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Basu P, Mwanahamuntu M, Pinder LF, Muwonge R, Lucas E, Nyambe N, Chisele S, Shibemba AL, Sauvaget C, Sankaranarayanan R, Prendiville W, Parham GP. A portable thermal ablation device for cervical cancer prevention in a screen-and-treat setting: a randomized, noninferiority trial. Nat Med 2024; 30:2596-2604. [PMID: 38918630 PMCID: PMC11405263 DOI: 10.1038/s41591-024-03080-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/17/2024] [Indexed: 06/27/2024]
Abstract
Implementing standard-of-care cryotherapy or electrosurgical excision to treat cervical precancers is challenging in resource-limited settings. An affordable technological alternative that is as effective as standard-of-care techniques would greatly improve access to treatment. This randomized controlled trial aims to demonstrate the noninferiority efficacy of a portable, battery-driven thermal ablation (TA) device compared to cryotherapy and electrosurgical excision (large loop excision of transformation zone (LLETZ)) to treat cervical precancer in a screen-and-treat program in Zambia. A total of 3,124 women positive on visual inspection with acetic acid and eligible for ablative therapy were randomized to one of the treatment arms. Human papillomavirus (HPV) testing was performed at baseline and at the follow-up. The primary outcome was treatment success, defined as either type-specific HPV clearance at the follow-up in participants positive for HPV at baseline, or a negative visual inspection with acetic acid test for those who had a negative HPV test at baseline. After a median follow-up of 12 months, treatment success rates were 74.0%, 71.1% and 71.4% for the TA, cryotherapy and LLETZ arms, respectively, thus demonstrating noninferiority (P = 0.83). TA was a safe and well-accepted procedure. Only 3.6% of those randomized to TA reported moderate-to-severe pain, compared to 6.5% and 1.9% for the cryotherapy and LLETZ arms, respectively. Thus, our randomized controlled trial demonstrates the safety and efficacy of TA, which is not inferior to cryotherapy or surgical excision.ClinicalTrials.gov registration: NCT02956239 .
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Affiliation(s)
- Partha Basu
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France.
| | - Mulindi Mwanahamuntu
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Leeya F Pinder
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Richard Muwonge
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Eric Lucas
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Namakau Nyambe
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Samson Chisele
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | | | - Catherine Sauvaget
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Walter Prendiville
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
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Parham GP, Egemen D, Befano B, Mwanahamuntu MH, Rodriguez AC, Antani S, Chisele S, Munalula MK, Kaunga F, Musonda F, Malyangu E, Shibemba AL, de Sanjose S, Schiffman M, Sahasrabuddhe VV. Validation in Zambia of a cervical screening strategy including HPV genotyping and artificial intelligence (AI)-based automated visual evaluation. Infect Agent Cancer 2023; 18:61. [PMID: 37845724 PMCID: PMC10580629 DOI: 10.1186/s13027-023-00536-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/13/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND WHO has recommended HPV testing for cervical screening where it is practical and affordable. If used, it is important to both clarify and implement the clinical management of positive results. We estimated the performance in Lusaka, Zambia of a novel screening/triage approach combining HPV typing with visual assessment assisted by a deep-learning approach called automated visual evaluation (AVE). METHODS In this well-established cervical cancer screening program nested inside public sector primary care health facilities, experienced nurses examined women with high-quality digital cameras; the magnified illuminated images permit inspection of the surface morphology of the cervix and expert telemedicine quality assurance. Emphasizing sensitive criteria to avoid missing precancer/cancer, ~ 25% of women screen positive, reflecting partly the high HIV prevalence. Visual screen-positive women are treated in the same visit by trained nurses using either ablation (~ 60%) or LLETZ excision, or referred for LLETZ or more extensive surgery as needed. We added research elements (which did not influence clinical care) including collection of HPV specimens for testing and typing with BD Onclarity™ with a five channel output (HPV16, HPV18/45, HPV31/33/52/58, HPV35/39/51/56/59/66/68, human DNA control), and collection of triplicate cervical images with a Samsung Galaxy J8 smartphone camera™ that were analyzed using AVE, an AI-based algorithm pre-trained on a large NCI cervical image archive. The four HPV groups and three AVE classes were crossed to create a 12-level risk scale, ranking participants in order of predicted risk of precancer. We evaluated the risk scale and assessed how well it predicted the observed diagnosis of precancer/cancer. RESULTS HPV type, AVE classification, and the 12-level risk scale all were strongly associated with degree of histologic outcome. The AVE classification showed good reproducibility between replicates, and added finer predictive accuracy to each HPV type group. Women living with HIV had higher prevalence of precancer/cancer; the HPV-AVE risk categories strongly predicted diagnostic findings in these women as well. CONCLUSIONS These results support the theoretical efficacy of HPV-AVE-based risk estimation for cervical screening. If HPV testing can be made affordable, cost-effective and point of care, this risk-based approach could be one management option for HPV-positive women.
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Affiliation(s)
- Groesbeck P Parham
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia.
| | - Didem Egemen
- HPV-AVE (PAVE) Initiative, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20850, USA
| | - Brian Befano
- Information Management Services Inc, Calverton, MD, USA
| | | | - Ana Cecilia Rodriguez
- HPV-AVE (PAVE) Initiative, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20850, USA
| | - Sameer Antani
- National Library of Medicine, NIH, Bethesda, MD, 20892, USA
| | - Samson Chisele
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
| | | | - Friday Kaunga
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
| | - Francis Musonda
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
| | - Evans Malyangu
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
| | | | - Silvia de Sanjose
- HPV-AVE (PAVE) Initiative, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20850, USA
| | - Mark Schiffman
- HPV-AVE (PAVE) Initiative, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20850, USA.
