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Hu T, Li K, He L, Huang F, Yang F, Chen S, Wang H, Ma D, Huang X, Wu P. Testing for viral DNA integration among HPV-positive women to detect cervical precancer: An observational cohort study. BJOG 2024; 131:309-318. [PMID: 37408516 DOI: 10.1111/1471-0528.17597] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 06/11/2023] [Accepted: 06/19/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE Human papillomavirus (HPV) integration is a crucial genetic step in cervical carcinogenesis. This study aimed to evaluate the performance of an HPV integration test for the triage of HPV-positive women. DESIGN An observational cohort study. SETTING A cervical cancer screening programme in China. POPULATION 1393 HPV-positive women aged 25-65 years undergoing routine cervical cancer screening and HPV integration testing with 1-year follow-up. METHODS The sensitivity, specificity, positive predictive value and negative predictive value between HPV integration and cytology were compared. MAIN OUTCOME MEASURES Cervical intraepithelial neoplasia grade 3 or more severe (CIN3+). RESULTS Among 1393 HPV-positive patients, 138 (9.9% [8.3-11.5%]) were HPV integration test positive compared with 537 who had abnormal cervical cytology (38.5% [36.0-41.1%]). Compared with cytology, HPV integration exhibited higher specificity (94.5% [93.3-95.8%] versus 63.8% [61.2-66.4%]) and equivalent sensitivity (70.5% [61.4-79.7%] versus 70.5% [61.4-79.7%]) for detection of CIN3+. HPV integration-negative women accounted for 90.1% (1255/1393) of the total population and had a low immediate CIN3+ risk (2.2%). At 1-year follow-up, the progression rate in the HPV integration-positive women was higher than in the HPV integration-negative women (12.0% versus 2.1%, odds ratio 5.6, 95% CI, 2.6-11.9). In 10 conservatively managed integration-negative CIN2 patients, all showed spontaneous regression and seven showed HPV clearance after 1-year follow-up. CONCLUSION The HPV integration test may be a precise risk stratification tool for HPV-positive women and could avoid excessive use of invasive biopsies.
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Affiliation(s)
- Ting Hu
- Department of Gynaecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kexin Li
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang He
- Department of Gynaecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fanwei Huang
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fan Yang
- Wuhan KDWS Biological Technology Co., Ltd, New Technology Platform, Wuhan, China
| | - Shimin Chen
- Wuhan KDWS Biological Technology Co., Ltd, New Technology Platform, Wuhan, China
| | - Hui Wang
- Department of Gynaecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Ding Ma
- Department of Gynaecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyuan Huang
- Department of Gynaecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peng Wu
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gynaecology and Obstetrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Lycke KD, Kahlert J, Petersen LK, Damgaard RK, Cheung LC, Gravitt PE, Hammer A. Untreated cervical intraepithelial neoplasia grade 2 and subsequent risk of cervical cancer: population based cohort study. BMJ 2023; 383:e075925. [PMID: 38030154 PMCID: PMC10685285 DOI: 10.1136/bmj-2023-075925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE To describe the long term risk of cervical cancer in women with untreated (that is, undergoing active surveillance) or immediately treated cervical intraepithelial neoplasia grade 2 (CIN2). DESIGN Nationwide population based historical cohort study. SETTING Danish healthcare registries. PARTICIPANTS Women with CIN2 diagnosed in 1998-2020 and aged 18-40 years at diagnosis, who had either active surveillance or immediate treatment with large loop excision of the transformation zone (LLETZ). Women with a previous record of CIN2 or worse or LLETZ were excluded. MAIN OUTCOME MEASURE A Weibull survival model for interval censored time-to-event data was used to estimate the cumulative risk of cervical cancer. Inverse probability treatment weighting was used to adjust estimates for age, index cytology, calendar year, and region of residence. RESULTS The cohort included 27 524 women with CIN2, of whom 12 483 (45%) had active surveillance and 15 041 (55%) had immediate LLETZ. During follow-up, 104 cases of cervical cancer were identified-56 (54%) in the active surveillance group and 48 (46%) in the LLETZ group. The cumulative risk of cervical cancer was comparable across the two groups during the active surveillance period of two years. Thereafter, the risk increased in the active surveillance group, reaching 2.65% (95% confidence interval 2.07% to 3.23%) after 20 years, whereas it remained stable in the LLETZ group at 0.76% (0.58% to 0.95%). CONCLUSIONS Undergoing active surveillance for CIN2, thereby leaving the lesion untreated, was associated with increased long term risk of cervical cancer compared with immediate LLETZ. These findings show the importance of continued follow-up of women having active surveillance.
