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Njoku RC, Martinelli M, Giubbi C, De Marco S, Torsello B, d’Avenia M, Sironi M, Bianchi C, Cocuzza CE. Evaluation of C-C Motif Chemokine Receptor 5 ( CCR5) as a Sample Adequacy Control in HPV Molecular Diagnostics. Diagnostics (Basel) 2024; 14:2194. [PMID: 39410598 PMCID: PMC11482552 DOI: 10.3390/diagnostics14192194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Revised: 09/26/2024] [Accepted: 09/27/2024] [Indexed: 10/19/2024] Open
Abstract
Background: Reliable Human Papillomavirus (HPV) testing and genotyping are essential for quality assurance in HPV-based primary screening, disease management and for monitoring the impact of HPV vaccination. The clinical validation of HPV molecular diagnostic assays has significantly contributed to these objectives; however, little emphasis has been placed on assuring sample quality. This study aimed to evaluate the accuracy of sample cellularity assessment using the C-C Motif Chemokine Receptor 5 (CCR5) gene target as a marker of sample adequacy in molecular diagnostics. Methods: Jurkat cell line samples were counted using both a Thoma cell-counting chamber and Fluorescence-Activated Cell Sorting (FACS). Jurkat cell line samples at three different concentrations were subsequently evaluated using the OncoPredict HPV Quality Control (QC) real-time PCR assay, employing CCR5 for molecular cellularity quantification. Results: The cellularity values obtained were comparable across the three different methods for all dilutions of the cell line tested. Conclusions: The results obtained from this study show that CCR5 represents a promising molecular marker for the accurate quantification of sample cellularity, confirming its use as a reliable sample adequacy control, thus reducing the risk of "false-negative" results.
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Affiliation(s)
- Ruth C. Njoku
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy;
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (C.G.); (S.D.M.); (B.T.); (M.S.); (C.B.); (C.E.C.)
| | - Marianna Martinelli
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (C.G.); (S.D.M.); (B.T.); (M.S.); (C.B.); (C.E.C.)
| | - Chiara Giubbi
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (C.G.); (S.D.M.); (B.T.); (M.S.); (C.B.); (C.E.C.)
| | - Sofia De Marco
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (C.G.); (S.D.M.); (B.T.); (M.S.); (C.B.); (C.E.C.)
| | - Barbara Torsello
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (C.G.); (S.D.M.); (B.T.); (M.S.); (C.B.); (C.E.C.)
| | - Morena d’Avenia
- UOSVD of Cytopathology and Screening, Department of Laboratory Medicines, Ospedale di Venere, Asl Bari, 70132 Bari, Italy;
| | - Manuela Sironi
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (C.G.); (S.D.M.); (B.T.); (M.S.); (C.B.); (C.E.C.)
| | - Cristina Bianchi
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (C.G.); (S.D.M.); (B.T.); (M.S.); (C.B.); (C.E.C.)
| | - Clementina E. Cocuzza
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (C.G.); (S.D.M.); (B.T.); (M.S.); (C.B.); (C.E.C.)
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Molano M, Machalek DA, Tan G, Garland S, Balgovind P, Haqshenas G, Munnull G, Phillips S, Badman SG, Bolnga J, Cornall AM, Gabuzzi J, Kombati Z, Brotherton J, Saville M, Hawkes D, Kaldor J, Toliman PJ, Vallely AJ, Murray GL. Performance of CADM1, MAL and miR124-2 methylation as triage markers for early detection of cervical cancer in self-collected and clinician-collected samples: an exploratory observational study in Papua New Guinea. BMJ Open 2024; 14:e081282. [PMID: 38904134 PMCID: PMC11191780 DOI: 10.1136/bmjopen-2023-081282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 06/02/2024] [Indexed: 06/22/2024] Open
Abstract
OBJECTIVE WHO recommends human papillomavirus (HPV) testing for cervical screening, with triage of high-risk HPV (hrHPV) positive women. However, there are limitations to effective triage for low-resource, high-burden settings, such as Papua New Guinea. In this exploratory study, we assessed the performance of host methylation as triage tools for predicting high-grade squamous intraepithelial lesions (HSIL) in self-collected and clinician-collected samples. DESIGN Exploratory observational study. SETTING Provincial hospital, same-day cervical screen-and-treat trial, Papua New Guinea. PARTICIPANTS 44 hrHPV+women, with paired self/clinician-collected samples (4 squamous cell carcinomas (SCC), 19 HSIL, 4 low-grade squamous intraepithelial lesions, 17 normal). PRIMARY AND SECONDARY OUTCOME MEASURES Methylation levels of CADM1, MAL and miR124-2 analysed by methylation-specific PCRs against the clinical endpoint of HSIL or SCC (HSIL+) measured using liquid-based-cytology/p16-Ki67 stain. RESULTS In clinician-collected samples, MAL and miR124-2 methylation levels were significantly higher with increasing grade of disease (p=0.0046 and p<0.0015, respectively). miR124-2 was the best predictor of HSIL (area under the curve, AUC 0.819) while MAL of SCC (AUC 0.856). In self-collected samples, MAL best predicted HSIL (AUC 0.595) while miR124-2 SCC (AUC 0.812). Combined miR124-2/MAL methylation yielded sensitivity and specificity for HSIL+ of 90.5% (95% CI 69.6% to 98.8%) and 70% (95% CI 45.7% to 88.1%), respectively, in clinician-collected samples, and 81.8% (95% CI 59.7% to 94.8%) and 47.6% (95% CI 25.7% to 70.2%), respectively, in self-collected samples. miR124-2/MAL plus HPV16/HPV18 improved sensitivity for HSIL+ (95.2%, 95% CI 76.2% to 99.9%) but decreased specificity (55.0%, 95% CI 31.5% to 76.9%). CONCLUSION miR124-2/MAL methylation is a potential triage strategy for the detection of HSIL/SCC in low-income and middle-income country.
