Screening for Cancer in Low- and Middle-Income Countries

Fine needle aspiration biopsy in low- and middle-income countries

Fine needle aspiration biopsy (FNAB) in low- and middle-income countries (LMIC), can provide minimally invasive, cost-effective tissue diagnosis with rapid assessment and specimen triage, which is advantageous in these resource-limited settings. Nevertheless, challenges such as equipment shortages, reagents, and lack of trained personnel exist. This article discusses the effectiveness of FNAB for diagnosis of malignant and inflammatory conditions across various organs, such as lymph nodes, breast, soft tissue, and thyroid and advocates for increased training opportunities and collaboration with academic centers to enhance diagnostic accuracy and access to pathology services.

The diagnostic accuracy of serum and plasma microRNAs in detection of cervical intraepithelial neoplasia and cervical cancer: A systematic review and meta-analysis

Studies suggest a need for new diagnostic approaches for cervical cancer including microRNA technology. In this review, we assessed the diagnostic accuracy of microRNAs in detecting cervical cancer and Cervical Intraepithelial Neoplasia (CIN). We performed a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline for protocols (PRISMA-P). We searched for all articles in online databases and grey literature from 01st January 2012 to 16th August 2022. We used the quality assessment of diagnostic accuracy studies tool (QUADAS-2) to assess the risk of bias of included studies and then conducted a Random Effects Meta-analysis. We identified 297 articles and eventually extracted data from 24 studies. Serum/plasma concentration miR-205, miR-21, miR-192, and miR-9 showed highest diagnostic accuracy (AUC of 0.750, 0.689, 0.980, and 0.900, respectively) for detecting CIN from healthy controls. MicroRNA panels (miR-21, miR-125b and miR-370) and (miR-9, miR-10a, miR-20a and miR-196a and miR-16-2) had AUC values of 0.897 and 0.886 respectively for detecting CIN from healthy controls. For detection of cervical cancer from healthy controls, the most promising microRNAs were miR-21, miR-205, miR-192 and miR-9 (AUC values of 0.723, 0.960, 1.00, and 0.99 respectively). We report higher diagnostic accuracy of upregulated microRNAs, especially miR-205, miR-9, miR-192, and miR-21. This highlights their potential as stand-alone screening or diagnostic tests, either with others, in a new algorithm, or together with other biomarkers for purposes of detecting cervical lesions. Future studies could standardize quantification methods, and also study microRNAs in higher prevalence populations like in sub-Saharan Africa and South Asia. Our review protocol was registered in PROSPERO (CRD42022313275).

HPV DNA status and clinical history of patients are supplements for accurate reporting of the cytological Pap smear

The present study was aimed at showing the importance of HPV DNA status and the clinical history of the patients required by the cytologist for accurate reporting. A total of 1250 symptomatic women who attended the gynaecology outpatient department of the Mahavir Cancer Sansthan and Nalanda Medical College, Patna, for pap smear examinations were screened and recruited for the study. Due to highly clinical symptoms out of the negative with inflammatory smears reported, one hundred and ten patients were randomly advised for biopsy and HPV 16/18 DNA analysis by a gynaecologist to correlate negative smears included in the study. Pap smear reports revealed that 1178 (94.24%) were negative for intraepithelial lesions (NILM) with inflammatory smears, 23 (1.84%) smears showed low-grade squamous intraepithelial lesions (LSIL), 12 (0.96%) smears showed high-grade squamous intraepithelial lesions, and 37 (2.96%) smears showed an atypical squamous cell of undetermined significance (ASC-US). A biopsy of 110 out of 1178 (NILM) patients revealed that 15 (13.63%) women had cervical cancer, 29 women had CIN I, 17 women had CIN II + CIN III, 35 women had benign cervical changes, and 14 women had haemorrhages. On the other hand, HPV 16/18 DNA was detected as positive in 87 out of 110. The high positivity of HPV in biopsied cases where frank cervical cancer and at-risk cancer were also observed in the negative smear-screened patients reveals that the HPV status and clinical history of the patients will be quite helpful to the cytologist for accurate reporting, and suggests that a negative HPV DNA result may be a stronger predictor of cervical cancer risk than a negative Pap test.

Research Progress on the Anti-Cancer Effects of Astragalus membranaceus Saponins and Their Mechanisms of Action

Astragalus membranaceus saponins are the main components of A. membranaceus, a plant widely used in traditional Chinese medicine. Recently, research on the anti-cancer effects of A. membranaceus saponins has received increasing attention. Numerous in vitro and in vivo experimental data indicate that A. membranaceus saponins exhibit significant anti-cancer effects through multiple mechanisms, especially in inhibiting tumor cell proliferation, migration, invasion, and induction of apoptosis, etc. This review compiles relevant studies on the anti-cancer properties of A. membranaceus saponins from various databases over the past two decades. It introduces the mechanism of action of astragalosides, highlighting their therapeutic benefits in the management of cancer. Finally, the urgent problems in the research process are highlighted to promote A. membranaceus saponins as an effective drug against cancer.

Association between serum P16ink4A concentration and CIN and cervical cancer among women attending a cervical cancer clinic in western Uganda: A case control study

Introduction

Tissue expression of P16ink4A is correlated with cervical lesions. In this study we determined the association between serum P16ink4A concentrations and cervical lesions among women attending the cervical cancer clinic at Mbarara Regional Hospital (MRRH) South Western Uganda.

Material and Methods

We recruited 90 cervical intraepithelial neoplasia (CIN) cases, 90 cervical cancer (CC) cases before treatment and 90 controls. Clinical and demographic data were recorded. Serum P16ink4A concentrations were measured by quantitative Elisa. Cases were confirmed with cytology and/or histology. Descriptive statistics and logistic regression were done with STATA 17 and P-values of <0.05 were considered statistically significant.

Results

The mean serum P16ink4A concentration among CIN cases, CC cases and controls was 1.11(+/-0.66) ng/ml, 1.45(+/-1.11) ng/ml and 1.13(+/-0.61) ng/ml respectively (p = 0.008). 50 % of CIN cases and controls as well as 60 % of CC cases had P16ink4A concentration above 0.946 ng/ml. There were increased odds of CIN for serum P16ink4A though statistically insignificant (AOR: 1.11, p-value: 0.70). There was also a statistically significant reduction in odds of CC for serum P16ink4A (AOR: 0.55, p-value: 0.01).

Conclusion

Serum P16ink4A may likely be associated with cervical lesions especially CC in our study population and this may aid detection of such lesions. Diagnostic utility studies for circulating P16ink4A in detection of cervical cancer are recommended.

Demand and willingness to pay for human papilloma virus vaccine for their daughters among mothers in Haryana, India: A contingent valuation study

OBJECTIVES

Cervical cancer accounts for 10 percent of cancer deaths among women in India. The human papillomavirus (HPV) vaccine can protect against infection but it is not included in India's universal immunisation programme. This study aimed to assess the demand and willingness to pay for the HPV vaccine among mothers of adolescent daughters.

METHODS

We conducted a contingent valuation exercise involving a hospital-based cross-sectional study to assess the demand for an HPV vaccine among mothers of adolescent daughters, their willingness to pay and its determinants. Participants were recruited at a tertiary care civil hospital in the city of Gurgaon in North India, and data was collected from December 2018 to February 2019. A questionnaire was administered to obtain demographic and awareness indicators. Payment cards were used to elicit the willingness to pay amount.

RESULTS

Out of 319 respondents, 79% were willing to pay for the vaccine. The mean maximum willingness to pay was INR 629 (USD 35), which was less than the vaccine market price of INR 2000-3000 (USD 117-175) per dose. Participant age and number of children significantly influenced demand, while family income and awareness of cervical cancer influenced willingness to pay for the HPV vaccine. Participants were willing to spend between 3% and 34% of their monthly income on the vaccine.

CONCLUSIONS

High demand and low willingness to pay for the HPV vaccine indicate low value perception of the health outcome among mothers of adolescent children in India. A strategy aimed at a price reduction of the vaccine and increasing its demand through improved awareness is important. At the same time, subsidising the vaccine in the short run is needed.

Development of a customized m-Health-based intervention to reduce loss to follow-up among patients undergoing treatment for cervical lesions at a rural referral Hospital, South Western Uganda

Background

Loss to follow-up (LTFU) in individuals undergoing cervical cancer treatment is a major challenge in many low resource settings. We describe development of a customized and tailored mHealth intervention for reducing LTFU among patients undergoing cervical cancer treatment at Mbarara Regional Referral Hospital (MRRH).

Methods

We interviewed all health care providers (HCPs) at the cervical cancer clinic of MRRH, between April and May 2023. Transcripts were subsequently derived, reviewed and coded to generate themes and categories using inductive content analytic approach. Four medical experts used this data to develop relevant SMS content, which was incorporated into an app.

Results

HCPs had owned a phone for 13.8 ≤ years, had worked at the clinic for 5 ≤ years, and used text messages regularly. Qualitative data revealed that the main challenge to re-engagement was absence of a reminder mechanism between HCPs and patients. HCPs preferred text and or audio mode of messaging to improve health care responsiveness to LTFUs, awareness, continuity of care, and health service uptake among the majority illiterate population; though with potential constraints of costs and workload. Identified key messaging content included; the importance of attending scheduled follow-ups, follow up visit date and clinic customization and tailoring the message to the intended recipient. SMS content was uploaded onto the cc-follow-up app platform and customized according to preferred language, day, frequency and time of delivery.