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Affiliation(s)
- Kathrine Dyhr Lycke
- Department of Obstetrics and Gynaecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynaecology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rikke Kamp Damgaard
- Department of Obstetrics and Gynaecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Patti E Gravitt
- Centre for Global Health, National Cancer Institute, Rockville, MD, USA
| | - Anne Hammer
- Department of Obstetrics and Gynaecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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3
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Guido R, Perkins RB. Management of Abnormal Cervical Cancer Screening Test: A Risk-based Approach. Clin Obstet Gynecol 2023; 66:478-499. [PMID: 37650663 DOI: 10.1097/grf.0000000000000794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Cervical cancer screening plays a major role in preventing cervical cancer. The field is based on understanding the natural history of human papillomavirus and its role in cervical cancer. Screening has evolved to assessing the risk for cervical intraepithelial neoplasia grade 3, a true cancer precursor, and performing diagnostic tests based on those risks. This article summarizes the present state of management of abnormal cervical cancer screening tests in the United States, based on the most recent 2019 American Society of Colposcopy and Cervical Pathology guidelines.
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Affiliation(s)
- Richard Guido
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of the UPMC System, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rebecca B Perkins
- Boston University School of Medicine Chobanian & Avedisian School of Medicine, Boston Medical Center, Massachusetts
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Malagón T, Trottier H, El-Zein M, Villa LL, Franco EL. Human Papillomavirus Intermittence and Risk Factors Associated With First Detections and Redetections in the Ludwig-McGill Cohort Study of Adult Women. J Infect Dis 2023; 228:402-411. [PMID: 36790831 PMCID: PMC10428201 DOI: 10.1093/infdis/jiad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND We assessed the incidence and risk factors for first detection and redetection with the same human papillomavirus (HPV) genotype, and prevalence of cytological lesions during HPV redetections. METHODS The Ludwig-McGill cohort study followed women aged 18-60 years from São Paulo, Brazil in 1993-1997 for up to 10 years. Women provided cervical samples for cytology testing and HPV DNA testing at each visit. A redetection was defined as a recurring genotype-specific HPV positive result after 1 or more intervening negative visits. Predictors of genotype-specific redetection were assessed using adjusted hazard ratios (aHR) with Cox regression modeling. RESULTS In total, 2184 women contributed 2368 incident HPV genotype-specific first detections and 308 genotype-specific redetections over a median follow-up of 6.5 years. The cumulative incidence of redetection with the same genotype was 6.6% at 1 year and 14.8% at 5 years after the loss of positivity of the first detection. Neither age (aHR 0.90; 95% confidence interval [CI], .54-1.47 for ≥45 years vs < 25 years) nor new sexual partner acquisition (aHR 0.98; 95% CI, .70-1.35) were statistically associated with genotype-specific redetection. High-grade squamous intraepithelial lesion prevalence was similar during first HPV detections (2.9%) and redetection (3.2%). CONCLUSIONS Our findings suggest many HPV redetections were likely reactivations of latent recurring infections.