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Affiliation(s)
- Monica Molano
- Centre for Women's Infectious Diseases, The Royal Women's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Dorothy A Machalek
- Centre for Women's Infectious Diseases, The Royal Women's Hospital, Parkville, Victoria, Australia
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Grace Tan
- Australian Centre for the Prevention of Cervical Cancer, Melbourne, Victoria, Australia
| | - Suzanne Garland
- The Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Prisha Balgovind
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Gholamreza Haqshenas
- The Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gloria Munnull
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Samuel Phillips
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Steven G Badman
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - John Bolnga
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- Obstetrics and Gynaecology, Modilon General Hospital, Madang, Papua New Guinea
| | - Alyssa Marie Cornall
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Josephine Gabuzzi
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- Obstetrics and Gynaecology, Modilon General Hospital, Madang, Papua New Guinea
| | - Zure Kombati
- Tininga Clinic, Mount Hagen General Hospital, Mount Hagen, Western Highlands Province, Papua New Guinea
| | - Julia Brotherton
- Australian Centre for the Prevention of Cervical Cancer, Melbourne, Victoria, Australia
- School of Population Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marion Saville
- Australian Centre for the Prevention of Cervical Cancer, Melbourne, Victoria, Australia
| | - David Hawkes
- Australian Centre for the Prevention of Cervical Cancer, Melbourne, Victoria, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Pamela Josephine Toliman
- Kirby Institute -Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew John Vallely
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Eastern Highlands Province, Papua New Guinea
| | - Gerald L Murray
- Centre for Women's Infectious Diseases, The Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Melbourne, Victoria, Australia
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Oommen AM, Basu P, Cherian AG, Zomawia E, Manoharan R, Pricilla RA, Viswanathan V, Oldenburg B, Subramanian S, Hawkes D, Saville M, Brotherton JML. Protocol for the formative phase of a trial (SHE-CAN) to test co-designed implementation strategies for HPV-based cervical screening among vulnerable women in two diverse settings in India. Implement Sci Commun 2023; 4:62. [PMID: 37291627 PMCID: PMC10249153 DOI: 10.1186/s43058-023-00436-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/08/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND In view of the WHO's call for the elimination of cervical cancer as a public health problem, and current low screening coverage, Indian policy makers need evidence on how to effectively implement cervical screening programmes, ensuring equity in access. Our study will follow the INSPIRE implementation framework to co-design and test HPV-based screening approaches in two states of India with different health system organisation, based on understanding the status of screening as currently implemented, readiness and challenges to transition to HPV-based screening, and preferences of key stakeholders. Here, we describe our protocol for the formative phase of the study (SHE-CAN). METHODS The study population includes women from vulnerable populations, defined as residents of tribal areas, rural villages, and urban slums, in the states of Mizoram and Tamil Nadu. The baseline assessment will use mixed methods research, with desktop reviews, qualitative studies, and surveys. A capacity assessment survey of screening and treatment facilities will be done, followed by interviews with healthcare providers, programme managers, and community health workers. Interviews will be conducted with previously screened women and focus group discussions with under and never-screened women and community members. Stakeholder workshops will be held in each state to co-design the approaches to delivering HPV-based screening among 30-49-year-old women. DISCUSSION The quality and outcomes of existing screening services, readiness to transition to HPV-based screening, challenges in providing and participating in the cervical cancer care continuum, and acceptability of screening and treatment approaches will be examined. The knowledge gained about the current system, as well as recognition of actions to be taken, will inform a stakeholder workshop to co-design and evaluate implementation approaches for HPV-based screening through a cluster randomised implementation trial.
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Affiliation(s)
- Anu Mary Oommen
- The University of Melbourne, Melbourne, Australia.
- Christian Medical College, Vellore, Tamil Nadu, India.
| | - Partha Basu
- International Agency for Research on Cancer, Lyon, France
| | | | - Eric Zomawia
- Population Based Cancer Registry, Aizawl, Mizoram, India
| | | | | | - Vidhya Viswanathan
- Directorate of Public Health and Preventive Medicine, Government of Tamil Nadu, Chennai, India
| | | | | | - David Hawkes
- Australian Centre for Prevention of Cervical Cancer, Melbourne, Australia
| | - Marion Saville
- Australian Centre for Prevention of Cervical Cancer, Melbourne, Australia
| | - Julia M L Brotherton
- The University of Melbourne, Melbourne, Australia
- Formerly Australian Centre for Prevention of Cervical Cancer, Melbourne, Australia
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4
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Vallely AJB, Saville M, Badman SG, Gabuzzi J, Bolnga J, Mola GDL, Kuk J, Wai M, Munnull G, Garland SM, Brotherton JML, Kelly-Hanku A, Morgan C, Toliman PJ, Kombati Z, Kariwiga G, Babona D, Tan G, Simms KT, Cornall AM, Tabrizi SN, Wand H, Guy R, Canfell K, Kaldor JM. Point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer in women in Papua New Guinea: a prospective, single-arm intervention trial (HPV-STAT). Lancet Glob Health 2022; 10:e1336-e1346. [PMID: 35878625 DOI: 10.1016/s2214-109x(22)00271-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/15/2022] [Accepted: 06/07/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND WHO recommends human papillomavirus (HPV) testing and same-day treatment for cervical screening in low-income and middle-income countries (LMICs); however, few published data exist on the validity of the strategy. We aimed to evaluate the clinical performance, treatment completion rates, adverse events profile, and acceptability of a fully integrated strategy, comprising point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation, for screening of cervical cancer in women in Papua New Guinea. METHODS HPV-STAT was a large-scale, prospective, single-arm intervention trial conducted at two clinical sites in Papua New Guinea. Cervical screening clinics with an on-site consultant gynaecologist were selected in consultation with national and provincial health authorities, church health services, and local stakeholders. Eligible participants were women aged 30-59 years attending cervical screening services at the two clinics, who were willing to comply with study procedures and able