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Morse RM, Brown J, Noble HE, Ríos López EJ, Kohler-Smith A, Soto S, Del Cuadro DL, Gonzales Díaz K, Figueredo Escudero M, Vásquez Del Aguila G, Carrillo Jara LE, Silva Delgado HF, Palacios VA, Santos-Ortiz C, Gravitt PE, Paz-Soldan VA. Women's perspectives on the acceptability and feasibility of an HPV screen-and-treat approach to cervical cancer prevention in Iquitos, Peru: a qualitative study. BMC Womens Health 2022; 22:414. [PMID: 36217187 PMCID: PMC9552409 DOI: 10.1186/s12905-022-01943-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The objective of this study was to explore women's experiences of a screen-and-treat approach with ablative therapy (referred to by the Spanish acronym TVT-TA) as a method of treatment following a positive HPV test in Iquitos, Peru. METHODS A total of 111 in-depth interviews were conducted with 47 HPV positive women who attended the TVT-TA procedure at a primary-level healthcare facility. Interviews were conducted immediately before, immediately after, and six-weeks after TVT-TA. RESULTS Most interviewed women reported experiencing moderate pain during ablative therapy and minimal pain immediately after and six weeks after ablative therapy. Women also stated that the pain was less intense than they had expected. The most common physical after-effects of treatment were bleeding and vaginal odor. Women experienced oscillating emotions with fear upon receiving a positive HPV result, calming after hearing about ablative therapy treatment, worry about pain from the treatment itself, relaxation with counseling about the procedure, and relief following treatment. CONCLUSIONS Nearly all participants emphasized that they were pleased with the TVT-TA process even if they had experienced pain during TVT-TA, recommended that TVT-TA be expanded and available to more women, and stated that TVT-TA was faster and easier than expected. This study found that TVT-TA is a feasible and acceptable means of treating HPV according to the women receiving the treatment.
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Affiliation(s)
- Rachel M Morse
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | | | - Helen E Noble
- Global Health Fogarty International Program, University of Washington Northern Pacific, Seattle, WA, USA
| | | | | | | | - Daniel Lenin Del Cuadro
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | - Karina Gonzales Díaz
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | - Magaly Figueredo Escudero
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | | | - Lita E Carrillo Jara
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | | | - Victor A Palacios
- Dirección de Prevención y Control de Cáncer, Ministerio de Salud, Lima, Peru
| | - Carlos Santos-Ortiz
- Dirección de Prevención y Control de Cáncer, Ministerio de Salud, Lima, Peru
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Valerie A Paz-Soldan
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
- Asociación Benéfica PRISMA, Lima, Peru.
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Selmouni F, Sauvaget C, Dangbemey DP, Kpebo DDO, Dieng NM, Lucas E, Chami Khazraji Y, Bennani M, Bekkali R, Basu P. Lessons Learnt From Pilot Cervical Cancer Screening and Treatment Programmes Integrated to Routine Primary Health Care Services in Benin, Cote d'Ivoire, and Senegal. JCO Glob Oncol 2022; 8:e2200051. [PMID: 36070534 PMCID: PMC9812504 DOI: 10.1200/go.22.00051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/04/2022] [Accepted: 07/20/2022] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The project aimed to implement pilot screening and treatment services for cervical cancer integrated with existing primary health centers (PHCs) in Benin, Cote d'Ivoire, and Senegal and evaluate these services using implementation research outcomes such as reach, effectiveness, adoption, and acceptability. MATERIALS AND METHODS The Ministry of Health in each country took the lead in setting up a stakeholder's group that designed a protocol tailored to the local context. The target age was 25-49 years in Benin and Cote d'Ivoire and 30-49 years in Senegal. Visual inspection with acetic acid (VIA) was the screening test, and thermal ablation (TA) was the ablative treatment of choice in all. The Ministry in each country identified 4-5 PHCs to set up screening and ablation services and one higher-level center for colposcopy referral. After a master-trainer led training program, nurses, midwives, or general practitioners screened opportunistically the eligible women attending the clinics. The VIA-positive women eligible for ablation were offered immediate treatment. RESULTS Between May 2018 and January 2021, 16,530 women were screened opportunistically. VIA positivity was 8.1% with huge variability within and between countries. Sixty-one percent of all VIA-positive cases were eligible for immediate TA, and 88% of them accepted same-day treatment. Compliance to TA at PHCs was 99%. Majority of women treated with TA complained of minor side effects. Significant dropouts occurred as the women were referred to colposcopy clinics. CONCLUSION Opportunistic screening provided as part of routine PHC service can screen many women and treat a significant proportion of screen-positive women with TA with minimal side effects. Primary concerns are the hard-to-reach women who remain out of opportunistic screening coverage and noncompliance of the screen-positive women referred to higher-level centers.
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Affiliation(s)
- Farida Selmouni
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Catherine Sauvaget
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Djima Patrice Dangbemey
- Department of Obstetrics and Gynaecology, Lagoon Mother and Child University Hospital Center, Faculty of Health Science, University of Abomey Calavi, Cotonou, Benin
| | | | - Ndeye Mbombe Dieng
- Division of Noncommunicable Disease Control, Senegal Ministry of Health and Social Action, Dakar, Senegal
| | - Eric Lucas
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Maria Bennani
- Foundation Lalla Salma, Cancer Prevention and Treatment, Rabat, Morocco
| | - Rachid Bekkali
- Foundation Lalla Salma, Cancer Prevention and Treatment, Rabat, Morocco
| | - Partha Basu
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
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