Conclusion

Tailoring an mHealth messaging intervention could help re-engage and reduce LTFU through improved information sharing, awareness, responsiveness, care engagement and medical compliance. A pilot study is required for our intervention in South Western Uganda.

Cervical cancer prevention: Feasibility of self-sampling and HPV testing in rural and urban areas of Bolivia: An observational study

BACKGROUND

Cervical cancer is a major health problem in Latin America. In 2019, the Italian Agency for Development Cooperation (La Paz regional site) conducted a pilot study to estimate the prevalence of high-risk human papillomavirus (HPV) and the feasibility of HPV screening in Bolivia through self-sampling and portable and transportable laboratory instruments for HPV testing in urban and rural areas.

METHODS

Women aged 20-65 years from La Paz (urban area), Toro Toro (rural area), and Acasio (rural area) were enrolled in local public health centers between Dec 1, 2019, and June 30, 2021. Self-sampling was carried out with the Viba-Brush system (Rovers, Oss, Netherlands) and samples were preserved in ThinPrep containers (Hologic Corporation, San Diego, CA, USA). The GeneXpert system (Cepheid, Sunnyvale, CA, USA) for high-risk HPV testing detects HPV E6 and E7 DNA via real-time PCR in a mobile system of easy execution requiring minimal manual intervention. The system provides results in about 1 h. The hr- HPV prevalence data, overall and partial genotyping, were analyzed considering the following age groups: 20-34, 35-44, and 45-65 years old.

FINDINGS

2168 women were enrolled: 614 (28.3%) in La Paz, 743 (34.3%) in Toro Toro, and 811 (37.4%) in Acasio. Only one sample was collected from each participant. 2043 (94.2%) of 2168 samples were adequate for HPV testing. 255 (12.5%) samples were positive for high-risk HPV. Comparing the urban area (La Paz) versus rural combined areas (Acasio+Toro Toro), using a logistic model, the HPV total rate was statistically significantly higher in the city of La Paz (15.0% vs 11.4%; OR:1.37;95% CI: 1.04-1.80). Furthermore, the HPV prevalence was declining by age, and the urban/rural odds ratio was 1.50; (95% IC 1.13-19). The overall HPV 16 positivity was 2.7% (55/2043) and for HPV 18/45 was 1.8% (37/2043) without any statistically significant differences between the three BHU enrolling centers. Only the prevalence of HPV group '39/56/66/68' was significantly higher in La Paz (p<0,001) in comparison to Acasio and Toro Toro.

INTERPRETATION

The total and age-adjusted prevalence of high-risk HPV infection in rural and urban areas in Bolivia, as measured with a validated test for screening, is similar to that observed in Europe and the USA. Our study shows that a screening protocol for HPV testing with self-sampling would be feasible in urban and rural areas in Bolivia, and that the reported high occurrence of cervical cancer in Bolivia is not related to a higher rate of high-risk HPV infections. Carrying out HPV tests locally avoids the issues associated with transportation and storage of the collected material and allows the participant to wait in the clinic for the test result, overcoming the very long response time for screening test in Bolivia.

Cervical Cancer Screening via Visual Inspection With Acetic Acid and Lugol Iodine for Triage of HPV-Positive Women

Importance

Limited evidence supports the performance of human papillomavirus (HPV) DNA testing as a primary screening method, followed by triage with visual inspection with acetic acid, in areas with limited health care resources, as suggested by the 2021 World Health Organization guidelines.

Objective

To evaluate the performance of visual inspection with acetic acid and Lugol iodine as a triage method for detecting cervical precancerous lesions among HPV-positive women in 1 visit.

Design, Setting, and Participants

This cohort study examined the implementation of a government-led cervical cancer screening program conducted from January 1, 2016, to December 31, 2020, in Ordos City, China. Female residents, aged 35 to 64 years, who understood the screening procedures and voluntarily participated were included in the study. Women were excluded if they reported never having had sexual intercourse, were pregnant, had a hysterectomy, or had ever undergone treatment for cervical lesions. Statistical analysis was conducted from December 2022 to December 2023.

Exposures

The program used the careHPV DNA assay as the primary screening method, and immediate triage was performed by visual inspection if HPV screening results were positive, with a 5-year screening interval. A colposcopy was performed for the women who had suspected cancer on visual inspection results or who were HPV positive and had abnormal visual inspection results, all in 1 visit.

Main Outcomes and Measures

The rate of compliance with colposcopy and the detection rate of cervical intraepithelial neoplasia grade 2 or higher (CIN2+).

Results

The study included 187 863 women (median age, 46 years [IQR, 40-52 years]) who participated in the program and had valid HPV test results. The overall prevalence of HPV positivity was 12.8% (24 070 of 187 863), and the adherence to triage with visual inspection among HPV-positive women was 93.9% (22 592 of 24 070). Among HPV-positive women, the rate of compliance with colposcopy was 65.6% (2714 of 4137), and the CIN2+ detection rate was 2.8% (643 of 22 592).

Conclusions and Relevance

The findings of this cohort study suggest that the implementation of HPV testing, visual inspection, and colposcopy within 1 visit may mitigate losses to follow-up, detect precancerous lesions, and hold significant implications for screening in comparable areas with limited health care resources.

Temporal patterns of cancer burden in Asia, 1990-2019: a systematic examination for the Global Burden of Disease 2019 study

Background

Cancers represent a challenging public health threat in Asia. This study examines the temporal patterns of incidence, mortality, disability and risk factors of 29 cancers in Asia in the last three decades.

Methods

The age, sex and year-wise estimates of incidence, mortality, and disability-adjusted life years (DALYs) of 29 cancers for 49 Asian countries from 1990 through 2019 were generated as a part of the Global Burden of Disease, Injuries and Risk Factors 2019 study. Besides incidence, mortality and DALYs, we also examined the cancer burden measured in terms of DALYs and deaths attributable to risk factors, which had evidence of causation with different cancers. The development status of countries was measured using the socio-demographic index. Decomposition analysis was performed to gauge the change in cancer incidence between 1990 and 2019 due to population growth, aging and age-specific incidence rates.

Findings

All cancers combined claimed an estimated 5.6 million [95% uncertainty interval, 5.1-6.0 million] lives in Asia with 9.4 million [8.6-10.2 million] incident cases and 144.7 million [132.7-156.5 million] DALYs in 2019. The age-standardized incidence rate (ASIR) of all cancers combined in Asia was 197.6/100,000 [181.0-214.4] in 2019, varying from 99.2/100,000 [76.1-126.0] in Bangladesh to 330.5/100,000 [298.5-365.8] in Cyprus. The age-standardized mortality rate (ASMR) was 120.6/100,000 [110.1-130.7] in 2019, varying 4-folds across countries from 71.0/100,000 [59.9-83.5] in Kuwait to 284.2/100,000 [229.2-352.3] in Mongolia. The age-standardized DALYs rate was 2970.5/100,000 [2722.6-3206.5] in 2019, varying from 1578.0/100,000 [1341.2-1847.0] in Kuwait to 6574.4/100,000 [5141.7-8333.0] in Mongolia. Between 1990 and 2019, deaths due to 17 of the 29 cancers either doubled or more, and 20 of the 29 cancers underwent an increase of 150% or more in terms of new cases. Tracheal, bronchus, and lung cancer (both sexes), breast cancer (among females), colon and rectum cancer (both sexes), stomach cancer (both sexes) and prostate cancer (among males) were among top-5 cancers in most Asian countries in terms of ASIR and ASMR in 2019 and cancers of liver, stomach, hodgkin lymphoma and esophageal cancer posted the most significant decreases in age-standardized rates between 1990 and 2019. Among the modifiable risk factors, smoking, alcohol use, ambient particulate matter (PM) pollution and unsafe sex remained the dominant risk factors between 1990 and 2019. Cancer DALYs due to ambient PM pollution, high body mass index and fasting plasma glucose has increased most notably between 1990 and 2019.

Interpretation

With growing incidence, cancer has become more significant public health threat in Asia, demanding urgent policy attention and guidance. Its heightened risk calls for increased cancer awareness, preventive measures, affordable early-stage detection, and cost-effective therapeutics in Asia. The current study can serve as a useful resource for policymakers and researchers in Asia for devising interventions for cancer management and control.

Funding

The GBD study is funded by the Bill and Melinda Gates Foundation.

Providing Diagnostic Pathology Services in Low and Middle-Income Countries

Diagnostic pathology services in low and middle-income countries are often hindered by lack of expertise, equipment, and reagents. However, there are also educational, cultural, and political decisions, which must be addressed in order to provide these services successfully. In this review, we describe some of the infrastructure barriers that must be overcome and provide 3 examples of implementing molecular testing in Rwanda and Honduras despite initial lack of resources.

Attitudes of women towards screening, prevention and treatment of cervical cancer in Namibia

Background

Cervical cancer is among the top causes of cancer-related deaths among women globally.