to provide written informed consent. Women self-collected vaginal specimens for point-of-care GeneXpert testing (Cepheid, Sunnyvale, CA, USA) for oncogenic HPV types. Women testing positive for HPV underwent pelvic examination followed by same-day thermal ablation or referral for gynaecology review. All HPV-positive women and a 15% random sample of HPV-negative women provided a clinician-collected cervical specimen for liquid-based cytology. The primary outcome was clinical performance (ie, sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of the strategy for the detection of high-grade squamous intraepithelial lesion (HSIL) or worse. This trial is registered with ISRCTN, ISRCTN13476702. FINDINGS Between June 5, 2018, and Jan 6, 2020, we recruited 4285 women, 3638 (84·9%) of whom tested negative for HPV and 647 (15·1%) tested positive for one or more oncogenic HPV type. Sensitivity of the algorithm to detect HSIL or worse was 85·4% (95% CI 81·0-89·6), with specificity 89·6% (88·6-90·6), PPV 35·2% (31·6-39·0), and NPV 98·9% (98·6-99·2). Among HPV-positive women, 602 (93·0%) received same-day thermal ablation and 42 (6·5%) were referred for gynaecology review, 37 (88·1%) of whom attended. Acceptability was high among both HPV-positive and HPV-negative women. Among the 329 HPV-positive women who attended a 3-month follow-up visit, 51 (15·5%) reported mild adverse symptoms that resolved in all cases by the follow-up visit. There were no serious adverse events. INTERPRETATION We conducted the first real-world evaluation of a fully integrated point-of-care HPV self-collect, test, and treat strategy for same-day cervical screening in a LMIC and found it to be effective, acceptable, and safe when implemented at scale in primary health-care facilities in Papua New Guinea. Our findings support the introduction and scale-up of HPV screening and treatment for the control and elimination of cervical cancer in LMICs, as recommended by WHO. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Andrew J B Vallely
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Kensington, NSW, Australia.
| | | | - Steven G Badman
- Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Kensington, NSW, Australia
| | - Josephine Gabuzzi
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; Department of Obstetrics and Gynaecology, Modilon General Hospital, Madang, Papua New Guinea
| | - John Bolnga
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; Department of Obstetrics and Gynaecology, Modilon General Hospital, Madang, Papua New Guinea
| | - Glen D L Mola
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Joseph Kuk
- Department of Obstetrics and Gynaecology, Mt Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Malts Wai
- Department of Obstetrics and Gynaecology, Mt Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Gloria Munnull
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; Department of Obstetrics and Gynaecology, Mt Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Suzanne M Garland
- Centre for Women's Infectious Diseases Research, Royal Women's Hospital, Melbourne, VIC, Australia; Infection and Immunity, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, VIC, Australia
| | - Julia M L Brotherton
- VCS Foundation, Melbourne, VIC, Australia; School of Population and Global Health, University of Melbourne, VIC, Australia
| | - Angela Kelly-Hanku
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Kensington, NSW, Australia
| | - Christopher Morgan
- Jhpiego, Johns Hopkins University Affiliate, Baltimore, MD, USA; Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, VIC, Australia
| | - Pamela J Toliman
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Zure Kombati
- Department of Pathology, Mt Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Grace Kariwiga
- Department of Obstetrics and Gynaecology, Alotau Provincial Hospital, Alotau, Papua New Guinea
| | - Delly Babona
- Department of Obstetrics and Gynaecology, St Mary's Vunapope Rural Hospital, Kokopo, Papua New Guinea
| | - Grace Tan
- VCS Foundation, Melbourne, VIC, Australia
| | - Kate T Simms
- Daffodil Centre, The University of Sydney-Cancer Council New South Wales, Sydney, NSW, Australia
| | - Alyssa M Cornall
- Centre for Women's Infectious Diseases Research, Royal Women's Hospital, Melbourne, VIC, Australia
| | - Sepehr N Tabrizi
- Centre for Women's Infectious Diseases Research, Royal Women's Hospital, Melbourne, VIC, Australia
| | - Handan Wand
- Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Kensington, NSW, Australia
| | - Rebecca Guy
- Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Kensington, NSW, Australia
| | - Karen Canfell
- Prince of Wales Clinical School, UNSW Sydney, Kensington, NSW, Australia; Daffodil Centre, The University of Sydney-Cancer Council New South Wales, Sydney, NSW, Australia
| | - John M Kaldor
- Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Kensington, NSW, Australia
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Chinula L, McGue S, Smith JS, Saidi F, Mkochi T, Msowoya L, Varela A, Lee F, Gopal S, Chagomerana M, Tomoka T, Mwapasa V, Tang J. A novel cervical cancer screen-triage-treat demonstration project with HPV self-testing and thermal ablation for women in Malawi: Protocol for a single-arm prospective trial. Contemp Clin Trials Commun 2022; 26:100903. [PMID: 35243124 PMCID: PMC8857441 DOI: 10.1016/j.conctc.2022.100903] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/20/2021] [Accepted: 02/07/2022] [Indexed: 01/25/2023] Open
Abstract
Cervical cancer is the leading cause of cancer mortality among Malawian women, despite being preventable through screening and preventive therapy. In 2004, Malawi implemented a national screening program, using visual inspection with acetic acid (VIA) and cryotherapy, but its success has been limited due to equipment and human resources challenges. Since the development of that program, new technologies for screening and treatment that are less resource-intensive and more scalable have become available. GeneXpert systems provide fast, accurate HPV results and are increasingly available in low-income countries. Self-collection for human papillomavirus (HPV) testing is a validated method for screening and improves uptake. Thermal ablation provides an alternative ablative treatment that is simpler to use than cryotherapy and can be performed with portable devices. Meanwhile, urine HPV testing methods provide promising options for primary screening. We designed a single-arm prospective study to investigate a novel HPV screen-triage-treat strategy among 1250 women in Lilongwe, Malawi. Our proposed strategy consists of (1) Xpert HPV testing of self-collected samples, (2) VIA and colposcopy for HPV-positive women, and (3) thermal ablation for HPV-positive/ablation-eligible women. We will collect cervical biopsies, Pap smears, and endocervical samples to validate the HPV results and VIA/colposcopy findings against endpoints of high-grade cervical intraepithelial neoplasia or cancer (CIN2+). We will evaluate same-day completion of our algorithm, its performance in triaging women for treatment, and 24-week treatment efficacy of thermal ablation. We will also explore the performance of HPV and methylation tests in urine samples, as compared to provider- and self-collected cervicovaginal samples.