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Affiliation(s)
- Talía Malagón
- Division of Cancer Epidemiology, Gerald Bronfman Department of Oncology, McGill University, Montréal, Canada
| | - Helen Trottier
- Département de Médecine Sociale et Préventive, Université de Montréal, Montréal, Canada
- Centre de Recherche, Centre Hospitalier Universitaire de Sainte-Justine, Montréal, Canada
| | - Mariam El-Zein
- Division of Cancer Epidemiology, Gerald Bronfman Department of Oncology, McGill University, Montréal, Canada
| | - Luisa L Villa
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Department of Radiology and Oncology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo L Franco
- Division of Cancer Epidemiology, Gerald Bronfman Department of Oncology, McGill University, Montréal, Canada
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5
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Barakzai SK, Nguyen A, Sehgal S, Matsuo K, Shi W, Veran-Taguibao S, Wilson ML, Gordon BJ. The clinical relevance of human papillomavirus negative status in unsatisfactory cervical cytology. Arch Gynecol Obstet 2023; 307:1021-1025. [PMID: 36484851 DOI: 10.1007/s00404-022-06870-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this study was to evaluate the clinical relevance of high-risk human papillomavirus (HR-HPV) negativity at the time of unsatisfactory cervical cytology. METHODS In this retrospective observational study, records were reviewed for patients who had unsatisfactory cervical cytology with HR-HPV testing performed from January 2015 through September 2019 at a large teaching hospital. Pathology results of follow-up cervical cytology and biopsies were assessed. RESULTS Of 1282 patients with unsatisfactory cervical cytology and negative HR-HPV testing, repeat cytology was negative for intraepithelial lesion (NIL) in 952 (75%) patients, unsatisfactory in 273 (22%) patients, and abnormal in 41 (3%) patients. Median follow-up time was 91 days. The concordance of HR-HPV status between initial unsatisfactory cervical cytology and subsequent satisfactory cervical cytology was 96.3% for HR-HPV negative patients and 68.8% for HR-HPV positive patients. Compared to women who were HR-HPV negative, women who were HR-HPV positive on initial unsatisfactory cytology were at higher risk of subsequent cervical intraepithelial neoplasia (CIN) 2 or greater (odds ratio = 4.91, 95% confidence interval: 1.34-18.03 for E6/E7 mRNA positivity alone; odds ratio = 46.13, 95% confidence interval: 13.45-158.01 for HR-HPV genotype 16 or 18/45 positivity). CONCLUSION In the 3 month follow-up of patients with unsatisfactory cervical cytology and negative HR-HPV testing, approximately 3% had abnormal cytology but no cases of HPV related pathology of CIN 2 or greater were found. There was high concordance of negative HR-HPV testing results with those on follow-up satisfactory cervical cytology.
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Affiliation(s)
- Syem K Barakzai
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA.
| | - Ailene Nguyen
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sanchala Sehgal
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Wenjing Shi
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Melissa L Wilson
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Brian J Gordon
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
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Hammer A, Blaakaer J, de Koning MNC, Steiniche T, Mejlgaard E, Svanholm H, Roensbo MT, Fuglsang K, Doorbar J, Andersen RH, Quint WGV, Gravitt PE. Evidence of latent HPV infection in older Danish women with a previous history of cervical dysplasia. Acta Obstet Gynecol Scand 2022; 101:608-615. [PMID: 35481603 DOI: 10.1111/aogs.14362] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Understanding whether human papillomavirus (HPV) may establish latency in the uterine cervix is important. A better understanding of HPV natural history is useful for clinical counseling of women attending screening and to accurately inform health prevention strategies such as screening and HPV vaccination. We evaluated the extent of latent HPV infections in older women with a history of abnormal cytology. MATERIAL AND METHODS We conducted a cross-sectional study in Aarhus, Denmark, from March 2013 through April 2015. Women were enrolled if they underwent cervical amputation or total hysterectomy because of benign disease. Prior to surgery, women completed a questionnaire and a cervical smear was collected for HPV testing and morphological assessment. For evaluation of latency (i.e., no evidence of active HPV infection, but HPV detected in the tissue), we selected women with a history of abnormal cervical cytology or histology, as these women were considered at increased risk of harboring a latent infection. Cervical tissue underwent extensive HPV testing using the SPF10-DEIA-LipA25 assay. RESULTS Of 103 women enrolled, 26 were included in this analysis. Median age was 55 years (interquartile range [IQR] 52-65), and most women were postmenopausal and parous. The median number of sexual partners over the lifetime was six (IQR 3-10), and 85% reported no recent new sexual partner. Five women (19.2%) had evidence of active infection at the time of surgery, and 19 underwent latency evaluation. Of these, a latent infection was detected in 11 (57.9%), with HPV16 being the most prevalent type (50%). Nearly 80% (n = 14) of the 18 women with a history of previous low-grade or high-grade cytology with no treatment had an active or latent HPV infection, with latent infections predominating. HPV was detected in two of the six women with a history of high-grade cytology and subsequent excisional treatment, both as latent infections. CONCLUSIONS HPV can be detected in cervical tissue specimens without any evidence of an active HPV infection, indicative of a latent, immunologically controlled infection. Modeling studies should consider including a latent state in their model when estimating the appropriate age to stop screening and when evaluating the impact of HPV vaccination.