Aim

The aim of the study was to assess the attitudes of women of reproductive age towards cervical cancer services in the Otjozondjupa region, Namibia.

Setting

The setting of this study was the Otjozondjupa region, one of the 14 regions of Namibia.

Methods

A quantitative, cross-sectional, descriptive study was used. The data were collected with a questionnaire from a stratified sample of 381 out of the 37066 study population of women of reproductive age across four districts of the region. Descriptive data analysis was performed using Statistical Package for Social Science version 25.

Results

The findings revealed that most respondents (83.1%) had an overall neutral attitude towards the screening, prevention, and treatment of cervical cancer; they were not concerned about the risk of cervical cancer and would not practice health-seeking behaviours regarding cervical cancer services.

Conclusions

The respondents were indifferent with regard to prevention, screening, and management services for cervical cancer, implying that they would not use available cervical cancer services.

Contributions

Attitudes of women of reproductive age towards cervical cancer services were highlighted. Subsequently, an educational programme for nurses to enhance the utilisation of cervical cancer services among women of reproductive age in the Otjozondjupa region, Namibia, was developed. Guidelines were developed to facilitate the implementation and evaluation of the educational programme activities to enhance the utilisation of cervical cancer screening services among women of reproductive age.

Unraveling cervical cancer screening dilemmas: histopathological insights from VIA and LEEP at bugando medical centre, Mwanza

BACKGROUND

The single-visit strategy, also known as the "screen-and-treat" approach, is widely used to screen for cervical cancer in low- and middle-income countries. The screen-and-treat approach leads to unnecessary or inadequate treatment. Thus, a study was conducted to determine the histopathological patterns of aceto-white lesions on visual inspection with acetic acid (VIA) in patients who underwent a Loop Electrosurgical Excision Procedure (LEEP) at Bugando Medical Centre between January 2016 and December 2020.

METHOD

A 5-year retrospective cross-sectional case record review was conducted on 329 women who had LEEP at Bugando Medical Centre following a positive VIA cervical screening test. A standard data abstraction form was used to collect patient information. Missing client information records and LEEP without histopathological results were exclusion criteria. For statistical analysis, STATA version 15 was used; in descriptive statistics, frequency, mean, and standard deviation were used. The Chi2 and Fisher's exact tests were used to investigate the relationship between patient characteristics and histopathological patterns, and a P-value of 0.05 was considered statistically significant in multinomial models.

RESULTS

This study looked at 329 patients who had LEEP following a VIA positive but were not eligible for cryotherapy. Our study participants had a mean age of 40 ± 8.2 SD. There were 203 (61.7%) patients with benign lesions, including 4 with schistosomiasis and 2 with cervical tuberculosis. The precancerous lesions were discovered in 100 cases (30.4%), and 26 (7.9%) already had invasive cervical cancer. Out of 100 patients with precancerous lesions, 58 (17.6%) and 42 (12.8%) have high- and low-grade squamous intraepithelial (HSIL and LSIL) lesions, respectively. The presence of a precancerous lesion was found to be associated with age 31-40 years (P-value 0.042) and HIV positivity (P-value 0.004).

CONCLUSION

Most patients in this study had benign cervical lesions, which do not require LEEP treatment. Nonetheless, a considerable percentage of invasive cervical malignancies and rare benign diseases such as schistosomiasis and cervical tuberculosis were identified. A screen-and-treat approach within well-equipped tertiary hospitals like Bugando Medical Centre should explore alternative options instead of relying solely on straight LEEP.

Comprehensive Review of Breast Cancer Consequences for the Patients and Their Coping Strategies: A Systematic Review

BACKGROUND

Women with breast cancer usually face multiple short-term and long-term problems in dealing with their acute and chronic symptoms during and after cancer treatment. However, serious gaps remain in addressing these issues in clinical and public health practice.

METHODS

According to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, we conducted a systematic literature search from 2000-2021 in electronic databases, including Medline, PubMed, Embase, Scopus, Web of Knowledge, and Google Scholar databases using predefined keywords.

RESULTS

The review identified several significant and interconnected problems in breast cancer patient's treatment and supportive care. The results revealed that these issues are very common among breast cancer patients, and specific attention and serious measures are needed to address these problems. Despite implementing different protocols and programs for covering and addressing these problems, serious gaps still exist in supporting breast cancer patients during clinical and follow-up care.

CONCLUSION

Developing innovative and holistic approaches and programs based on the multifactorial assessment of symptoms are suggested for addressing and covering the multidimensional requirements of this population. Consequently, thorough evaluation, education, treatment, and referrals should be provided for the most common sequelae of these patients by including appropriate medication, exercise, counselling, occupational therapy, and complementary therapies. The present study provides a more comprehensive source of information about breast cancer patient's medical and supportive needs in comparison with individual studies on symptom experiences.

Cancer screening research in Bangladesh: Insights from a scoping review

This scoping review summarises the findings of research conducted on cancer screening in Bangladesh, including the prevalence, awareness, barriers, and evaluation of screening programmes, by performing a comprehensive search of electronic databases and gray literature. 25 studies that met inclusion criteria were included in the final analysis. Most of the studies were about screening for cervical cancer, were quantitative, were cross-sectional, and were conducted in hospital settings. The main challenges to screening uptake were shyness, fear, a lack of knowledge, and an inadequate understanding of the concept of screening. Visual inspection with acetic acid (VIA) was found to be a simple and cost-efficient way to detect early-stage cervical cancer. However, breast self-examination (BSE) was reported to be insufficient. Education was found to have a positive impact on cancer screening knowledge and practice, but more needs to be done to improve screening rates, such as the utilisation of media, particularly in rural areas. The results of this scoping review highlight Bangladesh's low cancer screening prevalence and uptake and suggest that targeted awareness campaigns and enhanced access to screening services are required to increase cancer screening uptake and reduce the cancer burden in Bangladesh.

Feasibility of 5-fluorouracil and imiquimod for the topical treatment of cervical intraepithelial neoplasias (CIN) 2/3

OBJECTIVES

To determine the feasibility (as measured by tolerability and safety) and efficacy of topical 5-fluorouracil (5-FU) and imiquimod for the treatment of cervical intraepithelial neoplasia (CIN) 2/3.

METHODS

This pilot prospective study was conducted in women aged 18-45 years with p16+ CIN 2/3. Participants underwent an 8-week alternating regimen of self-applied 5% 5-FU on weeks 1, 3, 5, and 7 and physician-applied imiquimod on weeks 2, 4, 6, and 8. Adverse events (AEs) were collected by symptom diary and clinical exam. Feasibility was measured by tolerability and safety (AEs) of the study intervention. Tolerability was assessed as the number of participants able to apply 50% or more of the treatment doses. The safety outcome was calculated as the number of participants who experienced "specified AEs" defined as possibly, probably, or definitely related grade 2 or worse AE or grade 1 genital AEs (blisters, ulcerations, or pustules) lasting more than 5 days. The efficacy of the intervention was determined by histology and high-risk human papillomavirus (hrHPV) testing was done after treatment.

RESULTS

The median age of the 13 participants was 27 ± 2.9 years. Eleven (84.61%) participants applied 50% or more of the treatment. All participants reported grade 1 AEs; 6 (46.15%) reported grade 2 AEs; and 0 reported grade 3/4 AEs. Three (23.08%) participants had specified AEs. Histologic regression to normal or CIN 1 among those completing 50% or more of the treatment doses was observed in 10 (90.91%) participants, and 7 (63.63%) tested negative for hr-HPV at the end of the study.

CONCLUSIONS

Topical treatment for CIN 2/3 with 5-FU/imiquimod is feasible, with preliminary evidence of efficacy. Topical therapies need further investigation as adjuncts or alternatives to surgical therapy for CIN 2/3.

New Paradigms in the Treatment of Cervical Cancer

Despite effective screening strategies and the development and implementation of prophylactic high-risk human papillomavirus vaccination, cervical cancer remains a significant public health burden. This burden is most pronounced in under-resourced countries without fully developed screening and vaccination programs, although the disease remains present worldwide, including in industrialized countries. To that end, the World Health Organization (WHO) has an active focus on the elimination of cervical cancer, with objective metrics to be achieved by countries by the year 2030. Although increased vaccination and screening will be needed to approach potential eradication of cervical cancer, as recognized by the WHO initiative, treatment will need to continue to not only be effective in the near term, but to improve outcomes as well. Accordingly, assessments to improve primary treatment options, including surgery for women with early-stage disease, modification of chemoradiation for those with locally advanced cervical cancer, and systemic therapy for those with recurrent or metastatic presentations, are ongoing. Accordingly, we highlight important areas of both recent and ongoing focus as they relate to improving cervical cancer outcomes.

Policy analysis of cervical cancer prevention in Iran based on the policy triangle model

BACKGROUND

Widespread use of screening in high-income countries has led to a significant reduction in cervical cancer mortality. Most low- and middle-income countries still have poorly organized screening programs. This study aimed at policy analysis of prevention and early detection of cervical cancer in Iran, a middle-income country.