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Affiliation(s)
- Lameck Chinula
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- University of North Carolina, Department of OB-GYN, Division of Global Women's Health, 3009 Old Clinic Building, CB 7570, Chapel Hill, NC, USA
| | - Shannon McGue
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Jennifer S. Smith
- University of North Carolina, Department of Epidemiology, McGavran-Greenberg Hall, Chapel Hill, 2103, NC, USA
| | - Friday Saidi
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Tawonga Mkochi
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Lizzie Msowoya
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Amanda Varela
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Fan Lee
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- University of North Carolina, Department of OB-GYN, Division of Global Women's Health, 3009 Old Clinic Building, CB 7570, Chapel Hill, NC, USA
| | | | - Maganizo Chagomerana
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Tamiwe Tomoka
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | | | - Jennifer Tang
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- University of North Carolina, Department of OB-GYN, Division of Global Women's Health, 3009 Old Clinic Building, CB 7570, Chapel Hill, NC, USA
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Nguyen DTN, Simms KT, Keane A, Mola G, Bolnga JW, Kuk J, Toliman PJ, Badman SG, Saville M, Kaldor J, Vallely A, Canfell K. Towards the elimination of cervical cancer in low-income and lower-middle-income countries: modelled evaluation of the effectiveness and cost-effectiveness of point-of-care HPV self-collected screening and treatment in Papua New Guinea. BMJ Glob Health 2022; 7:bmjgh-2021-007380. [PMID: 35241461 PMCID: PMC8896000 DOI: 10.1136/bmjgh-2021-007380] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/23/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction WHO has launched updated cervical screening guidelines, including provisions for primary HPV screen-and-treat. Papua New Guinea (PNG) has a high burden of cervical cancer, but no national cervical screening programme. We recently completed the first field trials of a screen-and-treat algorithm using point-of-care self-collected HPV and same-day treatment (hereafter self-collected HPV S&T) and showed this had superior clinical performance and acceptability to visual inspection of the cervix with acetic acid (VIA). We, therefore, evaluated the effectiveness, cost-effectiveness and resource implications of a national cervical screening programme using self-collected HPV S&T compared with VIA in PNG. Methods An extensively validated platform (‘Policy1-Cervix’) was calibrated to PNG. A total of 38 strategies were selected for investigation, and these incorporated variations in age ranges and screening frequencies and allowed for the identification of the optimal strategy across a wide range of possibilities. A selection of strategies that were identified as being the most effective and cost-effective were then selected for further investigation for longer-term outcomes and budget impact estimation. In the base case, we assumed primary HPV testing has a sensitivity to cervical intraepithelial neoplasia 2 (CIN2+) + of 91.8% and primary VIA of 51.5% based on our earlier field evaluation combined with evidence from the literature. We conservatively assumed HPV sampling and testing would cost US$18. Costs were estimated from a service provider perspective based on data from local field trials and local consultation. Results Self-collected HPV S&T was more effective and more cost-effective than VIA. Either twice or thrice lifetime self-collected HPV S&T would be cost-effective at 0.5× gross domestic product (GDP) per capita (incremental cost-effectiveness ratio: US$460–US$656/life-years saved; 1GDPper-capita: US$2829 or PGK9446 (year 2019)) and could prevent 33 000–42 000 cases and 23 000–29 000 deaths in PNG over the next 50 years, if scale-up reached 70% coverage from 2023. Conclusion Self-collected HPV S&T was effective and cost-effective in the high-burden, low-resource setting of PNG, and, if scaled-up rapidly, could prevent over 20 000 deaths over the next 50 years. VIA screening was not effective or cost-effective. These findings support, at a country level, WHO updated cervical screening guidelines and indicate that similar approaches could be appropriate for other low-resource settings.
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Affiliation(s)
| | - Kate T Simms
- Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Adam Keane
- Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Glen Mola
- Department of Reproductive Health, Obstetrics and Gynecology, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, CND, Papua New Guinea.,Department of Obstetrics and Gynecology, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - John Walpe Bolnga
- Department of Obstetrics and Gynecology, Modilion Hospital, Mango, Madang, Papua New Guinea
| | - Joseph Kuk
- Department of Obstetrics and Gynecology, Mt Hagen Provincial Hospital, Mt Hagen, Western Highlands Province, Papua New Guinea
| | - Pamela J Toliman
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Steven G Badman
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Marion Saville
- Australian Centre for the Prevention of Cervical Cancer, Melbourne, Victoria, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Vallely
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Karen Canfell
- Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
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Tiiti TA, Mashishi TL, Nkwinika VV, Molefi KA, Benoy I, Bogers J, Selabe SG, Lebelo RL. Evaluation of ILEX SelfCerv for Detection of High-Risk Human Papillomavirus Infection in Gynecology Clinic Attendees at a Tertiary Hospital in South Africa. J Clin Med 2021; 10:jcm10214817. [PMID: 34768334 PMCID: PMC8584638 DOI: 10.3390/jcm10214817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The SelfCerv Self-Collection Cervical Health Screening Kit (Ilex Medical Ltd., Johannesburg, South Africa) is an applicator tampon designed for self-collection of vaginal samples for the detection of human papillomavirus (HPV) deoxyribonucleic acid (DNA) and E6/E7 messenger ribonucleic acid (mRNA). The study aimed to evaluate the performance of the SelfCerv applicator tampon for the detection of hr-HPV for cervical cancer screening, and further to investigate women's experiences and preferences regarding self-sampling. METHODS Vaginal samples were collected from 527 gynecology clinic attendees aged ≥18 years at a tertiary hospital in Gauteng Province, South Africa. Self-samples were collected using the SelfCerv kit, followed by endocervical samples collected by a healthcare professional using Cervex-Brush® Combi. Participants completed a self-administered questionnaire on self-sampling experiences and preferences. Both samples were tested for 14 high-risk (hr) HPV types and E6/E7 mRNA using the Abbott RealTime HR-HPV and Aptima HR-HPV mRNA assays, respectively. RESULTS The overall agreement for hr-HPV typing between 527 paired samples was good (87.1%; κ =0.74) with high sensitivity (86.2%) and specificity (88.0%). HPV-16 (96.4%; κ = 0.83) had higher agreement rate than HPV-18 (96.8%; κ = 0.72) and the other 12 hr-HPVs (86.5%; κ = 0.72). Two hundred and eighty-five (285) sample pairs tested for E6/E7 mRNA showed fair agreement (70.2%; κ= 0.34). Furthermore, self-sampling was reported as comfortable (90.5%) and painless (86.7%), with 88.4% of women preferring self-collection. CONCLUSIONS Self-collected samples had good agreement with the healthcare professional-collected samples for the detection of hr-HPV DNA and the procedure was highly preferred by women. Self-sampling using SelfCerv can be used as an alternative to healthcare professional sampling in clinic-based routine cervical cancer screening.