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Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Gødstrup Hospital, Gødstrup, Denmark
| | - Jan Blaakaer
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Torben Steiniche
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Else Mejlgaard
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Svanholm
- Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Mette T Roensbo
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Katrine Fuglsang
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - John Doorbar
- Department of Pathology, University of Cambridge, Cambridge, UK
| | - Rikke H Andersen
- Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Wim G V Quint
- DDL Diagnostic Laboratory, Viroclinics-DDL, Rijswijk, the Netherlands
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Hurtado-Salgado E, Cárdenas-Cárdenas L, Salmerón J, Luna-Gordillo R, Ortiz-Panozo E, Allen-Leigh B, Saavedra-Lara N, Franco EL, Lazcano-Ponce E. Comparative performance of the human papillomavirus test and cytology for primary screening for high-grade cervical intraepithelial neoplasia at the population level. Int J Cancer 2021; 150:1422-1430. [PMID: 34921727 DOI: 10.1002/ijc.33905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
The World Health Organization recommends high-risk human papillomavirus (hrHPV)-based screening for women 39 to 49 years, based on the greater accuracy of hrHPV-based screening for cervical cancer detection. Many cervical cancer screening programs have incorporated hrHPV testing and multiple early cervical cancer detection strategies have been evaluated, mostly under controlled conditions. However, there are few evaluations of combined hrHPV and cytology strategies post-implementation at the population level. Our study sought to estimate the relative yield of hrHPV testing compared to cervical cytology, as a primary screening test for cervical intraepithelial neoplasia grade 2+ (CIN2+), used at the population level. We analyzed screening data from Mexico's public cervical cancer prevention program from 2010 to 2015 in women 35 to 64 years. The study population consisted of two cohorts: one from a total of 2 881 962 cytology-based screening tests and another from a total of 2 004 497 hrHPV-based screening tests, which are concurrent in time. We performed a relative yield analysis using Poisson regression models to compare the effectiveness of hrHPV testing for CIN2+ with cervical cytology. A total of 4 886 459 records were analyzed, including 23 999 biopsies; 0.12% (n = 6166) had a CIN2+ histologic diagnosis. hrHPV testing with cytological triage detects twice as many CIN2+ cases as screening using cytology alone.
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Affiliation(s)
- Erika Hurtado-Salgado
- Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Luz Cárdenas-Cárdenas
- Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Jorge Salmerón
- Political, Population and Health Research Center, School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | | | - Eduardo Ortiz-Panozo
- Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Betania Allen-Leigh
- Reproductive Health Division, Center for Population Health Research, National Institute of Public Health, Mexico City, Mexico
| | - Nenetzen Saavedra-Lara
- School of Public Health of Mexico, National Institute of Public Health, Cuernavaca, Mexico
| | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, Montreal, Canada
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Ribeiro A, Corrêa F, Migowski A, Leal A, Martins S, Raiol T, Marques CP, Torres KL, Novetsky AP, Marcus JZ, Wentzensen N, Schiffman M, Rodriguez AC, Gage JC. Rethinking Cervical Cancer Screening in Brazil Post COVID-19: A Global Opportunity to Adopt Higher Impact Strategies. Cancer Prev Res (Phila) 2021; 14:919-926. [PMID: 34607876 DOI: 10.1158/1940-6207.capr-21-0110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/05/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022]
Abstract
The World Health Organization global call to eliminate cervical cancer encourages countries to consider introducing or improving cervical cancer screening programs. Brazil's Unified Health System (SUS) is among the world's largest public health systems offering free cytology testing, follow-up colposcopy, and treatment. Yet, health care networks across the country have unequal infrastructure, human resources, equipment, and supplies resulting in uneven program performance and large disparities in cervical cancer incidence and mortality. An effective screening program needs multiple strategies feasible for each community's reality, facilitating coverage and follow-up adherence. Prioritizing those at highest risk with tests that better stratify risk will limit inefficiencies, improving program impact across different resource settings. Highly sensitive human papillomavirus (HPV)-DNA testing performs better than cytology and, with self-collection closer to homes and workplaces, improves access, even in remote regions. Molecular triage strategies like HPV genotyping can identify from the same self-collected sample, those at highest risk requiring follow-up. If proven acceptable, affordable, cost-effective, and efficient in the Brazilian context, these strategies would increase coverage while removing the need for speculum exams for routine screening and reducing follow-up visits. SUS could implement a nationwide organized program that accommodates heterogenous settings across Brazil, informing a variety of screening programs worldwide.