MATERIALS AND METHOD

This qualitative retrospective study, extended by the health policy triangle model, was conducted from July 2020 to September 2021. A sample of this study consisted of 43 participants, including 16 key policy experts; nine 11 senior health system managers, 13 executives, and 3 clients selected purposefully. Data were collected through semi-structured interviews using the interview guide and analyzed using a framework analysis method based on the policy triangle model in MAXQDA2020.

RESULTS

Nine themes, 15 subthemes, and 36 codes were extracted based on the 4 dimensions of the model; stakeholder analysis challenges, including conflict of interest and decision-making challenges. Moreover, the most important policy process challenges indicated the weakness of monitoring and evaluation systems and weakness of using scientific principles in policy making. Weakness of organizational and intersectoral structure and weakness of executive management were obtained among the challenges in the context analysis. Finally, the most important challenges related to content analysis are weaknesses in applying scientific principles in policy making, including weaknesses in standard operating procedures, and low use of HTA capacity in developed guidelines.

CONCLUSION

A wide range of economic, social, and cultural problems can affect cervical cancer prevention policies. Several strategies are suggested to overcome these challenges, including allocating separate funds to cancer prevention programs, using structures to sustain prevention programs, designing, and using them to improve public awareness.

Cancer and Atrial Fibrillation Comorbidities Among 25 Million Citizens in Shanghai, China: Medical Insurance Database Study

BACKGROUND

With population aging, the prevalence of both cancer and atrial fibrillation (AF) have increased. However, there is scarce epidemiological data concerning the comorbid state of cancer and AF in low- and middle-income countries, including China.

OBJECTIVE

We aimed to evaluate the site-, sex-, and age-specific profiles of cancer and AF comorbidities in Chinese populations.

METHODS

Data from the Shanghai Municipal Health Commission database between 2015 and 2020 were screened, covering all medical records of Shanghai residents with medical insurance. Site-specific cancer profiles were evaluated for the population with AF relative to the age- and sex-adjusted population of residents without AF. The sex distribution and peak age of cancer diagnosis were also assessed.

RESULTS

A total of 25,964,447 adult patients were screened. Among them, 22,185 patients presented cancers comorbid with AF (median 77, IQR 67-82 years of age; men: n=13,631, 61.44%), while 839,864 presented cancers without AF (median 67, IQR 57-72 years of age; men: n=419,020, 49.89%), thus yielding a higher cancer prevalence among residents with AF (8.27%) than among those without AF (6.05%; P<.001). In the population with AF, the most prevalent cancer type was lung cancer, followed by colorectal, male genital organ, stomach, breast, liver, bladder, thyroid, leukemia, and esophageal cancers. AF was associated with an average of nearly 1.4-fold (prevalence ratio [PR] 1.37, 95% CI 1.35-1.38) increased prevalence of cancer after adjusting for age and sex. For site-specific analyses, an increased prevalence of cancer in the population with AF was observed in 20 of 21 cancer sites. This increased prevalence was most prominent for nonsolid tumors, including multiple myeloma (PR 2.56, 95% CI 2.28-2.87), leukemia (PR 1.73, 95% CI 1.57-1.90), and non-Hodgkin lymphoma (PR 1.59, 95% CI 1.43-1.77); intrathoracic malignancies, including mediastinum (PR 2.34, 95% CI 1.89-2.90), lung (PR 1.64, 95% CI 1.59-1.69), and esophageal cancers (PR 1.41, 95% CI 1.28-1.56); bone and soft tissue neoplasms (PR 1.56, 95% CI 1.37-1.77); and kidney cancer (PR 1.53, 95% CI 1.36-1.72). Cancer prevalence in the population with AF relative to that in the population without AF was higher in men than in women in 14 of 18 cancer sites, and female predominance was only observed for thyroid cancer. The peak age of index cancer diagnosis was lower in the population with AF (age group: 70-74 years) than in that without AF (age group: 75-79 years), especially for specific cancer types, including thyroid, central nervous system, mediastinum, esophageal, bladder, and biliary cancers.

CONCLUSIONS

Patients with AF are associated with increased prevalence, heightened male predominance, and younger peak age of cancer. Further studies are needed to determine whether early screening of specific cancers is cost-effective and beneficial for patients with AF.

Lung Cancer Screening in Asia: An Expert Consensus Report

INTRODUCTION

The incidence and mortality of lung cancer are highest in Asia compared with Europe and USA, with the incidence and mortality rates being 34.4 and 28.1 per 100,000 respectively in East Asia. Diagnosing lung cancer at early stages makes the disease amenable to curative treatment and reduces mortality. In some areas in Asia, limited availability of robust diagnostic tools and treatment modalities, along with variations in specific health care investment and policies, make it necessary to have a more specific approach for screening, early detection, diagnosis, and treatment of patients with lung cancer in Asia compared with the West.

METHOD

A group of 19 advisors across different specialties from 11 Asian countries, met on a virtual Steering Committee meeting, to discuss and recommend the most affordable and accessible lung cancer screening modalities and their implementation, for the Asian population.

RESULTS

Significant risk factors identified for lung cancer in smokers in Asia include age 50 to 75 years and smoking history of more than or equal to 20 pack-years. Family history is the most common risk factor for nonsmokers. Low-dose computed tomography screening is recommended once a year for patients with screening-detected abnormality and persistent exposure to risk factors. However, for high-risk heavy smokers and nonsmokers with risk factors, reassessment scans are recommended at an initial interval of 6 to 12 months with subsequent lengthening of reassessment intervals, and it should be stopped in patients more than 80 years of age or are unable or unwilling to undergo curative treatment.

CONCLUSIONS

Asian countries face several challenges in implementing low-dose computed tomography screening, such as economic limitations, lack of efforts for early detection, and lack of specific government programs. Various strategies are suggested to overcome these challenges in Asia.

A Narrative Synthesis of Literature on the Barriers to Timely Diagnosis and Treatment of Cancer in Sub-Saharan Africa

Poor cancer survival outcomes in sub-Saharan Africa (SSA) have been linked to delays in diagnosis and treatment. Here we present a detailed overview of the qualitative literature evaluating the barriers to receiving timely diagnosis and treatment of cancer in SSA. The PubMed, EMBASE, CINAHL, PsycINFO databases were searched to identify qualitative studies reporting on barriers to timely diagnosis of cancer in SSA published between 1995 and 2020. A systematic review methodology was applied, including quality assessment and narrative data synthesis. We identified 39 studies, of which 24 focused on breast or cervical cancer. Only one study focused on prostate cancer and one on lung cancer. When exploring factors contributing to delays, six key themes emerged from the data. The first theme was health service barriers, which included: (i) inadequate numbers of trained specialists; (ii) limited knowledge of cancer among healthcare providers; (iii) poor co-ordination of care; (iv) inadequately resourced health facilities; (v) negative attitudes of healthcare providers towards patients; (vi) high cost of diagnostic and treatment services. The second key theme was patient preference for complementary and alternative medicine; the third was the limited understanding of cancer among the population. The fourth barrier was a patient's personal and family obligations; the fifth was the perceived impact of cancer and its treatment on sexuality, body image and relationships. Finally, the sixth was the stigma and discrimination faced by patients following a diagnosis of cancer. In conclusion, health system, patient level and societal factors all influence the likelihood of timely diagnosis and treatment for cancer in SSA. The results provide a focus for targeting health system interventions, particular with regards to awareness and understanding of cancer in the region.

Barriers to adherence to cytology exam: a case study in low-income Colombian women

BACKGROUND

Cervical cytology is essential for the early detection of cervical cancer. However, in Colombia, only 50% of women with subsidized health insurance were screened in 2019, compared to 100% of women with contributory insurance. This disparity highlights significant barriers that must be addressed. This study aimed to identify the factors that contribute to or hinder adherence to cervical cytology screening among low-income women with subsidized health insurance in a public primary care network in Cali, Colombia, from 2014 to 2018.

METHODS

In a qualitative case study, the experience of women and health care and administrative personnel was recovered. Forty-seven women participated in seven focus group discussions. Five other women using the program participated in in-depth interviews. Finally, we interviewed eight people from the healthcare area and the health services administration. The qualitative data collected underwent content analysis, guided by the theoretical framework of Social Determinants of Health. Within this framework, five interconnected dimensions that influence adherence were incorporated.

RESULTS

Adherence is a multifactorial phenomenon, and in relation to attendance at cervical cytology, the analysis delved into the mechanisms that affect it in a low-income context. Barriers to adherence were identified across multiple dimensions, including social and economic factors, health conditions, and patient-related factors, among both adherent and non-adherent women. Among adherent women, barriers and facilitators related to the healthcare team and system, as well as patient-related factors, were identified.

CONCLUSIONS

The findings of this research can be useful in developing personalized interventions and strategies to improve adherence and screening outcomes in low-income settings. It is necessary to increase the resources of health insurance entities to establish effective communication channels with women who attend the cervical cancer prevention program.

Comparative Analysis of Conventional Cytology and Liquid-Based Cytology in the Detection of Carcinoma Cervix and its Precursor Lesions

Context

The conventional smears (CS) and Liquid based cytology (LBC) are important tools to detect carcinoma cervix and its precursor lesions.

Aims

The present study was done to compare the cytomorphological features of cervical lesions using both techniques and compare with the histopathological diagnosis.