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Affiliation(s)
- Teboho Amelia Tiiti
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa; (T.A.T.); (T.L.M.); (V.V.N.); (S.G.S.)
- Laboratory of Cell Biology and Histology, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerpen, Belgium; (I.B.); (J.B.)
| | - Tebogo Loraine Mashishi
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa; (T.A.T.); (T.L.M.); (V.V.N.); (S.G.S.)
| | - Varsetile Varster Nkwinika
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa; (T.A.T.); (T.L.M.); (V.V.N.); (S.G.S.)
- South African Vaccination and Immunization Centre, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Kgotlaethata Aaron Molefi
- Department of Obstetrics and Gynaecology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa;
| | - Ina Benoy
- Laboratory of Cell Biology and Histology, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerpen, Belgium; (I.B.); (J.B.)
- Algemeen Medisch Laboratorium (AML), Sonic Healthcare, 2020 Antwerpen, Belgium
| | - Johannes Bogers
- Laboratory of Cell Biology and Histology, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerpen, Belgium; (I.B.); (J.B.)
- Algemeen Medisch Laboratorium (AML), Sonic Healthcare, 2020 Antwerpen, Belgium
- Department of Anatomical Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Selokela Gloria Selabe
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa; (T.A.T.); (T.L.M.); (V.V.N.); (S.G.S.)
- National Health Laboratory Service, Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Ramokone Lisbeth Lebelo
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa; (T.A.T.); (T.L.M.); (V.V.N.); (S.G.S.)
- South African Vaccination and Immunization Centre, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
- National Health Laboratory Service, Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
- Correspondence: ; Tel.: +27-12521-3038
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Badman SG, Vallely AJ, Pardo C, Mhango LP, Cornall AM, Kaldor JK, Whiley D. A comparison of ThinPrep against four non-volatile transport media for HPV testing at or near the point of care. Pathology 2020; 53:264-266. [PMID: 33358758 DOI: 10.1016/j.pathol.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 10/22/2022]
Abstract
The Xpert HPV Test is used at point of care for cervical screening in a number of low and middle income countries (LMIC). It is validated for use with ThinPrep-PreservCyt transport medium which has a high methanol content and is therefore classified as a dangerous good for shipping, making cost, transportation and use challenging within LMIC. We compared the performance of ThinPrep against four non-volatile commercially available media for human papillomavirus (HPV) point of care testing. Ten-fold serial dilutions were prepared using three HPV cell lines each positive for 16, 18 or 31 and with each suspended in five different media types. The media types consisted of Phosphate Buffered Saline (ThermoFisher Scientific, USA), Sigma Virocult (Medical Wire and Equipment, UK), MSwab (Copan, Italy) Xpert Transport Media (Cepheid, USA) and ThinPrep-PreservCyt (Hologic, USA). A total of 105 Xpert HPV tests were conducted in a laboratory setting, with seven 10-fold dilutions of each of the three HPV genotypes tested in all five media types. The lowest HPV 10-fold dilution detected for any media, or cell line was the fifth dilution. MSwab was the only medium to detect HPV to the fifth dilution across all three cell types. MSwab transport media may be a suitable alternative to ThinPrep for Xpert HPV point of care testing. A field based, head to head comparison of both media types using the Xpert HPV assay is warranted to confirm these laboratory based findings.
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Affiliation(s)
- S G Badman
- Kirby Institute, UNSW Sydney, NSW, Australia.