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Affiliation(s)
- Ana Ribeiro
- Department of Pharmacy, Faculty of Health Sciences, University of Brasília (UNB), Brasília, District Federal, Brazil. .,Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil
| | - Flávia Corrêa
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Arn Migowski
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Aline Leal
- General Coordination of Specialized Care, Health Care Secretariat, Ministry of Health (MS), Brasília, District Federal, Brazil
| | - Sandro Martins
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil
| | - Tainá Raiol
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil
| | - Carla P Marques
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil.,Department of Public Health, Faculty of Ceilândia, University of Brasília (UNB), Brasília, District Federal, Brazil
| | - Katia L Torres
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil.,Amazon State Oncology Control Foundation (FCECON), Manaus, Amazonas, Brazil
| | - Akiva P Novetsky
- Rutgers New Jersey Medical School (NJMS), Newark, New Jersey.,Rutgers Cancer Institute of New Jersey (CINJ), New Brunswick, New Jersey
| | - Jenna Z Marcus
- Rutgers New Jersey Medical School (NJMS), Newark, New Jersey
| | - Nicolas Wentzensen
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
| | - Mark Schiffman
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
| | - Ana Cecilia Rodriguez
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
| | - Julia C Gage
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
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9
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Mills JM, Morgan JR, Dhaliwal A, Perkins RB. Eligibility for cervical cancer screening exit: Comparison of a national and safety net cohort. Gynecol Oncol 2021; 162:308-314. [PMID: 34090706 DOI: 10.1016/j.ygyno.2021.05.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine eligibility for discontinuation of cervical cancer screening. METHODS Women aged 64 with employer-sponsored insurance enrolled in a national database between 2016 and 2018, and those aged 64-66 receiving primary care at a safety net health center in 2019 were included. Patients were evaluated for screening exit eligibility by current guidelines: no evidence of cervical cancer or HIV-positive status and no evidence of cervical precancer in the past 25 years, and had evidence of either hysterectomy with removal of the cervix or evidence of fulfilling screening exit criteria, defined as two HPV screening tests or HPV plus Pap co-tests or three Pap tests within the past 10 years without evidence of an abnormal result. RESULTS Of the 590,901 women in the national claims database, 131,059 (22.2%) were eligible to exit due to hysterectomy (1.6%) or negative screening (20.6%). Of the 1544 women from the safety net health center, 528 (34.2%) were eligible to exit due to hysterectomy (9.3%) or negative screening (24.9%). Most women did not have sufficient data available to fulfill exit criteria: 382,509 (64.7%) in the national database and 875 (56.7%) in the safety net hospital system. Even among women with 10 years of insurance claims data, only 41.5% qualified to discontinue screening. CONCLUSIONS Examining insurance claims in a national database and electronic medical records at a safety net institution led to remarkably similar findings: two thirds of women fail to qualify for screening exit. Additional steps to ensure eligibility prior to screening exit may be necessary to decrease preventable cervical cancers among women aged >65. CLINICAL TRIAL REGISTRATION N/A.