Settings and Design

This was a prospective observational study over a period of 1.5 years at a tertiary care hospital.

Methods and Material

A total of 969 women in the age group of 21-65 years presenting with either routine screening or complaints of vaginal bleeding, discharge, or pelvic pain were enrolled for the study. Both the CS and LBC smears were analyzed and compared with the corresponding histopathology diagnosis. The data was analyzed using Statistical Package for the Social Sciences (SPSS) software and P values <0.05 were considered significant.

Results

There were 8.57% unsatisfactory smears in CS as compared to 0.5% in LBC smears. Liquid-based cytology was superior to conventional preparations in terms of smear adequacy, lesser hemorrhagic and inflammatory background, and presence of more endocervical cells. Liquid-based cytology showed a better yield in detecting all the types of epithelial cell lesions with a concordance rate of 73.9% between the two techniques. On histopathology correlation of these lesions, LBC had a higher sensitivity (96.67%) and diagnostic accuracy (99.08%) as compared to CS (73.33% and 92.66%, respectively).

Conclusions

Liquid-based cytology is superior to conventional cytology for the detection of epithelial cell lesions. Reduction in the unsatisfactory smears, a cleaner background, and better representation of the sample are more significantly appreciated on LBC in contrast to CS.

Screening Guidelines and Programs for Cervical Cancer Control in Countries of Different Economic Groups: A Narrative Review

Screening guidelines and practices differ according to resource availability and continually update as scientific developments take place. In this article, we have reviewed screening guidelines and programs for cervical cancer prevention in selected countries belonging to different economic groups viz high income, middle income, and low income. We have selected six countries - the United States of America (USA), the United Kingdom (UK), India, South Africa, Bangladesh, and Malawi. Considerable differences are observed across the health systems. Countries with established screening guidelines complemented by organised nationwide programs or insurance practices have much better screening rates. Human Papilloma Virus (HPV) DNA testing is currently the test of choice in the majority of settings for cervical cancer screening due to its higher sensitivity (up to 90-100%) and longer screening intervals (three to five years). It is also cost-effective, less dependent on operator expertise, and suitable for all settings as compared to a Pap smear test or visual inspection with acetic acid (VIA). Self-sampling of HPV can further help to improve screening coverage by increasing opportunities of reaching to women who would otherwise not participate in screening programs. Resource-constrained countries recommend VIA-based screening in their national programs due to its low cost. The share of cervical cancer is higher in middle and low-income countries as they have lower screening coverage, compared to high-income countries. The main barriers faced in the implementation of the program in low-income countries (LICs) are pertaining to the health system, patient-specific challenges, and healthcare provider-specific challenges.

A Review of Community Awareness for Colorectal Cancer Screening and Prevention in North and Central Asian Countries

OBJECTIVES

Colorectal cancer (CRC) incidence and mortality rates are increasing in low- and middle-income countries (LMIC), including North and Central Asian countries (NCAC). Screening and risk factor reduction can aid in the prevention of colorectal cancer, but communities lack awareness of these screening programs. The review assessed community awareness about CRC screening and prevention in NCAC to facilitate cancer control policies. Study type and methods: For this scoping review, we searched PubMed/Medline, Embase, and the Cochrane Library for articles on community awareness about CRC screening and prevention in NCAC according to inclusion and exclusion criteria.

RESULTS

Eight of 677 articles from five of the 15 NCAC countries met the criteria. Most of the studies utilized a survey design. The results indicated low awareness of the availability of CRC screening and poor knowledge of CRC symptoms. Knowledge of CRC screening modalities was also inadequate. Some countries also lack CRC screening programs.

CONCLUSION

Community unawareness is a significant barrier to screening program utilization and sustenance. Community health awareness programs (CHAP) are needed to improve the uptake of CRC screening in NCAC. The NCAC should include CHAP as an integral component of the CRC control plan. Long-term cancer control in LMIC could be adapted using the step-ladder pyramidal approach.

Analysis of Cancer Research Projects in Sub-Saharan Africa: A Quantitative Perspective on Unmet Needs and Opportunities

PURPOSE

To evaluate the scope and types of cancer research projects in sub-Saharan Africa (SSA) to identify research gaps and inform future efforts.

METHODS

This retrospective observational study summarized information on cancer research projects in SSA from the International Cancer Research Partnership (ICRP) between 2015 and 2020, alongside 2020 cancer incidence and mortality data from the Global Cancer Observatory. SSA cancer research projects were identified as led by investigators in SSA countries, or by investigators in non-SSA countries with collaborators in SSA, or in database keyword searches. Projects from the Coalition for Implementation Research in Global Oncology (CIRGO) were also summarized.

RESULTS

A total of 1,846 projects were identified from the ICRP database, funded by 34 organizations in seven countries (only one, Cancer Association of South Africa, based in SSA); only 156 (8%) were led by SSA-based investigators. Most projects focused on virally induced cancers (57%). Across all cancer types, projects were most frequently related to cervical cancer (24%), Kaposi sarcoma (15%), breast cancer (10%), or non-Hodgkin lymphoma (10%). Gaps were observed for several cancers with higher incidence/mortality burden in SSA; for example, prostate cancer accounted for only 4% of projects but 8% of cancer-related deaths and 10% of new cases. Approximately 26% were dedicated to etiology. Treatment-related research declined over the study period (14%-7% of all projects), while projects related to prevention (15%-20%) and diagnosis/prognosis (15%-29%) increased. Fifteen CIRGO projects were identified; seven were relevant across multiple cancer types, and 12 focused either wholly or partially on cancer control (representing 50% of the total research effort).

CONCLUSION

This analysis shows notable discrepancies between cancer burden and research projects and identifies opportunities for future strategic investments in cancer care in SSA.

Value of non-coding RNAs to assess lymph node status in cervical cancer

Cervical cancer (CC) is the fourth cancer in women and is the leading cause of cancer death in 42 countries. Lymph node metastasis is a determinant prognostic factor, as underlined in the latest FIGO classification. However, assessment of lymph node status remains difficult, despite the progress of imaging such as PET-CT and MRI. In the specific setting of CC, all data underlined the need for new biomarkers easily available to assess lymph node status. Previous studies have underlined the potential value of ncRNA expression in gynecological cancers. In this review, we aimed to evaluate the contribution of ncRNAs in tissue and biofluid samples to determine lymph node status in CC with potential impact on both surgical and adjuvant therapies. In tissue samples, our analysis found that there are arguments to support the role of ncRNAs in physiopathology, differential diagnosis from normal tissue, preinvasive and invasive tumors. In biofluids, despite small studies especially concerning miRNAs expression, promising data opens up new avenue to establish a non-invasive signature for lymph node status as well as a tool to predict response to neo- and adjuvant therapies, thus improving management algorithm of patients with CC.

Association between obesity and cervical intraepithelial neoplasia: results from a case control study in south western Uganda

BACKGROUND

Though obesity has been said to be associated with a number of malignancies including cervical cancer, its association with cervical intraepithelial neoplasia (CIN) is still a contentious issue. This study was designed to determining the prevalence and association between obesity and CIN.

METHODS

This was an unmatched case control study, involving women with cervical intraepithelial neoplasia (cases) and those negative for intraepithelial lesions or malignancy (controls) at the cervical cancer clinic of Mbarara Regional Referral Hospital, in south-western Uganda, between April and November 2022. Cases and controls provided written informed consent and were recruited in a ratio of 1:1. Cases were identified by visual inspection with acetic acid (VIA) and subsequent confirmation with cytology and/or histology. Demographic information was collected using an enrolment form and height, weight and waist circumference were recorded. We calculated body mass index (BMI) and identified obese women as those with body mass index of ≥ 30 kg/m² from both case and control groups. Central obesity was defined as waist: height ration of ≥ 0.5. Data was analysed using STATA version 17. Categorical variables were analysed using proportions, chi-square and logistic regression analysis to determine association between obesity and CIN. Our level of statistical significance was set at ≤ 0.05.

RESULTS

The prevalence of general and central obesity among cases was 25.5% (24/94) and 0% (0/94) respectively while the prevalence of general and central obesity among controls was 33.3% (37/111) and 0% (0/111) respectively. There was an increased prevalence of general obesity among women with low grade squamous intraepithelial lesions (LSIL). However, there was no statistically significant association between general obesity and CIN. Factors associated with general obesity included residing in Mbarara city (AOR 2.156, 95%CI 1.085-4.282, P-value 0.028), age group of 31-45 years (AOR 2.421, 95%CI 1.577-9.705, P-value 0.003) and ≥ 46 years (AOR 1.971, 95%CI 1.022-11.157, P-value 0.046).

CONCLUSION

We observed an increased prevalence of general obesity among women with LSIL. However, there was no association between obesity and CIN. Factors associated with general obesity included residing in Mbarara city, and being in the age groups of 31-40 and ≥ 46 years. This highlights the need to rethink management of CIN to control other non-communicable diseases that could arise due to general obesity.

MicroRNAs in exhaled breath condensate: A pilot study of biomarker detection for lung cancer

INTRODUCTION

Quantitation of microRNAs secreted by lung cells can provide valuable information regarding lung health. Exhaled breath condensate (EBC) offers a non-invasive way to sample the secreted microRNAs, and could be used as diagnostic tools for lung cancer.