| | - A J Vallely
- Kirby Institute, UNSW Sydney, NSW, Australia; Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - C Pardo
- Centre for Clinical Research, The University of Queensland, Brisbane, Qld, Australia
| | - L P Mhango
- Centre for Clinical Research, The University of Queensland, Brisbane, Qld, Australia
| | - A M Cornall
- Centre for Women's Infectious Diseases, Royal Women's Hospital, Melbourne, Vic, Australia; Molecular Microbiology Research Group, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Vic, Australia
| | - J K Kaldor
- Kirby Institute, UNSW Sydney, NSW, Australia
| | - D Whiley
- Centre for Clinical Research, The University of Queensland, Brisbane, Qld, Australia
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9
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Cubie HA, Campbell C. Cervical cancer screening - The challenges of complete pathways of care in low-income countries: Focus on Malawi. ACTA ACUST UNITED AC 2020; 16:1745506520914804. [PMID: 32364058 PMCID: PMC7225784 DOI: 10.1177/1745506520914804] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cervical cancer is the fourth most common cancer among women globally, with approximately 580,000 new diagnoses in 2018. Approximately, 90% of deaths from this disease occur in low- and middle-income countries, especially in areas of high HIV prevalence, and largely due to limited prevention and screening opportunities and scarce treatment options. In this overview, we describe the opportunities and challenges faced in many low- and middle-income countries in delivery of cervical cancer detection, treatment and complete pathways of care. In particular, drawing on our experience and that of colleagues, we describe cervical screening and pathways of care provision in Malawi, as a case study of a low-resource country with high incidence and mortality rates of cervical cancer. Screening methods such as cytology – although widely used in high-income countries – have limited relevance in many low-resource settings. The World Health Organization recommends screening using human papillomavirus testing wherever possible; however, although human papillomavirus primary testing is more sensitive and detects precancers and cancers earlier than cytology, there are currently costs, infrastructure considerations and specificity issues that limit its use in low- and middle-income countries. The World Health Organization accepts the alternative screening approach of visual inspection with acetic acid as part of ‘screen and treat’ programmes as a simple and inexpensive test that can be undertaken by trained health workers and hence give wider screening coverage; however, subjectivity and variability in interpretation of findings between providers raise issues of false positives and overtreatment. Cryotherapy using either nitrous oxide or carbon dioxide is an established treatment for precancerous lesions within ‘screen and treat’ programmes; more recently, thermal ablation has been recognized as suitable to low-resource settings due to lightweight equipment, short treatment times, and hand-held battery-operated and solar-powered models. For larger lesions and cancers, complete clinical pathways (including loop excision, surgery, radiotherapy, chemotherapy and palliative care) are required for optimal care of women. However, provision of each of these components of cancer control is often limited due to limited infrastructure and lack of trained personnel. Hence, global initiatives to reduce cervical mortality need to adopt a holistic approach to health systems strengthening.
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Affiliation(s)
- Heather A Cubie
- Global Health Academy and Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Christine Campbell
- Global Health Academy and Usher Institute, The University of Edinburgh, Edinburgh, UK
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10
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Toliman P, Phillips S, de Jong S, O'Neill T, Tan G, Brotherton J, Saville M, Kaldor J, Vallely A, Tabrizi S. Evaluation of p16/Ki-67 dual-stain cytology performed on self-collected vaginal and clinician-collected cervical specimens for the detection of cervical pre-cancer. Clin Microbiol Infect 2020; 26:748-752. [DOI: 10.1016/j.cmi.2019.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 10/05/2019] [Accepted: 10/16/2019] [Indexed: 12/19/2022]
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Mungo C, Ibrahim S, Bukusi EA, Truong HHM, Cohen CR, Huchko M. Scaling up cervical cancer prevention in Western Kenya: Treatment access following a community-based HPV testing approach. Int J Gynaecol Obstet 2020; 152:60-67. [PMID: 32347550 DOI: 10.1002/ijgo.13171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 01/28/2020] [Accepted: 04/14/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate access to treatment after community-based HPV testing as testing within screen-and-treat programs has the potential to lower mortality from cervical cancer in low-resource settings. METHODS A prospective cohort study was conducted in western Kenya in 2018. Women aged 25-65 years underwent HPV self-testing. HPV-positive women were referred for cryotherapy. Participant data were obtained from questionnaires during screening and treatment. The proportion successfully accessing treatment and variables associated with successful treatment was determined. RESULTS Of the 750 women included, 140 (18.6%) tested positive for HPV. Of them, 135 were notified of their results, of whom 77 (59.2%) sought treatment and 73 (52.1%) received cryotherapy. Women who received treatment had a shorter time from screening to result notification (median 92 days, interquartile range [IQR] 84-104) compared to those who did not (97 days, IQR 89-106; P=0.061). In adjusted analyses, women with a history of cervical cancer screening (odds ratio [OR] 11, 95% confidence interval [CI] 1.42-85.20) and those electing result notification through a home visit (OR 4, 95% CI 1.23-14.17) were significantly more likely to acquire treatment at follow-up. CONCLUSION Linkage to treatment after community-based HPV screening in this population was low, highlighting the need for strategies aimed at strengthening treatment linkage in similar settings.
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12
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Self-Collection for Cervical Screening Programs: From Research to Reality. Cancers (Basel) 2020; 12:cancers12041053. [PMID: 32344565 PMCID: PMC7226191 DOI: 10.3390/cancers12041053] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 12/16/2022] Open
Abstract
In 2018, there were an estimated 570,000 new cases of cervical cancer globally, with most of them occurring in women who either had no access to cervical screening, or had not participated in screening in regions where programs are available. Where programs are in place, a major barrier for women across many cultures has been the requirement to undergo a speculum examination. With the emergence of HPV-based primary screening, the option of self-collection (where the woman takes the sample from the vagina herself) may overcome this barrier, given that such samples when tested using a PCR-based HPV assay have similar sensitivity for the detection of cervical pre-cancers as practitioner-collected cervical specimens. Other advantages of HPV-based screening using self-collection, beyond the increase in acceptability to women, include scalability, efficiency, and high negative predictive value, allowing for long intervals between negative tests. Self-collection will be a key strategy for the successful scale up of cervical screening programs globally in response to the WHO call for all countries to work towards the elimination of cervical cancer as a public health problem. This review will examine self-collection for HPV-based cervical screening including the collection devices, assays and possible routine laboratory processes considering how they can be utilized in cervical screening programs.
