the lack of a screening service in their living area (42.2%) were the perceived barriers for screening uptake.

CONCLUSIONS

Cervical screening knowledge was low among women and less than half had heard of screening. Women also had low experience of screening. The lack of a screening service, the absence of symptoms and not knowing about screening were the perceived reasons for the low uptake. Hence, awareness campaigns and education should be undertaken by health professionals. Access and availability of screening service is also essential to improve screening uptake.

Evaluation of cytology as secondary triage in visual inspection after application of 4% acetic acid-based cervical cancer screening program

Context (Background):

Visual-based screening techniques are low cost and have good sensitivity. Hence, they appear promising for primary screening in low-resource settings. However, to reduce referrals for diagnostic colposcopy, there is need to triage these screen-positive women with test with good specificity.

Aims:

The study aims to evaluate the performance of cytology as triage for visual inspection after application of 4% acetic acid (VIA) screen-positive women.

Settings and Design:

Community-based cervical cancer screening using VIA was implemented among socioeconomically disadvantaged women in Mumbai, India.

Methods:

Cytology was performed on screen-positive women. All primarily screen-positive women underwent colposcopy. Directed biopsies were obtained among women with positive findings on colposcopy. The gold standard used for final disease status was histopathology or negative colposcopy.

Statistical Analysis Used:

Test characteristics of cytology as triage test.

Results:

Among the 138,383 population, 16,424 eligible women were screened with VIA. 785 (4.78%) women were VIA positive and 580 women participated in triage with cytology. The sensitivity and specificity of cytology at threshold of atypical squamous cells of undetermined significance in detecting ≥cervical intraepithelial neoplasia (CIN) 2 were 75.0 and 94.7, respectively. The positive and negative predictive values of cytology as triage test were 23.1 and 99.4, respectively, and the false positivity and false negativity rates were 5.34 and 25.0, respectively.

Conclusion:

Cytology triage with VIA can reduce referrals for colposcopy to 4.97% of original referrals but may miss around 25%, of high-grade CIN. The substantial reduction in referrals has special implication for low-resource settings, wherein compliance to referral and availability of diagnostic facilities are poor.

Neuropilin-1 is associated with the prognosis of cervical cancer in Henan Chinese population

Objective: Neuropilin-1 has been reported to be a valuable diagnostic biomarker in patients with cervical intraepithelial neoplasia (CIN) and early cervical cancer. The aim of this study was to investigate the association between Neuropilin-1 and the prognosis of cervical cancer in Henan Chinese population.

Methods: Tissues were collected in The Third Affiliated Hospital of Zhengzhou University between 2010 and 2012, determining the level and expression of Neuropilin-1 in different cervical lesions by immunohistochemistry. The cell proliferation assay, wound-healing assays and Transwell assay were performed to explore the ability of proliferation, migration and invasion for Hela and Caski cells after NRP-1 was knocked down by shRNA transfection. Western blotting was performed to investigate the role of NRP-1 in endothelial-to-mesenchymal transition (EndMT). Tumor xenografts model was used to evaluate the effect of NRP-1 on the tumor growth.

Results: The expression of NRP-1 was upregulated in the tumor tissues compared with the CIN and normal tissues (P<0.0001). The overall survival time of the high NRP-1 expression group was significantly shorter than that of the low NRP-1 expression group (P<0.0001); NRP-1-depleted cells had dramatically lower rate of proliferation, migration and invasion compared to control cells (all P<0.05). Depletion of NRP-1 significantly suppressed the growth of CaSki xenograft tumor in nude mice.

Conclusions: The current study demonstrated that NRP-1 expression is significantly correlated with the progression of CC. Notably, high NRP-1 expression is correlated with a poorer survival in patients with CC, and has been shown to be an independent prognostic factor.

Visual techniques for cervical cancer screening in Colombia

Introduction: Direct visual inspection for cervical cancer screening remains controversial, whereas colposcopy-biopsy is considered the gold standard for diagnosis of preneoplastic cervical lesions.Objectives: To determine the rates of cervical intraepithelial neoplasia grade 2 or more and of false positives for colposcopy and direct visual inspection.Materials and methods: Women aged 25-59 underwent direct visual inspection with acetic acid (VIA), Lugol’s iodine (VIA-VILI), and colposcopy. Punch biopsies were obtained for all positive tests. Using histology as the gold standard, detection and false positive rates were compared for VIA, VIA-VILI, and colposcopy (two thresholds). Sensitivity and false positive ratios with the corresponding 95% confidence intervals were estimated.Results: We included 5,011 women in the analysis and we obtained 602 biopsies. Positivity rates for colposcopy high-grade and low-grade diagnosis were 1.6% and 10.8%. Positivity rates for VIA and VIA-VILI were 7.4% and 9.9%. VIA showed a significantly lower detection rate than colposcopy with low-grade diagnosis as the threshold (SR=0.72; 95% CI 0.57-0.91), and significantly lower false positive rate (FPR=0.70; 95% CI 0.65-0.76). No differences between VIA-VILI and colposcopy low-grade threshold were observed. VIA and VIA-VILI showed significantly higher detection and false positive rates than colposcopy high-grade threshold. Sensitivity rates for visual inspection decreased with age and false positive rates increased. For all age groups, false positive rates for VIA and VIA-VILI were significantly higher than colposcopy.Conclusions: Detection rates for VIA-VILI similar to colposcopy low-grade threshold represent a chance to reduce cervical cancer mortality through see-and-treat approaches among women with limited access to health care. Lower detection rates suggest reviewing high-grade colposcopy findings as the threshold for biopsy in certain settings.