MATERIALS & METHODS

EBC samples from twenty treatment-naïve patients with pathologically confirmed lung cancer and twenty healthy subjects were profiled for miRNAs expression. Selected microRNAs were further validated, using quantitative-PCR, in an independent set of 10 subjects from both groups.

RESULTS

A total of 78 miRNAs were found to be significantly upregulated in the EBC of lung cancer patients compared to the control group. Six of these 78 miRNAs were shortlisted for validation. Of these, miR-31-3p, let7i, and miR-449c were significantly upregulated, exhibited good discriminatory power.

DISCUSSION

Differential expression of miRNAs secreted by lung cells could be quantitated in EBC samples, and could be used as a potential non-invasive tool for early diagnosis of lung cancer.

A synthesis of evidence for cancer-specific screening interventions: A Preventive Medicine Golden Jubilee Review

The goal of cancer screening guidelines is to inform health practitioners to practice evidence-based cancer prevention. Cancer screening aims to detect treatable precancerous lesions or early-stage disease to enable actions aimed at decreasing morbidity and mortality. Continuous assessment of the available evidence for or against screening interventions by various organizations often results in conflicting recommendations and create challenges for providers and policymakers. Here we have summarized the current cancer screening recommendations by five leading organizations in North America and Europe: the National Cancer Institute's Physician Data Query (PDQ), the U.S. Preventive Services Task Force (USPSTF), the Canadian Task Force on Preventive Health Care (CTFPHC), the Cochrane Database of Systematic Reviews (CDSR), and the UK National Screening Committee for the National Health Service (UK NSC). All organizations assess evidence based on strength, quality, and quantity, and recommendations are similar although with differences with respect to screening start and stop ages. Recommendations are consistent for colorectal cancer screening with fecal occult blood test or fecal immunochemical test, cervical cancer screening with Pap-test, HPV-test, or co-testing, and breast cancer screening with mammography. However, guidelines vary with respect to age to start and end screening and testing frequency. Tests that have proven to be inefficient or whose use is capable of causing harm are routinely recommended against. Continuous review of screening guidelines is necessary to evaluate the many promising screening tests currently under investigation.

The diagnostic accuracy of serum microRNAs in detection of cervical cancer: a systematic review protocol

BACKGROUND

Cervical cancer remains a public health problem worldwide, especially in sub-Saharan Africa. There are challenges in timely screening and diagnosis for early detection and intervention. Therefore, studies on cervical cancer and cervical intraepithelial neoplasia suggest the need for new diagnostic approaches including microRNA technology. Plasma/serum levels of microRNAs are elevated or reduced compared to the normal state and their diagnostic accuracy for detection of cervical neoplasms has not been rigorously assessed more so in low-resource settings such as Uganda. The aim of this systematic review was therefore to assess the diagnostic accuracy of serum microRNAs in detecting cervical cancer.

METHODS

We will perform a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. We will search for all articles in MEDLINE/PubMed, Web of Science, Embase, and CINAHL, as well as grey literature from 2012 to 2022. Our outcomes will be sensitivity, specificity, negative predictive values, positive predictive values or area under the curve (Nagamitsu et al, Mol Clin Oncol 5:189-94, 2016) for each microRNA or microRNA panel. We will use the quality assessment of diagnostic accuracy studies (Whiting et al, Ann Intern Med 155:529-36, 2011) tool to assess the risk of bias of included studies. Our results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Diagnostic Test Accuracy studies (PRISMA-DTA). We will summarise studies in a flow chart and then describe them using a structured narrative synthesis. If possible, we shall use the Lehmann model bivariate approach for the meta analysis USE OF THE REVIEW RESULTS: This systematic review will provide information on the relevance of microRNAs in cervical cancer. This information will help policy makers, planners and researchers in determining which particular microRNAs could be employed to screen or diagnose cancer of the cervix.

SYSTEMATIC REVIEW REGISTRATION

This protocol has been registered in PROSPERO under registration number CRD42022313275.

Usefulness of high-risk HPV early oncoprotein (E6 and E7) serological markers in the detection of cervical cancer: A systematic review and meta-analysis

We reviewed the literature on the importance of selected anti-high-risk human papillomavirus (HR-HPV) antibodies (namely, 16/18 and early oncoproteins E6 and E7) as potential serological markers for early detection of individuals at high risk of cervical cancer. We searched for studies in PubMed and Embase databases published from 2010 to 2020 on antibodies against HR-HPV E6 and E7 early proteins and cervical cancer. Pooled sensitivity and specificity for HPV16 and HPV18 antibodies were calculated using a bivariate hierarchical random-effects model. A total of 69 articles were identified; we included three studies with 1550 participants. For the three HPV16/18 E6 and E7 antibody tests, enzyme-linked immunosorbent assay-based assays had a sensitivity of 18% for detecting CIN2+ (95% confidence interval [CI]: 15-21) and a specificity of 96% (95% CI: 92-98), for slot-blot, sensitivity was 28.9% (95% CI: 23.3-35.1) and specificity was 72% (95% CI: 66.6-77.0) for detecting CIN2+, and for multiplex HPV serology assay based on a glutathione S-transferase, sensitivity was 16% (95% CI: 8.45-28.6) and specificity was 98% (95% CI: 97-99) for detecting invasive cervical cancer. HR-HPV16/18 E6 and E7 serological markers showed high specificity, but sensitivity was suboptimal for the detection of cervical cancer in either population screening settings or as point-of-care screening tests.

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.

Performance of HPV testing, Pap smear and VIA in women attending cervical cancer screening in Kilimanjaro region, Northern Tanzania: a cross-sectional study nested in a cohort

OBJECTIVE

There is a concern about performance of the screening approaches, where information on the quality of novel and affordable screening approaches that will perform well in remote areas is warranted. This lack of information makes it difficult to prioritise resource use in efforts to improve cervical cancer outcomes. We aimed to compare the diagnostic value of human papillomavirus (HPV) testing on self-collected samples, Pap smear and visual inspection of the cervix with acetic acid (VIA) tests for detection of high-grade cervical intraepithelial neoplasia or worse (CIN2+).

DESIGN

A combined cross-sectional and cohort study.

SETTING

Three primary healthcare centres in Kilimanjaro region, Tanzania.

PARTICIPANTS

1620 women undergoing cervical cancer screening from December 2018 to September 2021. Inclusion criteria were being aged 25-60 years, and no history of premalignant or cervical cancer. Exclusion criteria were overt signs of cancer and previous hysterectomy.

INTERVENTIONS

Participants underwent HPV self-sampling with Evalyn Brush and Care HPV kit assay was used to determine prevalence of high-risk HPV infection. Women with positive HPV test were together with a random sample of HPV negative women scheduled for follow-up where VIA was performed, and Pap smear and cervical biopsies obtained.

RESULTS

Of 1620 women enrolled, 229 (14.1%) were HPV positive and 222 of these attended follow-up together with 290 (20.8%) women with negative HPV test. On VIA, 17.6% were positive. On Pap smear, 8.0% were classified as high-grade squamous intraepithelial lesion. The sensitivity and specificity, respectively, of the various tests, compared with histopathology for the detection of CIN2+ were: HPV test 62.5%, 59.3%; Pap smear 82.8%, 82.1% and; VIA 48.4%, 56.8%. When combined, the sensitivity and specificity for HPV and Pap smear were 90.6%, 70.6% while HPV and VIA were 65.6% and 75.5% for the detection of CIN2+.

CONCLUSIONS

The performance of care HPV testing on self-collected samples opens the possibility of increasing coverage and early detection in resource-constrained settings.

Socioeconomic inequalities in prostate cancer screening in low- and middle-income countries: An analysis of the demographic and health surveys between 2010 and 2019

INTRODUCTION

Prostate cancer screening is a valuable public health tool in the early detection of prostate cancer. In this study, we aimed to determine the socioeconomic inequalities in the coverage of prostate cancer screening in Low and Middle-Income Countries (LMICs).

METHODS

This was a retrospective analysis of men's recode data files that were collected by the Demographic and Health Surveys (DHS) in LMICs (Armenia, Colombia, Honduras, Kenya, Namibia, Dominican Republic, and the Philippines). We included surveys that were conducted from 2010 to 2020 and measured the coverage of prostate cancer screening and the study population was men aged 40 years or older. Socioeconomic inequality was measured using the Concertation Index (CIX) and the Slope Index of Inequality (SII).

RESULTS

Eight surveys from seven countries were included in the study with a total of 47,863 men. The coverage of prostate cancer screening was below 50% in all the countries with lower rates in the rural areas compared to the urban areas. The pooled estimate for the coverage of screening was 10.4% [95% CI, 7.9-12.9%). Inequalities in the coverage of prostate cancer screening between the wealth quintiles were observed in the Democratic Republic, Honduras, and Namibia. Great variation in inequalities in the coverage of prostate cancer screening between rural and urban residents was observed in Colombia and Namibia.

CONCLUSION

The coverage of prostate cancer screening was low in LMICs with variations in the coverage by the quintile of wealth (pro-rich) and type of place of residence (pro-urban).