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13
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Nodjikouambaye ZA, Adawaye C, Mboumba Bouassa RS, Sadjoli D, Bélec L. A systematic review of self-sampling for HPV testing in Africa. Int J Gynaecol Obstet 2020; 149:123-129. [PMID: 32037532 DOI: 10.1002/ijgo.13112] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/24/2019] [Accepted: 02/06/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Human papillomavirus (HPV) testing may be feasible for primary cervical cancer screening in low-resource countries. OBJECTIVE To compare self-sampling by women with clinician-performed sampling for HPV testing in Africa. SEARCH STRATEGY MEDLINE, Google scholar, EMBASE, and several journals were searched from 2000 until 2015 using relevant terms. SELECTION CRITERIA Selected studies compared self-sampled and clinician-sampled HPV tests. DATA COLLECTION AND ANALYSIS Data extraction forms included description of the type of HPV screening, description of any additional intervention components, study design, sample size, follow-up periods, analytic approach, reported numerical outcomes, results, and limitations. RESULTS Twenty-five studies were identified. Women of a wide age range were successful at self-sampling in many African countries. More than 95% of self-samples yielded HPV DNA results. The concordance in test results between self-collected samples and clinician-collected samples was reasonably high in most studies. In all studies, the quality of cytology from self-sampling matched that of clinician-sampling. Women were generally positive about self-collection, but noted some concerns. CONCLUSION Self-sampling for HPV DNA testing seems to represent a feasible alternative to the Pap test. Further research is needed to provide a solid evidence base to inform using of self-sampling for HPV DNA testing for primary cervical cancer screening.
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Affiliation(s)
- Zita Aleyo Nodjikouambaye
- Ecole Doctorale Régionale d'Infectiologie Tropicale, Franceville, Gabon.,Cabinet Médical de Gynécologie Obstétrique "La Renaissance Plus", N'Djamena, Chad
| | - Chatté Adawaye
- Institut National Supérieur des Sciences et Techniques d'Abéché, Abéché, Chad
| | - Ralph-Sydney Mboumba Bouassa
- Ecole Doctorale Régionale d'Infectiologie Tropicale, Franceville, Gabon.,Laboratoire de Virologie, Hôpital Européen Georges Pompidou, Paris, France.,Faculté de Médecine Paris Descartes, Université Paris Descartes (Paris V), Sorbonne Paris Cité, Paris, France
| | - Damthéou Sadjoli
- Cabinet Médical de Gynécologie Obstétrique "La Renaissance Plus", N'Djamena, Chad.,Service de Gynécologie-Obstétrique, Hôpital de la Mère et de l'Enfant, N'Djamena, Chad.,Faculte' des Sciences de la Sante' Humaine, Universite' de N'Djamena, N'Djamena, Chad
| | - Laurent Bélec
- Laboratoire de Virologie, Hôpital Européen Georges Pompidou, Paris, France.,Faculté de Médecine Paris Descartes, Université Paris Descartes (Paris V), Sorbonne Paris Cité, Paris, France
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14
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Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, Bray F. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health 2020; 8:e191-e203. [PMID: 31812369 PMCID: PMC7025157 DOI: 10.1016/s2214-109x(19)30482-6] [Citation(s) in RCA: 1964] [Impact Index Per Article: 491.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The knowledge that persistent human papillomavirus (HPV) infection is the main cause of cervical cancer has resulted in the development of prophylactic vaccines to prevent HPV infection and HPV assays that detect nucleic acids of the virus. WHO has launched a Global Initiative to scale up preventive, screening, and treatment interventions to eliminate cervical cancer as a public health problem during the 21st century. Therefore, our study aimed to assess the existing burden of cervical cancer as a baseline from which to assess the effect of this initiative. METHODS For this worldwide analysis, we used data of cancer estimates from 185 countries from the Global Cancer Observatory 2018 database. We used a hierarchy of methods dependent on the availability and quality of the source information from population-based cancer registries to estimate incidence of cervical cancer. For estimation of cervical cancer mortality, we used the WHO mortality database. Countries were grouped in 21 subcontinents and were also categorised as high-resource or lower-resource countries, on the basis of their Human Development Index. We calculated the number of cervical cancer cases and deaths in a given country, directly age-standardised incidence and mortality rate of cervical cancer, indirectly standardised incidence ratio and mortality ratio, cumulative incidence and mortality rate, and average age at diagnosis. FINDINGS Approximately 570 000 cases of cervical cancer and 311 000 deaths from the disease occurred in 2018. Cervical cancer was the fourth most common cancer in women, ranking after breast cancer (2·1 million cases), colorectal cancer (0·8 million) and lung cancer (0·7 million). The estimated age-standardised incidence of cervical cancer was 13·1 per 100 000 women globally and varied widely among countries, with rates ranging from less than 2 to 75 per 100 000 women. Cervical cancer was the leading cause of cancer-related death in women in eastern, western, middle, and southern Africa. The highest incidence was estimated in Eswatini, with approximately 6·5% of women developing cervical cancer before age 75 years. China and India together contributed more than a third of the global cervical burden, with 106 000 cases in China and 97 000 cases in India, and 48 000 deaths in China and 60 000 deaths in India. Globally, the average age at diagnosis of cervical cancer was 53 years, ranging from 44 years (Vanuatu) to 68 years (Singapore). The global average age at death from cervical cancer was 59 years, ranging from 45 years (Vanuatu) to 76 years (Martinique). Cervical cancer ranked in the top three cancers affecting women younger than 45 years in 146 (79%) of 185 countries assessed. INTERPRETATION Cervical cancer continues to be a major public health problem affecting middle-aged women, particularly in less-resourced countries. The global scale-up of HPV vaccination and HPV-based screening-including self-sampling-has potential to make cervical cancer a rare disease in the decades to come. Our study could help shape and monitor the initiative to eliminate cervical cancer as a major public health problem. FUNDING Belgian Foundation Against Cancer, DG Research and Innovation of the European Commission, and The Bill & Melinda Gates Foundation.