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Affiliation(s)
- Jacqueline M Mills
- Department of Obstetrics and Gynecology, Boston University School of Medicine/ Boston Medical Center, Boston, MA, United States of America.
| | - Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States of America.
| | - Amareen Dhaliwal
- Boston University School of Medicine, Boston, MA, United States of America.
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/ Boston Medical Center, Boston, MA, United States of America.
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10
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Hammer A, Gravitt P. Clinical implications of transitioning from cytology to human papillomavirus-based cervical cancer screening. Acta Obstet Gynecol Scand 2021; 100:371-372. [PMID: 33739440 DOI: 10.1111/aogs.14107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Patti Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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A proposed new generation of evidence-based microsimulation models to inform global control of cervical cancer. Prev Med 2021; 144:106438. [PMID: 33678235 PMCID: PMC8041229 DOI: 10.1016/j.ypmed.2021.106438] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 01/30/2023]
Abstract
Health decision models are the only available tools designed to consider the lifetime natural history of human papillomavirus (HPV) infection and pathogenesis of cervical cancer, and the estimated long-term impact of preventive interventions. Yet health decision modeling results are often considered a lesser form of scientific evidence due to the inherent needs to rely on imperfect data and make numerous assumptions and extrapolations regarding complex processes. We propose a new health decision modeling framework that de-emphasizes cytologic-colposcopic-histologic diagnoses due to their subjectivity and lack of reproducibility, relying instead on HPV type and duration of infection as the major determinants of subsequent transition probabilities. We posit that the new model health states (normal, carcinogenic HPV infection, precancer, cancer) and corollary transitions are universal, but that the probabilities of transitioning between states may vary by population. Evidence for this variability in host response to HPV infections can be inferred from HPV prevalence patterns in different regions across the lifespan, and might be linked to different average population levels of immunologic control of HPV infections. By prioritizing direct estimation of model transition probabilities from longitudinal data (and limiting reliance on model-fitting techniques that may propagate error when applied to multiple transitions), we aim to reduce the number of assumptions for greater transparency and reliability. We propose this new microsimulation model for critique and discussion, hoping to contribute to models that maximally inform efficient strategies towards global cervical cancer elimination.
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Paul P, Hammer A, Rositch AF, Burke AE, Viscidi RP, Silver MI, Campos N, Youk AO, Gravitt PE. Rates of New Human Papillomavirus Detection and Loss of Detection in Middle-aged Women by Recent and Past Sexual Behavior. J Infect Dis 2020; 223:1423-1432. [PMID: 32870982 DOI: 10.1093/infdis/jiaa557] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/27/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Understanding the source of newly detected human papillomavirus (HPV) in middle-aged women is important to inform preventive strategies, such as screening and HPV vaccination. METHODS We conducted a prospective cohort study in Baltimore, Maryland. Women aged 35-60 years underwent HPV testing and completed health and sexual behavior questionnaires every 6 months over a 2-year period. New detection/loss of detection rates were calculated and adjusted hazard ratios were used to identify risk factors for new detection. RESULTS The new and loss of detection analyses included 731 women, and 104 positive for high-risk HPV. The rate of new high-risk HPV detection was 5.0 per 1000 woman-months. Reporting a new sex partner was associated with higher detection rates (adjusted hazard ratio, 8.1; 95% confidence interval, 3.5-18.6), but accounted only for 19.4% of all new detections. Among monogamous and sexually abstinent women, new detection was higher in women reporting ≥5 lifetime sexual partners than in those reporting <5 (adjusted hazard ratio, 2.2; 95% confidence interval, 1.2-4.2). CONCLUSION Although women remain at risk of HPV acquisition from new sex partners as they age, our results suggest that most new detections in middle-aged women reflect recurrence of previously acquired HPV.
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Affiliation(s)
- Proma Paul
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anne Hammer
- Department of Obstetrics and Gynecology, Regional Hospital West Jutland, Herning, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anne E Burke
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Raphael P Viscidi
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michelle I Silver
- Division of Public Health Sciences, Washington University School of Medicine, St Louis, Missouri, USA
| | - Nicole Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ada O Youk
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patti E Gravitt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine Baltimore, Maryland, USA
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