POLICY SUMMARY

To achieve the desired impact of prostate cancer screening services in LMICs, it is important that the coverage of screening programs targets men living in rural areas and those in low wealth quintiles.

Barriers and Facilitators to Cervical Cancer Screening in Western Kenya: a Qualitative Study

About nine out of 10 cervical cancer deaths occur in low-resource countries, with a particularly high burden in sub-Saharan Africa. The objectives of this study were to assess barriers and facilitators to cervical cancer screening in western Kenya from the perspectives of community members and healthcare providers. We conducted two focus groups with female community members (n = 24) and one with providers (n = 12) in Migori County, Kenya. Discussion guides queried about knowledge and awareness of cervical cancer prevention; structural, social, and personal barriers; and facilitators towards cervical cancer screening uptake. Group discussions were recorded, transcribed, and analyzed for emerging themes. Participants in both groups reported low awareness of HPV and cervical cancer screening in the community, and identified that as a main barrier to screening. Community members reported fear of pain and embarrassment as significant barriers to a screening pelvic exam. They also reported that providers' lack of knowledge and discomfort with a sensitive subject were significant barriers. A personal connection to cervical cancer and/or screening was associated with willingness to screen and awareness. Providers reported workload and lack of supplies and trained staff as significant barriers to offering services. Based on these findings, we identified three intervention components to address these facilitators and barriers to screening. They include utilizing existing social networks to expand awareness of cervical cancer risk and screening, training non-physician health workers to meet the demand for screening, and employing female-driven screening techniques such as self-collection of specimens for HPV testing. Cervical cancer prevention programs must take into account the local realities in which they occur. In low-resource areas in particular, identifying low-cost, effective, and culturally appropriate strategies for addressing poor screening uptake is important given limited funding. This study took a formative approach to identify facilitators and barriers to cervical cancer screening based on focus groups and interviews with community members and healthcare providers.

The Global Incidence, Mortality, and Burden of Breast Cancer in 2019: Correlation With Smoking, Drinking, and Drug Use

Background

Female breast cancer (FBC) is the most common type of cancer and is associated with a considerable disease burden as well as significant mortality rates. The present study aimed to provide an update on the incidence, mortality, and burden of FBC in 2019, based on the Global Burden of Disease (GBD) Study.

Materials

The incidence, death rate, disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs), the age-standardized rates (ASR) of FBC in 204 countries, and a variety of classifications, were retrieved from the Global Burden of Disease Study. Data on tobacco use, alcohol consumption, and drug use were collected. The incidence, mortality, and burden of FBC were registered and compared between regions. Associations between age-standardized incidence rates and age-standardized mortality rates of FBC with smoking, drinking, and drug use were determined.

Results

The highest incidence of FBC was observed in countries with a high socioeconomic status such as those of the European continent. Despite the lower incidence of FBC in countries with a low socio-demographic index (SDI), mortality rates secondary to FBC are higher in these countries than in high-income countries. The highest age-standardized mortality rate has been reported in the Eastern Mediterranean Region (EMRO), followed by the African Region (AFRO). The highest age-standardized rates of DALY and YLL per 100,000 population in 2019 were observed in lower-income countries, while the highest ASR of YLD per 100,000 population was reported in high-income countries.

Conclusion

The present GBD-based study provides a comprehensive review of the incidence, mortality, and burden of FBC in 2019. The incidence of FBC is higher in regions with a higher socioeconomic status, whereas mortality rates and DALYs are higher in poorly developed regions. We suggest better screening measures and early detection programs for the latter regions.

PROSTATE CANCER AND HIS INFLUENCE ON REPRODUCTIVE HEALTH

The aim of the study. Based on the data of the National Cancer Registry the research aims at conducting an analysis of morbidity and mortality of the male population of Ukraine for prostate cancer from 2014 to 2019. Materials and Methods. We have studied the indicators of the proportion of malignant neoplasms of the pelvic organs among the ten main nosological forms of malignant neoplasms in the morbidity of the male population of Ukraine, the proportion of malignant neoplasms of the pelvic organs among the ten major nosological forms of malignant neoplasms in the mortality of male malignancies in Ukraine, mortality from malignant neoplasms of the prostate in Ukraine and the percentage of morphologically and histologically confirmed cases of malignant neoplasms of the prostate in Ukraine in the period from 2014 to 2019. Results and Discussion. Among the ten main nosological forms of malignant neoplasms in the structure of the incidence of malignant neoplasms in the male population, the share of diseases of malignant neoplasms of the prostate in 2019 is 12.4%. The proportion of malignant neoplasms of the prostate in the mortality structure of the male population of Ukraine from 2014 to 2019 increased from 8.3% to 9.7%, respectively, while the proportion of malignant neoplasms of the rectum and bladder were in some years higher or equal to 2019. The absolute number of cases of malignant neoplasms of the prostate from 2014 to 2019 increased from 6851 cases to 8178 cases, i.e. by 1327 cases, which is 16.23%. Mortality of the male population of Ukraine from malignant neoplasms of the prostate from 2014 to 2019 fluctuated, with an increase in 2017 and a decrease in 2018, but the mortality rate increased from 3119 cases in 2014 to 3323 cases in 2019. The average percentage of morphologically confirmed cases of malignant neoplasms of the prostate was 90.6±0.81%, and the average percentage of histologically confirmed cases of malignant neoplasms of the prostate was 83.57±1.06. Correlation-regression analysis of the growth of the incidence of malignant neoplasms of the prostate in Ukraine for the next 5 years showed that the number of cases will increase significantly but will not exceed 10,000 cases. Correlation-regression analysis of the growth of mortality from malignant neoplasms of the prostate in Ukraine for the next 5 years showed that by 2024 mortality from this pathology will reach almost 3,500 cases per year. Conclusions. The obtained data indicate a clear trend towards an increase in morbidity and mortality from malignant neoplasms of the prostate. Among the main factors that may influence this are the low level of vaccination of male and female population of Ukraine from highly oncogenic strains of human papillomavirus, lack of motivation of the male population of Ukraine to a comprehensive screening of the prostate after 45 years and low awareness of the need for such screening, availability of three-component vaccines against human papillomavirus on the pharmaceutical market of Ukraine, while vaccination with seven-component vaccines against this virus is routine in the European Union. Further research on the coverage of the male population with vaccination and on the awareness of the male population of Ukraine about the risks of prostate cancer is necessary in terms of preventing reproductive dysfunction and the proper formation of reproductive health in general.

A Socio-Ecological Framework for Cancer Prevention in Low and Middle-Income Countries

Cancer incidence and mortality rates continue to rise globally, a trend mostly driven by preventable cancers occurring in low-and middle-income countries (LMICs). There is growing concern that many LMICs are ill-equipped to cope with markedly increased burden of cancer due to lack of comprehensive cancer control programs that incorporate primary, secondary, and tertiary prevention strategies. Notably, few countries have allocated budgets to implement such programs. In this review, we utilize a socio-ecological framework to summarize primary (risk reduction), secondary (early detection), and tertiary (treatment and survivorship) strategies to reduce the cancer burden in these countries across the individual, organizational, community, and policy levels. We highlight strategies that center on promoting health behaviors and reducing cancer risk, including diet, tobacco, alcohol, and vaccine uptake, approaches to promote routine cancer screenings, and policies to support comprehensive cancer treatment. Consistent with goals promulgated by the United Nations General Assembly on Noncommunicable Disease Prevention and Control, our review supports the development and implementation of sustainable national comprehensive cancer control plans in partnership with local communities to enhance cultural relevance and adoption, incorporating strategies across the socio-ecological framework. Such a concerted commitment will be necessary to curtail the rising cancer and chronic disease burden in LMICs.

Female healthcare providers’ knowledge, attitude, and practice towards cervical cancer screening and associated factors in public hospitals of Northwest Ethiopia

Objective:

Cervical cancer is the fourth most common gynaecological cancer in the world. Its incidence and burden are high in developing regions, especially in sub-Saharan Africa. The World Health Organization plans to increase vaccination, screening, and treatment of cases to 90%, 70%, and 90%, respectively, in developing countries by 2030. Therefore, the aim of this study was to assess knowledge, attitudes, and practices of cervical cancer screening and predictors among female healthcare providers.

Methods:

Institution-based cross-sectional survey was done from 4 March to 20 April 2019. The data were collected using a structured questionnaire. The data were entered into EpiData version 3.1 and analysed with SPSS version 25. Logistic regression analysis was used to identify associations. After controlling for confounders, an independent association was declared at a p-value of 0.05 with a 95% confidence interval.

Results:

Of a total of 404 participants, half were nurses. One hundred seventy-seven (43.8%) had adequate knowledge, 124 (30.7%) had a favourable attitude, and 35 (8.7%) had regular screening practice. The availability of trained personnel in the health facility and regular screening were variables associated with knowledge. Participants’ attitude was shown association with profession, level of education, and knowledge. Moreover, knowledge of the causes of cervical cancer and knowledge of screening were variables significantly associated with screening practice.

Conclusion and recommendations:

Unfortunately, there is low adequate knowledge, low favourable attitude, and irregular screening practice of cervical cancer in the study area. Despite their own effects, their knowledge and attitude may affect the vast majority of their clients. Therefore, this finding calls for prompt action, such as training for participants to increase awareness, to shape their attitudes, and to increase the uptake of screening services.