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Affiliation(s)
- Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium.
| | | | - Laia Bruni
- Consortium for Biomedical Research in Epidemiology and Public Health, Barcelona, Spain; Unit of Infections and Cancer, Catalonian Institute of Oncology, Barcelona, Spain
| | | | - Mona Saraiya
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlanta, GA, USA
| | - Jacques Ferlay
- International Agency for Research on Cancer, Lyon, France
| | - Freddie Bray
- International Agency for Research on Cancer, Lyon, France
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15
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Sarfati D, Dyer R, Vivili P, Herman J, Spence D, Sullivan R, Weller D, Bray F, Hill S, Bates C, Foliaki S, Palafox N, Luciani S, Ekeroma A, Hospedales J. Cancer control in small island nations: from local challenges to global action. Lancet Oncol 2019; 20:e535-e548. [PMID: 31395475 PMCID: PMC7746435 DOI: 10.1016/s1470-2045(19)30511-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 12/16/2022]
Abstract
Cancer is a leading cause of death in small island nations and is forecast to increase substantially over the coming years. Governments, regional agencies, and health services of these nations face daunting challenges, including small and fragile economies, unequal distribution of resources, weak or fragmented health services, small population sizes that make sustainable workforce and service development problematic, and the unavailability of specialised cancer services to large parts of the population. Action is required to prevent large human and economic costs relating to cancer. This final Series paper highlights the challenges and opportunities for small island nations, and identifies ways in which the international community can support efforts to improve cancer control in these settings. Our recommendations focus on funding and investment opportunities to strengthen cancer-related health systems to improve sharing of technical assistance for research, surveillance, workforce, and service development, and to support small island nations with policy changes to reduce the consumption of commodities (eg, tobacco and unhealthy food products) that increase cancer risk.
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Affiliation(s)
- Diana Sarfati
- Department of Public Health, University of Otago, Wellington, Wellington, New Zealand.
| | - Rachel Dyer
- Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
| | - Paula Vivili
- Public Health Division, Pacific Community, Noumea, New Caledonia
| | | | | | - Richard Sullivan
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - David Weller
- James Mackenzie Professor of General Practice, Usher Institute of Population Health, Sciences and Informatics, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Freddie Bray
- Cancer Surveillance Section, International Agency for Research on Cancer, Lyon, France
| | - Sarah Hill
- Global Health Policy Unit, University of Edinburgh, Edinburgh, UK
| | - Christopher Bates
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, Melbourne, VIC, Australia
| | - Sunia Foliaki
- Centre for Public Health Research, Massey University-Wellington Campus, Wellington, New Zealand
| | - Neal Palafox
- Pacific Regional Cancer Programs, Department of Family Medicine and Community Health, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA; Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Silvana Luciani
- Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Alec Ekeroma
- Obstetrics and Gynaecology, University of Otago, Wellington, Wellington, New Zealand; National University of Samoa, Le Papaigalagala Campus, To'omatagi, Samoa
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16
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Ekeroma A, Dyer R, Palafox N, Maoate K, Skeen J, Foliaki S, Vallely AJ, Fong J, Hibma M, Mola G, Reichhardt M, Taulung L, Aho G, Fakakovikaetau T, Watters D, Toliman PJ, Buenconsejo-Lum L, Sarfati D. Cancer management in the Pacific region: a report on innovation and good practice. Lancet Oncol 2019; 20:e493-e502. [PMID: 31395474 DOI: 10.1016/s1470-2045(19)30414-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 12/12/2022]
Abstract
Pacific island countries and territories (PICTs) face the challenge of a growing cancer burden. In response to these challenges, examples of innovative practice in cancer planning, prevention, and treatment in the region are emerging, including regionalisation and coalition building in the US-affiliated Pacific nations, a point-of-care test and treat programme for cervical cancer control in Papua New Guinea, improving the management of children with cancer in the Pacific, and surgical workforce development in the region. For each innovation, key factors leading to its success have been identified that could allow the implementation of these new developments in other PICTs or regions outside of the Pacific islands. These factors include the strengthening of partnerships within and between countries, regional collaboration within the Pacific islands (eg, the US-affiliated Pacific nations) and with other regional groupings of small island nations (eg, the Caribbean islands), a local commitment to the idea of change, and the development of PICT-specific programmes.
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Affiliation(s)
- Alec Ekeroma
- National University of Samoa, Le Papaigalagala Campus, To'omatagi, Samoa; Department of Obstetrics and Gynaecology, University of Otago, Wellington, Wellington, New Zealand.
| | - Rachel Dyer
- Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
| | - Neal Palafox
- Pacific Regional Cancer Programs, Department of Family Medicine and Community Health, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HA, USA; Population Sciences in the Pacific Program (Cancer Prevention in the Pacific), University of Hawaii Cancer Center, Honolulu, HA, USA
| | - Kiki Maoate
- Pacific Islands Programme, Royal Australasian College of Surgeons, Melbourne, VIC, Australia; Department of Paediatric Surgery, Christchurch Public Hospital, Christchurch, New Zealand
| | - Jane Skeen
- Starship Blood and Cancer Centre, Starship Children's Health, Auckland, New Zealand
| | - Sunia Foliaki
- Centre for Public Health Research, Massey University-Wellington Campus, Wellington, New Zealand
| | - Andrew J Vallely
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - James Fong
- Obstetrics and Gynaecology Unit, Colonial War Memorial Hospital, Ministry of Health, Suva, Fiji; Fiji National University, Suva, Fiji
| | - Merilyn Hibma
- Cervical Cancer Prevention in the Pacific Alliance, Dunedin, New Zealand; Department of Pathology, University of Otago, Dunedin, New Zealand
| | - Glen Mola
- Department of Obstetrics, Gynaecology and Reproductive Health, Port Moresby General Hospital, Port Moresby, Papua New Guinea; School of Medicine and Health Sciences, University of Papua New Guinea, Boroko, Papua New Guinea
| | - Martina Reichhardt
- Cancer Council of the Pacific Islands, Yap State Department of Health Services, Yap State, Federated States of Micronesia
| | - Livinston Taulung
- Cancer Council of the Pacific Islands, Kosrae State Department of Health Services, Kosrae State, Federated States of Micronesia
| | - George Aho
- Department of Paediatrics, Vaiola Hospital, Nuku'alofa Tonga
| | | | - David Watters
- Deakin University and Barwon Health, University Hospital Geelong, Geelong, VIC, Australia
| | - Pamela J Toliman
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Lee Buenconsejo-Lum
- Pacific Regional Cancer Programs, Department of Family Medicine and Community Health, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HA, USA
| | - Diana Sarfati
- Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
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