Addition of digital VIA/VILI to conventional naked-eye examination for triage of HPV-positive women: A study conducted in a low-resource setting

BACKGROUND

World Health Organization guidelines for cervical cancer screening recommend HPV testing followed by visual inspection with acetic acid (VIA) for triage if HPV positive. In order to improve visual assessment and identification of cervical intraepithelial neoplasia grade 2 and worse (CIN2+), providers may use visual aids such as digital cameras.

OBJECTIVES

To determine whether combined examination by naked-eye and digital VIA (D-VIA) and VILI (D-VILI) improves detection of CIN2+ as compared to the conventional evaluation.

MATERIALS AND METHODS

Women (30-49 years) living in Dschang (West Cameroon) were prospectively invited to a cervical cancer screening campaign. Primary HPV-based screening was followed by VIA/VILI and D-VIA/VILI if HPV-positive. Health care providers independently defined diagnosis (pathological or non-pathological) based on naked-eye VIA/VILI and D-VIA/VILI. Decision to treat was based on combined examination (VIA/VILI and D-VIA/VILI). Cervical biopsy and endocervical curettage were performed in all HPV-positive participants and considered as reference standard. Diagnostic performance of individual and combined naked-eye VIA/VILI and D-VIA/VILI was evaluated. A sample size of 1,500 women was calculated assuming a prevalence of 20% HPV positivity and 10% CIN2+ in HPV-positive women.

RESULTS

Due to the COVID-19 pandemic, the study had to terminate prematurely. A total of 1,081 women with a median age of 40 (IQR 35.5-45) were recruited. HPV positivity was 17.4% (n = 188) and 26 (14.4%) had CIN2+. Naked-eye VIA and D-VIA sensitivities were 80.8% (95% CI 60.6-93.4) and 92.0% (95% CI 74.0-99.0), and specificities were 31.2% (95% CI 24-39.1) and 31.6% (95% CI 24.4-39.6), respectively. The combination of both methods yielded a sensitivity of 92.3% (95% CI 74.9-99.1) and specificity of 23.2% (95% CI 16.8-30.7). A trend towards improved sensitivity was observed, but did not reach statistical significance.

CONCLUSION

Addition of D-VIA/VILI to conventional naked-eye examination may be associated with improved CIN2+ identification. Further studies including a larger sample size are needed to confirm these results.

Cervical cancer screening among HIV-positive women in urban Uganda: a cross sectional study

Background

Women living with Human Immunodeficiency Virus (HIV) are at a high risk for early development of cervical cancer. Adherence to cervical cancer prevention strategies in this population is vital for the early detection and treatment of cervical cancer. This study aimed to determine the prevalence and factors associated with cervical cancer screening among HIV-positive women attending an urban HIV care center in Uganda.

Methods

This cross-sectional study included 205 HIV-positive women receiving care at an urban HIV care center. An interviewer-administered questionnaire was used to capture sociodemographic information, history of screening for cervical cancer, and reproductive health characteristics. Logistic regression analysis was used to determine the factors associated with cervical cancer screening.

Results

Of the 205 HIV-positive women with a mean age of 37.5 ± 8.87 that participated in the study, majority (n = 201, 98%) were aware of cervical cancer screening. Ninety participants (44%) had ever been screened for cervical cancer and only 33 (16.1%) had been screened in the past year. Obtaining information about cancer of the cervix and cervical cancer screening from health care professionals was significantly associated with higher levels of cervical cancer screening (adjusted odds ratio = 5.61, 95% confidence interval: 2.50–12.61, p value < 0.001).

Conclusion

This study highlights the low prevalence of cervical cancer screening among HIV-positive women and underscores the role of health professionals as an effective source of information on cervical cancer and cervical cancer screening. Patient education programs in HIV prevention and care facilities should emphasize cervical cancer screening messages to enhance the uptake of screening services.

Evaluation of Prostate Cancer Screening Strategies in a Low-Resource, High-risk Population in the Bahamas

Importance

The benefit of prostate-specific antigen screening may be greatest in high-risk populations, including men of African descent in the Caribbean. However, organized screening may not be sustainable in low- and middle-income countries.

Objective

To evaluate the expected population outcomes and resource use of conservative prostate-specific antigen screening programs in the Bahamas.

Design Setting and Participants

Prostate cancer incidence from GLOBOCAN and prostate-specific antigen screening data for 4300 men from the Bahamas were used to recalibrate 2 decision analytical models previously used to study prostate-specific antigen screening for Black men in the United States. Data on age and results obtained from prostate-specific antigen screening tests performed in Nassau from 2004 to 2018 and in Freeport from 2013 to 2018 were used. Data were analyzed from January 15, 2021, to March 23, 2022.

Interventions

One or 2 screenings for men aged 45 to 60 years and conservative criteria for biopsy (prostate-specific antigen level >10 ng/mL) and curative treatment (Gleason score ≥8) were modeled. Categories of Gleason scores were 6 or lower, 7, and 8 or higher, with higher scores indicating higher risk of cancer progression and death.

Main Outcomes and Measures

Projected numbers of tests and biopsies, prostate cancer (over)diagnoses, lives saved, and life-years gained owing to screening from 2022 to 2040.

Results

In this decision analytical modeling study, screening histories from 4300 men (median age, 54 years; range, 13-101 years) tested between 2004 and 2018 at 2 sites in the Bahamas were used to inform the models. Screening once at 60 years of age was projected to involve 40 000 to 42 000 tests (range between models) and prevent 500 to 600 of 10 000 to 14 000 prostate cancer deaths. Screening at 50 and 60 years doubled the number of tests but increased lives saved by only 15% to 16%. Among onetime strategies, screening once at 60 years of age involved the fewest tests per life saved (74-84 tests) and curative treatments per life saved (1.2-2.8 treatments).

Conclusions and Relevance

The findings of this decision analytical modeling study of prostate cancer screening in the Bahamas suggest that limited screening offered modest benefits that varied with screening ages and number of tests. The results can be combined with data on capacity constraints and evaluated relative to competing national public health priorities.

Factors contributing to delayed childhood cancer care in low- and middle-income countries: A systematic review protocol

BACKGROUND

Significant disparities exist for timely access to cancer care for children, with the highest disparities in low- and middle-income countries (LMICs). This study aims to conduct a systematic review that identifies the factors contributing to delayed care of childhood cancers in LMICs.

METHODS

We will conduct a systematic review with search strings compliant with the PICO framework: (1) the Population-children (aged 0-18 years) from LMICs; (2) the Exposure-factors contributing to timely childhood cancer care; (3) the Outcome-delays in childhood cancer care.

DISCUSSION

Our study is an essential step to guide strategic interventions to assess the myriad of factors that prevent children from accessing timely cancer care in LMICs. The results will be submitted for publication in a peer-reviewed journal and shared with institutions related to the field.

Uptake and correlates of cervical cancer screening among women attending a community-based multi-disease health campaign in Kenya

INTRODUCTION

Despite the increased risk of cervical cancer among HIV-positive women, many HIV-care programs do not offer integrated cervical cancer screening. Incorporating self-collected Human Papillomavirus (HPV) testing into HIV programs is a potential strategy to identify women at higher risk for cervical cancer while leveraging the staffing, infrastructure and referral systems for existing services. Community-based HIV and HPV testing has been effective and efficient when offered in single-disease settings.

METHODS

This cross-sectional study was conducted within a community outreach and multi-disease screening campaigns organized by the Family AIDS Care and Education Services in Kisumu County, Kenya. In addition to HIV testing, the campaigns provided screening for TB, malaria, hypertension, diabetes, and referrals for voluntary medical male circumcision. After these services, women aged 25-65 were offered self-collected HPV testing. Rates and predictors of cervical cancer screening uptake and of HPV positivity were analyzed using tabular analysis and Fisher's Exact Test. Logistic regression was performed to explore multivariate associations with screening uptake.

RESULTS

Among the 2016 women of screening age who attended the outreach campaigns, 749 women (35.6%) were screened, and 134 women (18.7%) were HPV-positive. In bivariate analysis, women who had no children (p < 0.01), who were not pregnant (p < 0.01), who were using contraceptives (p < 0.01), who had sex without using condoms (p < 0.05), and who were encouraged by a family member other than their spouse (p < 0.01), were more likely to undergo screening. On multivariable analysis, characteristics associated with higher screening uptake included: women aged 45-54 (OR 1.62, 95% CI 1.05-2.52) compared to women aged 25-34; no children (OR 1.65, 95% CI 1.06-2.56); and family support other than their spouse (OR 1.53, 95% CI 1.09-2.16). Women who were pregnant were 0.44 times (95% CI 0.25-0.76) less likely to get screened. Bivariate analyses with participant characteristics and HPV positivity found that women who screened HPV-positive were more likely to be HIV-positive (p < 0.001) and single (p < 0.001).

CONCLUSIONS

The low screening uptake may be attributed to implementation challenges including long waiting times for service at the campaign and delays in procuring HPV test kits. However, given the potential benefits of integrating HPV testing into HIV outreach campaigns, these challenges should be examined to develop more effective multi-disease outreach interventions.